Solomin LN Ed The Basic Principles of External Skeletal Fixa

The Basic Principles of External Skeletal Fixation
Using the Ilizarov and Other Devices

Leonid Nikolaevich Solomin
Editor
The Basic Principles

of External Skeletal
Fixation Using the Ilizarov
and Other Devices
Second Edition
Editor
Leonid Nikolaevich Solomin, M.D., Ph.D.
Professor of Orthopedic Surgery
R.R. Vreden Russian Research Institute
of Traumatology and Orthopedics
St. Petersburg
Russia
Professor of the Surgery Chair

Medical Faculty of Saint Petersburg
State University
St. Petersburg
Russia
Honourable Professor of Russian Ilizarov

Scientific Center “Restorative Traumatology
and Orthopedics”
Kurgan
Russia
ISBN 978-88-470-2618-6 ISBN 978-88-470-2619-3 (eBook)

DOI 10.1007/978-88-470-2619-3
Springer Milan Heidelberg New York Dordrecht London
Library of Congress Control Number: 2012956313
© Springer-Verlag Italia 2008, 2012

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This book is devoted to our Teachers.
This book is intended for those, who got connected with the External Fixation
and still have a desire to learn it in such a way as to improve it.
Foreword
Basic Principles of External Fixation, now in its second edition, has become a standard textbook
for those interested in external fixation. The second edition extends well beyond the Ilizarov
technique and its technology and now includes advances such as six-axis deformity correction.
There are also new applications for the treatment of the spine, which is not usually considered
for external fixation, and for cosmetic surgery of the limbs. In expanding on the first edition,
Solomin has not only updated his vast contributions but has also added new material by
numerous other authors, from Russia and around the world. No other book on external fixation
is as comprehensive as this one. Solomin is to be congratulated for his efforts in recognizing
the need for a new edition even though the previous one is by no means out of date. Indeed, this
second edition reminds us that external fixation is an ever-evolving technology and that to stay
current requires fresh, authoritative, and instructive publications such as this one.
Dror Paley, M.D., FRCSC

Director of Paley Advanced
Limb Lengthening Institute
West Palm Beach, Florida, USA
vii
Dear Colleagues!
With this book, the authors have provided a resource that allows readers to fully explore the
techniques and applications inspired by the method of the academician G.A. Ilizarov. Ilizarov’s
genius was to create not only a methodology and the equipment to carry it out, but also to set
forth a unique philosophy that quickly found support and further development from experts all
over the world. Thus, distraction osteogenesis, management of the regeneration and morpho-
genesis of body tissues, the use of minimally invasive techniques, the stability of bone-frag-
ment fixation, and the importance of early weight-bearing revolutionized orthopedic surgery in
the 20th century. These original approaches have continued to undergo refinement and
modification during the third millennium.
Of equal importance with the Ilizarov approach is the understanding that the role of external
fixation is not as an absolute alternative to other forms of treatment, but as a primary method
that is deeply integrated with other aspects of orthopedic surgery. An essential requirement of
any orthopedist performing external fixation is that he or she must have sufficient skills to
recognize and manage possible complications, including non-unions and osteomyelitis. This
manual is therefore an invaluable source of ideas and inspiration for experts who are able to
“think outside the box”; that is, who have the ability to exploit the many possibilities of the
Ilizarov approach to treat a wide variety of orthopedic pathologies. External fixation is a
method of a thousand permutations and as such often requires the willingness to improvise,
while using the algorithms, advice, and recommendations provided in this monograph as guid-
ance. Like a game of chess, for each patient there are a typically a large number of subsequent
moves, e.g., regarding the details of the frame, that follow once the initial structure is chosen.
To learn the “rules of the game” to avoid the mistakes made by several generations of orthope-
dists, and to not box oneself into an orthopedic “checkmate in three moves” is why this book
has been written.
Alexander V. Gubin, M.D., Ph.D.

Director of the Russian Ilizarov Scientific Center
for Restorative Traumatology and Orthopedics
Kurgan, Russia
ix
Contents
After the title of each chapter, all Authors, who have contributed to that chapter, are listed. The
specific authorship of the individual paragraphs is given after each section title.
Part I General Aspects of External Fixation
1 General and Special Aspects of External Fixation . . . . . . . . . . . . . . . . . . . . . . 3

Leonid Nikolaevich Solomin and Stuart Alan Green
1.1 Historical Background and Classification. . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Advantages and Disadvantages, Indications and Contraindications . . . . . 9
1.3 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.4 General Terms of External Fixation Constructs . . . . . . . . . . . . . . . . . . . . 18
2 Biomechanical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.1 Relationship Between the Transosseous Elements
and the Surrounding Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.2 Control of Bone Fragment Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.2.1 Moving the External Supports with the Transosseous
Modules Fixing the Bone Fragments . . . . . . . . . . . . . . . . . . . . 25
2.2.2 Moving the Transosseous Elements Relative
to the External Supports; External Supports
and Modules Remain Immobile . . . . . . . . . . . . . . . . . . . . . . . . 25
2.3 Control of Bone Fragment Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.3.1 Number of Transosseous Elements . . . . . . . . . . . . . . . . . . . . . . 41
2.3.2 Diameter and Type of Transosseous Elements . . . . . . . . . . . . . 41
2.3.3 Wire Tension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.3.4 Levels of Transosseous Element Insertion . . . . . . . . . . . . . . . . 41
2.3.5 Plane of Orientation of the Transosseous Elements . . . . . . . . . 41
2.3.6 Distance from the Bone to the External Support . . . . . . . . . . . 43
2.3.7 External Support Geometry. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.3.8 Number of Connecting Rods. . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3 Internal Contradictions of External Fixation.
Combined External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.2 Method of the Unified Designation of External Fixation (MUDEF) . . . . 49
3.3 Reference Positions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.4 Use of Different Types of Transosseous Elements and External Support 49
3.5 Module Transformation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.6 Minimum Number of External Supports and Transosseous Elements . . . 49
3.7 Computer Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.8 Converting to Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
xi
xii Contents
4 Method of Unified Designation of External Fixation (MUDEF) . . . . . . . . . . . 53

4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
4.2 Symbols Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.3 Coordinates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.3.1 Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.3.2 Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4 Designation of Transosseous Elements. . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4.1 Designation of K-wires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4.2 Designation of Half-Pins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4.5 Designation of the External Support Frame . . . . . . . . . . . . . . . . . . . . . . . 58
4.6 Designation of the Entire Device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.7 Additional Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5 Atlas for the Insertion of Transosseous Element Reference Positions . . . . . . 63
Leonid Nikolaevich Solomin, Roman Nikolaevich Inyushin,
Pavel Nikolaevich Kulesh, Maxim Vasil’evich Andrianov,
Dmitry Alexandrovich Mykalo, Nikolay Fedorovich Fomin,
Sergey Valerjevich Majkov, and Konstantin Andreevich Ukhanov
5.1 Upper Arm (L.N. Solomin, R.N. Inyushin) . . . . . . . . . . . . . . . . . . . . . . . 65
5.2 Ulna (L.N. Solomin, P.N. Kulesh). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
5.2.1 Ulna, Mid-Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
5.2.2 Ulna, Supination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.2.3 Ulna, Pronation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
5.3 Radius (L.N. Solomin, P.N. Kulesh) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
5.3.1 Radius, Mid-Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
5.3.2 Radius, Supination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
5.3.3 Radius, Pronation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
5.4 Femur (L.N. Solomin, M.V. Andrianov). . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.5 Tibia (L.N. Solomin, D.A. Mykalo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
5.6 Foot (L.N. Solomin, N.F. Fomin, S.V. Majkov, K.A.Ukhanov) . . . . . . . . 142
5.6.1 Cross-Sectional Cuts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
5.6.2 Oblique Cuts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
5.7 Pelvis (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
6 Preoperative Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
6.2 X-Ray Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
6.2.1 Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
6.2.2 Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
6.2.3 Imaging of the Lower Limbs. . . . . . . . . . . . . . . . . . . . . . . . . . . 169
6.2.4 X-Ray Examination of the Upper Limbs . . . . . . . . . . . . . . . . . 174
7 Principles of Frame Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
7.1 Identification of the Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
7.2 Identification of the Optimal Levels for the Insertion
of Transosseous Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
7.3 Identification of the Optimal Transosseous Elements on the Basis
of Safe Positions and Reference Positions . . . . . . . . . . . . . . . . . . . . . . . . 186
7.4 Identification of the Optimal Levels for Positioning
the External Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Contents xiii
7.5 Identification of the Type and Size of the External Supports

Corresponding to the Selected Transosseous Elements and Their
Insertion Levels While Allowing for Module Transformation . . . . . . . . . 192
7.6 Marking the Selected Levels and Positions on the Segment
for Transosseous Element Insertion and External Support Placement . . . 195
7.7 Transosseous Element Insertion, External Support Installation,
and Frame Assembly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
7.8 Ilizarov Method of Corticotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
8 Features of Reparative Osteogenesis and the Management
of Distraction Osteogenesis in External Fixation . . . . . . . . . . . . . . . . . . . . . . . 219
Sergey Aleksandrovich Erofeev and Elena Andreevna Shchepkina
8.1 Introduction (S.A. Erofeev). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
8.2 Distraction Osteogenesis (S.A. Erofeev). . . . . . . . . . . . . . . . . . . . . . . . . . 220
8.3 Features of Osteogenesis in External Fixation Depending
on Various Mechanical and Biological Factors (S.A. Erofeev) . . . . . . . . 223
8.3.1 Mechanical Factors (Stability of Bone Fragment Fixation) . . . 223
8.3.2 Biological Factors (Maintenance of Blood Supply,
Bone Marrow and Periosteum) . . . . . . . . . . . . . . . . . . . . . . . . . 223
8.4 Osteogenesis Management (S.A. Erofeev) . . . . . . . . . . . . . . . . . . . . . . . . 231
8.4.1 Optimal Regimens and Distraction Types. . . . . . . . . . . . . . . . . 231
8.4.2 Reparative Regeneration of the Bone After Rupture
of the Distraction Regenerate . . . . . . . . . . . . . . . . . . . . . . . . . . 234
8.5 Distraction Osteogenesis Stimulation (S.A. Erofeev). . . . . . . . . . . . . . . . 234
8.5.1 Dynamic (Compression) Loadings
on the Osteogenesis Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
8.5.2 Use of the Bone Marrow and Growth Factors . . . . . . . . . . . . . 238
8.5.3 Stimulation of Distraction Osteogenesis Using
Intramedullary Curved Wires . . . . . . . . . . . . . . . . . . . . . . . . . . 239
8.6 Special Features of Distraction Osteogenesis
in Lengthening Over a Nail (S.A. Erofeev) . . . . . . . . . . . . . . . . . . . . . . . 241
8.7 Osteogenesis Stimulation by Different Types of Grafts (S.A. Erofeev) . . 242
8.8 Use of the Bone Marrow Cells, Morphogenetic Proteins,
and Growth Factors (E.A. Shchepkina) . . . . . . . . . . . . . . . . . . . . . . . . . . 245
9 External Fixation at the Vreden Russian Research
Institute of Traumatology and Orthopedics . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
9.2 The Early Experience in External Fixation (1961–1968) . . . . . . . . . . . . . 257
9.3 Consolidation of External Fixation (1968–2001) . . . . . . . . . . . . . . . . . . . 262
9.4 Present Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Part II Specific Aspects of External Fixation
10 Fractures of the Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

10.1 Proximal Humerus (11-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
10.2 Diaphyseal Fractures (12-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
10.2.1 Proximal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
10.2.2 Middle Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
10.2.3 Distal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
10.2.4 Radial Nerve Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
10.3 Distal Humerus (13-). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
xiv Contents
11 Fractures of the Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh
11.1 Proximal Forearm (21-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . 343
11.2 Diaphyseal Fractures (22-) (L.N. Solomin, P.N. Kulesh) . . . . . . . . . . . . . 346
11.2.1 Ulnar Diaphysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
11.2.2 Radial Diaphysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
11.2.3 Diaphysis of the Radius and Ulna. . . . . . . . . . . . . . . . . . . . . . . 359
11.3 Distal Forearm (23-) (L.N. Solomin, P.N. Kulesh) . . . . . . . . . . . . . . . . . . 369
12 Fractures of the Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Leonid Nikolaevich Solomin and Viktor Alexandrovich Vilensky
12.1 Proximal Femur (31-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
12.2 Diaphyseal Fractures (32-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . 385
12.2.1 Proximal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
12.2.2 Middle Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
12.2.3 Distal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
12.3 Distal Femur (33-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
12.4 Patella (91.1-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
12.5 External Fixation for the Treatment of Periprosthetic Fractures
of the Femur (L.N. Solomin, V.A. Vilensky) . . . . . . . . . . . . . . . . . . . . . . 418
12.5.1 ECD Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
12.5.2 ECD Placement Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
12.5.3 Other Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
13 Fractures of the Tibia and Fibula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Leonid Nikolaevich Solomin and Tracy J. Watson
13.1 Proximal Tibia and Fibula (41-) (L.N. Solomin, T.J. Watson) . . . . . . . . . 437
13.1.1 Surgical Technique for Limited Internal Fixation with
Spanning External Fixation of Tibial Plateau Fractures . . . . . . 442
13.1.2 Arthroscopy and Fracture Management . . . . . . . . . . . . . . . . . . 457
13.2 Diaphyseal Fractures (42-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . 459
13.2.1 Proximal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
13.2.2 Middle Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
13.2.3 Distal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
13.3 Distal Tibia and Fibula (43-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . 484
13.4 Ankle Injuries (44-) (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
13.5 Chronic Ankle Injuries (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . 502
14 Open Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Alexander A. Lerner and Leonid Nikolaevich Solomin
14.1 Fixation Methods in the Treatment of Open Limb Fractures . . . . . . . . . . 507
14.2 Debridement and Primary Bone Fixation Using Unilateral
External Fixation Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
14.3 Final Bone Reconstruction Using Circular and
Hybrid External Fixation Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
14.3.1 Conversion from Primary Unilateral External
Fixation Devices with Half-Pin Preservation . . . . . . . . . . . . . . 519
14.3.2 Hybrid External Fixation Devices. . . . . . . . . . . . . . . . . . . . . . . 520
14.4 The Ilizarov Device as a Basic Frame. . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
14.4.1 Special Features of the Ilizarov Circular Device
in the Treatment of Open Peri-articular Fractures . . . . . . . . . . 525
14.5 Universal Reduction Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Contents xv
15 Malunited Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535

16 Basic Principles of External Fixation in the Correction
of Long-Bone Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Leonid Nikolaevich Solomin, Konstantin Igorevich Novikov, Anna Majorovna
Aranovich, Mark Eidelman, and Pavel Nikolaevich Kulesh
16.1 Terminology and Classification (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . 541
16.2 Planning the Correction of a Deformity (L.N. Solomin) . . . . . . . . . . . . . 544
16.3 The General Principles of Deformity Correction (L.N. Solomin) . . . . . . 547
16.3.1 Correction of Axial Translation:
Shortening or Lengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
16.3.2 Peripheral Translation Correction . . . . . . . . . . . . . . . . . . . . . . . 547
16.3.3 Correction of Angular Deformities . . . . . . . . . . . . . . . . . . . . . . 548
16.3.4 Torsion Deformity Correction. . . . . . . . . . . . . . . . . . . . . . . . . . 558
16.4 Order of Deformity Components Correction (L.N. Solomin). . . . . . . . . . 561
16.5 Basic Principles of Long-Bone Deformity Correction
in the Lower Limbs (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
16.5.1 Referent Lines of the Lower Limbs and Their
Mutual Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
16.5.2 Length Discrepancies of the Lower Limbs . . . . . . . . . . . . . . . . 568
16.5.3 Peripheral Translation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
16.5.4 Angular Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
16.5.5 Torsion Deformities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
16.5.6 Examples of Deformity Correction Planning in the Femur:
The Basic Frames Assemblies . . . . . . . . . . . . . . . . . . . . . . . . . 576
16.5.7 Examples of Deformity Correction Planning
for the Lower Legs: The Basic Frame Assemblies . . . . . . . . . . 593
16.6 Technical Tips and Tricks for the Correction of Deformities
of the Humerus and Forearm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
16.6.1 Referent Lines of the Upper Limbs and
Their Mutual Relations (L.N. Solomin, P.N. Kulesh). . . . . . . . 615
16.6.2 Upper-Limb Length Discrepancies . . . . . . . . . . . . . . . . . . . . . . 617
16.6.3 Peripheral Translation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
16.6.4 Angular Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
16.6.5 Torsion Deformities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
in the Humerus: The Basic Frames Assemblies . . . . . . . . . . . . 619
in the Forearm Bones (L.N. Solomin, P.N. Kulesh) . . . . . . . . . 632
16.7 Special Features of Deformity Correction
in Achondroplasia (K.I. Novikov, A.M. Aranovich). . . . . . . . . . . . . . . . . 641
16.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
16.7.2 Special Features of Long Bone Formation
in the Lower Limb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
16.7.3 Special Features of Humerus Formation. . . . . . . . . . . . . . . . . . 648
16.7.4 Special Features in the Formation of the Forearm Bones . . . . . 651
16.7.5 General Principles of Operative Treatment. . . . . . . . . . . . . . . . 651
16.7.6 Special Features of Lengthening and Deformity Correction
of the Lower Limbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
16.7.7 Lengthening and Correction of Upper Limb Deformities. . . . . 661
16.7.8 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
16.7.9 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 664
xvi Contents
16.8 Principles of Limb Lengthening and Deformity Correction

in Children and Adolescents (M. Eidelman). . . . . . . . . . . . . . . . . . . . . . . 666
16.8.1 Prediction of Leg Length Discrepancy . . . . . . . . . . . . . . . . . . . 668
16.8.2 Basic Principles of Treatment of Leg Length Discrepancy . . . 670
16.8.3 Limb Lengthening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 670
16.8.4 Osteosynthesis by Circular External Fixation. . . . . . . . . . . . . . 675
16.8.5 Supramalleolar Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
16.8.6 Correction of Deformities in Children by Partial
Epiphysiodesis (Hemiepiphysiodesis) . . . . . . . . . . . . . . . . . . . 682
16.8.7 Principles of Deformity Correction of the Upper Extremities . 684
17 Deformity Correction and Fracture Treatment Using
the Software-Based Ortho-SUV Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705
Leonid Nikolaevich Solomin, Alexander Igorevich Utekhin,
and Viktor Alexandrovich Vilensky
17.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705
17.2 Design of the Ortho-SUV Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
17.2.1 Strut Design of an Ortho-SUV Frame. . . . . . . . . . . . . . . . . . . . 709
17.2.2 External Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
17.3 Ortho-SUV Frame Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
17.3.1 Assembling the Universal Reduction Unit . . . . . . . . . . . . . . . . 719
17.4 Modes of Ortho-SUV Frame Operation . . . . . . . . . . . . . . . . . . . . . . . . . . 725
17.4.1 Fast Struts Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
17.4.2 Deformity Correction Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
17.5 Software for the Ortho-SUV Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
17.5.1 Parameters Measured on the Frame . . . . . . . . . . . . . . . . . . . . . 732
17.5.2 Parameters Measured on X-Ray . . . . . . . . . . . . . . . . . . . . . . . . 732
17.5.3 Working with the Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
17.6 Application of the Ortho-SUV Frame: Clinical Cases . . . . . . . . . . . . . . . 775
17.6.1 Fracture Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
17.6.2 Diaphyseal Deformities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
17.6.3 Metaphyseal Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 787
17.6.4 Deformity Correction of the Foot . . . . . . . . . . . . . . . . . . . . . . . 793
17.6.5 Knee Joint Stiffness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793
17.7 Tips and Tricks for Using the Ortho-SUV Frame. . . . . . . . . . . . . . . . . . . 794
18 Basics of Aesthetic Correction of the Lower Extremities. . . . . . . . . . . . . . . . . 805
Leonid Nikolaevich Solomin, Oleg Anatoljevich Kaplunov,
Pavel Nikolaevich Kulesh, and Alexander Aleksandrovich Artemev
18.1 Introduction (L.N. Solomin, O.A. Kaplunov, P.N. Kulesh) . . . . . . . . . . . 805
18.2 Correction of the Shape of the Legs
(L.N. Solomin, O.A. Kaplunov, P.N. Kulesh) . . . . . . . . . . . . . . . . . . . . . . 809
18.2.1 Special Features of the Examination. . . . . . . . . . . . . . . . . . . . . 809
18.2.2 X-Ray Examination Features . . . . . . . . . . . . . . . . . . . . . . . . . . 809
18.2.3 Preoperative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810
18.2.4 Preoperative Planning Software: “Leg Shape Correction”
(O.A. Kaplunov) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
18.2.5 Correction of Leg Shape Using Circular Fixators
(L.N. Solomin, O.A. Kaplunov, P.N. Kulesh) . . . . . . . . . . . . . . 816
18.2.6 Correction of Leg Shape Using
Semicircular Fixators (L.N. Solomin, P.N. Kulesh) . . . . . . . . . 818
Contents xvii
18.2.7 Postoperative Period

(L.N. Solomin, O.A. Kaplunov, P.N. Kulesh) . . . . . . . . . . . . . . 819
18.2.8 Volume and Contour of the Lower Legs
(L.N. Solomin, O.A. Kaplunov) . . . . . . . . . . . . . . . . . . . . . . . . 827
18.3 Growth and Length of the Lower Extremities Under
Aesthetic Indications (A.A. Artemjev, O.A. Kaplunov, L.N. Solomin) . . 830
18.4 Complications (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 840
19 Non-unions, Pseudoarthroses, and Long-Bone Defects . . . . . . . . . . . . . . . . . . 841
Leonid Nikolaevich Solomin, Dmitry Jur’evich Borzunov,
Redento Mora, Vladimir Ivanovich Shevtsov, and Luisella Pedrotti
19.1 Introduction (L.N. Solomin, D.J. Borzunov, R. Mora) . . . . . . . . . . . . . . . 841
19.2 Non-unions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 842
19.3 Parafocal Osteotomy (L. Pedrotti) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
19.4 Long-Bone Defects (L.N. Solomin, D.J. Borzunov, R. Mora) . . . . . . . . . 854
19.4.1 Polylocal Osteosynthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861
19.4.2 Tibiofibular Synostosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 872
19.5 Treatment of Congenital Tibial Pseudoarthrosis Using
the Ilizarov Method of Transosseous Osteosynthesis (V.I. Shevtsov) . . . 879
19.5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879
19.5.2 Etiology of Congenital Pseudoarthrosis . . . . . . . . . . . . . . . . . . 880
19.5.3 Signs and Symptoms of Tibial Congenital Pseudoarthroses. . . 880
19.5.4 Morphology and Biochemistry . . . . . . . . . . . . . . . . . . . . . . . . . 881
19.5.5 Treatment of Congenital Pseudoarthrosis . . . . . . . . . . . . . . . . . 881
19.5.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888
19.5.7 Results of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892
20 Combined Strained Fixation of the Long Bones . . . . . . . . . . . . . . . . . . . . . . . . 895
20.1 Equipment for CSF and Principles of Its Application . . . . . . . . . . . . . . . 896
20.2 Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
20.3 Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902
20.4 Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
20.4.1 Ulna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906
20.4.2 Radius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907
20.4.3 CSF of Both Forearm Bones: Combined Fixation . . . . . . . . . . 909
20.5 Clavicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920
20.5.1 External Fixation of the Clavicle . . . . . . . . . . . . . . . . . . . . . . . 923
20.6 Postoperative Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
21 Pelvic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933
Aleksey Vladimirovich Runkov and Leonid Nikolaevich Solomin
21.1 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
21.2 Principles of External Device Assembly for the Fixation of
Pelvic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935
21.2.1 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935
21.2.2 Osteosynthesis in Stable and Partially Stable
Pelvic Injuries (61-A, 61-B) . . . . . . . . . . . . . . . . . . . . . . . . . . . 936
21.2.3 Osteosynthesis in Vertically Unstable Pelvic Injuries (61-C) . . 936
21.2.4 External Fixation of Acetabular Fractures . . . . . . . . . . . . . . . . 943
21.3 External Fixation of Malunited Pelvic Fractures
and Pelvic Deformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 960
21.4 Postoperative Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967
xviii Contents
22 Foot and Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 969

Alexander Kirienko, Leonid Nikolaevich Solomin,
Natalya Grigorjevna Shikhaleva, Vladimir Ivanovich Shevtsov,
Mikhail Jur’evich Danilkin, and Konstantin Andreevich Ukhanov
22.1 Reference Lines and Angles of the Foot
(L.N. Solomin, K.A. Ukhanov). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 969
22.2 Foot Injuries (L.N. Solomin). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 978
22.2.1 Forefoot Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 978
22.2.2 Midfoot Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 979
22.2.3 Hindfoot Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 981
22.3 Closed Correction of Foot Deformities (L.N. Solomin) . . . . . . . . . . . . . . 984
22.4 Foot Osteotomies (A. Kirienko) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988
22.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988
22.4.2 Osteotomy of the Heel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988
22.4.3 Astragalocalcaneal Osteotomies . . . . . . . . . . . . . . . . . . . . . . . . 989
22.4.4 Osteotomies of the Middle Part of the Foot . . . . . . . . . . . . . . . 995
22.4.5 Osteotomy of the Anterior Part of the Foot. . . . . . . . . . . . . . . . 1000
22.5 Fusion of the Joints of the Foot (A. Kirienko, L.N. Solomin) . . . . . . . . . 1010
22.5.1 Fusion of the Ankle Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010
22.5.2 Subtalar Joint Fusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1011
22.5.3 Fusion of Ankle and Subtalar Joints . . . . . . . . . . . . . . . . . . . . . 1013
22.5.4 Triple Joint Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013
22.5.5 Panarthrodesis of the Foot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017
22.5.6 Fusion of the Lisfranc Joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1018
22.6 Basics of External Fixation in Hand Surgery
(N.G. Shikhaleva, V.I. Shevtsov, M.J. Danilkin). . . . . . . . . . . . . . . . . . . . 1023
22.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
22.6.2 Indications and Contraindications for Transosseous
Osteosynthesis of the Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
22.6.3 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
22.6.4 Osteosynthesis of Fractures of the Hand Bones
with the Mini-fixator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024
22.6.5 Deformity Correction of the Bones of the Hand Using
External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1027
22.6.6 Transosseous Osteosynthesis in the treatment
of Post-traumatic Stumps of the Hand . . . . . . . . . . . . . . . . . . . 1035
22.6.7 Congenital Anomalies of the Hand . . . . . . . . . . . . . . . . . . . . . . 1035
22.6.8 Syndactyly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036
22.6.9 Contractures of the Joints of the Hand . . . . . . . . . . . . . . . . . . . 1039
22.6.10 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
22.6.11 Result of Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
23 Large-Joint Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047
Leonid Nikolaevich Solomin, Elena Aleksandrovna Volokitina,
Jury Petrovich Soldatov, and William Dean Terrell
23.1 Shoulder (L.N. Solomin). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047
23.2 Elbow (L.N. Solomin, J.P. Soldatov) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051
23.3 Wrist (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1059
23.4 External Fixation of the Hip Joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1062
23.4.1 Support Osteotomies Using the Ilizarov
Technique (E.A.Volokitina, L.N. Solomin). . . . . . . . . . . . . . . . 1062
23.4.2 Femur Lowering Before Hip Replacement
(E.A.Volokitina, L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . 1081
Contents xix
23.4.3 Deformity Correction of the Proximal Femur Before

Total Hip Replacement (E.A.Volokitina) . . . . . . . . . . . . . . . . . . 1092
23.4.4 Arthrodiatasis (W.D. Terrell). . . . . . . . . . . . . . . . . . . . . . . . . . . 1107
23.4.5 Hip-Joint Fusion (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . 1119
23.5 Knee (L.N. Solomin). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1121
23.6 Ankle (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1150
24 Infectious Complications of Long-Bone Fractures . . . . . . . . . . . . . . . . . . . . . . 1157
Maurizio A. Catagni and Leonid Nikolaevich Solomin
24.1 General Data (L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157
24.2 General Strategy of Pseudoarthrosis Treatment (M.A. Catagni) . . . . . . . 1159
24.2.1 Non-unions Without Bone Loss . . . . . . . . . . . . . . . . . . . . . . . . 1160
24.2.2 Non-union with Bone Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1170
24.3 Infected Non-union . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1196
24.4 Skin Problems in Infected Non-unions . . . . . . . . . . . . . . . . . . . . . . . . . . . 1219
24.5 Massive Segmental Tibial Bone Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1239
24.6 Frame Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1247
25 Features of External Fixation in Children,
the Elderly, and the Senile. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249
Jury Evgen’evich Garkavenko, Elena Andreevna Shchepkina,
and Leonid Nikolaevich Solomin
25.1 Indications and Features of External Fixation in Children . . . . . . . . . . . . 1249
25.1.1 External Fixation in Children with Acquired
Limb Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1258
25.2 Features of External Fixation in the Elderly
and the Senile (E.A. Shchepkina, L.N. Solomin) . . . . . . . . . . . . . . . . . . . 1279
26 Combined and Consecutive Use of External and Internal Fixation . . . . . . . . 1309
Mehmet Kocaoğlu, Leonid Nikolaevich Solomin, Erkal F. Bilen,
Alexandr Nikolaevich Chelnokov, John E. Herzenberg,
and Florian Maria Kovar
26.1 Lengthening Over a Nail (LON)
(M. Kocaoğlu, L.N. Solomin, E.F. Bilen) . . . . . . . . . . . . . . . . . . . . . . . . . 1309
26.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1309
26.1.2 Indications and Contraindications. . . . . . . . . . . . . . . . . . . . . . . 1310
26.1.3 Special Features of the Equipment . . . . . . . . . . . . . . . . . . . . . . 1310
26.1.4 Femoral LON: Surgical Technique . . . . . . . . . . . . . . . . . . . . . . 1310
26.1.5 Tibial LON: Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . 1312
26.1.6 Distraction Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1323
26.1.7 Removal of the External Fixator . . . . . . . . . . . . . . . . . . . . . . . . 1323
26.1.8 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1324
26.2 Bone Transport Over Nail (BTON) (M. Kocaoğlu, E.F. Bilen,
L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1329
26.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1329
26.2.4 General Principles of the BTON
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1330
26.2.5 Femoral BTON Surgical Technique . . . . . . . . . . . . . . . . . . . . . 1331
26.2.6 Tibial BTON Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . 1332
26.2.7 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
26.2.8 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
xx Contents
26.3 Sequential External Fixation and Nailing (SEFaN) (A.N. Chelnokov,

L.N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1344
26.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1344
26.3.4 General Principles of the SEFaN Surgical Technique. . . . . . . . 1345
26.3.5 Femoral SEFaN Surgical Technique . . . . . . . . . . . . . . . . . . . . . 1347
26.3.6 Tibial SEFaN Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . 1347
26.3.7 Upper Arm and Forearm SEFaN Surgical Technique. . . . . . . . 1355
26.3.8 Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1362
26.3.9 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1362
26.4 External Fixation Assisted Nailing (EFAN) and External Fixation
Assisted Plating (EFAP) for Deformity Correction
(J.E. Herzenberg, F.M. Kovar) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1363
26.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1363
26.4.2 Goals of Deformity Correction . . . . . . . . . . . . . . . . . . . . . . . . . 1363
26.4.5 External Fixator Assisted Retrograde Nailing
for Acute Distal Femur Valgus Deformity Correction:
26.4.6 External Fixator Assisted Plating (EFAP)
for Distal Femur Valgus Deformity Correction:
26.4.7 Postoperative Care. Additional Concepts . . . . . . . . . . . . . . . . . 1370
27 Applications of External Fixation in Long Bone Tumor . . . . . . . . . . . . . . . . . 1379
Hiroyuki Tsuchiya and Katsuhiro Hayashi
27.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1379
27.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1379
27.3 Classification of Reconstruction
with Distraction Osteogenesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1380
27.4 Type 1: Diaphyseal Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1383
27.5 Type 2: Metaphyseal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1383
27.6 Type 3: Epiphyseal Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1383
27.7 Type 4: Subarticular Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1383
27.8 Type 5: Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1384
27.9 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1384
28 Application of Transosseous Osteosynthesis in Vertebrology . . . . . . . . . . . . . 1391
Alexander Nikolaevich Djachkov, Alexander Timofeevich Khudiaev,
Oksana Germanovna Prudnikova, and Oleg Sergeevich Rossik
28.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1391
28.2 Equipment Properties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1391
28.3 Special Principles in the Application of Transosseous
Osteosynthesis in Vertebrology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1392
28.4 Transosseous Osteosynthesis in the Management of Patients
with “Uncomplicated” Fractures of the Thoracic and Lumbar Spine. . . . 1393
with Complicated Fractures of the Thoracic and Lumbar Spine . . . . . . . 1397
with Neglected Lesions of the Thoracic and Lumbar Spine . . . . . . . . . . . 1400
with Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1405
Contents xxi
28.8 Transosseous Osteosynthesis in the Management

of Patients with Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1409
28.9 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1413
28.9.1 Complications During Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 1413
28.9.2 Postoperative Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . 1413
28.10 Efficacy of Transosseous Osteosynthesis Application
in Vertebrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1414
29 Correction of the Sizes and Forms of the Jaws . . . . . . . . . . . . . . . . . . . . . . . . . 1417
Metin Orhan
29.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1417
29.2 Indications and Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1417
29.3 Special Features of the Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1418
29.3.1 Extraoral Distractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1418
29.3.2 Intraoral Distractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1418
29.4 General Principles of the Surgical Techniques in Maxillary
and Mandibular Distraction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1420
29.4.1 RED Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1420
29.4.2 Segmental DO Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . 1420
29.5 Postoperative Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1420
29.5.1 RED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1420
29.5.2 Intraoral Distractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1420
29.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1423
30 Application of External Fixation in Skull Surgery . . . . . . . . . . . . . . . . . . . . . . 1425
Alexander Nikolaevich Djachkov, Alexander Timofeevich Khudiaev,
and Oksana Germanovna Prudnikova
30.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1425
30.2 Theoretical Basis Underlying the Use of Transosseous Osteosynthesis
in Craniosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1425
30.3 Etiology and Pathogenesis of Brain Ischemia. . . . . . . . . . . . . . . . . . . . . . 1428
30.4 Clinical Manifestations and the Diagnosis of Cerebral Ischemic Lesions 1428
30.5 Transosseous Osteosynthesis for the Treatment of Patients
with Cranial Vault Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1429
30.6 Transosseous Osteosynthesis for the Treatment of Patients
with Disturbed Cerebral Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1431
30.7 Efficacy of Transosseous Osteosynthesis in Craniosurgery . . . . . . . . . . . 1431
30.8 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1435
31 External Fixation in the Treatment of Chronic Limb Ischemia . . . . . . . . . . . 1437
Vladimir Dmitrievich Shatokhin
31.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1437
31.3 Preoperative Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1440
31.4 Stimulation of the Blood Supply and Microcirculation by Forming
a Bone Splinter Followed by Its Consequent Transversal Transport . . . . 1440
31.5 Stimulation of the Peripheral Circulation Using Wires Implanted into
the Medullary Cavity of a Long Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1442
31.6 Revascularizing Bone Trepanation (RBT) in the Stimulation
of the Blood Supply and Microcirculation . . . . . . . . . . . . . . . . . . . . . . . . 1443
31.7 Stimulation of the Blood Supply and Microcirculation by
Creating Tunnels in the Bone Metaphysis . . . . . . . . . . . . . . . . . . . . . . . . 1444
31.8 Stimulation of the Blood Supply and Microcirculation Using
a “Scooping Out” Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1445
xxii Contents
31.9 Stimulation of the Blood Circulation and Microcirculation by

Fenestration and Dosed Damage of the Bone Marrow . . . . . . . . . . . . . . . 1446
31.10 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1446
31.11 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1446
32 General Principles of Patient Management
in the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1449
32.1 Position in Bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1449
32.2 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1449
32.3 Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1449
32.4 Exercise Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1451
32.5 Physio- and Pharmacotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1454
32.6 Biomechanical Device State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1454
32.7 Outpatient Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1458
32.8 Device Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1471
33 Complications and Solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1475
Part III Supplementary Materials
34 External Fixation: a Brochure Containing

Useful Information for Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1495
Leonid Nikolaevich Solomin, Tatyana Nikolaevna Vorontsova,
and Victor Viktorovich Ershov
34.1 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1495
34.1.1 What Is External Fixation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1495
34.1.2 Design of External Fixation Devices . . . . . . . . . . . . . . . . . . . . 1497
34.1.3 How Is New Bone Formed? . . . . . . . . . . . . . . . . . . . . . . . . . . . 1497
34.1.4 Your Core Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1499
34.2 Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1499
34.3 The Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1501
34.3.1 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1503
34.3.2 Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1503
34.3.3 Personal Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1503
34.3.4 Sex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1503
34.3.5 Quit Smoking!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1503
34.3.6 Physiotherapy Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1503
34.3.7 Removal of the External Fixation Device . . . . . . . . . . . . . . . . . 1504
34.4 Possible Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1504
A Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1504
A.1 Appendix A: Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1504
A.2 Appendix B: Frame Manipulation . . . . . . . . . . . . . . . . . . . . . . 1505
A.3 Appendix C: Your Orthopedic Status Diary . . . . . . . . . . . . . . . 1509
A.4 Appendix D: Walking with the Aid of
Crutches or a Cane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1509
A.5 Appendix E: Clothing Adjustments . . . . . . . . . . . . . . . . . . . . . 1511
A.6 Appendix F: Isometric Exercises . . . . . . . . . . . . . . . . . . . . . . . 1512
A.7 Appendix G: Rehabilatory Gymnastics . . . . . . . . . . . . . . . . . . 1515
Contents xxiii
35 Method for the Definition of “Reference Positions”

for the Insertion of Transosseous Elements. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1519
Leonid Nikolaevich Solomin, Maxim Vasil’evich Andrianov,
Roman Nikolaevich Inyushin, Dmitry Alexandrovich Mykalo,
and Pavel Nikolaevich Kulesh
35.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1519
35.2 Main Principles in the Determination of Positions with Minimum
Soft-Tissue Displacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1519
35.2.1 Skin Displacement Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 1520
35.2.2 Fascia Displacement Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 1520
35.2.3 Muscle Displacement Evaluation . . . . . . . . . . . . . . . . . . . . . . . 1520
35.3 Determination of Positions with Minimum Soft-Tissue Displacement . . 1523
35.3.1 Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1523
35.3.2 Upper Arm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1523
35.3.3 Lower Leg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1523
35.3.4 Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1524
36 Method for Rigidity Testing of External Fixation Assemblies. . . . . . . . . . . . . 1531
Leonid Nikolaevich Solomin, Petr Iosiphovich Begun,
and Vladimir Anatol’evich Nazarov
36.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1531
36.3 General Theoretical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1532
36.3.1 Transosseous Module Classification . . . . . . . . . . . . . . . . . . . . . 1532
36.3.2 Method for the Unified Designation of External Fixation . . . . 1536
36.3.3 Modeling the Displacing Forces . . . . . . . . . . . . . . . . . . . . . . . . 1536
36.3.4 Primary Standard for the Rigidity of Transosseous Modules . . 1537
36.4 Experimental Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1539
36.4.1 Investigating the Rigidity of Transosseous Modules
of the First (M1) and Second (M2) Orders . . . . . . . . . . . . . . . . 1539
36.4.2 Investigating the Rigidity of Third-Order Modules (M3) . . . . . 1541
Appendixes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1545
Instead of the Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1569
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1571
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1587
Contributors
Maxim Vasil’evich Andrianov, M.D., Ph.D. Department of Orthopedics, City Adult

Outpatient Department No 6, St. Petersburg, Russia
Anna Majorovna Aranovich, M.D., Ph.D. Department of Orthopedics, Russian Ilizarov
Scientific Center “Restorative Traumatology and Orthopedics”, Kurgan, Russia
Alexander Aleksandrovich Artemev, M.D., Ph.D. Department of Traumatology
and Orthopedics, Mitischi City Clinical Hospital, Mitischi, Moscow, Russia
Petr Iosiphovich Begun Department of Mechanics, The State Electrotechnical University,
St. Petersburg, Russia
Erkal F. Bilen, M.D., FEBOT Department of Orthopedics, Istanbul Memorial Hospital,
Istanbul, Turkey
Dmitry Jur’evich Borzunov, M.D., Ph.D. Department of Orthopedics, Russian Ilizarov
Maurizio A. Catagni, M.D. Department of Orthopedics, Lecco General Hospital, Lecco, Italy
Alexandr Nikolaevich Chelnokov, M.D., Ph.D. Department of Orthopedic Traumatology,
Ural Scientific Research Institute of Traumatology and Orthopedics, Ekaterinburg, Russia
Mikhail Jur’evich Danilkin, M.D., Ph.D. Department of Hand Surgery, Russian Ilizarov
Alexander Nikolaevich Djachkov, M.D., Ph.D. Scientific Medical Department on
Organization and Methodical Work, Russian Ilizarov Scientific Center “Restorative
Traumatology and Orthopedics”, Kurgan, Russia
Mark Eidelman, M.D. Technion Faculty of Medicine, Rambam Health Care Campus,
Meyer’s Children Hospital, Haifa, Israel
Sergey Aleksandrovich Erofeev, M.D., Ph.D. Department of Traumatology and Orthopedics,
Professor of the Chair of Traumatology and Orthopedics, Omsk State Medical Academy,
Omsk, Russia
Victor Viktorovich Ershov Department of Orthopedics, City Urgent Hospital,
Kaliningrad, Russia
Nikolay Fedorovich Fomin, M.D., Ph.D. Department of Surgery, Kirov Military Academy,
Jury Evgen’evich Garkavenko, M.D., Ph.D. Department of Orthopedics, Turner Research
Children’s Orthopedic Institute, St. Petersburg, Pushkin, Russia
Stuart Alan Green, M.D. Department of Orthopedic Surgery, University of California,
Irvine, Los Alamitos, CA, USA
xxv
xxvi Contributors
Katsuhiro Hayashi, M.D., Ph.D. Department of Orthopedic Surgery, Graduate School

of Medical Science, Kanazawa University, Kanazawa-shi, Isikawa-ken, Japan
John E. Herzenberg, M.D., FRCSC Department of Orthopedics, Sinai Hospital
of Baltimore, Baltimore, MD, USA
Roman Nikolaevich Inyushin, M.D., Ph.D. Department of Orthopedics, City Polyclinic
No 25, St. Petersburg, Russia
Oleg Anatoljevich Kaplunov, M.D., Ph.D. Department of Orthopedics, The Orthopedic
Center of City Clinical Hospital No. 3, Volgograd, Russia
Alexander Timofeevich Khudiaev, M.D., Ph.D. Department of Neurosurgery, Russian
Ilizarov Scientific Center “Restorative Traumatology and Orthopedics”, Kurgan, Russia
Alexander Kirienko, M.D. External Fixation Division, Istituto Clinico Humanitas,
Rozzano, Milano, Italy
Mehmet Kocaoğlu, M.D. Department of Orthopedics and Traumatology, Istanbul Medical
Faculty, Istanbul University, Capa, Istanbul, Turkey
Florian Maria Kovar, M.D. Department of Traumatology, AKH-Vienna,
Medical University Vienna, Vienna, Austria
Pavel Nikolaevich Kulesh, M.D., Ph.D. Department of Traumatology and Orthopedics,
R.R. Vreden Russian Research Institute of Traumatology and Orthopedics,
Professor of Surgery, Chair of Medical Faculty of Saint Petersburg State University,
Honourable Professor of Russian Ilizarov Scientific Center “Restorative Traumatology
and Orthopedics”, Kurgan, Russia
Alexander A. Lerner, M.D., Ph.D. Faculty of Medicine in Galilee, Bar-Ilan University,
Zefat, Israel
Department of Orthopedic Surgery, Ziv Medical Center, Zefat, Israel
Sergey Valerjevich Majkov Department of Orthopedics, R.R. Vreden Russian Research
Institute of Traumatology and Orthopedics, Professor of Surgery, Chair of Medical Faculty
of Saint Petersburg State University, St. Petersburg, Russia
Honourable professor of Russian Ilizarov Scientific Center “Restorative Traumatology
Redento Mora, M.D. Department of Orthopedics, University of Pavia, Polo Universitario
“Citta di Pavia”, Pavia, Italy
Dmitry Alexandrovich Mykalo, M.D., Ph.D. Department of Orthopedics, R.R. Vreden
Russian Research Institute of Traumatology and Orthopedics, Professor of Surgery,
Chair of Medical Faculty of Saint Petersburg State University, St. Petersburg, Russia
Vladimir Anatol’evich Nazarov, M.D., Ph.D. Department of Orthopedics, R.R. Vreden
Konstantin Igorevich Novikov, M.D., Ph.D. Department of Orthopedics, Russian Ilizarov
Metin Orhan Faculty of Dentistry, Department of Orthodontics, Gazi University,
Ankara, Turkey
Luisella Pedrotti, M.D. Department of Orthopedics, University of Pavia, Polo Universitario
“Citta di Pavia”, Pavia, Italy
Contributors xxvii
Oksana Germanovna Prudnikova, M.D., Ph.D. Department of Neurosurgery, Russian

Ilizarov Scientific Center “Restorative Traumatology and Orthopedics”, Kurgan, Russia
Oleg Sergeevich Rossik, M.D., Ph.D. Department of Neurosurgery, Russian Ilizarov
Aleksey Vladimirovich Runkov, M.D., Ph.D. Department of Traumatology and
Orthopedics, Ural Scientific Research Institute of Traumatology and Orthopedics,
Ekaterinburg, Russia
Elena Andreevna Shchepkina, M.D., Ph.D. Department of Orthopedics, R.R. Vreden
Vladimir Dmitrievich Shatokhin, M.D., Ph.D. Department of Orthopedics,
Kalinin Regional Clinical Hospital, Samara, Russia
Vladimir Ivanovich Shevtsov, M.D., Ph.D. Department of Orthopedics,
The Russian Academy of Medical Sciences, Moscow, Russia
Natalya Grigorjevna Shikhaleva, M.D., Ph.D. Department of Hand Surgery,
Russian Ilizarov Scientific Center “Restorative Traumatology and Orthopedics”,
Kurgan, Russia
Jury Petrovich Soldatov, M.D., Ph.D. Department of Orthopedics, Russian Ilizarov
Leonid Nikolaevich Solomin, M.D., Ph.D. Professor of Orthopedic Surgery, R.R. Vreden
Russian Research Institute of Traumatology and Orthopedics, St. Petersburg, Russia
Professor of the Surgery Chair, Medical Faculty of Saint Petersburg, State University,
Honourable Professor of Russian Ilizarov, Scientific Center “Restorative Traumatology
William Dean Terrell, M.D. Department of Orthopedics, Pinnacle Orthopedics
and Sport Medicine Specialists, Marietta, GA, USA
Hiroyuki Tsuchiya, M.D., Ph.D. Department of Orthopedic Surgery, Graduate School
of Medical Science, Kanazawa University, Kanazawa-shi, Isikawa-ken, Japan
Alexander Igorevich Utekhin Department of Innovation and Development,
“Ortho-SUV” Ltd., St. Petersburg, Russia
Konstantin Andreevich Ukhanov Department of Orthopedics, Central Regional Hospital,
Gatchina, Russia
Viktor Alexandrovich Vilensky, M.D., Ph.D. Department of Orthopedics, R.R. Vreden
Elena Aleksandrovna Volokitina, M.D., Ph.D. Department of Traumatology
and Orthopedics, Ural State Medical Academy, Ekaterinburg, Russia
Tatyana Nikolaevna Vorontsova, M.D., Ph.D. Department of the Public Health,
R.R. Vreden Russian Research Institute of Traumatology and Orthopedics, Professor of
Surgery, Chair of Medical Faculty of Saint Petersburg State University, St. Petersburg, Russia
Tracy J. Watson, M.D. Department of Traumatology and Orthopedics, Saint Louis
University Health Science Center, St. Louis, MO, USA
Department of Traumatology and Orthopedics, Saint Louis University School of Medicine,
St. Louis, MO, USA
Introduction
External fixation is a method of treating bone, joint, and soft-tissue injuries as well as correcting
skeletal deformities by attaching bones to an external device that stabilizes the injured or
deformed limb. Additionally, it allows manipulation of the limb segments to achieve restora-
tion of their length and alignment. A synonym for external fixation is external osteosynthesis.
In contrast, internal osteosynthesis employs devices implanted under the skin and muscle.
External braces, cast splints, and orthotic devices are not considered external fixators.
Extrafocal osteosynthesis, compression osteosynthesis, and distraction osteosynthesis are
not synonymous with external fixation. These techniques can be utilized with either internal or
external osteosynthesis, either separately or in combination. For example, an external fixator
can be used to apply compression and distraction at the same time.
Transosseous osteosynthesis is the term commonly used in the Russian-speaking
literature.
The book is divided into two parts. Part I deals with general aspects and principles. The
information presented in Part II builds on that provided in Part I. The methods of external
fixation by means of wire devices described in the following chapters evolved from the prin-
ciples developed by G.A. Ilizarov and the school of external fixation that he established.
However, we also discuss alternative methods of combined external fixation (CEF) that are
consistent with the principles explored in Chap. 3 of Part I.
The indications for the use of external fixation refer to the international classification of the
Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) for
fractures and soft-tissue injuries. The position of the joint and the amplitude of its movements
are described in the text on the basis of the neutral zero position method, accepted as the inter-
national standard [1].
The general stages in the process of external fixation of long-bone fractures are:
1. Identification of injuries and the basis for their correction
2. Preoperative preparation
3. Rough elimination of the displacement of bone fragments using an orthopedic table or
traction device
4. Insertion of basic transosseous elements
5. Assembly of external supports (the “frame” of the device)
6. Insertion of the reductionally fixing transosseous elements and their dynamic fixation to
the external supports
7. Achievement of the specified spatial orientation of the bone fragments and splinters in a
single-step (less frequently, over a period of time) and rigid fixation of the reductionally
fixing transosseous elements to the external supports
8. At combined (hybrid) external fixation: insertion and rigid fixation of stabilizing tran-
sosseous elements to external supports
9. Variation of the technique depending on the segment, the level of bone destruction, and the
tasks involved in restorative surgery
10. Implementation of the tasks of the postoperative period
xxix
xxx Introduction
Information concerning basic training in external fixation can be obtained at http://rniito.

org/solomin, http://rniito.org/download/basic-9-days-eng.pdf, and http://rniito.org/download/
basic-4-days-eng.pdf, and http://ortho-suv.org
The chapters in Part II address the external fixation of fractures and orthopedic pathologies
and their specific features.
New opportunities in fracture treatment using the computer-navigation-based Ortho-SUV
Frame are the subject of Chap. 17. Several variants of training courses for the Ortho-SUV are
offered; the interested reader is referred to:
http://ortho-suv.org
http://www.rniito.org/download/ortho-suv-course-9-eng.pdf
http://www.rniito.org/download/ortho-suv-Iliz-course-9-engl.pdf
http://www.rniito.org/download/ortho-suv-course-4-eng.pdf.
Information concerning the combined and consecutive use of external and internal fixation
is provided in Chap. 26 and at http://www.rniito.org/download/exfix-nail-course-9-engl.pdf
and http://www.rniito.org/download/exfix-nail-course-4-engl.pdf, and http://ortho-suv.org
Training in the use of the Ortho-SUV Frame at the reader’s hospital can be arranged. For
details, see http://www.rniito.org/download/ortho-suv-course-out-eng.pdf and http://ortho-
suv.org. Further questions can be sent to solomin.leonid@gmail.com and orthosuv@gmail.
com.
Part I
General Aspects of External Fixation
General and Special Aspects
of External Fixation 1
1.1 Historical Background and Classification
The first external fixator was described by the American J.

Emsberry, in 1831. In 1843, the French physician Malgaigne
introduced a device for treating fractures of the patella and
olecranon (Fig. 1.1). It resembled a clamp and was known as
the Malgaigne fixator.
The widespread practical use of external fixation was
popularized by surgeons Clayton Parkhill (1898, Denver, Fig. 1.1 Malgaigne fixator
Colorado, USA) and Albin Lambotte (1902, Belgium). In
the 1930s, 1940s, and 1950s, other surgeons such as Otto Research had shown that in all locomotive system tissues
Stader, Roger Anderson, Raul Hoffmann, Robert and Jean subjected to dosed distraction, a singular type of reaction
Judet, and Jacques Vidal continued the development of exter- takes place, namely, an increase in cellular energy exchange
nal fixation devices by improving the clamp, pin, and bar and proliferative activity reproducing the signs of natural
technologies. In the former Soviet Union, a 30-year period of growth. Specifically, G.A. Ilizarov discovered an earlier
intensive development occurred beginning in the 1950s based unknown general biological property of tissues (not only
on the efforts of G.A. Ilizarov, K. Sivash, O. Gudushauri, bone, but also muscular, chondral, nerve, and other tissue
V. Kalnberz, M. Volkov, O. Oganesyan, V. Demianov, and types) to respond to dosed distraction with growth and
S. Tkachenko. Various types of external fixation devices are regeneration.
shown in Fig. 1.2. What did this discovery mean and what has been its prac-
The development of external fixation is thoroughly tical importance? First of all, this law was the basis for vari-
connected with the name of Gavriil Abramovich Ilizarov ous methods of treatment:
(1921–1992). He designed a frame in 1951 and in 1954 was • Bone deformity correction and modeling of bone thick-
awarded patent #98471 (authorship of the device) for “the ness and shape
method of healing of bone fractures and the device for the • Lengthening of shortened limbs and growth regulation,
realization of this method.” However, the main achievement either increase, arrest, or decrease
of Ilizarov was not only and not most importantly an origi- • Replacement of defects of bones, vessels, muscles, nerves,
nal circular external fixation device; rather, it was his and skin without grafting
discovery of what came to be known as the Ilizarov effect. • Changing the shape of the spine
All these methods are discussed in subsequent chapters of
this book.
L.N. Solomin, M.D., Ph.D. (*) Currently, more than 1,000 external fixation devices are
R.R. Vreden Russian Research Institute of Traumatology commercially available for orthopedic use. All of the exter-
and Orthopedics, 8 Baykova Str., nal fixator devices have similar components and can be
St. Petersburg 195427, Russia
divided into six frame types (Table 1.1).
e-mail: solomin.leonid@gmail.com
Types I and II are single-plane devices while all other
S.A. Green, M.D.
frame types are multiplanar. Only console transosseous ele-
Department of Orthopedic Surgery, University of California, Irvine,
3771 Katella Avenue, Suite 310, Los Alamitos, CA 90720, USA ments (half-pin constructs) can be fixed in monolateral
e-mail: sgreen@uci.edu (type I) and sectorial (type II) external supports. The
L.N. Solomin (ed.), The Basic Principles of External Skeletal Fixation Using the Ilizarov and Other Devices, 3
DOI 10.1007/978-88-470-2619-3_1, © Springer-Verlag Italia 2008, 2012
4 L.N. Solomin and S.A. Green
a b c
d e f
Fig. 1.2 Fixation devices. Lambotte (a), Hoffman-Vidal (b), G. Ilizarov (c), V. Kalnberz (d), Volkov-Oganesian (e), V. Demianov (f)
1 General and Special Aspects of External Fixation 5
g h i
j k l
Fig. 1.2 (continued) S. Tkachenko (g), O. Gudushauri (h), K. Sivash (i), A. Lee (j), A. Barabash (k), Synthes (l)
m n o
p q r
Fig. 1.2 (continued) Biomet (m), OrthoFix (n), Stryker (o), Taylor Spatial Frame (p), Ortho-SUV Frame (q), Ilizarov hexapod system (r)
Table 1.1 Principal types of external fixation devices

Type Examples Features Schemes
I. Monolateral Lambotte, Hoffmann, AO/ASIF, 1. Built only on pins that capture both cortices but do not
Wagner, Afaunov, Sushko pass completely through the bone (console transosseous
elements, known as half-pins)
2. All transosseous elements are installed in one plane and
on one side
3. The free ends of the pins are fixed to longitudinal
connecting bars
II. Bilateral Charnley, Hoffmann, Vidal- 1. Built on through-and-through Steinmann pins or

Adrey, Roger-Anderson, Key, K-wires
Hey-Groves, Gryaznukhin 2. All transosseous elements are inserted in one plane and
pass through both cortices (true transfixation pins)
3. The transosseous elements are joined using longitudinal
connecting bars on each side, thus forming the “frame”
III. Sectorial (arch) AO/ASIF, SKID 1. Pin placement is limited to sector a (0° < a < 180°)
2. Pin divergence of up to 180° does not include the
placement of true transfixation transosseous elements
(wires and Steinmann pins)
3. Devices are attached to and built upon the console
transosseous elements (half-pins, console wires)
Table 1.1 (continued)

Type Examples Features Schemes
IV. Semicircular Fischer, Hoffmann-Vidal, 1. External supports geometrically form sector b
Gudushauri, Sivash, Volkov- (180° ≤ b < 360°)
Oganesyan 2. All types of transosseous elements can be used
(Steinmann rods, K-wires, S-screws, half-pins)
V. Circular Ilizarov, Kalnberz, Demianov, 1. The external rings and connecting bars completely
Tkachenko, Lee, Kronner, surround the limb at the level of the application
Monticelli-Spinelli, Ettinger 2. This frame geometry can be varied to form many
configurations. e.g., ring, oval, square, and polygon
3. All types of transosseous elements can be used
(Steinmann pins, half-pins, wires)
VI. Hybrid Biomet hybrid external fixator, This type of external fixation device can combine all the
(combined) Sheffield hybrid external fixator, features of types I–V
OrthoFix hybrid external fixator,
Taylor Spatial Frame, Ortho-SUV
Frame
mounting of frame types IV–VI is based on wires or pins, or External fixation techniques can be classified according
a combination of the two. All the above features are impor- to the following characteristics:
tant for determining the biomechanical, clinical, and perfor- • The insertion of transosseous elements in the treatment of
mance features of each type of external fixation device. The wounds of a bone (fracture, non-union etc.) and soft tis-
constructions mentioned as examples of circular devices sues: intrafocal, extrafocal
(type V) are the usual members of this group. The majority • The biomechanical condition between the bone fragments
are used in the clinic as hybrid constructions with sectional, (neutral, compression, distraction): combined (consecu-
semicircular, and circular external supports. tive, alternating, synchronous)
• The zones of mechanical influence on the bone fragments: 3. Risk of joint stiffness (“transfixion pin-induced joint
monolocal, bilocal, polylocal stiffness”)
• The quantity and quality of the zones of osteogenesis 4. The frequently large size of the external fixation device,
(bone formation): monolocal, bilocal, polylocal which can be aesthetically unpleasant for the patient and
These techniques are discussed in later chapters devoted often requires the use of special clothing to cover the
specifically to each aspect of external fixation. device
Among the currently available external fixation devices, 5. Patient compliance, perhaps the biggest disadvantage, as
the apparatus of G.A. Ilizarov is the most versatile. Although continued treatment is problematic in a noncompliant
the entire array of components appears very complex, at least patient not performing the required adjustments or a third
on initial examination, the device allows the construction of party performing ill-conceived adjustments
essentially any configuration to achieve transosseous osteo- There are numerous indications for external fixation: (1)
synthesis. Additionally, it permits the use of any method of Fractures of virtually all bones of the skeleton, including the
osteosynthesis, either alone or in combination, and the appli- pelvis, humerus, forearm, clavicle, femur, tibia, and foot/ankle,
cation of these methods simultaneously within the same can be treated. The frames may be applied at any level: diaphy-
limb. Based on this versatility, in this book we pay particular seal, epi-/metaphyseal, or intra-articular, and in the repair of
attention to this specific device. simple, comminuted, segmental, open or closed fractures. They
are also advantageous in the treatment of fractures with the
potential for soft-tissue contamination and infection. (2)
1.2 Advantages and Disadvantages, Malunion, delayed union, and nonunion, including due to trau-
Indications and Contraindications matic deformities, soft-tissue or bony defects, and infection, are
also amenable to external fixation. (3) Patients with orthopedic
Each method of osteosynthesis has its own distinct pathologies are also candidates for external fixation, including
advantages and disadvantages. The advantages of exter- those with congenital deformities, bony defects, and infection,
nal fixation in the treatment of orthopedic conditions as well as those requiring segmental bone resections for patho-
include: logical conditions. (4) Joint pathology, such as malformations,
1. Minimal disruption of soft tissues within the region contractures, dislocations, and conditions such as dysplasia or
of trauma or fracture, with preservation of the blood degenerative disease are likewise treatable by this approach.
supply—an important consideration, as local vascularity Specifically, the basic indications for the use of external
is a major factor in regeneration for bone healing fixators include:
2. Provision of stable fixation outside the zone of injury 1. Fractures and dislocations accompanying soft-tissue
3. The opportunity for closed reduction and repositioning of damage
bone fragments, which can be accomplished in all three 2. Penetrating injuries to joints, including injuries resulting
planes simultaneously from gunshot wounds
4. Facilitation of an earlier return to function of the injured 3. The rapid stabilization of fractures in hemodynamically
extremity unstable patients, including those with multiple fractures
5. The ability to manipulate the biomechanical rigidity of the or multiple injuries
fixation device as it relates to the fixation of bone fragments 4. Fractures with extensive damage, including comminution
6. The variety of uses for the treatment of pathological and and periosteal stripping (C3 in the AO/ASIF
traumatic orthopedic diseases, with the versatility of the classification)
device providing practically unlimited potential 5. Situations in which the use of internal fixation is con-
7. The opportunity to adjust the device based on the patient’s traindicated in a particular patient, including the pres-
clinical and radiographic progress, even indefinitely, for ence of acute or chronic focal infection
the treatment of various orthopedic conditions, including 6. (Infected) malunions, non-unions, traumatic deformi-
the reconstruction of bony defects ties, and soft-tissue or bony defects
8. The unique opportunity to study issues of bone and soft tissue 7. (Infected) congenital deformities, bony defects, and seg-
regeneration in both the clinical and basic science settings mental bone resections for pathological conditions
The basic disadvantages of external fixation include: 8. Aesthetic surgery involving limb lengthening, correc-
1. The relative complexity of using external fixation devices, tion of legs shape, etc.
especially those of types IV–VI 9. In joint pathology (malformations, contractures, dislo-
2. The need for to constantly monitor patients with these cations, dysplasia or degenerative disease)
devices, given the possibilities of loosening and failure 10. Reconstructive operations: “tibialization” of the fibula,
of the hardware and the constant risk of pin/wire site lengthening of a stump, correction of hand or foot
inflammation and deep pin-tract infection throughout the deformities; arthrodesis (including lengthening
entire period of frame application and use arthrodesis)
11. In patients with chronic ischemic vascular conditions, With the universal joint (Table 1.2, 15), the use of two-
such as obliterating endarteritis, diabetes, peripheral vas- plane hinges, which can be assembled from a standard post,
cular disease, etc., but requiring distraction osteogenesis can be avoided.
12. Growing (via lengthening) of soft tissues: skin, muscles, Traction clips (Table 1.2, 23) are supplied at the site of
tendons, vessels, nerves wire fixation and have a cube shape that can be easily grasped
13. Ancillary uses, e.g., elimination of a luxation before with a wrench.
joint arthroplasty Curved half-pins (Table 1.2, 26) allow the use of a smaller
14. Use of wire- or half-pin-based distractors in internal sector for fixation (Chap. 2.10).
fixation performance Extracortical bone clamps (Table 1.2, 23) facilitate the
However, there are also a few basic contraindications to introduction of a pin when the medullary canal is obstructed
the use of external fixation: by a large foreign body, for example, in the case of peri-
1. The surgeon’s lack of familiarity with the use and prosthetic fractures (Chap. 11.5).
mechanics of external fixation, particularly distraction When the use of standard wire is impossible (due, for
osteogenesis example, to the projection of vessels and nerves) or not fea-
2. Impossibility of constant monitoring of the patient during sible (due, for example, to tissue thickness or a splinter in the
the fixation period interbone space), a device for the reduction of bone splinters,
3. Inability to monitor external fixation and fracture healing also referred to as a “fork device” (Table 1.2, 30) can be sub-
postoperatively because of social or compliance issues, stituted (Chap. 2).
or the inability of the patient to follow postoperative rec- If disc clips (Table 1.2, 32) are not readily available for
ommendations and advice because of age-related issues, the fixation of gauze dressings, then plastic or rubber protec-
psychoemotional status, alcohol or narcotic abuse, or any tion stoppers in diameters of 10–15 mm for pins/wires and
factor that may inhibit a patient’s judgment regarding the 20–25 mm for half-pins should be used (Fig. 7.17h and
care and management of an external fixator 1.11.4.12h).
4. Gross hemodynamic instability, in which even rapid Table 1.3 shows the basic instruments for external
application of spanning external fixation would compro- fixation.
mise the patient’s prognosis The surgical drill (Table 1.3, 1) should have a reverser
5. Gross contamination of soft tissues, which through the and an adaptor for wire insertion.
placement of external fixator pins or wires which would A device for the division of an extremity into levels
put the patient at increased risk of infection (Table 1.3, 2) allows the rapid and precise definition of a
6. HIV-positive patients who would otherwise benefit from limb segment or a level to which transosseous elements can
nonoperative management of their fractures be attached (see Sect. 1.8).
7. Situations in which the use of external fixation has no clear Lever wire tensioners (Table 1.3, 4) are a standard of the
advantage over conservative treatment and/or internal fixation device and are assembled from the Ilizarov set. They allow
Quite often there are not absolute indications for appli- wires in inaccessible locations to be tightened.
cation of external fixation, i.e. there is a proved (valid, The tissue protector sleeve and trochar (Table 1.3, 6) are uti-
reasonable) choice between internal and external fixation. lized for the introduction of half-pins. They allow the drill to be
In similar cases external fixation should be applied, when directed at the desired angle (Figs. 7.23 and 7.24).
in concrete conditions of this orthopedic department it The cortex at the proposed pin site is carefully predrilled
will provide result of treatment better (at least, not worse), using a surgical drill (Table 1.3, 7), avoiding damage to the
than at application of internal fixation, and threat of severe soft tissue prior to the introduction of a half-pin. A stop on
complications is lower. Among “concrete conditions of the drill bits control the depth of drill penetration (Fig. 7.23).
orthopedic department”, experience and skill of external If bayonet drills are used, it is necessary to apply an adapter
fixation application, equipment, conditions for postopera- sleeve to ensure that the half-pin is strictly in the center of the
tive care should first of all be taken into consideration. pin clamp (Table 1.3, 8; Fig. 7.25).
Special half-pin wrenches (Table 1.3, 9) are either stan-
dard or assembled from the Ilizarov set. The latter is supplied
1.3 Equipment with a slot for bending of the wire ends.
The controlling device for bone fragment reduction and
An external fixation set includes both the standard details of support orientation is assembled from the traction clip
the Ilizarov apparatus and additional devices, shown in with calibrated wires (Table 1.3, 12, Figs. 7.22, 7.23, and
Table 1.2. 7.26).
Slotted female posts and the Barabash cube (Table 1.2, A surgical chisel (Table 1.3, 13) with a T-shaped handle
7 and 31) may be used as a clamp for half-pins and for the should be supplied to simplify performing a corticotomy
reduction of bone fragments (Chap. 2). (Chap. 7).
Table 1.2 External fixation components set

Item no. Appellation Features Component
1 Half-rings Diameter (mm): 80, 100, 110,
(metal and 120, 130, 140, 150, 160, 180,
composite; 200, 220, 240
Fig. 2.18)
2 Arches 3/4, Diameter (mm): 80, 100, 110,

5/8, 2/3, 1/3, 120, 130, 140, 150, 160, 180,
1/4 rings 200, 220, 240
(metal and
composite)
3 Wire arches Radius (mm): 80, 100, 110,

120, 130, 140, 150, 160
4 Half-pin arches <or> 90°, 120°

(metal and
composite)
5 Post: male Number of holes: 1, 2, 3, 4
6 Post: female Number of holes: 1, 2, 3, 4
7 Posts: female, Number of “holes”: 2, 3, 4

slotted
(continued)

8 Connection Number of holes: 2, 3, 4, 5, 6, 7, 8,
plates 9, 10, 12, 17
9 Connection Number of holes: 1 + 1, 1 + 2, 2 + 2

plates: twisted
and curved
10 Connection Number of holes: 9, 11, 13, 15

plates with
threaded ends
11 Threaded rods Length (mm): 30, 60, 80, 100, 120,

150, 200, 250, 300
12 Telescopic rods Length (mm): 100, 190, 220,

310, 400
13 Oblique
support
connection
14 Sockets and Length (mm): 20, 40, 60

bushes
15 Universal joint
16 Bolts, nuts,
nuts with neck,
washers,
slotted
washers,
spherical
washers couple

17 Wires Diameter (D) 1.5 mm, length (L)
250 mm; D 1.8 mm, L 370 mm
18 Wires with Diameter (D) 1.5 mm, length (L)
stopper: olive 250 mm; D 1.8 mm, L 400 mm
and curved
19 Console wires Intraosteal part length (mm):

10, 15, 20, 30, 40, 50
20 Wire fixation Slotted; cannulated

bolts
21 Wire fixation
frame
22 Threaded rods- Length (mm): 40, 50, 60, 80, 100

slotted
23 Traction clip Length (mm): 40, 50, 60, 80, 100
24 Metaphyseal Diameter (D) 6 mm, length

half-pins (L) 100 mm; D 6 mm, L 120 mm;
D 6 mm, L 140 mm; D 6 mm,
L 160 mm; D 6 mm, L 180 mm;
D 6 mm, L 200 mm; D 6 mm,
L 220 mm; D 6 mm, L 250 mm:
D 5 mm, L 100 mm: D 5 mm,
L 120 mm; D 5 mm, L 150 mm;
D 4.5 mm, L 60 mm; D 4.5 mm,
L 90 mm: D 4.5 mm, L 120 mm
25 Cortical Diameter (D) 6 mm, length (L)

half-pins 100 mm; D 6 mm, L 120 mm;
D 6 mm, L 140 mm; D 6 mm,
L 160 mm; D 6 mm, L 180 mm;
D 6 mm, L 200 mm; D 6 mm,
L 220 mm; D 5 mm, L 100 mm;
D 5 mm, L 120 mm; D 5 mm,
L 150 mm; D 4 mm, L 60 mm;
D 4 mm, L 90 mm; D 4 mm,
L 120 mm
(continued)

26 Half-pins Diameter (D) 6 mm, length (L)
curved 100 mm; D 6 mm, L 140 mm;
D 5 mm, L 160 mm; D 5 mm,
L 100 mm; D 5 mm, L 140 mm;
D 5 mm, L 160 mm: D 4.5 mm,
L 100 mm; D 4.5 mm, L 140 mm;
D 4.5 mm, L 160 mm
27 Pin clamps Number of holes: 1, 2, 3, 4
28 L-shaped pin
clamp
29 Extracortical Five dimension-types

bone clamps
and handhold
for insertion
30 Device for
reduction of
bone splinters
(“fork device”)
31 Advanced
reduction
Barabash cube
32 Disc clips
Table 1.3 Instruments

Item no. Appellation Features Instrument
1 Surgical drill
2 Device for division

of an extremity into
levels
3 Wire tensioners Standard and dynamometric
4 Lever wire Dynamometric and assem-

tensioners bled from the standard
Ilizarov set
5 Surgical wrenches Standard and tubular
6 Tissue protector
sleeve and trochar
7 Drill with stopper Diameter (mm): 2.7, 3.8, 4.5,

4.8

Item no. Appellation Features Instrument
8 Bayonet drills and Diameter (mm): 2.7, 3.8, 4.5,
adapter sleeve 4.8
9 Half-pin wrenches
10 Regular flat-nose
and round-nose
pliers
11 Wire-cutter and pin-

cutter
12 Controlling device
for bone fragment
reduction and
support orientation
13 Surgical chisels
Fig. 1.3 (a, b) The storage and

a
sterilization of external fixation
sets require special containers
b
Furthermore, the application of an external fixator requires If the arrangement of the apparatus includes only the
a radiolucent orthopedic table with an attached device for basic support on one of the bone fragments, both the basic
applying skeletal traction. and reductionally fixing transosseous elements are fixed to it.
For the storage and sterilization of external fixation equip- In this case, the reductionally fixing transosseous elements
ment, special containers are used (Fig. 1.3). are connected to the base support with the help of posts
Additional equipment for performing combined strained (Fig. 1.5).
fixation is discussed Chap. 20. The hardware and software Stabilizing transosseous elements are additional tran-
used for computer-assisted external fixation (Ortho-SUV sosseous elements that can be used in configuring the device
Frame) are presented in Chap. 17. to increase osteosynthetic rigidity. As a rule, these are half-
pins that are fixed to reductionally fixing supports after bone
fragment reduction.
1.4 General Terms of External The basic and reductionally fixing transosseous elements
Fixation Constructs and supports to which they are fixed make up a transosseous
module that fixes the bone fragment. The presence of two
External fixation uses the following transosseous elements: bone fragments implies two transosseous modules: proximal
• Trans-segmental elements: transfixation K-wires and and distal (Fig. 1.4). The basic support with both basic and
Steinmann pins reductionally fixing transosseous elements is also a tran-
• Console elements: S-screws, half-pins and console wires sosseous module (Fig. 1.5). The classification of transosseous
In the device assembly used in the treatment of fractures, modules is presented in Chap. 36.
exterior supports of the frame are called basic supports. If the device assembly includes a transosseous module
Transosseous elements fixed to the basic supports are the applied temporarily on an adjacent segment, it is referred to
basic transosseous elements. The supports located between as an auxiliary transosseous module, and the apparatus fixing
the basic supports are called reductionally fixing or interme- the fracture as either of the basic or main type (Fig. 1.6).
diate supports. Reductionally fixing transosseous elements Reductionally fixing transosseous elements are absent
are fixed to the reductionally fixing supports (Fig. 1.4). if bone fragment correction is performed with the aid of
proximal basic support
proximal basic
transosseous elements
proximal
transosseous
module
reductionally-fixed
reductionally-fixed
(intermediate) supports
distal
transosseous
module distal basic
transosseous element
Fig. 1.4 Standard arrangement

of external fixation devices for
fractures distal basic support
Fig. 1.5 Standard arrangement of proximal basic support

external fixation devices for
fractures when one of bone
fragments is short
proximal basic
proximal
transosseous
module
reductionally-fixed
reductionally-fixed
(intermediate) support
distal distal basic

transosseous transosseous elements
module
distal basic support
mutually moving transosseous modules fixing each bone

fragment (Chap. 2.2). In this case, the modules fixing each
bone fragment will consist of 1–2 supports in which basic auxiliary
and stabilizing transosseous elements are fixed (Figs. 1.7 and transosseous
7.11). As a rule, basic transosseous elements are inserted module
perpendicular to the longitudinal axis of a corresponding
bone fragment as this facilitates the assembly of the basic
supports.
When transosseous modules are connected by hinges, the
two located diametrically opposite each other relative to
the bone and which ensure rotation of the modules along the
given trajectory are called axial hinges. The hinges (or
connecting rods, fixed to the modules by means of hinges) basic frame
transmitting force to the modules in order to allow their
movement are swivel hinges (Fig. 1.8).
In case of a monolocal synchronous distraction-compres-
sion external fixation (Chap. 2.11), the bone fragment mod-
ules are placed perpendicular to the anatomic axis of the
relevant bone fragment. The transosseous modules are then
connected by hinges located on the convex and concave sur-
faces of the segment. Some of these can be considered as
“compression hinges” and the others as “distraction hinges”
(Fig. 1.9) and they differ accordingly from the axial and Fig. 1.6 An auxiliary transosseous module is fixed to the basic frame
swivel hinges shown in Fig. 1.8. by means of hinge subsystem
Fig. 1.7 Standard arrangements

of external fixation devices for
deformity correction
stabilizing half-pin proximal

transosseous
module
basic half-pin
stabilizing half-pin
basic wire
stabilizing half-pin distal

transosseous
module
stabilizing half-pins stabilizing

support
proximal
transosseous
basic half-pin module
basic
stabilizing half-pin support
distal
stabilizing half-pin basic
transosseous
support
module
basic half-pin
Fig. 1.8 Designation of hinges

Proximal
transosseous module
Swivel hinge Axial hinges
Distal
transosseous module
“Distraction”
“Compression” hinge
hinge
Fig. 1.9 “Compression” and

“distraction” hinges
Biomechanical Principles
2
The biomechanics of external fixation consist of three a

inter-related aspects: (1) the relationship between the
transosseous elements (wires, half-pins) and the surrounding
tissues; (2) the control of bone fragment position; (3) the b
control of bone fragment rigidity. These are discussed in the
following sections.
2.1 Relationship Between the Transosseous

Elements and the Surrounding Tissues
c
Clinical implementation of the knowledge describing the
biomechanical inter-relationships of the transosseous ele- d
ments and the surrounding tissue enables the bone frag-
ments to be forcibly fixed in such as way as to reduce device
destabilization occurring because of bone resorption around Fig. 2.1 Variant forms of the cutting end of the wires: (a) three-facet,
the wires and half-pins as well as the risk of pin-induced (b) feather, (c) single-facet, (d) drill
joint stiffness and inflammatory complications (pin-tract
infections).
To ensure the formation of an adequate bone–metal block The biomechanical principles for the insertion of the half-
after insertion of the wires, while taking care to reduce the pins also have their peculiarities. Half-pins for insertion into
risk of bone burn, it is necessary to use wires with special the diaphysis and metaphysis should be inserted with respect
shapes, i.e., those with feather (bayonet-wires), single-facet, to the cortical and spongy thread. Prior to insertion of a half-
or drill cutting ends (Fig. 2.1). The feather-type cutting end pin into diaphyseal bone, a canal is formed with a diameter
partially “breaks” the canal whereas the single-facet cutting corresponding to the half-pin size, taking into account the
end enables the formation of a canal corresponding to the density of the bone tissue. The canal diameter is 2.7 mm for
wire diameter. In addition, interrupted drilling is important at a 4-mm half-pin; 3.8 mm for a 5-mm half-pin; and 4.8 mm
the maximal rotation rate of 850 revolutions per minute, as is for a 6-mm half-pin. In osteoporosis, the canal diameter must
cooling of the wire with alcohol and regulating (up to 20 N) be reduced by 0.1–0.2 mm. Insertion of the half-pin through
the axial pressure exerted upon the wire. both cortical plates, in the projection of the mid-diaphyseal
line is mandatory (Chap. 7). Experiments have confirmed the
advantages of a thrust thread over a triangular thread [2].
L.N. Solomin, M.D., Ph.D. The biological compatibility of the transosseous elements
R.R. Vreden Russian Research Institute of Traumatology
can be improved by forming a biologically inert (metal–
and Orthopedics, 8 Baykova Str.,
St. Petersburg 195427, Russia ceramic) and biologically active (calcium phosphate) cover-
e-mail: solomin.leonid@gmail.com ing on their surface, which may solve the problem of
24 L.N. Solomin
providing stable fixation of the implant in the bone [2–5]. phenomenon plays an important role in the development of
The use of transosseous elements covered with hydroxyapa- soft-tissue inflammation due to the chronic trauma produced
tite promotes optimal transosseous synthesis in osteoporosis by transosseous elements.
[6, 7] (Fig. 2.2). Hence, the approach to developing and cre- There are two main ways to prevent pin-induced joint
ating transosseous elements for a particular orthopedic stiffness. The first involves the creation of a “store” of soft
pathology should be recognized. tissue by rendering in the extremity corresponding positions
It is well known that soft tissues are displaced relative to for insertion of the transosseous elements through the
the bone during joint movement. Transosseous elements fix “flexor” and “extensor” surfaces of the segment (Fig. 2.3a).
the skin, fascia, and muscles to the bone, thereby limiting the The second involves insertion of transosseous elements
physiological mobility of the soft tissues. The effect of insert- where there is minimum soft-tissue displacement for all pos-
ing the wires and half-pins of an external fixation device can sible movements of the joints adjacent to the segment
be compared to the creation of many local myofasciodeses. (Fig. 2.3b). These positions serve as the basis for establish-
Thus, one should consider the contractures occurring as a ing the so-called reference positions (RPs) for insertion of
consequence of using an external fixation device; these are the transosseous elements. These are discussed in Chap. 5
referred to as “transfixation pin-induced joint stiffness” and and a description of the method for establishing the RPs is
in the Russian literature as “transfixion contracture.” This presented in Chap. 35.
Fig. 2.2 Hydroxyapatite-coated

half-pins
1 2
Fig. 2.3 Methods to prevent

transfixation pin-induced joint
stiffness: (a) change of position
of an adjacent segment at wire
insertion 3 4
2 Biomechanical Principles 25
Fig. 2.3 (continued) (b) use of positions with the minimal soft-tis- surface in each of 12 positions. As shown, after knee-joint flexion, skin
sue displacement (here shown as an experiment on a cadaver). The con- displacement is absent in the projection of position 8
trol support is located at level VII. Feelers are positioned on the skin
2.2 Control of Bone Fragment Position 2.2.2 Moving the Transosseous Elements
Relative to the External Supports;
To ideally control the bone fragment position, the external External Supports and Modules
fixation device should allow directed movement of the frag- Remain Immobile
ments within the three-plane space (six standard degrees of
freedom) both in a single step and stepwise over time. Changes These methods are illustrated in Figs. 2.10, 2.11, 2.12, 2.13,
in the spatial location of the bone fragments can be achieved 2.14, 2.15, 2.16, and 2.17.
in two ways. The first involves mutually moving the external Since the early 1990s, computer navigation for the repo-
supports fixing each bone fragment; the transosseous ele- sitioning of bone fragments has been actively developed.
ments are statically fixed in the supports. The movement of The majority of investigations involve so-called passive nav-
transosseous modules with respect to each another can be car- igation: i.e., identifying the optimal assemblage of external
ried out either by the use of unified reduction nodes (“Ilizarov fixation devices for fragment transference with the aid of
hinges”) or according to the principles of the Stewart platform special software [8, 13, 14]. A particular focus has been soft-
and its analogues (Ortho-SUV Frame, Taylor Spatial Frame). ware for producing optimal device assembly and for the cor-
The second consists of moving the transosseous elements that rection of congenital and acquired deformities of the long
fix the bone fragments while the external supports and device bones [9, 15, 16].
modules remain immobile. In practice, the two repositioning A recent step in passive computer navigation was the
methods (moving the external supports or moving the tran- development of devices for external fixation that are com-
sosseous elements) complement each other. We consider each pletely integrated with the software, i.e., the Taylor Spatial
variant in more detail in the following sections. Frame (TSF), Ortho-SUV Frame, and Ilizarov hexapod sys-
tem (Fig. 1.2p–r). For instance, in the TSF, 23 parameters
identified radiographically and by measurements of several
2.2.1 Moving the External Supports parameters of the frame are transformed into concrete rec-
with the Transosseous Modules ommendations by the computer program: i.e., the change in
Fixing the Bone Fragments the length of each of the six struts necessary to achieve the
required orientation of the bone fragments is identified and
The various aspects of this method are illustrated in Figs. 2.4, defined [17–21]. In this context, the work of Glozman et al.
2.5, 2.6, 2.7, 2.8, and 2.9. [22] on simplifying the processing of radiographic images to
For transverse movement (translation) of the bone frag- generate the necessary data for input to the computer is par-
ments, the two most commonly used methods are: (1) estab- ticularly important. The advantages of the use of Ortho-SUV
lishing the connective half-pins at an angle, considering that Frame hardware and software are discussed in Chap. 17.
fragment displacement and distraction occur simultaneously Transitional methods leading to active navigation include
in the transverse plane (Fig. 2.5a, b); (2) assembly of a uni- electromechanical devices temporarily attached to the device
form node (Fig. 2.5c, d). to enable repositioning of the fragments under fluoroscopy
26 L.N. Solomin
a c
b d
Fig. 2.4 In longitudinal transference (lightening), in order to avoid the bone is a more reliable way to avoid angular deformation. Therefore,
angular deformation due to an eccentric effect (eccentric distension or in hybrid devices, establishing an additional support for distraction is
compression), the transosseous modules fixing the bone fragments recommended. The individual locations of the connecting half-pins
must be connected with rods situated bilaterally relative to the bone and enable special calculations to be used [8]. In the diagrams, rational
in the same plane. The use of circular and semicircular devices in which (or efficient) (a, b) and irrational (or inefficient) (c, d) methods of
the half-pins connecting the modules are located in two planes encircling distraction using hybrid devices are illustrated
guidance [23] and devices for automatic distraction [24–27]. of the surgeon involves superimposition of the modules onto
Active navigation, which will undoubtedly become increas- each bone fragment, approval of the trajectory created by the
ingly important in the near future, involves a complex of machine for fragment transference and, after the automatic
modules that automatically determines the spatial localiza- repositioning step, assembly of the transosseous modules
tion of the bone fragments, creates the necessary trajectory into an external fixation device to perform the internal
for their movement, and performs this movement. The work fixation [28].
Fig. 2.5 Approaches to

the elimination of
transverse fragment
displacement (a, c from [9])
28 L.N. Solomin
Fig. 2.5 (continued)

Fig. 2.6 In the combination of transverse fragment displacement with angular deformation, the reductionally fixing supports are transferred using
trailing bars (From [10])
30 L.N. Solomin
a
Fig. 2.7 Intermediate fragment reduction
Fig. 2.8 (a, b) In the correction of angular deformation, transosseous
modules fixing the bone fragments are connected with a hinge
subsystem. For further details on Ilizarov hinges, see Chap. 16
Fig. 2.9 The rotational transference (torsion) of fragments is achieved

with the aid of a sloped arrangement of the connective half-pins (a, b)
or using assemblies of uniform derotation nodes (c, d). Additional
information is given in Chap. 16
32 L.N. Solomin
c
Fig. 2.10 The use of bent wires and/or wires with stops is a classic repositioning in the frontal plane should be used (b). For traction, both
approach in external fixation and, owing to its high efficacy, the one that wire pullers and traction clamps are recommended. These simplify
is most often used for repositioning in fractures (a). To achieve maxi- repositioning and facilitate maintenance of the wire pull in the postop-
mum proficiency in the method of external fixation, wires inserted for erative period
34 L.N. Solomin
Fig. 2.11 (a–c) To eliminate

transverse displacement of a
fragment, a half-pin can be used
as the “pusher” or “puller.” Note
that the female posts must have a
longitudinal slit (see Table 1.2)
and the nuts must be
complemented with
hemispherical washers. Moving
the half-pin in the slotted post
during reduction avoids its
Z-shaped deformation
a b
c
Fig. 2.11 (continued) d

(d) Movement calculation
scheme for a half-pin bone
fragment
α1 α2
r
90°
a1
90°
a2
D
a1 = ( 0.5D-r Sinα1) tgα1+r (1+Cosα1)
a2 = 0.5D tgα2+r (1/Cosα2-1)
a b
Fig. 2.12 This device (see Table 1.2) enables the bone fragment to be moved in two planes. For transference of the fragment in the plane perpen-
dicular to the plane of insertion of the half-pin, the device is moved along the threaded rod attached to the device ring (a, b)
36 L.N. Solomin
Fig. 2.13 In the transference of the transosseous elements relative to

the external supports for repositioning, the following points should be
kept in mind: If the basic transosseous elements are not perpendicular
to the bone’s long axis, then changing the spatial orientation of the bone
fragment with the repositioning/fixation wire (half-pin) will induce a
Z-like deformation of the basic wires (as shown in the diagram) or of
the basic half-pins. In this case, the bone fragment is subjected to the
actions of two differently directed forces: the repositioning force
induced by the action of the reductionally fixing transosseous element
and the force occurring from elastic deformation of the basic tran-
sosseous element. The latter acts to return the bone fragment to the
initial position, reducing the rigidity of the osteosynthesis and increas-
ing the threat of a secondary displacement. Deformation of the
repositioning/fixation wire is not shown. An analogous situation arises
in transference of the reductionally fixing supports (Fig. 2.6)
Fig. 2.12 (continued) In addition, the half-pin can be used as a
“pusher” or “puller” (c, d) as described in Fig. 2.11. In this device, there
is no need to use hemispherical washers
a b
Fig. 2.14 If after reduction of the bone fragments there is deformation of the basic transosseous elements (a, b)
38 L.N. Solomin
c d
Fig. 2.14 (continued) Additional stabilizing wires or half-pins must be inserted and fixed to the supports (c). This allows detachment of the deformed
basic transosseous elements from the support and the opportunity to fix them again to the corresponding support, avoiding deformation (d)
Fig. 2.15 Rotation of the bone fragment can be achieved by moving the wire ends in the support (From [9])
Fig. 2.16 Repositioning of the bone fragments with the aid of Kirschner wires (a) and console wires (b) (From [11, 12])
40 L.N. Solomin
a b
Fig. 2.17 (a–c) Situations may arise in which the use of wires and from the external side of the segment (there are no main vessels or
console wires for fragment repositioning is impossible (e.g., in the nerves here, and soft-tissue displacement is relatively small during
proximity of main vessels and nerves) or inadvisable (extreme soft-tis- movement of the hip and knee joints). If both longitudinal displacement
sue thickness). Most often, such circumstances occur if the fragment is and transverse transference are required, a fork-like half-pin with a lon-
located at the internal, posterior surface of the middle third of the gitudinal channel in the shank end is used. In the first stage, the frag-
humerus or femur or in the interbone space of the ulna/radius or ment is pressed with its fork-like curvature into the main bone fragment.
tibia/fibula. In these cases, a fork-shaped half-pin is employed (Table A 1.5-mm wire is inserted in the half-pin canal and the bone fragment
1.2). When this device is used on the forearm, the diameter of the repo- is then drilled with this wire, thus providing its fixation to the half-pin.
sitioning wire is 2–3 mm. For example, when the bone fragment is The fragment is then relocated in the desired direction
located along the posterior surface of the femur, the device is inserted
2.3 Control of Bone Fragment Rigidity
Several parameters influence the rigidity of bone fragment

fixation and are relevant for all types of transosseous devices;
these are discussed below.
The more rigid the material used in the manufacture of the
external fixation device’s components, the stronger the rigidity of
the bone fragment fixation. Along with stainless steel, titanium
alloys and chromium-cobalt-molybdenum alloys are used
(Fig. 2.18). The durability of these alloys is three-fold higher,
whereas their mass is two-fold lower. Synthetic polymer materi-
als suitable for use in the transosseous device frames are currently
under development.
As the transosseous elements are more elastic than the external
supports and the bars connecting them, the rigidity of the tran-
sosseous synthesis to a considerable extent depends on the prin-
ciples guiding the insertion and use of the transosseous elements. Fig. 2.18 Composite and aluminum alloy supports
2.3.1 Number of Transosseous Elements 2.3.4 Levels of Transosseous Element Insertion
The greater the number of transosseous elements inserted The greater the distance between the level of insertion of
into each bone fragment, the greater the rigidity of the tran- the basic and reductionally fixing transosseous elements of
sosseous synthesis. One should remember, however, that a each bone fragment (Fig. 2.20), the greater the distance
greater number of interventions leads to a proportional between the level of insertion of the basic and stabilizing
increase in the degree of trauma and an increase in the risk of transosseous elements (Fig. 2.21), and the greater the rigid-
pin-induced joint stiffness. ity of the osteosynthesis. Therefore in the fixation of stabi-
lizing half-pins it is necessary to use four-hole posts. This
does not necessarily involve insertion of the wire and half-
2.3.2 Diameter and Type of Transosseous pins through the joint cavity and within 1–3 cm from the
Elements pathological focus.
In clinical practice, transosseous elements 1.5–6 mm in

diameter are most commonly used. Increasing the diameter 2.3.5 Plane of Orientation of the Transosseous
of the transosseous elements will lead to an increase in the Elements
rigidity of the bone fragment fixation. However, the dilemma
is that along with the increase in element thickness there is The “neutral” angle for crossing of the wires in the support is 60°.
an increase in both the mechanical injury to the tissues and With a wider angle, the wires will exert a mutual pulling action,
the rigidity of the bone–device block. Reducing the diameter and with a narrower angle a weakening action (Fig. 2.22). If it is
of the elements reduces the rigidity, but enhancement of the possible to use an angle <45°, the external support should be ori-
tension in the bone leads to its resorption, which to some ented by an angle of 45° to the most displacing forces. However,
extent may be compensated for by using supports and stop- to increase support rigidity, it is necessary to insert additional
per tubes or by altering the tension of the wire (Fig. 2.19). transosseous elements at some distance from the support
Transosseous elements with an angular thread provide (Fig. 2.23).
good rigidity of the bone–metal block. For similar diameters, If the transosseous elements are placed perpendicular to
trans-segmental transosseous elements offer greater rigidity each other, the system will respond “universally” to pos-
than console elements. sible displacing forces. The topographic-anatomic specifics
of the majority of extremity segment levels, which govern
the localization of the RPs, in the majority of cases will
2.3.3 Wire Tension predetermine this universal response if console tran-
sosseous elements (half-pins and console wires) are used.
Insufficient tension of the wires reduces the rigidity of the The expedience of inserting a half-pin at an angle to the
bone fragment fixation. The reference force of the wire strain displacing force has been confirmed. It is partly explained by
in the ring is 900–1100 N, and in the unclosed support the increased distance between a support and the level of
500–700 N. insertion of a half-pin into a bone. Thus, the greatest rigidity
a b
Fig. 2.19 (a, b) Increased

osteosynthetic rigidity using
wires fitted with a stopper. The
wires are inserted “in the
passer’s” direction
42 L.N. Solomin
Fig. 2.20 (a, b) The greater the a b B

A
distance between the level of
insertion of the basic and
reductionally fixing transosseous
elements, the greater the rigidity
of the osteosynthesis: A < B,
P1 < P2
P1
P2
a b
P2
P1
Fig. 2.21 (a–c) The greater the distance between the level of insertion of the basic and stabilizing transosseous elements, the greater the rigidity
of the osteosynthesis: A1 > A2 > A3, P1 > P2 > P3
c 2.3.6 Distance from the Bone to the External

Support
The shorter the distance, the greater the rigidity provided

by the construction (Fig. 2.26). To avoid compression of
swollen soft tissues, it is necessary to provide a certain
clearance between the skin and the support’s internal rim.
The rim has to be established individually for each segment
and type of pathological condition operated upon and
should be 1.5–5 cm.
2.3.7 External Support Geometry

P3
There is a direct dependence between the magnitude of seg-
ment coverage at each insertion level of the transosseous ele-
ments and the rigidity of the external fixation. Therefore, the
Fig. 2.21 (continued) trend of increasing bone fragment fixation rigidity proceeds
from the type V device (circular) in the direction of the type
I device (Table 1.1). The use of closed external supports
will be provided with a support to which a half-pin to be enables the wire to be optimally stretched, providing a wider
inserted at an angle to a bone fragment is fixed by means of range of possible transosseous element insertion angles.
a four-hole post (Figs. 2.24 and 2.25).
Fig. 2.22 The “neutral”

angle for wires crossing in the
support is 60°
Fig. 2.23 To increase support

rigidity, additional transosseous
elements must be inserted at
some distance from the support
44 L.N. Solomin
Fig. 2.24 To provide the greatest rigidity of bone fragment fixation when a half-pin-based module is used, the half-pins should be inserted at
corresponding angles: b1 = 120° ± 10°, b2 = 70° ± 10°, a = 60° ± 10°
1 2 3 4
Fig. 2.25 Rigidity of a combined (hybrid) support. (a) To obtain the the longitudinal axis of the bone fragment) 70° (70° ± 10°). (b) Thus,
greatest rigidity of bone fragment fixation using a combined (hybrid) the support with wire and half-pin positions provides different bone
support, angle a (between the wire and half-pin insertion planes) should fragment fixation rigidities: 4 > 3 > 2 > 1
be 60° (75° ± 15°) and angle b (angle between the half-pin insertion and
Fig. 2.26 The shorter the

distance between the bone and
the external support, the greater
the rigidity of the bone fragment
fixation
2.3.8 Number of Connecting Rods the nodes of the model fixation, the force-generating ele-
ments, and the movement transducers. The models are
The closed (ring) supports and reductionally fixing (interme- assembled using native or artificial bone, wooden or plastic
diate) and basic supports should be connected by three rods. cylinders, or metal tubes. The model can be fixed in the car-
Use of a fourth connecting rod does not increase osteosyn- cass in different ways, the displacing force applied in differ-
thetic rigidity. If one or both reductionally fixing (intermedi- ent ways, the transducers allocated in different ways, and the
ate) supports are of the open type (one-third, two-thirds or algorithm for carrying out the experiment may also be dif-
three-quarter rings), use of a fourth connecting rod increases ferent. Therefore, an objective comparison of the results of
osteosynthetic rigidity by 18–22% (Fig. 2.27). An obligatory studies by the various authors is hardly possible. Moreover,
condition for this purpose is the uniform distribution of con- the number of such studies seems to increase yearly. Chapter
necting rods on all supports; grouping the connecting cores 36 presents a method for rigidity testing of an external
in the next holes will reduce fixation rigidity. fixation construct.
Conflicts often arise between the biomechanical require- In addition to stand tests, external fixation devices can be
ments of each component of the external fixation (and other optimized through mathematical modeling using computer
requirements of the external fixation device) because of the software especially designed or adapted for the tasks that
contradictory requirements that must be fulfilled to achieve need to be resolved. The efficacy of the finite element method
an optimal solution. In these situations, one should be guided is now recognized [2, 8, 9, 13, 29–32]. However, studies
by the priorities of the osteosynthesis tasks to arrive at a com- aimed at defining the optimal parameters for bone fragment
promise that will maximize the efficiency factor of each tran- fixation rigidity at all stages of healing currently remain the
sosseous element and each external support (see Chap. 3). most relevant, and methods objectifying the durability of
As in the case of the biomechanics involved in changing bone mechanical restoration on the basis of biomechanical,
the spatial orientation of the bone fragment, the multiple fac- laboratory, optical, electrophysiological, radiological, and
tors affecting bone fragment fixation rigidity in the external other types of monitoring are being intensively developed
fixation serves as a basis for determining the directions for [8, 33–40], Unfortunately, at the time of this writing, not one
optimizing the assembly of the transosseous devices. of these methods, for various reasons, has been widely
Most clinical studies of the biomechanics of external applied in clinical practice. Furthermore, there is as yet no
fixation involve stand tests of external fixation models. The unanimous opinion as to what the bone fragment fixation
importance of the results obtained in such experiments by rigidity should be at each stage of bone anatomy restoration.
many researchers in different countries cannot be overesti- We conclude this chapter by noting that biomechanics is
mated. However, apart from the natural limitations associ- a rapidly evolving field of knowledge. There is a relatively
ated with experiments involving models, both the large number of published works dedicated to the biome-
interpretation of the data and their use in practice emphasize chanics of osteosynthesis (including the biomechanics of
the fact that there is no single commonly accepted method external fixation). It can thus be reasonably expected that a
for carrying out a stand test. At present, there are a number solution to the above-stated problems will be found in the
of devices that differentiate among the “original” carcass, relatively near future.
46 L.N. Solomin
Fig. 2.27 Optimum number

of connecting rods
(If both supports are ring type − 3

connecting rods)
3
Internal Contradictions of External
Fixation. Combined External Fixation 3
3.1 Introduction (interdependent) entities as sources (generators) of self-

movement and development. At the same time, according to
The assembly of an external fixation apparatus must fully this definition, external fixation has a significant potential for
accord with the most recent developments in transosseous optimization.
osteosynthesis. The experimental/theoretical and clinical Thus two questions arise: What type of frame configuration
knowledge base is currently such that the rigidity of bone is appropriate for the further advancement of external
fragment fixation in relation to the diameter of the tran- fixation? Can improvements in the construction of any type
sosseous elements used, their type and crossing angle, the of frame resolve all the existing internal contradictions of
geometry of the external supports, the distance between modern external fixation? In our opinion, however, these
external supports, etc., can be predicted. As discussed in questions are irrelevant. We consider that the development of
Chap. 2, the biomechanics of external fixation consist of a single type of external fixation device would divert scientific
three interconnected parts: (1) the relationship between the and clinical studies from their primary goal. In our opinion,
transosseous elements (wires, half-pins) and the surrounding a specific set of criteria (requirements) should be developed
tissue; (2) the control of bone fragment position; (3) the con- and applied so that each frame is clinically effective, that is,
trol of bone fragment rigidity. it is capable of resolving a particular clinical problem. We
However, these three components quite often mutually apply the following principles to the construction of an exter-
conflict because of opposing requirements to achieve the nal fixation device:
optimum result. In most cases, the requirement to control 1. Use of the method of unified designation of external
bone fragment rigidity is central to the internal contradic- fixation (MUDEF)
tions of external fixation (Figs. 3.1, 3.2, and 3.3). 2. Establishment of reference positions (RPs) for the inser-
There are also contradictions among some other important tion of transosseous elements
factors in the assembly of the external fixation device, for 3. Use of different types of external support (closed circular,
example: piezoelectric effects, frame automation and moni- and open semicircular, sectorial, bilateral or monolateral)
toring, convenience of the frame use, and patient comfort. and transosseous elements (trans-segmental wires and
Thus no external fixation device is perfect. In referring to Steinmann rods, and console S-screws, half-pins and con-
“contradictions in external fixation” we use the word “console wires) depending on the specific indications
tradictions” in a positive sense, implying opposing interac- 4. Consideration of the possibility of module transformation
tions and interconnected entities as sources of self-movement of the external fixation device
and development. In other words, as defined by [41] a pre- 5. Use of the minimum number of external supports and
requisite of contradiction (in the philosophical sense) is the transosseous elements to provide a quality of bone frag-
interaction (intercommunion) of opposed and interconnected ment reduction and fixation that is not worse than that
provided by the Ilizarov fixation device
6. Application of computer navigation programs in the plan-
L.N. Solomin, M.D., Ph.D. ning and use of osteosynthesis
7. Possibility of converting to internal fixation
St. Petersburg 195427, Russia These principles are discussed in detail in the following
e-mail: solomin.leonid@gmail.com and elsewhere in this volume.
48 L.N. Solomin
A B
F G
Px
PY
A<B F>G Px < PY
Fig. 3.1 The diameter of the transosseous elements can be increased to Increasing the distance between the supports in the modules fixing each
increase the rigidity of the osteosynthesis but this will result in greater bone fragment contributes to the rigidity of fixation but increases the
operative damage. Increasing the number of wires and half-pins bulkiness of the frame. Moreover, there is greater danger of transfixion-
increases the rigidity of bone fragment fixation but this will increase pin-induced joint stiffness because the level of wire insertion approaches
both operative damage and the danger of transfixion-pin-induced joint the joints
stiffness due to polylocal myofasciodeses and of pin-tract infection.
A B
F G
Px
PY
A<B F>G Px < PY
Fig. 3.2 Orienting the transosseous elements at angles of 50–90° to some cases. The risk of transfixion-pin-induced joint stiffness and pin-
each other will increase the rigidity of the osteosynthesis. However, tract infection increases as well
pin-induced injury to the principal vessels and nerves may occur in
3 Internal Contradictions of External Fixation. Combined External Fixation 49
Fig. 3.3 A circular apparatus

provides the greatest opportunity
for fragment reduction and is the
most rigid. However, at the same
time its dimensions are much
larger than those of other types
of external fixation devices.
Arranging the bone fragments in
the center of a ring support tends
to increase the stability and
simplify the management of the
fragments but this implies an
increase in the ring diameter;
because the rigidity of the
osteosynthesis is reduced, the
dimensions of the apparatus will
need to be increased
The use of MT enables the conditions for bone fragment

3.2 Method of the Unified Designation union (“regenerate training” in Ilizarov’s terminology) to be
of External Fixation (MUDEF) optimized while reducing the risk of transfixion-pin-induced
joint stiffness and pin-tract infections and increasing patient
Chapter 3 consists of a detailed discussion of MUDEF. comfort by decreasing frame bulkiness. Examples of the suc-
cessful use of MT in clinical practice are presented in the
second part of this book.
3.3 Reference Positions The general scheme of MT is shown in Fig. 3.4.
The use of RPs reduces the risk of damage to the main ves-
sels and nerves as well as the occurrence of transfixion-pin- 3.6 Minimum Number of External Supports
induced joint stiffness and pin-tract infections. Detailed and Transosseous Elements
information is provided in Chap. 5.
The parameters to achieve rigid bone fragment fixation at
each stage of bone fragment union have yet to be defined.
3.4 Use of Different Types of Transosseous Therefore, the aspirations of many authors to obtain an
Elements and External Support osteosynthesis with a rigidity greater than that provided
by the Ilizarov device can seldom be fulfilled. Instead, it
The types of external support and transosseous elements should be appreciated that the Ilizarov device has enabled
used are determined on the basis of a reasonable compromise the efficient reduction and fixation of bone fragments over
in accordance with the principles of frame construction dis- decades of its application and its design has set the standard
cussed in Chap. 7, with reference to the information provided for external fixation. Nonetheless, many of the newly devel-
in Chap. 5. oped configurations of external fixation device have several
advantages compared to the standard device as they can
be assembled using a smaller number of transosseous ele-
3.5 Module Transformation ments and supports while conferring reduction and fixation
qualities better than those allowed by the original Ilizarov
The following considerations must be taken into account in apparatus.
module transformation: (MT) All of the frame assemblies for combined external fixation
• Gradually decreasing the quantity of connecting rods and recommended in this volume have been preliminarily tested
transosseous elements and meet these requirements (Chaps. 35 and 36). The condi-
• Reducing the quantity of supports without insertion of tions for the arrangement of an external support and the tran-
additional transosseous elements sosseous elements that together provide the best possible
• Changing the geometry of the external support by its par- osteosynthetic rigidity without increasing the need for addi-
tial dismantling tional wires and half-pins are presented in Chaps. 2.2. and 2.3.
50 L.N. Solomin
a b c
Fig. 3.4 General scheme of modular transformation (MT). (a) Basic frame assembly; (b) first stage of MT: dismantling of the basic supports; (c)
second stage of MT: partial dismantling of the reductionally fixing supports
3.7 Computer Navigation logical to consider external fixation in relation to these two
terms.
Computer navigation is highly advisable in cases involving According to [41], a conjunction is a connection, an
the correction of complex deformations and deformities of arrangement of parts to form the whole, assuming connec-
intermediate complexity (Chap. 16). The Ortho-SUV Frame tions of mutual conformity. A combination is also a connec-
(Fig. 1.2q, Chap. 17) conforms with all of the above-mention, an arrangement of parts to form the whole, or a
tioned requirements. connection in mutual conformity of something, and usually
something congenerous. Both terms suggest a complicated
idea: a system comprising ways to achieve a particular goal;
3.8 Converting to Internal Fixation a number of ways united with a common aim and directed
towards achieving an advantage. The term “combined”
See Chap. 26. includes the concepts contained in the term “conjunction.”
By discussing external fixation in terms of these seven That is why it is universal and terminologically more accept-
criteria we seek to bring it to a new qualitative level. able for the situation under consideration herein. But it
However, this necessitates the appropriate designation of should also be noted that the expression “combined osteo-
the direction of external fixation. Such an approach to exter- synthesis” has yet to be widely accepted. Definitions of com-
nal fixation implies a conjunction or a combination of dif- bined osteosynthesis in the literature include:
ferent types of support, transosseous elements, and the 1. The use both of external and internal fixation for the
biomechanical conditions between supports. Thus, it is osteosynthesis of one bone [42–48].
3 Internal Contradictions of External Fixation. Combined External Fixation 51
2. Simultaneous use of several types of implants on one An overall analysis of the terms used in the orthopedic
bone; for example, a nail and a wire [49–53]. literature reveals the use of the word “hybrid,” as in hybrid
3. Osteosynthesis of each bone of a two-bone segment by osteosynthesis, hybrid external fixation, or osteosynthesis by
different types of fixators; for example, in the case of a hybrid device. The concept underlying the use of these
forearm fracture, plate osteosynthesis of the radius and terms implies a change from a combination of external and
nailing of the ulna [54]. internal fixation [63, 64] to a combination of two types of
4. The use of internal fixation and external fixation of dif- external fixation device, for example, the AO tubular exter-
ferent segments in case of multiple fractures; for exam- nal fixer and the Ilizarov frame [65–67].
ple, internal fixation of the femur and external fixation of It has been established, both experimentally and theoreti-
the lower leg in the same patient. cally, that the biomechanics of bone fragment fixation with
5. The application of an external fixation device with exter- wires and half-pins differ greatly from each other [9, 27,
nal supports of different geometries: circular, semicircu- 68–72]. The biomechanics of devices based on wires and
lar, sectorial [55]. half-pins also have unique [73–79]. Therefore osteosynthesis
6. Different biomechanical states between supports of the using a wire/half-pin hybrid apparatus should classified in
frame; for example, alternating compression and distrac- subgroup 2b.
tion [56, 57]. Based on these definitions and classification, the term
7. Bone fragment fixators of different types of material; for “combined external fixation” (CEF) has a quite specific
example, metal and polymer [58]. meaning. In CEF and for osteosynthesis, a wire/half-pin
8. The use of a “wire-pin” frame assembly together with device as well as devices with both wires and half-pins can
bone grafting [59]. be used. The term “hybrid external fixation” refers to the use
9. A combination of internal fixation and the insertion of of wires, half-pins, and various types of external support.
various materials into the fracture gap to stimulate bone Hence, we can further define “combined external fixation” as
callus formation [60]. “wire-/half-pin-based external fixation” or “hybrid external
10. Simultaneous use of an implant and bone cement for fixation.” Furthermore, if the set of criteria (requirements)
bone fragment fixation [61, 62]. are not shared, we cannot compare CEF with these other
We define combined osteosynthesis as the conjunction in definitions.
one bone of fixators with two or more biomechanical modes Thus, CEF is not an artificially created entity; rather, it
of interaction with that bone to enhance the efficiency in incorporates the best practices of external fixation using all
achieving the aims of osteosynthesis: the establishment of possible types of transosseous devices and applying the most
the necessary spatial arrangement of the bone fragments, recent advances, as discussed above.
rigid fixation of the bone fragments, and maintenance The most frequently used CEF frame assembly is a group
(improvement) of the function of the extremities in the post- VI external fixation device (Table 1.1), although its use may
operative period. not be strictly necessary. In some cases, the tasks of osteosyn-
For more accurate terminologies, the terms associative or thesis may be optimally carried out using sector, semicircu-
conjunctive osteosynthesis should be used for cases involv- lar, circular, and even monolateral configurations. However,
ing the separate osteosynthesis of two-bone segments using we repeat, that the full set of requirements for CEF should be
different bone fixators, and osteosynthesis with a combined observed, as the adherence to the principles of transosseous
fixator for cases in which the bone fixator consists of differ- element insertion and apparatus assembly largely resolves
ent materials, e.g., metal and a polymer. Finally, the expres- the above-discussed internal contradictions of external
sion combination of an osteosynthesis device and an fixation.
additional substance should be used in cases in which, to The Russian Federation patents on which the method of
achieve the goals of treatment, various materials are inserted CEF is based are listed in Table 3.1.
at the location of the fracture to increase the rigidity of the In this book, alongside original methods of external
osteosynthesis or to stimulate bone formation. fixation developed at the Russian Ilizarov Scientific Center,
A combined osteosynthesis can now be classified as device assemblies meeting the criteria established for CEF
follows: are presented. Their experimental validation (establishing
1. Uncontrolled combined osteosynthesis (internal fixation), the optimal positions for insertion of the transosseous ele-
which is either (a) neutral or (b) compressive with one- ments, biomechanics of bone fragment fixation rigidity), in
stage compression or dynamic compression addition to our own data, was carried out by (in alphabetical
2. Controlled combined osteosynthesis, which is either (a) a order) M.V. Andrianov, R.E. Injushin, P.N. Kulesh, S.V.
combination of internal fixation and external fixation or Majkov, D.A. Mykalo, V.A. Nazarov, L.N. Solomin, and
(b) combined osteosynthesis with external fixation N.V. Fomin.
52 L.N. Solomin
Table 3.1 Russian Federation patents awarded for combined external fixation devices and innovations
Patent number Title Awarded to
1657168 A method for clavicle defect treatment A.P. Barabash, L.N. Solomin
1750665 A method for long bone osteosynthesis A.P. Barabash, L.N. Solomin
4706740 A method for wire insertion and a device for its realization A.P. Barabash, L.N. Solomin
2062611 A method for tibial bone fracture osteosynthesis A.P. Barabash, L.N. Gordienko, V.P. Culms, N.V. Tishkov,
V.V. Shevchenko
2069994 A method for proximal femur deformity correction A.P. Barabash, L.N. Solomin
2089099 A device for definition of an angle and the level of wire insertion A.P. Barabash, L.N. Solomin
2121814 A method for proximal part forearmbone reconstruction A.P. Barabash, L.N. Solomin, J.A. Barabash
2123307 A method for treatment of long bone damage and a device A.P. Barabash, L.N. Solomin
for its realization
2139005 A device for external fixation L.N. Solomin, A.P. Barabash, M.E. Puseva, S.A.
Yevseyev, N.B. Svarchevsky
2160060 A method for bone cyst treatment and a device for its realization L.N. Solomin, A.P. Barabash, A.V. Erusalimtsev
2202967 A method for replacement of long bone defect L.N. Solomin, A.P. Barabash, J.A. Barabash
2193368 A clamp for external fixation L.N. Solomin, N.V. Kornilov, A.V. Vojtovich, O.P.
Shabaldo, V.V. Dolgopolov, V.A, Nazarov
2202967 Â device for bone drilling L.N. Solomin, N.V. Kornilov, V.A. Nazarov, I.V. Shaljuga,
J.V. Stetsjunich
2199967 A method for humeral bone transosseous osteosynthesis A.P. Barabash, J.A. Barabash, L.N. Solomin
2202300 A method for skeletal traction L.N. Solomin, S.A. Evseeva
2206286 A method for reduction of chronic dislocations of a humeral L.N. Solomin, N.V. Kornilov, A.V. Vojtovich,
bone E.A. Shchepkina, S.V. Gavrilov, V.A. Nazarov,
V.J. Komogortsev
2218083 A method for definition of soft tissues displacement and a device L.N. Solomin, A.V. Vojtovich, M.V. Andrianov,
for its realization V.A. Nazarov, R.E. Injushin, P.P. Kulesh
2233640 A device for bone fragment repositioning and fixation L.N. Solomin, N.V. Kornilov, A.V. Vojtovich,
V.A. Nazarov, M.E. Puseva, M.V. Andrianov
2246139 A method for external fixation construct rigidity testing L.N. Solomin, A.V. Vojtovich, P.I. Runner, V.A. Nazarov,
and a device for its realization M.V. Andrianov
2257866 An extracortical clamp device L.N. Solomin, N.V. Kornilov, M.V. Andrianov,
V.A. Nazarov, P.N. Kulesh, R.E. Injushin
2261675 A method for tibia and fibula external fixation L.N. Solomin, N.V. Kornilov, V.A.Nazarov, D.A. Mykalo
2250085 A method for bone graft fixation in treatment of long bone L.N. Solomin, N.V. Kornilov, S.P. Lushnikov
defects
2270631 A method for humeral bone combined external fixation L.N. Solomin, R.E. Injushin
2290888 A method for ulnar bone combined external fixation L.N. Solomin, P.N. Kulesh
2293535 A method for femur lengthening L.N. Solomin, M.V. Andrianov
2303416 A device for bone fragment reduction in external fixation L.N. Solomin, J.S. Zakutnev, V.A. Vilenskij, P.N. Kulesh,
P.P. Oganezov
2310408 A method of modular external fixation of tibia and fibula L.N. Solomin, D.A. Mykalo
2324449 A device for treatment of periprosthetic fractures L.N. Solomin, V.A. Vilensky
2328233 A method of external fixation of forearm with preservation L.N. Solomin, P.N. Kulesh, M.E. Puseva
of rotation function
2336842 An external fixation device “SUV-frame” L.N. Solomin, A.I. Utekhin, V.A. Vilensky
2343852 A method of stimulation of distraction regenerate L.N. Solomin, O.A. Jachnyj
2352283 Apparatus for external fixation “Solomin-Utekhin-Vilensky” L.N. Solomin, V.A. Utekhin, V.A. Vilensky
87618 An extracortical clamp device “Ortho-SUV” L.N. Solomin, V.A. Utekhin, V.A. Vilensky
2370223 A method of module external fixation using the Taylor Spatial L.N. Solomin, V.A. Vilensky, S.S. Toropov, S.V. Maykov
Frame
2376951 A method of long bone defect replacement L.N. Solomin, K.L. Korchagin, K.V. Zakrevsky,
A.V. Takmakov
94862 A device for modeling moving bone fragments A.I. Utekhin
2391933 A method of external fixation of long bones (in aesthetic L.N. Solomin, P.N. Kulesh, E.P. Sorokin, K.L. Korchagin,
surgery) S.S. Toropov
2391932 A method of prophylaxis of secondary displacement L.N. Solomin, P.N. Kulesh, K.L. Korchagin
at external fixation
2440058 A method of external fixation using computer-assisted SUV- L.N. Solomin, K.L. Korchagin
Frame at knee joint stiffness
Method of Unified Designation
of External Fixation (MUDEF) 4
4.1 Introduction where it is dangerous to pass K-wires and half-pins. The

use of the coordinates in any of the atlases significantly
External fixation for the treatment of orthopedic and trauma facilitates definition of the dangerous sectors and safe
patients is a technically demanding procedure. Consequently, corridors during the operation.
the type of transosseous element (K-wires, S-screws, half- • Facilitation of routine work during the recording of exter-
pins), their levels and crossing positions, the levels of the nal fixation operations to produce a record that is self-
external supports of the fixator, and the biomechanical rela- explanatory.
tionship between the supports must be strictly controlled and • Improvement in the accuracy and comprehensiveness of
standardized. remote consultations (including teleconsultations):
Text annotations, even those accompanied by explanatory MUDEF allows the recommended configuration of the
figures, may be grossly inaccurate because they leave too external fixation device for a specific case to be sent and
much room for data interpretation. The three-dimensional received, and adequate data exchange during online con-
image achieved using computer techniques is by far the most ferencing/consultations.
precise approach; however, the creation of such images to • Simplified updating of the computer database: The opti-
serve as models for all of the situations encountered in exter- mal configurations of external fixation devices in cases of
nal fixation would be very expensive and laborious. different orthopedic and traumatological pathologies can
With the use of a minimal number of symbols, MUDEF readily be stored.
of the long bones provides a comprehensive description of • Estimating and detailing of complications: For example,
the type and spatial orientation of the transosseous elements, pin-tract infections are the most frequent complication in
the order and direction of their crossing, and the form (geom- external fixation. MUDEF allows identification of the lev-
etry) and dimensions of the external supports, as well as the els and positions at which pin-tract infection most often
biomechanically indicated relationship between the supports. occurs. Similarly, the transosseous elements that cause
Additionally, MUDEF provides other advantages: pain and limit the range of motion of the joints can be
• Study of the method of external fixation: The use of identified.
MUDEF in instructional lectures, monographs, manuals, • Unification of scientific research on external fixation
and original articles allows accurate recording of the devices: The most important characteristics of external
entire algorithm of the operation and avoids failure of the fixation devices are: the option to change the spatial ori-
method due to inaccuracy and to mistakes made during its entation of bone fragments (reduction); the rigidity of the
implementation. fixation; the possibility to maintain extremity function.
• Elimination of pin-induced damage to neurovascular During the development of generally accepted criteria
structures: In Germany, Italy, the USA, and Russia, atlases for each characteristic, the application of MUDEF allows
have been published that provide schemes for the trans- the specific configurations of external fixation devices to
verse sections of the extremities and designate the sectors be compared in order to select those that are optimal.
• Increasing the accuracy in the description of a local area:
The locations of punctures, incisions, and drains can be
L.N. Solomin, M.D., Ph.D. defined.
• Overcoming language barriers and establishment of a
St. Petersburg 195427, Russia universal international code for the description of exter-
e-mail: solomin.leonid@gmail.com nal fixator constructions.
54 L.N. Solomin
Table 4.1 Standard and additional symbols used in MUDEF

Standard symbols Additional symbols
1. Roman numerals from 0 to IX designate the level of the wire or 8. For olive wire designation, the correspondent position is indicated
half-pin insertion. in bold type.
2. Arabic numerals from 1 to 12 designate the position of the wire or 9. Numerals define the insertion order of the transosseous elements.
half-pin insertion. 10. A line drawn under the symbols of the transosseous elements
3. A comma (,) is placed between symbols indicating level and shows that all of them are fixed to the common support.
position and between symbols indicating position and orientation of 11. A continuous line drawn under symbols of transosseous elements
the half-pin insertion. shows that they are fixed to a single, common support of the frame.
4. A dash (-) between symbols indicates the positions in the projection 12. Symbols to designate the device type:
through which wire is passed. mon. = monolateral
5. A semicolon followed by a space (; ) divides the groups of symbols bil. = bilateral
defining the transosseous elements. sec. = sectorial
6. Numerals indicate the angle of half-pin insertion (in degrees). sem. = semicircular
7. Parentheses ( ) enclose the designation of transosseous elements cir. = circular
passing through the radius or fibula. hyb. = hybrid
13. Symbols are used to designate the support form; for example, 3/4
indicates a three-quarter circle (i.e., missing a 90° section); 1/2
indicates a semicircle, etc.
14. Numerals indicate the dimensions of the support (in mm); for
example, the diameter of a circular support.
15. Symbols are used to specify the biomechanical relationship
between the supports:
16. ––; ←→; →←; ––o––; ←o→
4.2 Symbols Used accordingly defined by positions 1–12. The long axis of the
bone is the center of division of each level into the 12 sectors
The standard and additional symbols used in MUDEF are (Figs. 4.3 and 4.4).
shown in Table 4.1. The additional symbols improve the
comprehensiveness and quality of the information obtained
with MUDEF, but they are not strictly obligatory. 4.4 Designation of Transosseous
Elements
4.3 Coordinates In MUDEF of the forearm and lower leg, the symbols for
the transosseous elements inserted through the radius and
For the long bones, MUDEF is based on a system of coordi- fibula, respectively, are enclosed in parentheses.
nates. With the help of these coordinates each segment of the Transosseous elements introduced between the levels (posi-
extremity is divided vertically (into levels) and horizontally tions) are designated with the symbol of the level (the posi-
(into positions). tion) closest to which the transosseous elements are to be
located. When a transosseous element is not inserted per-
pendicular to the longitudinal axis of a bone fragment, the
4.3.1 Levels thickness of the soft tissues must be taken into account dur-
ing the planned insertion of the half-pin or wire at a refer-
Vertically, each segment of the extremity is divided into eight ence level.
basic and equally spaced levels designated by Roman numerals
from I to VIII (Fig. 4.1). The device illustrated in Fig. 4.2 is used
for the rapid designation of all or any one of the basic levels. 4.4.1 Designation of K-wires
For trans-segmental transosseous elements (e.g., K-wires,

4.3.2 Positions Steinmann rods, Kalnberz rods), it is necessary to designate
two positions on opposite sides of the bone, for example
Each transverse section at each level is divided into 12 equal 3 and 9, 6 and 12, 1 and 7 (Figs. 4.5 and 4.6). The annotation
radiating sectors (similar to a clock-face); the sectors are V,2-5 indicates that the K-wire is out of the bone. This system
4 Method of Unified Designation of External Fixation (MUDEF) 55
II
III
IV
VI
VII
VIII
IX
Fig. 4.1 Division of each segment into levels. Levels I and VIII are the radius. The most prominent lateral part of the greater trochanter is
located in the metaphyses of the long bones, where the proximal and located at level I of the femur, and the epicondylus lateralis at level
distal basic transosseous elements are passed in the majority of external VIII. Level I of the lower leg is located at the tibial tuberosity, and level
fixation operations. Level I of the humerus is the level of the greater VIII at the distal tibiofibular syndesmoses. Levels 0 and IX are located
tuberculum (40 mm distal to the acromion), and level VIII is the level at the proximal and distal epiphyses of the bones of each segment; they
of the epicondylus lateralis. Level I of the forearm is at the level of the are rarely used in external fixation. The distances between levels 0 and I
column of the radius (40–50 mm distal to the apex of the olecranon), and between levels VIII and IX are less than the distance between the
and level VIII is 30 mm proximal to the apex of the styloid process of basic levels
I I
II
II
III
IV
III V
VI
IV VII
VIII
VI
VII Fig. 4.2 This device is used for the rapid designation of all or any one
of the basic levels. It consists of 14 jointed laths each measuring;
80 × 30 mm. The side joints of the device are at the projections of levels
I and VIII, and the whole segment is equally divided to give the location
of every level. An elastic tape marked with each of the eight levels can
VIII be used for the same purpose
56 L.N. Solomin
11 12 1 1 12 11
10 10
2 2
9 3 3 9
8 4 4 8
a 7 6 5 b 5 6 7
Fig. 4.3 Designation of positions at level IV on the right (a) and left extremities. According to the topographico-anatomic features of the
(b) femurs. By convention, position 3 is always located on the medial humerus and femur, positions 2, 3, 4, and 5 can only be imagined
surface of the segment, and position 12 anteriorly. Applying this theoretically at levels 0 and I (and in some individuals, also at level II)
guideline avoids failure in designating the positions on the right and left
12
11 1
12
10 2
11 1
10
2
9 3
9 3
8 4
7 5
8 4
6
a 7 5 b
6
Fig. 4.4 Designation of positions on the ulna (a) and radius (b) at level IV of the right forearm in the mid-position between supine and prone.
Thus, 24 positions are indicated at each of the ten levels of the forearm and the lower leg: 12 positions relative to each bone of the segment
11 12 1
I
II 10 2
III
IV 9 3
VI 8 4
VII
7 6 5
VIII
IV,9-3
Fig. 4.5 For the designation of wires passing perpendicular to the long by the indicating the corresponding position in bold type. This designa-
axis of the segment, the following conditions must be marked: level of tion is the clarifying one. For example, if a K-wire with an olive is
passage and, after a comma, the two positions through which it is con- passed at level IV in the frontal plane, in a lateral to medial direction,
sistently passed. Positions through which a wire is consistently passed then it is designated IV,9-3
are separated using an en dash (−). A wire with an olive is designated
11 12 1
I
II 10
2
III
IV 3
9
4
VI 8
Fig. 4.6 If a wire with an olive

is passed at an angle to the VII
long-bone axis, that is from one 7 6 5
level to another (for example,
from level III to level IV) in a VIII
lateral to medial direction, then it
is designated II,9-IV,3 III,9-IV,3
58 L.N. Solomin
12 12
a b
11 1 1
11
10 2 2
10
9 3 9 3
8 4 8 4
7 5
6 7 5
6
I,5-11(I,5-11) (a) VIII,6-12(VIII,6-12) (a)
I,5-11(I,5-11) (b)
VIII,6-12(VIII,6-12) (b)
Fig. 4.7 (a, b) Designation of wires passing through both bones of the theses (VIII,6-12) shows that the wire passes through the radius as
forearm in standard (a) and clarifying (b) variants. Positions relative well. If a wire with an olive passes at level VIII of the forearm from
to the radial bone are not shown. In the mid-position of the forearm the side of the radius, then it is designated (VIII,12-6)VIII,12-6. The
(between supine and prone), at the majority of levels (except level I), proximal radioulnar joint is not strictly located in the sagittal plane.
the ulna and radius are located one above the other. Consequently, posi- Consequently, the common designation for the ulna and radius at level
tions 6 and 12 of both bones are also located one above the other. In this I is axis 5–11 (and not 6–12 as for all the other levels). Thus, it is neces-
case, a wire with an olive passing at level VIII from the side of the ulna sary to designate a wire with an olive (passing at level I, thus beginning
can be represented as shown in (b): position 6 of the ulna → position with the ulna through both bones) as shown in (a). A wire with an olive
12 of the ulna → position 6 of the radius → position 12 of the radius. passing at level I of the forearm from the side of the radius is designated
That is why the VIII,6-12 designation corresponds to a wire through (I,11-5)I,11-5. Note that the parts of the designation indicating the ulnar
the ulna. Doubling the designation by adding a designation in paren- and radial portions of a wire are not separated by a space
can be used to designate a drain placed at this level in the wires) it is necessary to indicate after a comma the following
projection of the mentioned positions. (Fig. 4.8): (a) the level of console transosseous element inser-
Several positions of the ulna and radius (and the tibia and tion, (b) the position of its insertion, and (c) the orientation
fibula) overlap. For MUDEF, this circumstance influences of its insertion in relation to the long bone axis (anatomic
the designation of wires that pass through both bones of the axis). By convention the angle is open proximally.
forearm or lower leg. Thus, the same wire may need to be Where the console transosseous element is passed through
designated twice: once for the part that passes through the both bones, it is designated using the symbol of only one posi-
ulna (tibia) and again for the part that passes through the tion because the skin is perforated only on one side; for exam-
radius (fibula) (Fig. 4.7). Another example is “a wire with an ple, VIII,6,90(VIII,6,90) (Fig. 4.9). This differs from the
olive passed at level VIII of the lower leg at the side of the designation of a wire passing through both bones (Fig. 4.7).
fibula, in the projection of positions 8 and 2.” Using MUDEF,
this description is designated in the standard variant as
(VIII,8-2)I,8-2 and in the clarifying one as (VIII,8-2)I,8-2. 4.5 Designation of the External
Support Frame
4.4.2 Designation of Half-Pins To encode the device supports, the designations of each tran-
sosseous element (K-wire, S-screw) fixed to the common
To accurately designate console transosseous elements (half- support are separated by semicolons and spaces (Figs. 4.10
pins, S-screws, stiletto-formed and curved rods, and console and 4.11).
60°
11 12 1
I
II 10 2
III
IV 9 3
8 4
VI
VII
7 6 5
VIII
II,8,60
Fig. 4.8 Designation of a half-pin inserted at level II in the projection of positions 8, at an angle of 60° to the longitudinal (anatomic) axis of the tibia
12
1 1
11
10 2 10 2
3 9 3
9
8 4 8
4
7 5 7
6 5
6
I,5,90(I,5,90) VIII,6,90(VIII,6,90)
Fig. 4.9 Examples of the designations of console wires passed through the bones of both forearm. The positions relative to the radius are not shown
60 L.N. Solomin
I,9-3; II,1,60 (a)

1 2
I,9-3; II,1,60 (b)
3/4 150
Fig. 4.10 Example of the designation of a hybrid (wire/half-pin) sup-

port in standard (a) and clarifying (b) variants. When the additional
symbols are used, all the designations of the transosseous elements
fixed to the present support must be united below using an unbroken
line. To designate the order of insertion of the transosseous elements
(sequence for performing the osteosynthesis), numbers corresponding
to the order of priority in which the transosseous elements are passed
are given above the designation of the wires and half-pins. Under the
unbroken line, the other additional symbols define both the form (geom-
etry) of the support (for example, 3/4 defines a three-quarter circle, i.e.,
minus a 90° section; 1/2, a semicircle) and the dimensions (in mm) of
the support (for example, the diameter of the circle support)
I,7-1; I,11-5 ⎯ IV,3-9 →← V,9-3 ⎯ VII,8-2; VII,10-4 (a)

1 2 5 6 3 4
I,7-1; I,11-5 ⎯ IV,3-9 →← V,9-3 ⎯ VII,8-2; VII,10-4 (b)
3/4 140 130 130 3/4 130
Fig. 4.12 Example of MUDEF of a humeral bone fracture 12-A3

in standard (a) and clarifying (b) variants according the description:
K-wire with an olive is inserted through the proximal metaphysis of the
humeral bone at right angles to the long axis of the segment and ori-
ented at an angle 75° to the frontal plane from posterior to anterior. A
second K-wire is passed in the same plane as the first at an angle 30° to
it. Two K-wires are passed through the epicondylar region of the
humerus at right angles to the long axis of the bone in the transverse
plane and oriented at 30° to each other (the angle is opened to the
outside). The Ilizarov device is mounted using three supports with a
diameter of 130 mm and one (proximal) support with a diameter of
140 mm. In such cases the basic supports of the device are geometrically
mounted in a three-quarter circle. To reduce the bone fragments, two
(VII,11,120); VII,8,120; VIII,6-12(VIII,6-12) (a) K-wires with a stop are inserted in the frontal plane, the first at a distance
equivalent to one-third of the length of the diaphysis from the proximal
2 3 1 end in a medial to lateral direction; and the second at a distance one-third
(VII,11,120); VII,8,120; VIII,6-12(VIII,6-12) (b) from the distal end in a lateral to medial direction. The interfragmental
120
compression is given
Fig. 4.11 Diagram of a support mounted at level VIII of the forearm
in standard (a) and clarifying (b) variants according to the descrip-
tion: “K-wire with an olive from the side of the ulna is passed through 4.6 Designation of the Entire Device
the distal metaphyses of both forearm bones. S-screw is inserted into
the radius at level VII in the projection of position 11 at an angle 120°.
To designate the configuration of the entire device (Figs. 4.12,
The second S-screw is inserted into the ulna at level VII in the projec-
tion of position 8 at an angle of 120° to the long axis of the bone. All 4.13, 4.14, and 4.15), other symbols are inserted between
the transosseous elements are fixed to the 120-mm circular support” those for the external supports in order to represent the
Fig. 4.13 Designation of the bone

transport operation (replacement of a
tibial defect by lengthening of the
proximal fragment) in standard (a) and
clarifying (b) variants. Note that the
designation (1,8-2)I,8-2 shows that the
olive of the K-wire is located on the
fibula. The designation of the K-wire
(VIII,8-2)VIII,8-2 shows the same
(I,8-2)I,8-2; I,4-10; II,1,60 IV,2-8; IV,4-10 VII,1,120; (VIII,8-2)VIII,8-2; VIII,4-10 (a)

1 2 3 7 8 6 4 5
(I,8-2)I,8-2; I,4-10; II,1,60 IV,2-8; IV,4-10 VII,1,120; (VIII,8-2)VIII,8-2; VIII,4-10 (b)
150 150 150
Table 4.2 Symbols used to represent biomechanical relationships

Symbol Biomechanical relationship
—— Neutral
→← Compression
←→ Distraction
––◦–– Hinge
←◦→ Distraction hinge
recommended biomechanical relationship between them, as

shown in Table 4.2.
4.7 Additional Data
If necessary, the number of levels and positions can be

increased, for example, up to 30 levels and 360 positions.
The following notes correspond to such conditions, for
example: XXII,162-342; XVIII,273,65.
Besides increasing the number of levels and positions, the
MUDEF user can apply the additional symbols as needed.
0,3-9; 0,8-2 –o– II,2,90; IV,2,90; V,2,90 (a)
They identify the type of console transosseous element (for
1 2 3 4 5
0,3-9; 0,8-2 –o– II,2,90; IV,2,90; V,2,90 (b) example, S-screw, half-pin, hooked rod), the material (from
2/3 160 mon. which the external device supports and transosseous ele-
ments are made), the diameter of the transosseous elements
Fig. 4.14 Designation of the Biomet-Merck device in standard (a) and
clarifying (b) variants
connecting the supports of the bar, etc.
62 L.N. Solomin
Fig. 4.15 Designation of the Ortho-SUV Frame in standard

(a) and clarifying (b) variants
II,1,120; III,9-3; IV,3,70 ⎯O-SUV ⎯ V,12,90; VI,3-9; VII,2,90 (a)

2 1 3 5 4 6
II,1,120; III,9-3; IV,3,70 ⎯O-SUV ⎯ V,12,90; VI,3,90; VII,2,90 (b)
150 150
We recommend using the following text descriptions to examples below:

designate the transosseous elements introduced into the ana- • Additionally, element II,1,60 was passed and fixed to the
tomic formations not included in the given schemes: proximal device support.
• “Two mutually crossing wires were passed through the • It is recommended that contralateral compression of the
acromion of the scapula and fixed to one external sup- fragments (1 mm/week) be performed using wire traction
port:” acr.,1-7; acr.,5-11 deviceV,9-3.
• “The half-pin was passed into the posterior surface of the • Due to incision of the soft tissue near half-pin V,2,90, it
olecranon at an angle 90°:” olecr.,6-90 was changed to wireV,4-10.
• “A wire was passed through the talus in the frontal plane:” • The signs of inflammation appeared in the region of
talus,3-9 K-wire VI,4-10 exiting at position 4.
During completion of the operative record, the only The last two examples illustrate the significant role of
features of the procedure that need to be recorded in text MUDEF of the long bones in the process of objectification of
form are the operative approach, the characteristics of complications.
the tissues, and any complications that arose. This An electronic version of MUDEF can be obtained at
procedure for the completion of the operative record results http://rniito.org/solomin/download/mudef.zip and http://ortho-
in medical documentation that is comprehensive and suv.org
unambiguous, as can be seen from the records given as
Atlas for the Insertion of Transosseous
Element Reference Positions 5
Leonid Nikolaevich Solomin, Roman Nikolaevich Inyushin,
Pavel Nikolaevich Kulesh, Maxim Vasil’evich Andrianov,
Dmitry Alexandrovich Mykalo, Nikolay Fedorovich
Fomin, Sergey Valerjevich Majkov,
and Konstantin Andreevich Ukhanov
The atlas of positions for the correct insertion of transosseous Reference positions (RP) for transosseous element inser-
elements utilizes the coordinate system of MUDEF (Chap. 4). tion are indicated at each level with an arrow. RPs are located
Each limb segment is divided into eight principal levels, and where soft-tissue displacement is at a minimum during
each level is marked by 12 positions. movement of the adjacent joint (the method for defining RPs
The major blood vessels and nerves at each level are is described in Chap. 35). Thus, the designation and use of
grouped into special zones designated by the letters A, B, C, RPs allows: (a) the avoidance of damage to the principal ves-
and D. Due to the characteristically variable anatomy, and sels and nerves, (b) a reduction in the incidence of pin-
taking into consideration the possible changes in surface induced joint stiffness, and (c) a reduction in the incidence of
anatomy following displacement of the bone fragments, the infectious complications (pin-tract infection).
areas adjacent to the vessels and nerves are considered con- Diagrams of the anatomic-functional sections for each
traindicated positions for the insertion of transosseous pins segment are shown below. Note that RPs are not located at
or wires. all levels but they are located symmetrically across a bone;
Of the 12 positions, those remaining after disallowing the for example, positions 3 and 9, 1 and 7, 6 and 12, etc. It is
contraindicated positions are considered safe positions; they possible to insert a wire at the projection of the positions
allow the insertion of transosseous elements without damage given, and to insert a half-pin using part of any recommended
to the principal vessels and nerves. position. Where there is no second (symmetrically located)
position, only a half-pin should be used. More detailed
information about the choice of transosseous elements is
presented in Chap. 7.
L.N. Solomin, M.D., Ph.D. (*) The images of the recommended transosseous elements
R.R. Vreden Russian Research Institute of Traumatology are accompanied by their MUDEF designations. As the angle
and Orthopedics, Professor of Surgery Chair, Medical Faculty of half-pin insertion is defined by the requirements to achieve
of Saint Petersburg State University, 8 Baykova Str., optimum biomechanics in a particular clinical situation, in
e-mail: solomin.leonid@gmail.com the submitted schemes the actual digital values of the inser-
tion angles of the half-pins are not specified.
R.N. Inyushin, M.D., Ph.D.
Department of Orthopedics, City Polyclinic No 25, Solodarnosti Str., 1, The acupuncture points and classic meridians are shown
St. Petersburg 193312, Russia in Fig. 5.1. The upper extremities are crossed by the follow-
P.N. Kulesh, M.D., Ph.D. • D.A. Mykalo, M.D., Ph.D. • S.V. Majkov ing meridians: lung (P), large intestine (GI), triple energizer
Department of Orthopedics, R.R. Vreden Russian Research (TR), small intestine (IG), heart (C), and pericardium (MC).
Institute of Traumatology and Orthopedics, 8 Baykova Str., The lower extremities are crossed by the following meridi-
St. Petersburg 195427, Russia ans: stomach (E), liver (F), spleen (Rp), kidneys (R), bladder
M.V. Andrianov, M.D., Ph.D. (V), and gallbladder (VB).
Department of Orthopedics, City Adult Outpatient Department No 6, The atlas shows the projections of the acupuncture points
Elizarov Str., 32, Build. 2, St. Petersburg 192148, Russia
and meridians on the skin. The zones where the levels are
N.F. Fomin, M.D., Ph.D. crossed by the meridians are designated in the section dia-
Department of Surgery, Kirov Military Academy,
Lebedeva Str., 6, St. Petersburg 199106, Russia grams according to the recommendations of [80]. The coinci-
dences of levels and the acupuncture points are designated
K.A. Ukhanov
Central Regional Hospital, Urotskogo Str., 1, according to the French system of transcription. Only the des-
Gatchina 188300, Russia ignations in letters correspond to the crossing of a level by a
64 L.N. Solomin et al.
a b
Fig. 5.1 (a, b) Meridian diagrams according to [86]
meridian. Where the safe positions and RPs are identified, the in order to achieve correct placement of the fixation ele-
projections of the acupuncture points and meridians are not ments. In cases of angular deformity, shortening, or dyspla-
shown because the meaning of a transosseous element pass- sia of the extremity, the ability to define the contraindicated
ing through a reflex zone is still a matter of controversy positions is enhanced by adjunctive studies such as comput-
[80–85]. erized tomography, MRI, and angiography.
The diagrams shown in the atlas are oriented in the ana- Figures for the following sections were taken from the
tomic-topographic norm. Prior to transosseous element 2005 electronic Atlas for Insertion of Transosseous Element
insertion, both elimination of the severe displacement of “Reference Positions” (http://rniito.org/solomin/download/
bone fragments and restoration of the limb axis are required atlas-engl.zip and http://ortho-suv.org).
5 Atlas for the Insertion of Transosseous Element Reference Positions 65
5.1 Upper Arm
Leonid Nikolaevich Solomin and

Roman Nikolaevich Inyushin
The figures show sections at each of the principal levels

(I–VIII) of the upper arm. In the anatomic functional sec-
tions of the upper arm, the thick arrows designate the posi-
tions at which soft-tissue displacement is minimal for all
movements of the shoulder and elbow joints: flexion, exten-
sion, abduction, rotation. The thin arrows designate the posi-
tions at which soft-tissue displacement is minimal for most
movements: flexion, extension, abduction.
Of 93 positions, 60 (64.5%) are safe positions as defined
according to MUDEF (positions 2–4 at level I are not consid-
ered due to anatomic constraints). In the humerus, there are
29 RPs (31.2%) for transosseous element insertion. The
insertion of K-wires is prudent and safe only at levels III,
IV,V,VII, and VIII.
On the humerus there are three Yin meridians with a
centrifugal direction of energy, those of the lung (P), heart
(C), and pericardium (MC). There are three Yang meridians
with a centripetal direction of energy, those of the large
bowel (GI), triple energizer (TR), and small bowel (IG).
The meridians on the humerus are represented by 22 active
points.
Level I (Figs. 5.2, 5.3, and 5.4)

Contraindicated positions: 3, 4
Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 8, 9, 10, 11
Comments. Only console transosseous elements can be used in the projection of positions 8, 9, and
10. The use of positions 8, 10, and 11 is optimal at this level because the transosseous elements will
minimally restrict soft-tissue displacement with shoulder joint motion.
11 12 1
2 A
a.axilaris; v.axilaris
10 n.medianus; n.ulnaris; n.radialis
GI
9 3
8 Tr
Fig. 5.2 4
IG
7 6 5
Fig. 5.3
The transosseous elements recommended for use at humeral level I are I,8; I,10; and I,11.
I,11 12
I,10
9 3
I,9
I,8
Fig. 5.4
Level II (Figs. 5.5, 5.6, and 5.7)

Contraindicated positions: 1, 2, 3, 4
Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 7, 8, 9,
and 10. The use of positions 8, 10, and 11 is optimal at this level because the transosseous elements
will minimally restrict soft-tissue displacement relative to the shoulder during motion of the gle-
nohumeral joint.
11 12 1
P
A
a.brachialis
2
10 v.brachialis
n.medianus
n.ulnaris
B
GI MC n.radialis
9 3
C
C n.musculo-cutaneus
Tr
Fig. 5.5
D
8 4 v.cephalica
IG
7 6 5
Fig. 5.6
The transosseous elements recommended for use at humeral level II are II,8; II,9; II,10; and II,11.
12
II,11
II,10
9 3
II,9
II,8
Fig. 5.7
Level III (Figs. 5.8, 5.9, and 5.10)

Safe positions: 2, 6, 7, 8, 9, 10, 11, 12
Reference positions: 9, 10, 11
10, and 11. The radial nerve lies close to the humerus in the projection of positions 4 and 5. The place-
ment of console transosseous elements at positions 10 and 11 should perforate only the anterolateral
cortical plate. The use of positions 9, 10, and 11 is optimal at this level because the transosseous ele-
ments will minimally impede soft-tissue displacement to the shoulder during motions of the gle-
nohumeral and (to a lesser degree) to the elbow joints.
12 1
11 P
A
a.brachialis
v.brachialis
10 n.medianus
2 n.ulnaris
MC2 n.cutaneus antebrachii medialis
n.cutaneus brachii medialis
v.basilica
GI C
9 3 B
n.radialis
Fig. 5.8 a.profunda brachii
C
n.musculo-cutaneus
4
8
IG
Tr13
7 6 5
Fig. 5.9
The transosseous elements recommended for use at humeral level III are III,9; III,10; and III,11.
12
III,11
III,10
9 3
III,9
Fig. 5.10
Level IV (Figs. 5.11, 5.12, and 5.13)

Contraindicated positions: 1, 3, 5, 6, 7
Safe positions: 2, 4, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 9, 11,
and 12. The close disposition of the radial nerve to the humeral bone in the projection of positions 5
and 6 suggests that in the projection of positions 11 and 12 console transosseous elements should be
used that perforate only the anterior cortical plate. The use of positions 8, 9, 10, and 11 is optimal at
this level because in this case the transosseous elements will minimally impede soft-tissue displace-
ment relative to the shoulder during motions of the adjacent joints.
11 12 P3 1
A
MC a.brachialis
2 v.brachialis; v.basilica
n.medianus; n.ulnaris
10
n.cutaneus antebrachii medialis
n.cutaneus brachii medialis
a.collateralis ulnaris superior
B
9 3 n.radialis
C a.profunda brachii
Fig. 5.11
GI14
C
n.musculo-cutaneus
8
4
IG
Tr
7 6 5
Fig. 5.12
The transosseous elements recommended for use at humeral level IV are IV,8; IV,9; IV,10; and IV,11.
IV,11 12
IV,10
9 3
IV,9
IV,8
Fig. 5.13
Level V (Figs. 5.14, 5.15, and 5.16)

Contraindicated positions: 1, 2, 3, 7, 8, 9
Safe positions: 4, 5, 6, 10, 11, 12
Reference positions: 4, 5, ,10
Comments. The use of positions 4, 10, and 11 is optimal at this level because the transosseous ele-
ments will minimally interfere with soft-tissue displacement relative to the shoulder during motions of
the adjacent joints.
11 12 1
P
A
a.brachialis
MC 2 v.brachialis; v.basilica
n.medianus; n.ulnaris
10
B
n.radialis
9 3 a.profunda brachii
GI C
C
n.musculo-cutaneus
Fig. 5.14
8
4
Tr13 IG
7
5
6
Fig. 5.15
The transosseous elements recommended for use at humeral level V are V,4; V,5; V,6; V,10; and V,4-10.
12
9 3
V,4−10
V,6
6
V,5
Fig. 5.16
Level VI (Figs. 5.17, 5.18, and 5.19)

Safe positions: 1, 4, 5, 6, 7, 8, 11
8. The use of positions 4, 7, and 8 is recommended at this level because the transosseous elements will
minimally impinge on the soft-tissue displacement relative to the shoulder during motions of the gle-
nohumeral and (to a lesser degree) elbow joints.
11 12 1 A
P a.brachialis
v.brachialis
n.medianus
v.basilica
2 n.cutaneus antebrachii medialis
MC
10
B
n.ulnaris
C2
9 3
C
Gl13 n.radialis
Fig. 5.17
a.profunda brachii
IG
8
Tr 4 D
n.musculo-cutaneus
7 6 5
Fig. 5.18
The transosseous elements recommended for use at humeral level VI are VI,4; VI,7; and VI,8.
12
9 3
VI,8
VI,4
VI,7 6
Fig. 5.19
Level VII (Figs. 5.20, 5.21, and 5.22)

Safe positions: 1, 3, 5, 6, 7, 8, 9
Comments. Only console transosseous elements can be used in the projection of positions 5, 6, and 8.
The use of positions 3, 8, and 9 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the shoulder during motions of the elbow joint.
11 12 1
A
P a.brachialis
MC
v.brachialis
v.basilica
2
10
Gl C
B
n.ulnaris
a.collateralis ulnaris
9 3 C
n.radialis
a.collateralis radialis
Fig. 5.20
D
n.musculo-cutaneus
8 Tr11
IG 4
7 6 5
Fig. 5.21
The transosseous elements recommended for use at humeral level VII are VII,3; VII,8; VII,9; and
VII,3-9.
12
VII,3−9
9 3
VII,8
Fig. 5.22
Level VIII (Figs. 5.23, 5.24, and 5.25)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
Comments. Positions 5, 6, and 7 are conditionally safe because the use of transosseous elements in
the olecranon will lead to a limitation of elbow-joint motion. Only console transosseous elements can
be used in the projection of position 8. The use of positions 3, 4, 8, and 9 is best at this level because
the transosseous elements will minimally impede the soft-tissue displacement relative to the shoulder
during motions of the elbow joint.
11 12 1
A
a.brachialis
v.v.brachialis
2
10 v.basilica
P5 MC3 n.mediamus
C3 a.collateralis ulnaris inferior
B
Gl12 n.ulnaris
9 3
IG8 C
n.radialis
Tr10 a.collateralis radialis
Fig. 5.23
D
8 4 n.musculo cutaneus
E
7 6 5
Fig. 5.24
The transosseous elements recommended for use at humeral level VIII are VIII,3; VIII,4; VIII,8;
VIII,9; and VIII,3-9.
12
VIII,3−9
9 3
VIII,8 VIII,4
Fig. 5.25
5.2 Ulna
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh
The figures show sections through the forearm at each of the

principal levels (I–VIII) relative to the ulna in the mid-posi-
tion (between pronation and supination, see pages 75–82), in
supination (see pages 83–90), and in pronation (see pages
91–98), respectively.
Our studies have demonstrated that physiological move-
ments in the radioulnar joints (forearm rotation) do not
exceed 12–140°: 65° ± 5° for supination and pronation.
Evaluation at level VIII showed that the ulna and radius are
placed strictly in the frontal plane. The noted position of the
radius relative to the ulna is represented in the diagrams.
We also determined that 77% of the positions are safe
positions for the insertion of transosseous elements. To pro-
vide functional rotation alone during fixation treatment, there
are only 26 RPs (30%), indicated by arrows. The positions
that provide only free flexion and extension in the elbow and
radiocarpal joints (33% of the positions) are indicated by a
thickened projection lines.
Wires inserted at six distal levels (the goal of which is to
change the spatial orientation of the bone fragments) must
later be changed to half-pins inserted in the orientation; these
are indicated by arrows.
On the forearm there are three Yin meridians with a cen-
trifugal direction of energy, those of the lung (P), heart (C),
and pericardium (MC). There are three Yang meridians with
a centripetal direction of energy: those of the bowel (GI),
triple energizer (TR), and intestine (IG). The meridians on
the forearm are represented by 27 active points.
In accordance with MUDEF, transosseous elements in the
radius are enclosed in parentheses. Note that (VIII,12-6)
VIII,12-6 and VIII,6-12(VIII,6-12) designate the same wire
inserted at level VIII through both bones, but in the first case
the wire is inserted from the radial side and in the second
from the ulnar side.
5.2.1 Ulna, Mid-Position
Level I (Ulna, mid-position) (Figs. 5.26, 5.27, and 5.28)

Contraindicated positions: 1, 3, 12
Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11
Reference positions: 4, 5, 6, 7, 8, 9, 10
Reference positions with safe rotation: 4, 5, 6, 7, 8, 9, 10
9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level. The transosseous elements will mini-
mally impinge on the soft tissues relative to the ulna during motions of the elbow and radioulnar joints.
11 12 1 A
a.radialis
v.radialis
a.ulnaris
GI11 P5 v.ulnaris
n.medianus
2 B
MC3 n.radialis
10
(r.superficialis et r.profundus)
C
n.ulnaris
C3
9 3
Fig. 5.26 Tr
IG8
8
4
7 6 5
Fig. 5.27
The transosseous elements recommended for use at ulnar level I are I,4; I,5; I,5(I,5); I,6; I,7; I,8; I,9;
I,10; and I,4-10.
12
1,9
9 3
1,4−10
1,8
1,6 1,5
1,7 6
Fig. 5.28
Level II (Ulna, mid-position) (Figs. 5.29, 5.30, and 5.31)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
and 9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the tran-
sosseous elements will minimally impinge on the soft tissues relative to the ulna during motions of the
elbow and radioulnar joint.
11 12 1 A
a.radialis
v.radialis
n.radialis (r.superficialis)
GI10
P
B
2 n.radialis (r.profundus)
10
MC C
n.ulnaris
Fig. 5.29 9 3 D
Tr n.medianus
C
a.ulnaris
v.ulnaris
IG
8
4
7 6 5
Fig. 5.30
The transosseous elements recommended for use at ulnar level II are II,4; II,5; II,6; II,6(II,6); II,7;
II,8; II,9; II,10; and II,4-10.
12
II,9
9 3
II,8
I,4−10
II,7 II,6 II,5
Fig. 5.31
Level III (Ulna, mid-position) (Figs. 5.32, 5.33, and 5.34)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 4, 5, 6, 7, 8
Comments. Only console transosseous elements can be used in the projection of positions 7 and 8.
The use of positions 4, 5, 6, 7, and 8 is optimal at this level because in this case the transosseous ele-
ments will minimally impinge on the soft-tissue displacement relative to the ulna during motions of the
elbow and radioulnar joint. The insertion of transosseous elements in the projection of positions 3, 9,
10, 11, and 12 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
n.radialis (r.superficials)
P
GI9
B
2
n.medianus
MC
10
Tr C
a.ulnaris
v.ulnaris
Fig. 5.32
D
9 3
C n.ulnaris
IG
8
7 6 5 4
Fig. 5.33
The transosseous elements recommended for use at the ulnar level III are III,3; III,4; III,5; III,6;
III,6(III,6); III,7; III,8; III,9; III,10; III,11; III,3-9; III,4-10; III,5-11; III,6-12(III,6-12); and (III,12)III,12.
12
(III,6−12)III,6−12
III,3−9
9 3
III,8
III,4−10
III,7 III,5−11
Fig. 5.34
Level IV (Ulna, mid-position) (Figs. 5.35, 5.36, and 5.37)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 5, 6, 7
9. The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous elements
will minimally impinge on the soft-tissue displacement relative to the ulna during motions of the
elbow and radioulnar joint, and during forearm rotation. The insertion of transosseous elements in the
projection of positions 4, 8, 9, and 10 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
P
GI
2 B
n.medianus
10
Tr C
MC a.ulnaris
v.ulnaris
Fig. 5.35 n.ulnaris
C
9 3
IG
4
7 6 5
Fig. 5.36
The transosseous elements recommended for use at ulnar level IV are IV,4; IV,5; IV,6; IV,6(IV,6);
IV,7; IV,8; IV,9; IV,10; and IV,4-10.
12
IV,9
9 3
IV,8
IV,4−10
IV,7 IV,6 IV,5
Fig. 5.37
Level V (Ulna, mid-position) (Figs. 5.38, 5.39, and 5.40)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 5, 6, 7, 8, 9, 10, 11, 12
The use of positions 5, 6, 7 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and radi-
oulnar joints and during forearm rotation. The insertion of transosseous elements in the projection of
positions 8, 9, 10, 11, and 12 will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
P6
GI7
2
B
10 MC n.medianus
C
Fig. 5.38 a.ulnaris
v.ulnaris
9 3
C n.ulnaris
IG7
4
7 6 5
Fig. 5.39
The transosseous elements recommended for use at ulnar level V are V,5; V,5-11; V,6; V,6-
12(V,6-12); V,6(V,6); V,7; V,8; V,9; V,10; V,11; and (V,12)V,12.
12
(V,12−6)V,12−6
V,10
V,9
9 3
V,8
V,7 V,5−11
6
Fig. 5.40
Level VI (Ulna, mid-position) (Figs. 5.41, 5.42, and 5.43)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11, 12
The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous elements
will minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and
radioulnar joint and during forearm rotation. The insertion of transosseous elements in the projection
of positions 8, 9, 10, 11, and 12 will provide free flexion and extension in the joints adjacent to the
forearm, but will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
GI
P 2
B
10
n.medianus
Tr6
Fig. 5.41 MC C
Tr7 a.ulnaris
9 3 v.ulnaris
n.ulnaris
C
IG
4
7 6 5
Fig. 5.42
The transosseous elements recommended for use at ulnar level VI are VI,5; VI,5-11; VI,6;
VI,6(VI,6); VI,6-12(VI,6-12); VI,7; VI,8; VI,9; VI,10; VI,11; and (VI,12)VI,12.
12
(VI,12−6)VI,12−6
VI,10
VI,9
9 3
VI,8
VI,7 VI,5−11
Fig. 5.43
Level VII (Ulna, mid-position) (Figs. 5.44, 5.45, and 5.46)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 6, 7
The use of positions 6 and 7 is optimal at this level because the transosseous wires will minimally
impede the soft-tissue displacement relative to the ulna with range of motion in the elbow, and to the
radioulnar joints during forearm rotation. The insertion of transosseous elements in the projection of
positions 5, 8, 9, 10, 11, and 12 will provide free flexion and extension in the radiocarpal joint, but will
limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
B
GI n.medianus
2
C
10 P
a.ulnaris
Tr5 v.ulnaris
n.ulnaris
Fig. 5.44 MC6
9 3
IG C4
8
4
7 6 5
Fig. 5.45
The transosseous elements recommended for use at ulnar level VII are VII,5; VII,5-11; VII,6;
VII,6-12(VII,6-12); VII,6(VII,6); VII,7; VII,8; VII,9; VII,10; VII,11; and (VII,12)VII,12.
12
(VII,12−6)VII,12−6
VII,10
VII,9
9 3
VII,8
VII,7 VII,5−11
6
Fig. 5.46
Level VIII (Ulna, mid-position) (Fig. 5.47, 5.48, and 5.49)

Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 6, 7, 8, 11, 12
Reference positions with safe rotation: 6
Comments. Only console transosseous elements can be used in the projection of positions 7, 8, 9
and 10. The use of position 6 is optimal at this level, as the transosseous elements will minimally inter-
fere with soft-tissue displacement relative to the ulna with elbow and radioulnar forearm rotation. The
insertion of transosseous elements in the projection of positions 7, 8 and 12 will allow unimpeded
flexion and extension at the radiocarpal joint, but will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
GI
P8 B
2 n.medianus
10
Tr4 MC C
a.ulnaris
v.ulnaris
9 3 n.ulnaris
Fig. 5.47
C6
IG5
8
4
7 6 5
Fig. 5.48
The transosseous elements recommended for use at ulnar level VIII are VIII,6; VIII,6-12(VIII,6-12);
VIII,6(VIII,6); VIII,7; VIII,8; and (VIII,12)VIII,12.
VII,11 12
(VIII,12−6)VIII,12−6
9 3
VIII,8
VIII,7
Fig. 5.49
5.2.2 Ulna, Supination
Level I (Ulna, supination) (Figs. 5.50, 5.51, and 5.52)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11
9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because the transosseous elements
will minimally impinge on the soft tissues relative to the ulna during motions of the elbow and the
radioulnar joint.
11 12 1
A
P5 a.radialis
v.v.radialis
a.ulnaris
v.v.ulnaris
MC3 n.medianus
10
2
B
GI11 n.radialis
C3
9 3 C
Fig. 5.50 n.ulnaris
Tr
IG8
8 4
7 6 5
Fig. 5.51
I,10; and I,4-10.
12
I,9
9 3
I,8 I,4-10
I,7 I,6 I,5

6
Fig. 5.52
Level II (Ulna, supination) (Figs. 5.53, 5.54, and 5.55)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
sosseous elements will minimally impinge on the soft tissues relative to the ulna during motions of the
elbow and the radioulnar joint.
11 12 1
A
a.radialis
P v.radialis
n.radialis
(r.superficialis)
MC
2
10 GI10 B
C
n.radialis (r.profundus)
C
n.ulnaris
Fig. 5.53 9 3
Tr
D
n.medianus
IG a.ulnaris
v.ulnaris
8
4
7 6 5
Fig. 5.54
II,8; II,9; II,10; and II,4-10.
12
II,9
9 3
II,8 II,4−10
II,7 II,6 II,5
Fig. 5.55
Level III (Ulna, supination) (Figs. 5.56, 5.57, and 5.58)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
and 8. The use of positions 4, 5, 6, 7, and 8 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the ulna during motions of the
elbow and the radioulnar joint. The insertion of transosseous elements in the projection of positions 3,
9, and 10 will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
P n.radialis
MC (r.superficialis)
B
2
10 n.medianus
C C
a.ulnaris
v.ulnaris
GI9
Fig. 5.56 9 3
D
Tr n.ulnaris
IG
8
4
7 6 5
Fig. 5.57
The transosseous elements recommended for use at ulnar level III are III,3; III,4; III,5; III,5(III,5);
III,6; III,7; III,8; III,9; III,10; III,3-9; and III,4-10.
12
III,3−9
9 3
III,8 III,4−10
III,7 III,6 III,5

6
Fig. 5.58
Level IV (Ulna, supination) (Figs. 5.59, 5.60, and 5.61)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
and 8. The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous ele-
ments will minimally impede soft-tissue displacement relative to the ulna during motions of the elbow
and the radioulnar joint. The insertion of transosseous elements in the projection of positions 3, 4, 8,
9, and 10 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
n.radialis
(r.superficialis)
P
MC B
2 n.medianus
10
C
C
GI
a.ulnaris
v.ulnaris
Fig. 5.59 n.ulnaris
9 3
Tr IG
8 4
7 6 5
Fig. 5.60
The transosseous elements recommended for use at ulnar level IV are IV,3; IV,4; IV,5; IV,5(IV,5);
IV,6; IV,7; IV,8; IV,9; IV,10; IV,3-9; and IV,4-10.
12
IV,10−4
IV,9−3
9 3
IV,8
IV,5
IV,7 IV,6
6
Fig. 5.61
Level V (Ulna, supination) (Figs. 5.62, 5.63, and 5.64)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
and 8. The use of position 6 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and the
radioulnar joint and during forearm rotation. The insertion of transosseous elements in the projection
of positions 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
but will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
n.radialis (r.superficials)
MC
10 P6 B
2 n.medianus
C
C
GI7 a.ulnaris
Fig. 5.62
v.ulnaris
9 3 n.ulnaris
IG7
Tr
4
8
7 6 5
Fig. 5.63
The transosseous elements recommended for use at ulnar level V are V,3; V,4; V,4(V,4); V,5; V,6;
V,7; V,8; V,9; (V,10)V,10; V,3-9; and V,4-10(V,4-10).
12
(V,10−4)V,10−4
V,9−3
9 3
V,8
V,5
V,7 V,6
6
Fig. 5.64
Level VI (Ulna, supination) (Figs. 5.65, 5.66, and 5.67)

Safe positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
7. The use of position 6 is optimal at this level because in this case the transosseous elements will mini-
mally impede soft-tissue displacement relative to the ulna during motions of the elbow and the radi-
oulnar joint and during forearm rotation. The insertion of transosseous elements in the projection of
positions 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
11 12 1
A
a.radialis
v.radialis
10 MC
P 2 B
n.medianus
C
GI C
Fig. 5.65 a.ulnaris
9 3 v.ulnaris
IG n.ulnaris
Tr7
Tr6
4
8
7 6 5
Fig. 5.66
The transosseous elements recommended for use at ulnar level VI are VI,3; VI,4; VI,4(VI,4); VI,5;
VI,6; VI,7; VI,8; VI,9; (VI,10)VI,10; VI,3-9; and VI,4-10(VI,4-10).
12
(VI,10−4)VI,10−4
VI,3−9
9 3
VI,8
VI,5
VI,7
VI,6
6
Fig. 5.67
Level VII (Ulna, supination) (Figs. 5.68, 5.69, and 5.70)

Safe positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
Reference positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
positions 2, 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
11 12 1 A
a.radialis
v.radialis
B
10
medianus
P MC6
2
C
C4 a.ulnaris
GI v.ulnaris
n.ulnaris
9 3
IG
Fig. 5.68 Tr5
8
7 6 5
Fig. 5.69
The transosseous elements recommended for use at ulnar level VII are VII,2; VII,3; VII,4; VII,4(VII,4);
VII,5; VII,6; VII,7; VII,8; VII,9; (VII,10)VII,10; VII,2-8; VII,3-9; and VII,4-10(VII,4-10).
12
(VII,10−4)VII,10−4
VII,9−3
9 3
VII,8−2
VII,7 VII,5
VII,6
6
Fig. 5.70
Level VIII (Ulna, supination) (Figs. 5.71, 5.72, and 5.73)

Safe positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
positions 2, 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
11 12 1
A
a.radialis
v.radialis
10
P6 B
MC 2
C n.medianus
C
Fig. 5.71 GI7 a.ulnaris
9 3 v.ulnaris
IG7 n.ulnaris
Tr
8
7 6 5
Fig. 5.72
The transosseous elements recommended for use at ulnar level VIII are VIII,2; VIII,3;
VIII,4; VIII,4(VIII,4); VIII,5; VIII,6; VIII,7; VIII,8; VIII,9; (VIII,10)VIII,10; VIII,2-8; VIII,3-9; and
VIII,4-10(VIII,4-10).
12
VIII,9−3
9 3
VIII,8−2
VIII,5
VIII,7
VIII,6
6
Fig. 5.73
5.2.3 Ulna, Pronation
Level I (Ulna, pronation) (Figs. 5.74, 5.75, and 5.76)

Safe positions: 2,4,5, 6, 7, 8, 9, 10, 11
9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the tran-
sosseous elements will minimally impede soft-tissue displacement relative to the ulna during motions
of the elbow and the radioulnar joint.
11 12 1
A
a.radialis
P5 v.v.radialis
GI11
a.ulnaris
v.v.ulnaris
n.medianus
2
10
MC3
B
n.radialis
9 3
Fig. 5.74 Tr C
C3 n.ulnaris
IG8
8
7 6 5 4
Fig. 5.75
I,10; and I,4-10.
12
I,9
9 3
I,8
I,4−10
I,7 I,5
I,6
6
Fig. 5.76
Level II (Ulna, pronation) (Figs. 5.77, 5.78, and 5.79)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
sosseous elements will minimally impede soft-tissue displacement relative to the ulna during motions
of the elbow and the radioulnar joint.
11 12 1
A
GI10 a.radialis
P v.radialis
n.radialis (superficialis)
2 B
a.radialis (r.profundus)
10 MC
C
n.ulnaris
Fig. 5.77 9 3
Tr C D
n.medianus
a.ulnaris
v.ulnaris
8
IG
7 6 5 4
Fig. 5.78
II,8; II,9; II,10; and II,4-10.
12
II,9
9 3
II,8
II,4−10
II,7 II,6
II,5
6
Fig. 5.79
Level III (Ulna, pronation) (Figs. 5.80, 5.81, and 5.82)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 4, 5, 6, 7, 8, 9
9. The use of positions 4, 5, 6, 7, 8, and 9 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the ulna during motions of the
elbow and the radioulnar joint. The insertion of transosseous elements in the projection of position 10
will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
GI9 n.radialis (r.superficialis)
B
2
n.medianus
P C
10
a.ulnaris
v.ulnaris
Fig. 5.80
MC D
9 3 n.ulnaris
Tr
8 IG
C
7 6 5 4
Fig. 5.81
The transosseous elements recommended for use at ulnar level III are III,4; III,5; III,6; III,7;
III,7(III,7); III,8; III,9; III,10; and III,4-10.
12
9 3
III,8
III,4−10
III,7 III,6 III,5
6
Fig. 5.82
Level IV (Ulna, pronation) (Figs. 5.83, 5.84, and 5.85)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 7, 8 and
9. The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous elements
will minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and
the radiocarpal joints and during forearm rotation. The insertion of transosseous elements in the pro-
jection of positions 4, 8, 9, 10, and 11 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
GI
2 B
n.medianus
10 C
P
a.ulnaris
v.ulnaris
Tr
n.ulnaris
Fig. 5.83 9 3
MC
IG
8 C
7 6 5 4
Fig. 5.84
The transosseous elements recommended for use at ulnar level IV are IV,4; IV,5; IV,6; IV,7;
IV,7(IV,7); IV,8; IV,9; IV,10; IV,11; IV,4-10; and IV,5-11.
12
IV,10−4
IV,9
9 3
IV,8
IV,7
IV,6 IV,5−11
6
Fig. 5.85
Level V (Ulna, pronation) (Figs. 5.86, 5.87, and 5.88)

Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
10. The use of position 6 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and radio-
carpal joints and during forearm rotation. The insertion of transosseous elements in the projection of
positions 1, 5, 7, 8, 9, and 10 will limit forearm rotation.
11 12 1 A
a.radialis,
v.radialis,
GI7 n.radialis
(r.superficialis)
2
P6 B
10 n.medianus
Tr
C
a.ulnaris
Fig. 5.86 v.ulnaris
9 3 n.ulnaris
MC
IG7
8 C
4
7 6 5
Fig. 5.87
The transosseous elements recommended for use at ulnar level V are (V,1)V,1; V,5; V,6; V,7; V,7-
1(V,7-1); V,7(V,7); V,8; V,9; and V,10.
12
(V,1−7)V,1−7
V,10
V,9
9 3
V,8
V,6 V,5
Fig. 5.88
Level VI (Ulna, pronation) (Figs. 5.89, 5.90, and 5.91)

Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
positions 1, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints but
11 12 1 A
a.radialis
v.radialis
Tr6
2
Tr7 GI B
n.medianus
10
P C
a.ulnaris
v.ulnaris
Fig. 5.89 9 3 n.ulnaris
IG
MC
C
8
4
7 6 5
Fig. 5.90
The transosseous elements recommended for use at ulnar level VI are (VI,1)VI,1; VI,5; VI,6; VI,7;
VI,7-1(VI,7-1); VI,7(VI,7); VI,8; VI,9; and VI,10.
12
(VI,1−7)VI,1−7
VI,10
VI,9
9 3
VI,8
VI,6 VI,5
Fig. 5.91
Level VII (Ulna, pronation) (Figs. 5.92, 5.93, and 5.94)

Safe positions: 1, 2, 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 9 and
positions 2, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints but
11 12 1 A
a.radialis
v.radialis
2 B
Tr5
GI n.medianus
10
C
P a.ulnaris
v.ulnaris
n.ulnaris
9 3
Fig. 5.92
MC6
IG
C
8
7 6 5
Fig. 5.93
The transosseous elements recommended for use at ulnar level VII are (VII,2)VII,2; VII,5; VII,6;
VII,7; VII,8; VII,8-2(VII,8-2); VII,8(VII,8); VII,9; and VII,10.
12 (VII,1−7)VII,1−7
VII,10
VII,9
9 3
VII,8
VII,6 VII,5
Fig. 5.94
Level VIII (Ulna, pronation) (Figs. 5.95, 5.96, and 5.97)

Safe positions: 1, 2, 6, 7, 8, 9, 10, 11, 12
Reference positions: 2, 6, 7, 8, 9, 10
and 11. The use of position 6 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and the
radiocarpal joints and during forearm rotation. The insertion of transosseous elements in the projection
of positions 2, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints but
11 12 1 A
a.radialis
v.radialis
2 n.radialis (r.superficialis)
Tr4 GI B
10 n.medianus
C
a.ulnaris
v.ulnaris
9 3
P8 n.ulnaris
Fig. 5.95 IG5
MC
C6
8
7 6 5
Fig. 5.96
The transosseous elements recommended for use at ulnar level VIII are (VIII,2)VIII,2; VIII,6;
VIII,7; VIII,8; VIII,8-2(VIII,8-2); VIII,8(VIII,8); VIII,9; and VIII,10.
12
VIII,10
VIII,9
9 3
VIII,6
VIII,7
Fig. 5.97
5.3 Radius and pericardium (MC). There are three Yang meridians with a
centripetal direction of energy, those of the large bowel (GI),
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh the triple energizer (TR), and the small bowel (IG). The
meridians on the forearm are represented by 27 active points.
The figures show sections through the forearm at each of the According to MUDEF, transosseous elements applied to
principal levels (I–VIII) relative to the radius in the mid- the radius are enclosed in parentheses. Note that (VIII,12-6)
position (between pronation and supination, see pages (100– VIII,12-6 andVIII,6-12(VIII,6-12) designate the same wire
107), in supination (see pages 108–115), and in pronation inserted at level VIII through both bones, but in the first case
(see pages 116–123). the wire is inserted from the radial side and in second it is
On the anatomic functional cross-sections of the forearm, inserted from the ulnar side.
the arrows indicate only the safe positions where, following
K-wire or half-pin insertion at that location, complete resto-
ration of rotational forearm function during the fixation
period can be expected. Thickened projection lines indicate
that the insertion of transosseous elements in the designated
locations will allow only the early restoration of flexion and
extension of the elbow and the wrist joint.
Of the 96 positions, 67 (68%) are safe positions as defined
according to MUDEF. Studies of soft-tissue movements rela-
tive to the radius during supination and pronation of the fore-
arm have demonstrated that the safe application of external
fixation elements to the radius is impossible without disturb-
ing rotational function. The insertion of transosseous ele-
ments in this context is possible only at levels VII and VIII
in the projections of 8 positions (8% of possible positions).
These are indicated by arrows. However, there are positions
that allow partial restoration of rotational function during the
fixation period (Table 5.1).
The RPs that allow only flexion and extension of the
elbow and radiocarpal joints and partial rotational function
(47% of total positions) are indicated by thickened projection
lines.
On the forearm there are three Yin meridians with a cen-
trifugal direction of energy, those of the lung (P), heart (C),
Table 5.1 Radius bone positions that allow forearm rotation

Positions partial rotation
Positions for rotation not except: supination Positions for rotation except: supination 30˚, Positions that allow complete
Level 10˚, pronation 10˚ pronation 25˚ rotation
I 8 – –
II – 8 –
III 9, 10, 11, 12 1, 8 –
IV 8, 9, 10 1, 11, 12 –
V 8, 9 10, 11, 12 –
VI – 1, 8, 9, 10, 11, 12 –
VII – 10 1, 11, 12
VIII – 10, 11 1, 12
5.3.1 Radius, Mid-Position
Level I (Radius, mid-position) (Figs. 5.98, 5.99, and 5.100)

Safe positions: 5, 6, 7, 8, 9, 10, 11
9 and 10. The use of positions 5, 6, 7, and 8 is best at this level because the transosseous elements will
minimally impede soft-tissue displacement relative to the radius during elbow range of motion.
11 12 1
A
a.radialis
v.radialis
GI11 P5 2 a.ulnaris
v.ulnaris
10 n.medianus
B
MC3 n.radialis
(superficialis et r.profundus)
C
9 3
n.ulnaris
C3
Fig. 5.98 Tr
8
IG8
4
7 6 5
Fig. 5.99
The transosseous elements recommended for use at radial level I are I,5(I,5); (I,6); (I,7); and (I,8).
12
9 3
(I,8)
(I,6) I,5(1,5)
(I,7)
Fig. 5.100
Level II (Radius, mid-position) (Figs. 5.101, 5.102, and 5.103)

Contraindicated positions: 1, 2, 3, 4, 11, 12
Safe positions: 5, 6, 7, 8, 9, 10
8, 9, and 10. The close approximation of the radial nerve to the radius is demonstrated in the projection
of positions 11 and 12. The use of console transosseous elements in the projection of positions 5 and
6 is safe if the elements perforate only the posterior cortical plate. The use of positions 5, 6, 7, and 8 is
optimal at this level because the elements will only minimally impinge on the soft-tissue displacement
relative to the radius during elbow range of motion.
11 12 1 A
a.radialis
v.radialis
GI10
P
10 B
C
9 3 n.ulnaris
MC
Fig. 5.101 D
n.medianus
8 Tr a.ulnaris
C v.ulnaris
4
IG
7 6 5
Fig. 5.102
The transosseous elements recommended for use at radial level II are (II,5); II,6(II,6); (II,7); and (II,8).
12
9 3
(II,8)
(II,7)
(II,5)
II,6(II,6)
6
Fig. 5.103
Level III (Radius, mid-position) (Figs. 5.104, 5.105, and 5.106)

Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used at positions 8, 9, and 10. The use of
positions 1, 5, 6, 7, 8, 9, 10, 11, and 12 is optimal as the transosseous elements will not inhibit soft-
tissue displacements of the radius during elbow range of motion.
11 12 1 A
a.radialis
2 v.radialis
GI9 P
10
B
n.medianus
MC
C
9 3
a.ulnaris
Tr v.ulnaris
D
C
8 n.ulnaris
Fig. 5.104
4
IG
7 6 5
Fig. 5.105
The transosseous elements recommended for use at radial level III are (III,1); (III,1-7); (III,5);
(III,5-11); III,6(III,6); III,6-12(III,6-12); (III,7); (III,8); (III,9); (III,10); (III,11); and (III,12).
(III,11-5) 12 (III,1-7)
(III,10)
(III,9)
9 3
(III,8)
III,6-12(III,6-12)
6
Fig. 5.106
Level IV (Radius, mid-position) (Figs. 5.107, 5.108, and 5.109)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 1, 6, 7, 8, 9, 10, 11, and 12 is optimal at this level, as the transosseous ele-
ments will not inhibit soft-tissue movement with range of motion of the elbow and radiocarpal joint.
11 12 1 A
2
a.radialis
v.radialis
P
GI
B
n.medianus
9 3
MC C
Tr
a.ulnaris
v.ulnaris
C n.ulnaris
8
Fig. 5.107 4
IG
7 6 5
Fig. 5.108
The transosseous elements recommended for use at radial level IV are (IV,1); (IV,1-7); IV,6(IV,6);
IV,6-12(IV,6-12); (IV,7); (IV,8); (IV,9); (IV,10); (IV,11); (IV,12); and (IV,12)IV,12.
(IV,11) 12 (IV,1−7)
(IV,10)
(IV,9)
9 3
(IV,8)
IV,6−12(IV,6−12)
Fig. 5.109
Level V (Radius, mid-position) (Figs. 5.110, 5.111, and 5.112)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 1, 6, 7, 8, 9, 10, 11, and 12 is optimal at this level, as the transosseous
elements will not inhibit soft-tissue movement of the radius with range of motion in the elbow and
radiocarpal joint.
11 12 1 A
2 a.radialis
v.radialis
10
GI7 P6
B
n.medianus
9 3
Tr
MC C
a.ulnaris
v.ulnaris
8 n.ulnaris
C 4
Fig. 5.110
IG7
7 6 5
Fig. 5.111
The transosseous elements recommended for use at radial level V are (V,1); (V,l-7); V,6(V,6);
V,6-12(V,6-12); (V,7); (V,8); (V,9); (V,10); (V,11); (V,12); and (V,12)V,12.
(V,11) 12
(V,10)
(V,9)
9 3
(V,8)
(V,7−1)
V,6−12(V,6−12)
Fig. 5.112
Level VI (Radius, mid-position) (Figs. 5.113, 5.114, and 5.115)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 1, 6, 7, 8, 9, 10, 11, and 12 is optimal at this level, as the transosseous
elements will not impede soft-tissue movement of the radius with range of motion in the elbow and
radiocarpal joint.
11 12 1
2
A
10 a.radialis
v.radialis
GI
P
B
9 3 n.medianus
Tr6
C
a.ulnaris
v.ulnaris
Tr7 n.ulnaris
8 MC
Fig. 5.113 4
C
IG
7 6 5
Fig. 5.114
The transosseous elements recommended for use at radial level V are (VI,1); (VI,l-7); VI,6(VI,6);
VI,6-12(VI,6-12); (VI,7); (VI,8); (VI,9); (VI,10); (VI,11); (VI,12); and (VI,12)VI,12.
(VI,11) 12 (VI,1−7)
(VI,10)
(VI,9)
9 3
(VI,8)
VI,6−12(VI,6−12)
6
Fig. 5.115
Level VII (Radius, mid-position) (Figs. 5.116, 5.117, and 5.118)

Safe positions: 1, 4, 6, 7, 8, 9, 10, 11, 12
11. The use of positions 11 and 12 is optimal at this level, as the transosseous elements will not impede
soft-tissue movement relative to the radius with range of motion in the elbow and radiocarpal joint.
The insertion of transosseous elements in the projection of positions 1, 6, 7, and 10 will, however, limit
forearm rotation.
11 12 1
2 A
10 a.radialis
v.radialis
GI B
n.medianus
P
9 3 C
Tr5 a.ulnaris
v.ulnaris
n.ulnaris
Fig. 5.116 MC6
8
4
IG C4
7 6 5
Fig. 5.117
The transosseous elements recommended for use at radial level VII are (VII,1); (VII,1-7);
VII,6(VII,6); VII,6-12(VII,6-12); (VII,7); (VII,10); (VII,11); (VII,12); and (VII,12)VII,12.
(VII,11) 12 (VII,1−7)
(VII,10)
9 3
VII,6−12(VII,6−12)
6
Fig. 5.118
Level VIII (Radius, mid-position) (Figs. 5.119, 5.120, and 5.121)

Safe positions: 1, 4, 6, 7, 8, 9, 10, 11, 12
Safe positions: 1, 6, 10, 11, 12
11. The use of positions 1 and 12 is optimal at this level, as the transosseous elements will not impede
soft-tissue movements relative to the radius with range of motion in the elbow and radiocarpal joint. The
insertion of transosseous elements in the projection of positions 6, 10, and 11 will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
2
10
B
GI n.medianus
P8
C
a.ulnaris
9 3 v.ulnaris
Tr4 MC n.ulnaris
Fig. 5.119
8 C6
4
IG5
7 6 5
Fig. 5.120
The transosseous elements recommended for use at radial level VI are (VIII,1); VIII,6(VIII,6);
VIII,6-12(VIII,6-12); (VIII,10); (VIII,11); (VIII,12); and (VIII,12)VIII,12.
(VIII,11) 12 (VIII,1−7)
(VIII,10)
9 3
VIII,6−12(VIII,6−12)
6
Fig. 5.121
5.3.2 Radius, Supination
Level I (Radius, supination) (Figs. 5.122, 5.123, and 5.124)

Forbidden positions: 1, 2, 3, 4
Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The close disposition of the radial nerve to the radial bone in the projection of position 1 rec-
ommends that in the projection of position 7 console transosseous elements are used that perforate
only the posterolateral cortical plate. The use of positions 5, 6, 7, 8, and 9 is optimal at this level
because in this case the transosseous elements will minimally impede soft-tissue displacement relative
to the radius during motions of the elbow.
11 12 1
P5 A
2 a.radialis
10 v.radialis
a.ulnaris
MC3 v.ulnaris
n.medianus
9 3
B
GI11 C3 n.radialis
(r.superficialis et r.profoundus)
Fig. 5.122
8 C
Tr 4 n.ulnaris
IG8
7 6 5
Fig. 5.123
The transosseous elements recommended for use at radial level I are I,5(I,5); (I,6); (I,7); (I,8) and (I,9).
12
(I,9)
9 3
(I,8)
(I,7) I,5(I,5)
(I,6)
Fig. 5.124
Level II (Radius, supination) (Figs. 5.125, 5.126, and 5.127)

Forbidden positions: 1, 2, 3, 4, 12
Safe positions: 5, 6, 7, 8, 9, 10, 11
9, and 10. The close disposition of the radial nerve to the radial bone in the projection of position 12
recommends that in the projection of position 6 console transosseous elements should be used that
perforate only the posterior cortical plate The use of positions 5, 6, 7, 8, and 9 is optimal at this level
because in this case the transosseous elements will minimally impede soft-tissue displacement relative
to the radius during motions of the elbow.
11 12 1
A
a.radialis
P 2 v.radialis
10 MC
B
GI10 C
C
9 3 n.ulnaris
D
Fig. 5.125 n.medianus
a.ulnaris
v.ulnaris
8
Tr
4
IG
7 6 5
Fig. 5.126
The transosseous elements recommended for use at radial level II are II,5(II,5); (II,6); (II,7); (II,8);
and (II,9).
12
(II,9)
9 3
(II,8)
(II,7) II,5(II,5)
(II,6)
Fig. 5.127
Level III (Radius, supination) (Figs. 5.128, 5.129, and 5.130)

Safe positions: 4, 5, 6, 7, 8, 9, 10
8, and 9. The use of positions 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the tran-
sosseous elements will minimally impede soft-tissue displacement relative to the radius during motions
of the elbow.
11 12 1 A
a.radialis
2 v.radialis
P
MC
10 B
n.medianus
C
a.ulnaris
9 3 v.ulnaris
C
D
n.ulnaris
8 GI9
Fig. 5.128
Tr
IG 4
7 6 5
Fig. 5.129
The transosseous elements recommended for use at radial level III are III,5(III,5); (III,6); (III,7);
(III,8), (III,9); and (III,10).
12
(III,9)
9 3
(III,8)
III,5(III,5)
(III,7) (III,6)
6
Fig. 5.130
Level IV (Radius, supination) (Figs. 5.131, 5.132, and 5.133)

Forbidden positions: 1, 2, 3
Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
9. The use of positions 4, 5, 6, 7, 8, 9, 10, and 11 is optimal at this level because in this case the tran-
of the elbow.
11 12 1 A
2 a.radialis
v.radialis
P
MC B
10 n.medianus
C
C a.ulnaris
9 3 v.ulnaris
GI n.ulnaris
8
Fig. 5.131
Tr IG
7 6 5
Fig. 5.132
The transosseous elements recommended for use at radial level IV are (IV,4); (IV,5); (IV,6); (IV,7);
(IV,8); (IV,9); (IV,10); (IV,11); (IV,10-4)IV,10-4; and (IV,11-5).
12
(IV,9)
9 3
IV,4−10(IV,4−10)
(IV,8)
(IV,5−11)
(IV,6)
(IV,7)
6
Fig. 5.133
Level V (Radius, supination) (Figs. 5.134, 5.135, and 5.136)

Safe positions: 1, 4, 5, 6, 7, 8, 9, 10
8, and 9. The use of positions 1, 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radius during
motions of the elbow and the radiocarpal joint.
12
(V,1−7)
9 3
(V,9)
Fig. 5.134 V,4−10(V,4−10)

(V,8)
(V,5)
(V,6)
Fig. 5.135
The transosseous elements recommended for use at radial level V are (V,l); V,4(V,4); (V,5); (V,6);
(V,7); (V,8); (V,9); (V,10); (V,10)V,10; (V,1-7); and (V,10-4)V,10-4.
11 12 1
A
2 a.radialis
v.radialis
MC
10 B
n.medianus
P6
C C
9 3 a.ulnaris
GI7 v.ulnaris
n.ulnaris
IG7
8
Tr
7 6 5
Fig. 5.136
Level VI (Radius, supination) (Figs. 5.137, 5.138, and 5.139)

Safe positions: 4, 5, 6, 7, 8, 9, 10
8, and 9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radius during
motions of the radiocarpal joint.
11 12 1 A
2 a.radialis
v.radialis
B
10 P MC n.medianus
C C
a.ulnaris
9 3
v.ulnaris
GI n.ulnaris
8 IG
Fig. 5.137
Tr7 Tr6
7 6 5
Fig. 5.138
The transosseous elements recommended for use at radial level VI are VI,4(VI,4); (VI,5); (VI,6);
(VI,7); (VI,8); (VI,9); (VI,10); (VI,10)VI,10; and VI,4-10(VI,4-10).
12
(VI,9)
9 3
(VI,8)
VI,4−10(VI,4−10)
(VI,7)
(VI,5)
(VI,6)
Fig. 5.139
Level VII (Radius, supination) (Figs. 5.140, 5.141, and 5.142)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
and 9. The use of position 7, 8, 9, 10, and 11 is optimal at this level because in this case the tran-
of the radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of
positions 4 and 5 will limit forearm rotation.
12 1
11
A
2 a.radialis
v.radialis
10 B
P MC6
n.medianus
C4
GI C
9 3
a.ulnaris
Fig. 5.140 v.ulnaris
n.ulnaris
IG
8 Tr5
7 6 5
Fig. 5.141
The transosseous elements recommended for use at radial level VII are VII,4(VII,4); (VII,5);
(VII,7); (VII,8); (VII,9); (VII,10); (VII,10)VII,10; (VII,11); (VII,10-4)VII,10-4; and (VII,5-11).
12
(VII,9)
9 3
(VII,8)
VII,4−10(VII,4−10)
(VII,7)
(VII,5−11)
Fig. 5.142
Level VIII (Radius, supination) (Figs. 5.143, 5.144, and 5.145)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
and 9. The use of position 8, 9, and 10 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the radius during motions of the
radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of positions
4 and 5 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
v.radialis (r.superficialis)
2
B
n.medianus
10
P6 C
MC
a.ulnaris
C v.ulnaris
n.ulnaris
9 3
Fig. 5.143 GI7
IG7
8 Tr
7 6 5
Fig. 5.144
The transosseous elements recommended for use at radial level VIII are VIII,4(VIII,4); (VIII,5);
(VIII,8); (VIII,9); (VIII,10); (VIII,10)VIII,10; and (VIII,10-4)VIII,10-4.
12
VIII,10−4(VIII,10−4)
(VIII,9)
9 3
(VIII,8)
(VIII,5)
Fig. 5.145
5.3.3 Radius, Pronation
Level I (Radius, pronation) (Figs. 5.146, 5.147, and 5.148)

Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The close disposition of the radial nerve to the radial bone in position 1 recommends that in
the projection of position 7 console transosseous elements should be used that perforate only the pos-
terolateral cortical plate. The use of positions 5, 7, 8, and 9 is optimal at this level because in this case
the transosseous elements will minimally impede soft-tissue displacement relative to the radial bone
during motions of the elbow.
11 12 1 a
a.radialis
v.v.radialis
2 a.ulnaris
P5 v.v.ulnaris
GI11
n.medianus
b
10 n. radialis
(r.superficialis et r.profoundus)
MC3
c
9 3 n. ulnaris
Fig. 5.146
8 Tr
C3
IG8 4
7 6 5
Fig. 5.147
The transosseous elements recommended for use at radial level I are I,5(I,5); (I,6); (I,7); (I,8); and (I,9).
12
(I,9)
9 3
(I,8)
(I,7)
(I,6) I,5(I,5)
Fig. 5.148
Level II (Radius, pronation) (Figs. 5.149, 5.150, and 5.151)

Forbidden positions: 1, 2, 3, 4, 11, 12
Safe positions: 5, 6, 7, 8, 9, 10
8, 9, and 10. The close disposition of the radial nerve to the radial bone in the projection of positions
11 and 12 recommends that in the projection of positions 5 and 6 console transosseous elements should
be used that perforate only the posterior cortical plate. The use of positions 5, 6, 7, 8, and 9 is optimal
at this level because in this case the transosseous elements will minimally impede soft-tissue displace-
ment relative to the radial bone during motions of the elbow.
11 12 1 A
a.radialis
GI10 v.radialis
P 2
B
10 n.radialis (r.profundus)
C
MC
n.ulnaris
9 3
D
Fig. 5.149 n.medianus
a.ulnaris
v.ulnaris
8
Tr
C
4
IG
7 6 5
Fig. 5.150
The transosseous elements recommended for use at radial level I are (II,5); II,6(II,6); (II,7); (II,8);
and (II,9).
12
(II,9)
9 3
(II,8)
(II,7)
II,6(II,6) (II,5)
Fig. 5.151
Level III (Radius, pronation) (Figs. 5.152, 5.153, and 5.154)

Safe positions: 6, 7, 8, 9, 10, 11, 12
10, and 11. The use of positions 6, 7, 8, and 9 is optimal at this level because in this case the tran-
sosseous elements will minimally impede soft-tissue displacement relative to the radial bone during
motions of the elbow.
11 12 1 A
a.radialis
v.radialis
GI9
10 B
n.medianus
P C
a.ulnaris
9 3 v.ulnaris
MC D
n.ulnaris
Fig. 5.152
8 Tr
IG C
7 6 5
Fig. 5.153
The transosseous elements recommended for use at radial level I are (III,6); III,7 (III,7); (III,8); and
(III,9).
12
(III,9)
9 3
(III,8)
III,7(III,7)
(III,6)
6
Fig. 5.154
Level IV (Radius, pronation) (Figs. 5.155, 5.156, and 5.157)

Safe positions: 6, 7, 8, 9, 10, 11, 12
9, 10, and 11. The use of positions 6, 7, 8, 9, and 10 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radial bone dur-
ing motions of the elbow.
11 12 1 A
2 a.radialis
v.radialis
10
GI
B
n.medianus
9 3 C
P a.ulnaris
v.ulnaris
n.ulnaris
Tr
Fig. 5.155 8
4
MC
IG
C
7 6 5
Fig. 5.156
The transosseous elements recommended for use at radial level IV are (IV,6); IV,7 (IV,7); (IV,8);
(IV,9); and (IV,10).
12
(IV,10)
(IV,9)
9 3
(IV,8)
IV,7(IV,7)
(IV,6)
Fig. 5.157
Level V (Radius, pronation) (Figs. 5.158, 5.159, and 5.160)

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, 3, 7, 8, 9, 10, 11, and 12 is optimal at this level because in this case
the transosseous elements will minimally impede soft-tissue displacement relative to the radial bone
during motions of the elbow and the radiocarpal joint.
11 12 1 A
a.radialis
10 2 v.radialis
GI7 n.radialis (r.superficialis)
B
P6 n.medianus
9 3
C
Tr a.ulnaris
v.ulnaris
n.ulnaris
Fig. 5.158 8 4
MC
IG7
C
7 6 5
Fig. 5.159
The transosseous elements recommended for use at radial level V are (V,1); (V,1)V,1; (V,1-7) V,1-7;
(V,2); (V,2-8); (V,3); (V,3-9); V,7(V,7); (V,8); (V,9); (V,10); (V,11); and (V,12).
(V,11) 12
(V,10) (V,12) (V,2−8)
(V,3−9)
9 3
V,7−1(V,7−1)
6
Fig. 5.160
Level VI (Radius, pronation) (Figs. 5.161, 5.162, and 5.163)

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, 3, 7, 8, 9, 10, and 11 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radial bone dur-
ing motions of the radiocarpal joint.
11 12 1 A
a.radialis
10 2 v.radialis
Tr6
GI B
Tr7 n.medianus
9 3 C
P
a.ulnaris
v.ulnaris
n.ulnaris
4
Fig. 5.161 8 MC
IG
7 6 5
Fig. 5.162
The transosseous elements recommended for use at radial level VI are (VI,1); (VI,1)VI,1; (VI,l-7)
VI,l-7; (VI,2); (VI,2-8); (VI,3); (VI,3-9); VI,7(VI,7); (VI,8): (VI,9); (VI,10); and (VI,11).
(VI,11) 12
(VI,10) (VI,2−8)
(VI,3−9)
9 3
VI,7−1(VI,7−1)
6
Fig. 5.163
Level VII (Radius, pronation) (Figs. 5.164, 5.165, and 5.166)

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, and 3 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the radial bone during motions of
the radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of posi-
tions 8, 9, 10 will limit forearm rotation.
11 12 1
A
10
2 a.radialis
v.radialis
Tr5
B
GI n.medianus
9 3
C
P a.ulnaris
v.ulnaris
n.ulnaris
Fig. 5.164
4
8
IG
MC6
C
7 6 5
Fig. 5.165
The transosseous elements recommended for use at radial level VII are (VII,1); (VII,1)VII,1;
(VII,2); (VII,2-8); (VII,3); (VII,3-9); (VII,8); (VII,9); and (VII,10).
(VII,11) 12
(VII,10) (VII,2)
(VII,3−9)
9 3
VII,7−1(VII,7−1)
6
Fig. 5.166
Level VIII (Radius, pronation) (Figs. 5.167, 5.168, and 5.169)

Safe positions: 1, 2, 3, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, and 3 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the radial bone during motions of
the radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of posi-
tions 8 and 9 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
10
Tr4 GI B
n.medianus
9 3 C
a.ulnaris
P8 v.ulnaris
IG5 n.ulnaris
Fig. 5.167
4
C6 MC
8
7 6 5
Fig. 5.168
The transosseous elements recommended for use at radial level VIII are (VIII,1); (VIII,2); (VIII,2)
VIII,2; (VIII,2-8)VIII,2-8; (VIII,3); (VIII,3-9); VIII,8(VIII,8); and (VIII,9).
12 (VIII,1)
(VIII,3-9)
9 3
VIII,8-2(VIII,8-2)
Fig. 5.169
5.4 Femur

Maxim Vasil’evich Andrianov
The figures show sections through the femur at each of the

principal levels (I–VIII).
Of the 93 positions defined in accordance with MUDEF,
positions 2, 3, and 4 at level I are eliminated due to obvious
anatomic constraints, 68 (73%) are considered safe posi-
tions, and 28 (30%) are identified as RPs for transosseous
element insertion. Wires are used only at levels VI, VII, and
VIII.
On the femur, there are three Yin meridians with a cen-
trifugal direction of energy, those of the liver (F), spleen (Rp)
and kidney (R). There are three Yang meridians with a cen-
tripetal direction of energy, those of the stomach (E), bladder
(V), and gallbladder (VB). The meridians on the femur are
represented by 21 active points.
Level I (Figs. 5.170, 5.171, and 5.172)

Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The use of positions 8 and 9 is optimal at this level because the transosseous elements will not
impinge on the soft-tissue movements relative to the femur during range of motion of the hip joint. In
positions 10 and 11, subcutaneous fascial release should be carried out in a proximal direction
(1–1.5 cm).
11 12 E 1 A
a.femoralis
v.femoralis
n.femoralis
10 2 B
n.ischiadicus
9 3
Fig. 5.170
VB
4
8
V
7 6 5
Fig. 5.171
The transosseous elements recommended for use at the femoral level I are I,8; I,9; I,10; and I,11.
12
I,11
I,10
I,9
9 3
I,8
Fig. 5.172
Level II (Figs. 5.173, 5.174, and 5.175)

Contraindicated positions: 1, 2 ,3, 4
Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The use of positions 8, 9, 10, and 11 is optimal at this level because the transosseous elements
will not impinge on the soft-tissue movements of the femur during range of motion of the hip joint. In
positions 10 and 11 subcutaneous fascial release should be carried out in a proximal direction
(1–1.5 cm).
11 12 1
E31 A
a.femoralis
v.femoralis
n.femoralis
10 Rp 2
B
n.ischiadicus
F10
9 3
Fig. 5.173 VB
8 R 4
V V
7 6 5
Fig. 5.174
The transosseous elements recommended for use at the femoral level II are II,8; II,9; II,10; and II,11.
12
II,11
II,10
9 3
II,9
II,8
Fig. 5.175

Contraindicated positions: 1, 2 ,3 ,4, 5
Safe positions: 6, 7, 8, 9, 10, 11, 12
10, and 11. The use of positions 9 and 10 is optimal at this level because the transosseous elements will
not interfere with the soft-tissue displacement of the femur during range of motion of the hip and (to a
lesser degree) the knee joint. In positions 10 and11, fasciotomy should be carried out proximally
(1–1.5 cm).
11 12 1 A
E a.femoralis
v.femoralis
2 n.femoralis
Rp
10 B
n.ischiadicus
C
VB a.profunda femoris
F
9 3 v.profunda femoris
Fig. 5.176
R
8
4
V
V36
7 6 5
Fig. 5.177
The transosseous elements recommended for use at the femoral level III are III,8; III,9; and III,10.
12
III,10
III,9
9 3
III,8
Fig. 5.178
Level IV (Figs. 5.179, 5.180, and 5.181)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 8, 9, and 10 is optimal at this level because the transosseous elements will
not impinge on the soft-tissue displacement of the femur during range of motion of adjacent joints.
11 12 1 A
E a.femoralis
v.femoralis
2 n.femoralis
10 B
Rp n.ischiadicus
C
VB a.profunda femoris
9 3 v.profunda femoris
Fig. 5.179 8
R 4
V V
7 6 5
Fig. 5.180
The transosseous elements recommended for use at femoral level IV are IV,8; IV,9; and IV,10
12
IV,10
IV,9
9 3
IV,8
Fig. 5.181
Level V (Figs. 5.182, 5.183, and 5.184)

Safe positions: 1, 2, 6, 7, 8, 9, 10, 11, 12
Reference positions: 8, 9
and 11. The use of positions 8 and 9 is optimal at this level because transosseous elements will not
impinge on the soft-tissue displacement of the femur during range of motion of adjacent joints.
11 12 1
E
A
2 a.femoralis
v.femoralis
10
n.saphenus
Rp11 B
n.ischiadicus
9 3
F
VB31
Fig. 5.182 8
4
R
V
V37
7 6 5
Fig. 5.183
The transosseous elements recommended for use at femoral level V are V,8 and V,9.
12
V,9
9 3
V,8
Fig. 5.184
Level VI (Figs. 5.185, 5.186, and 5.187)

Safe positions: 1, 2, 3, 6, 7, 8, 9, 10, 11, 12
The use of positions 3, 7, 8, and 9 is optimal at this level because the transosseous elements will not impinge
on the soft tissues of the femur during range of motion at the knee and (to a lesser degree) hip joints.
11 12 1
E32 A
2 n.ischiadicus
10 B
a.femoralis
v.femoralis
Rp
C
n.saphenus
9 3
F D
VB32 n.saphena magna
8
Fig. 5.185
4
R
7 6 5
Fig. 5.186
The transosseous elements recommended for use at femoral level VI are VI,3; VI,7; VI,8; VI,9; and
VI,3-9.
12
VI,3−9
9 3
VI,8
VI,7
6
Fig. 5.187

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
will not cause soft-tissue impingement of the femur during range of motion in the knee joint.
11 12 1
E 2 A
a.poplitea
10 v.poplitea
B
Rp10 n.tibials
n.peroneus communis
9 3
C
n.saphenus
F
VB D
8 n.saphena magna
Fig. 5.188
4
R
V
V
7 6 5
Fig. 5.189
The transosseous elements recommended for use at femoral level VII are VII,3; VII,4; VII,8; VII,9;
and VII,3-9.
12
VII,9−3
9 3
VII,8
VII,4
Fig. 5.190

Safe positions: 1, 2, 3, 4, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 11, 12
and 1. The use of positions 3, 4, 8, and 9 is optimal at this level because the transosseous elements will
not impede soft-tissue displacements of the femur during range of motion of the knee joint.
11 12 1 A
a.poplitea
v.poplitea
2
E
10
B
n.peroneus communis
Rp
C
9 3 n.saphenus
v.saphena magna
F
VB33
Fig. 5.191 8
4
R
V36
V
7 6 5
Fig. 5.192
The transosseous elements recommended for use at femoral level VIII are VIII,3; VIII,4; VIII,8;
VIII,9; and VIII,3-9.
12
VIII,9−3
9 3
VIII,8
VIII,4
Fig. 5.193
5.5 Tibia

Dmitry Alexandrovich Mykalo
The figures show sections through the tibia at each of the

principal levels (I–VIII).
Of the 96 positions defined in accordance with MUDEF,
75% (72 positions) are designated as safe positions and 49
(51%) as tibial RPs for transosseous element insertion.
On the tibia, there are three Yin meridians with a centrifu-
gal direction of energy, those of the liver (F), spleen (Rp),
and kidney (R).There are three Yang meridians with a cen-
tripetal direction of energy, those of the stomach (E), bladder
(V), and gallbladder (VB). The meridians on the tibia are
represented by 34 active points.
Level I (Figs. 5.194, 5.195, and 5.196)

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
will not impede soft-tissue displacement of the tibia during range of motion in the knee joint.
11 12 1
2
A
10 a.poplitea
E v.poplitea
n.tibialis
Rp B
9 3 a.peroneus communis
VB34
C
F8 n.saphenus
A v.saphena magna
B
8
Fig. 5.194 R10 4
V40
7 6 5
Fig. 5.195
The transosseous elements recommended for use at level I of the tibia are I,2; I,3; I,9; I,10; and I,3-9.
12
I,10 I,2
I,3−9
9 3
B A
Fig. 5.196
Level II (Figs. 5.197, 5.198, and 5.199)

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
12. The use of positions 1, 2, 3, 4, 9, and 10 is optimal at this level because the transosseous elements
will minimally impede soft-tissue displacement of the tibia during range of motion in the knee joint.
10 11 12 1 2 A
a.tibialis posterior
E36 v.tibialis posterior
n.tibialis
B
9 3 n.peroneus superficialis
n.peroneus profundus
C
VB C
Rp9
A a.tibials anterior
D
B v.tibials anterior
8
F7 4
D
v.saphena parva
n.cutaneus surae medialis
Fig. 5.197
E
E R
v.saphena magna
7 V55 5 n.suralis
6
Fig. 5.198
The transosseous elements recommended for use at level II of the tibia are II,1; II,2; II,3; II,4; II,9;
II,10; II,3-9; and II,4-10.
12
II,1
II,2
9 3
II,3−9
A D
B
II,4−10
Fig. 5.199

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
12. The use of positions 1, 2, 3, 4, 9, 10, and 12 is optimal at this level because the transosseous ele-
ments will impede soft-tissue displacement of the tibia during range of motion of the knee joint.
10 11 12 1 2 A
v.tibialis posterior
E
n.tibialis
9 3 B
a.tibialis anterior
RP v.tibialis anterior
B n.peroneus profundus
VB F C
A D
4 v.saphena parva
8 n.cutaneus surae medialis
D
Fig. 5.200 v.saphena magna
R
n.saphenus
V56
7 6 5
Fig. 5.201
The transosseous elements recommended for use at level III of the tibia are III,1; III,2; III,3; III,4;
III,9; III,10; III,12; III,3-9; and III,4-10
12
III,12 III,1 III,2
III,4−10
9 3
III,3−9
A D
Fig. 5.202
Level IV (Figs. 5.203, 5.204, and 5.205)

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
12. The use of positions 1, 2, 3, 4, 9, 10, 11, and 12 is optimal at this level because the transosseous
elements will not impede the soft-tissue motion of the tibia during range of motion of adjacent joints.
11 12 1 2
10 A
E n.tibialis
B
9 3 a.tibialis anterior
v.tibialis anterior
VB
B
F
C
A D
v.saphena parva
n.cutaneus surae medialis
8
4
R D
Fig. 5.203 n.saphena
v.saphena magna
C
V57
7 6 5
Fig. 5.204
The transosseous elements recommended for use at level IV of the tibia are IV,1;IV,2; IV,3; IV,4;
IV,9; IV,10; IV,11; IV,12; IV,3-9; and IV,4-10.
12
IV,11 IV,12 IV,1
IV,2
IV,4−10
9 3
IV,3−9
Fig. 5.205
Level V (Figs. 5.206, 5.207, and 5.208)

Contraindicated positions: 1, 2, 3, 4, 7, 9, 10, 11, 12
and 12. The use of positions 1, 2, 3, 4, 9, and 12 is optimal at this level because the transosseous ele-
ments will not impede soft-tissue displacement of the tibia during range of motion of adjacent joints.
11 12 1
10 2
E39 A
E n.tibialis
9 3
B
VB35 B a.tibialis anterior
v.tibialis anterior
A Rp7
C
8
VB36 D 4 v.saphena parva
F n.cutaneus surae medialis
D
Fig. 5.206 n.saphenus
v.saphena magna
R
V C
7 6 5
Fig. 5.207
The transosseous elements recommended for use at level V of the tibia are V,1; V,2; V,3; V,4; V,9;
V,12; V,3-9; and V,4-10.
12
V,12 V,1
V,4−10 V,2
9 3
V,3−9
B
Fig. 5.208
Level VI (Figs. 5.209, 5.210, and 5.211)

Safe positions: 1, 2, 3, 4, 7, 8, 10, 11, 12
and 12. Note the close approximation of the tibialis anterior neuro-vascular bundle to the lateral tibial
shaft at position 9. Thus, console transosseous elements from position 3 should perforate only the
medial cortical plate. Insertion of K-wires in the frontal plane is possible through the anterior third of
the tibia at this level. The use of positions 1, 2, 3, 4, and 12 is optimal at level VI because the tran-
sosseous elements will not impinge on soft-tissue displacement of the tibia during range of motion of
the ankle and (to a lesser degree) the knee.
11 12 1
10 E 2 A
n.tibialis
F
9 B 3 B
a.tibialis anterior
VB37 v.tibialis anterior
Rp n.peroneus profundus
D
C
8 A 4 v.saphena parva
Fig. 5.209 n.suralis
R D
v.saphena magna
n.saphenus
C
V59
7 6 5
Fig. 5.210
The transosseous elements recommended for use at level VI of the tibia are VI,1; VI,2; VI,3; VI,4;
VI,12; and VI,4-10.
12
VI,12 VI,1
VI,4−10 VI,2
9 B 3
VI,3
Fig. 5.211

Safe positions: 1, 2, 3, 4, 7, 8, 9, 10, 12
Comments. Only console transosseous elements can be used in the projection of position 12. The
use of positions 1, 2, 3, 4, 8, and 9 is optimal at this level because transosseous elements will not
impinge on soft-tissue displacements of the tibia during range of motion of the ankle.
11 12 1 2 A
10
E
B n.tibialis
F B
RP v.tibialis anterior
VB39 n.peroneus profundus
D
R8 C
v.saphena parva
8 A 4 n.suralis
R7
D
Fig. 5.212
v.saphena magna
n.saphenus
C
V
7 6 5
Fig. 5.213
The transosseous elements recommended for use at level VII of the tibia are VII,1; VII,2; VII,3;
VII,4; VII,8; VII,9; VII,3-9; VII,4-10; and VII,2-8(2–8).
12
VII,1
9 3
VII,3−9
A VII,4−10
(VII,8−2)VII,8−2
C
Fig. 5.214

Safe positions: 1, 2, 3, 4, 7, 8, 9, 10, 12
Comments. Insertion of transosseous elements at this level is contraindicated at positions 5 and 11.
There is a high risk of injury to the anterior and posterior tibial neurovascular structures with insertion
portals at these locations. The use of positions 1, 2, 3, 4, 8, 9, and 10 is optimal at this level because
the transosseous elements will not impinge on soft-tissue displacement of the tibia during range of
motion of the ankle.
10 11 12 1 2 A
E
B n.tibialis
F B
Rp v.tibialis anterior
VB39 n.peroneus profundus
D C
R8 v.saphena parva
8 4 n.suralis
A
R7
D
Fig. 5.215 v.saphena magna
n.saphenus
C
V
7 6 5
Fig. 5.216
The transosseous elements recommended for use at level VIII of the tibia are VIII,1; VIII,2; VIII,3;
VIII,4; VIII,9; VIII,10; VIII,3-9, VIII,2-8(2–8); and VIII,4-10.
12
VII,1
B
9 3
VII,3−9
VII,4−10
A
C
(VII,8−2)VII,8−2
Fig. 5.217
5.6 Foot
Leonid Nikolaevich Solomin, Nikolay Fedorovich Fomin,

Sergey Valerjevich Majkov, and
Konstantin Andreevich Ukhanov
Fig. 5.218
On p.p. 142–156 sections of the foot are presented 14 cross- displacement are considered have not been identified.
sectional and on p.p. 157–159 - 3 oblique cuts. However, whenever possible, the insertion of transosseous
To date, “reference positions” of the foot, i.e., positions in elements in a projection of positions with tendons should be
which not only the main vessels and nerves but also soft-tissue avoided: formally, they are regarded as “safe positions.”
5.6.1 Cross-Sectional Cuts
I
Level I
Toe a–e: Contraindicated positions:
II Safe positions: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
III
IV
V a b
VI
VII
VIII
IX
XI
XII
XIII
c d
XIV
Fig. 5.219
Fig. 5.220 (a–e)

I Level II
Toe a: Contraindicated positions: 3, 9
II
Safe positions: 1, 2, 4, 5, 6, 7, 8, 10, 11, 12
III
Toe b: Contraindicated positions: 3, 9
IV
V Safe positions: 1, 2, 4, 5, 6, 7, 8, 10, 11, 12
Toe c–e: Contraindicated positions: 3, 9
Safe positions: 1, 2, 4, 5, 6, 7, 8, 10, 11, 12
VI
VII
VIII
IX
a b
XI
XII
XIII
XIV
Fig. 5.221
c d
Fig. 5.222 (a–e)

I Level III
Toe a–e: Contraindicated positions: 2, 3, 4, 8, 9, 10
II
Safe positions: 1, 5, 6, 7, 11, 12
III
IV
V a b
VI
VII
VIII
IX
XI
XII
XIII
c d
XIV
Fig. 5.223
Fig. 5.224 (a–e)

I Level IV
Toe a–b: Contraindicated positions: 2, 3, 4, 8, 9, 10
II
Safe positions: 1, 5, 6, 7, 11, 12
III
Toe c: Contraindicated positions: 2 ,3, 4, 8, 9, 10
IV
V Toe d–e: Contraindicated positions: 2, 3, 4, 8, 9, 10
Safe positions: 1, 5, 6, 7, 11, 12
VI
VII a b
VIII
IX
XI
XII
XIII
XIV
Fig. 5.225
c d
Fig. 5.226 (a–e)

I Level V
a: Contraindicated positions: 2, 5, 7, 10
II
Safe positions: 1, 3, 4, 6, 8, 9, 11, 12
III
b: Contraindicated positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
IV
V Safe positions: 1, 11, 12
c: Contraindicated positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
Safe positions: 11, 12
VI
d: Contraindicated positions: 1, 2, 4, 7, 8, 9, 10
VII
VIII Safe positions: 3, 5, 6, 11, 12
e: Contraindicated positions: 1, 2, 4, 5, 6, 7, 8, 10, 11
IX Safe positions: 3, 8, 9, 12
X
a b
XI
XII
XIII
XIV
Fig. 5.227
c d
Fig. 5.228 (a–e)

I Level VI
a: Contraindicated positions: 6, 8, 9, 10, 11, 12
II
Safe positions: 1, 2, 3, 4, 5, 7
III
b: Contraindicated positions: 3, 4, 6, 7, 8, 9
IV
V Safe positions: 1, 2, 5, 8, 10, 11, 12
c: Contraindicated positions: 5, 6, 9, 10, 12
d: Contraindicated positions: 1, 2, 3, 4, 5, 7, 10
VI
e: Contraindicated positions: 1, 2, 3 ,5
VII
VIII Safe positions: 4, 6, 7, 8, 9, 10, 11, 12
IX
a b
XI
XII
XIII
XIV
Fig. 5.229
c d
Fig. 5.230 (a–e)

I Level VII
a: Contraindicated positions: 1, 6, 8, 9, 11
II Safe positions: 2, 3, 4, 5, 7, 10, 12
III
b: Contraindicated positions: 2, 3, 6, 7, 9
IV
V Safe positions: 1, 4, 5, 8, 10, 11, 12
c: Contraindicated positions: 1, 3, 4, 5, 6, 7, 8, 9
Safe positions: 2, 4, 10, 11, 12
VI
VII d: Contraindicated positions: 1, 2, 4, 5, 6, 7, 9, 10, 12
VIII Safe positions: 3, 5, 7, 8, 11
e: Contraindicated positions: 1, 2, 3, 4
IX Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
X a b
XI
XII
XIII
XIV
Fig. 5.231
c d
Fig. 5.232 (a–e)

I Level VIII
a: Contraindicated positions: 3, 4, 7, 8, 10, 11, 12
II
Safe positions: 1, 2, 3, 4, 5, 6, 9
III
b: Contraindicated positions: 2, 6, 9
IV
V Safe positions: 1, 3, 4, 5, 7, 8, 10, 11, 12
c: Contraindicated positions: 2, 5, 7, 9, 10
Safe positions: 1, 3, 4, 6, 8, 11, 12
VI
d: Contraindicated positions: 3, 4, 6, 10, 11, 12
VII
VIII e: Contraindicated positions: 1, 4
Safe positions: 2, 3, 5, 6, 7, 8, 9, 10, 11, 12
IX
a b
X
XI
XII
XIII
XIV
Fig. 5.233
c d
Fig. 5.234 (a–e)

I Level IX
a: Contraindicated positions: 3, 7, 8, 11
II
Safe positions: 1, 2, 4, 5, 6, 9, 12
III
b: Contraindicated positions: 1, 6 , 7
IV
V Safe positions: 2, 3, 4, 5, 8, 9, 10, 11, 12
c: Contraindicated positions: 2, 3, 5, 6
Safe positions: 1, 3, 4, 7, 8, 9, 10, 11, 12
VI
d: Contraindicated positions: 2, 4, 5
VII
VIII Safe positions: 1, 3, 6, 7, 8, 9, 10, 11, 12
IX
a b
XI
XII
XIII
XIV
Fig. 5.235
c d
Fig. 5.236 (a–d)

I Level X
a: Contraindicated positions: 6, 7, 12
II Safe positions: 1, 2, 3, 4, 5, 8, 9, 10, 11
III
IV
V Safe positions: 2, 3, 5, 7, 8, 9, 10, 11, 12
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.237
Fig. 5.238 (a, b)

I Level XI
II Safe positions: 2, 4, 6, 8, 9, 10
III
IV
V Safe positions: 2, 3, 5, 7, 8, 9, 10, 11, 12
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.239
Fig. 5.240 (a, b)
I Level XII
II Safe positions: 1, 3, 4, 6, 8, 9, 10
III
b: Contraindicated positions: 1, 3, 4, 5, 12
IV
V Safe positions: 2, 6, 7, 8, 9, 10, 11
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.241
Fig. 5.242 (a, b)

I Level XIII
a: Contraindicated positions: 4, 5
II Safe positions: 1, 2, 3, 6, 7, 8, 9, 10, 11, 12
III
b: Contraindicated positions: 3, 4
IV
V Safe positions: 1, 2, 5, 6, 7, 8, 9, 10, 11, 12
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.243
Fig. 5.244 (a, b)
I Level XIV
Contraindicated positions: None
II Safe positions: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
III
IV
V 1 12 11
VI
VII
VIII
2 10
IX
XI
3 9
XII
XIII
XIV
Fig. 5.245 4 8
5 6 7
Fig. 5.246
III II I 5.6.2 Oblique Cuts
Level I (oblique)
Toe a: Contraindicated positions: 1, 2, 5, 12
Safe positions: 3, 4, 6, 7, 8, 9, 10, 11
Toe b: Contraindicated positions: 1, 2, 12
Safe positions: 1, 3, 4, 5, 6, 7, 8, 9, 10, 11
Toe c: Contraindicated positions: 2, 4
Safe positions: 1, 3, 5, 6, 7, 8, 9, 10, 11, 12
Fig. 5.247
a b
Fig. 5.248 (a–c)

III II I Level II (oblique)

Toe a: Contraindicated positions: 1, 4, 5, 11, 12
Safe positions: 2, 3, 6, 7, 8, 9, 10
Safe positions: 3, 4, 5, 6, 7, 8, 9, 10, 11
Fig. 5.249
a b
Fig. 5.250 (a, b)

III II I Level III (oblique)

Toe a: Contraindicated positions: 1, 2, 5, 11, 12
Safe positions: 3, 4, 6, 7, 8, 9, 10
Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Fig. 5.251
a b
Fig. 5.252 (a, b)

5.7 Pelvis
The positions for the insertion of transosseous elements

through the pelvis are determined in accordance with two
main requirements: (1) the safety of the major vessels,
nerves, and intrapelvic structures, and (2) the optimal mor-
phometric parameters (width, height, length, bone density)
to maintain strong fixation of the wires and half-pins.
However, as indicated in Chap. 2, optimal positioning for the
insertion of transosseous elements (the reference positions)
requires consideration of soft-tissue displacement in relation
to the bone during movement of the adjacent joints.
Positions with minimal soft-tissue displacement are asso- Fig. 5.253 An olive wire (1) is inserted into the anterior-upper spine
ciated with a lower risk of pin-induced joint stiffness and of the iliac bone. The shank end of the wire is bent internally at an angle
pin-tract infections. As reference positions for the pelvis of 30–35° and distally at an angle of 40–45°. The wire must pass
have not yet been determined, the “available positions” are through the thick part of the anterior third of the iliac bone and exit at
the junction with the middle part. A second wire (2) is inserted some-
presented below [1, 87–98]. The angles of deviation of the what anterior to the exit point of wire 1, its exit oriented towards the
tail of the transosseous elements relative to the sagittal plane junction between the middle and posterior thirds of the iliac bone crest.
of the body are indicated in the figure legends. The wire is inserted until its end protrudes 30–40 mm. Then, on the
It is necessary to bear in mind that literature recommen- opposite side, next to the soft tissues, a corrugated or bayonet-like
flexural stop block is formed. The shank end is pulled until the stop
dations concerning the angles of insertion of the transosseous block contact is plunged into the bone
elements relative to the “human body axis” are based on the
anatomic-topographic characteristics of the intact pelvis.
However, in practice, they are quite difficult to implement inserted along the inner aspect of the ilium (as for an intrapel-
when there is bone fragment displacement, multiple lesions, vic Novocaine block) to serve as a marker for determining
and obvious soft-tissue edema, and in obese patients. the plane for half-pin insertion. The most ventral half-pin is
The “closed” insertion of transosseous elements facili- inserted into the ilium wing and set back 10 mm from the
tates the use of: (a) probes (needles, wires) to determine the anterior upper spine. The projection of the external border of
limits of the internal and external cortical plates, at the sites the bone diameter can also be indicated by a wire or needle
of insertion and exit, when placing the wires, and (b) marker. Following the skin incision, a conical recess is made
fluoroscopy or X-ray imaging with radio-opaque markers. with the aid of an awl, 5 mm in diameter, to perforate the
In difficult cases, one should resort to open insertion of upper cortical plate. The awl must be inserted set back from
the half-pins. An incision should be made in the soft tissues the crest of the inner margin at a distance equal to one-third
so that the direction of insertion of the transosseous element of its thickness (Fig. 5.257a).
can be controlled visually. In any case, final radiographic For insertion of a half-pin with stepped diameters, a recess
confirmation of the correctness of positioning of the tran- of up to 5 mm is made with a 5-mm awl. Then, in the center
sosseous elements is mandatory. of the recess, a canal of 40–50 mm is made using a flexible
Wires should be inserted through the wing of the ilium 2-mm awl inserted parallel to the inner needle marker. During
(Figs. 5.250 and 5.251). According to [96], the wires should formation of the canal with the awl, resistance from the bone
be inserted not lower than the anterior inferior iliac spine in may be sensed as a slight characteristic crunch, which is an
front, and the posterior inferior iliac spine in back. For half- indirect sign of the absence of perforation of the compact
pin insertion, the crests of the iliac wing, the anterior spines, layer. If the awl is noted to dip, it should be reinserted. The
the supra-acetabular area, the pubic bones and the lateral stepped half-pin is inserted into the formed canal to a depth
masses of the sacrum should be used (Figs. 5.252 and 5.253). of 40–50 mm, so that the part of the half-pin of greater diam-
As mentioned above, the angle of the iliac wing depends eter enters the bone to a depth of 10–20 mm (Fig. 5.254d).
on the degree of displacement of the pelvis half and the sex On the Figs. 5.255–5.261 the tips and tricks of half-pin inser-
of the patient. Therefore, an injection needle or a thin wire is tion are presented.
3 Fig. 5.254 A method for fixing the iliac bone crest using two parallel
pairs of wires was devised by Shevtsov and Tropin of the Russian
Ilizarov Research Center. Wire 1 is a half pin inserted into the anterior-
upper spine, with its exit oriented towards a point situated 3 cm above
the posterior third of the posterior-upper spine of the iliac bone wing.
Wire 2 is inserted 1.5 cm below and set back from wire 1 and parallel to
it. The exit site of wire 2 must be 1.5 cm above the posterior-upper
spine. Wire 3 is inserted at the junction between the anterior and middle
1
thirds of the iliac bone crest at an angle of 35–40° relative to wire 1 and
2 directed towards the posterior-lower spine of the iliac bone. Wire 4 is
inserted 1.5 cm cranially from wire 3 and parallel to it, with its exit
oriented towards the posterior-upper spine. Wires 1 and 4 are inserted at
an angle of 25–40° (the optimal angle being 28°) relative to the sagittal
plane. For wires 2 and 3 the angle of the bend is 25–35° (the optimal
angle being 32°). If the bend angle is greater than the recommended
range the major vessels may be damaged in the area of the sacroiliac
joint. If the bend angle is insufficient, the wires only pass through the
anterior half-round of the iliac bone wing (From [96])
a b
c
d
Fig. 5.255 (a–d) In the anterior third of the iliac bone crest, half pins inserted to a depth of up to 3.5–4 cm along the iliac bone wing parallel
are inserted to a depth of up to 5 cm along the iliac bone wing, bending to the body axis (at an angle of 90° relative to the sagittal axis), with the
the half-pin end cranially at an angle of 40–45° and laterally at an angle shank end bent laterally at an angle 30–35°
of 30–35°. In the middle third of the iliac bone crest, half-pins are
Fig. 5.256 Correct (a) and incorrect (b, c) insertion a b c

of the half-pin (From [99, 100])
a b c d
1/3 5mm
2/3
Fig. 5.257 Insertion of half-pins into the iliac bone wing. (a) Landmark for insertion of the awl. (b) Insertion of a thick awl. (c) Insertion of a thin
awl. (d) Insertion of a half-pin with two diameters (From [101])
Fig. 5.258 (a–c) A half-pin is inserted to a depth a

of 3–3.5 cm into the anterior-upper spine of the
iliac bone after bending the half pin end internally
at an angle of 30–35° and distally at an angle of
30–35°. A half-pin is inserted to a depth of 3–4 cm
into the anterior-lower spine of the iliac bone, with
the tail bent at an angle of 8–10°
c
a b
c d
5−7 mm
Fig. 5.259 Half-pins are inserted 1–1.5 cm above the margin of the (c, d) is controlled fluoroscopically in two projections. The pin is
acetabulum into the supratrochanter area (a, b) at an angle 10–60° rela- inserted 5–7 mm from the inner edge of the pubic bone and 5–7 mm
tive to the frontal plane. Half-pins are inserted in the horizontal plane from the edge of the pubic joint to a depth of 3–4 cm until it is 2–3 mm
3–5 cm more proximally from the projection of the greater trochanter beyond the lower edge of the pubic bone (From [101])
apex to a depth of 4–5 cm. Insertion of the half-pins into the pubic bone
a b
Fig. 5.260 (a–d) A needle is inserted into the posterior third of the inner cortex in ruptures of the sacroiliac joint. A channel is then formed
crest of the iliac bone with the patient lying on his or her side. The parallel to the needle into which a half-pin is inserted until it exits
posterior-upper spines of the iliac bones are identified by palpation and, beyond the edge of the iliac bone. Up to three half-pins may be inserted
at that level, a marker needle is inserted para-osseously along the exter- from the posterior-upper to posterior-lower spine of the iliac bone
nal cortex in fractures of the lateral mass of the sacrum, or along the
Fig. 5.261 In the sacrum, half-pins are inserted to a depth of 1.5 cm

into the upper part of the lateral mass at level S1, i.e., directly through
the crest of the iliac bone and sacroiliac joint
Note After the title of this chapter, all Authors, who have contributed
to the chapter, are listed. The specific authorship of the individual para-
graphs is given after each section title.
Preoperative Preparation
6
6.1 Introduction The features of X-ray examination at fractures and ortho-

pedic pathology are presented in Sect. 6.2. The principles
In transosseous osteosynthesis, preoperative preparation guiding the individual selection of an apparatus for osteosyn-
includes clinical examination of the patient’s general condi- thesis are considered in Chap. 7.
tion and the local status of the surgical site. Laboratory tests Crutches of the necessary size should be made available
consist of general analysis of blood and urine, blood group beforehand for patients with pathologies of the lower
and Rhesus factor determination, blood sugar and serum extremities. In addition, at least two cotton covers for the
albumin levels, coagulation tests, determination of markers apparatus should be provided preoperatively. The cotton
of hepatitis B and C, HIV status, and the Wassermann test. cover should not enclose the fingers or toes (hand or foot).
Indications for a conservative approach to treatment During winter, an additional cover with external water-
include swelling pressure of the soft tissue of the injured proofing and internal insulating layers is necessary. Patients
extremity (increase in the circumference of a circle at any will also need to have available special clothes with the
level by >50–60 mm), change in skin color, asymmetry in sleeve or trouser leg, as appropriate, enlarged to accom-
blood flow >40%, and disturbances in homeostasis resulting modate the apparatus. A foot support is necessary for
in hypercoagulation. Drug therapy includes adequate dosages patients with external fixation of the tibia and fibula.
of spasmolytics, anticoagulants, and thrombolytics. Exercise Detailed information describing further supplies is pro-
therapy and reflexotherapy are also advisable. Treatment with vided in Chap. 34.
active monitoring and adjustment is continued for 3–7 days. Legislation in most countries requires that the patient be
The presence of a specified symptom complex is not a informed not only of the treatment plan, but also of the basic
contraindication to use of the “basic variant” of external features of external fixation to an extent that will ensure
fixation in patients with fractures in which only basic tran- compliance during the postoperative period. In the case of
sosseous elements are inserted. In this approach, moderate external fixation in a child, a similar conversation must take
distraction between basic supports is performed for the rough place with the parents. Informed consent is signed by both
elimination of displaced bone fragments. Assembly of the sides.
device can be completed later. In addition, it is necessary to warn the patient about the
A full diagnosis of patients with polytrauma and in those inconveniences of frame-bearing and to make sure the patient
with accompanying diseases requires the advice of other spe- understands the implications of the passage of transosseous
cialists: therapists, surgeons, neurosurgeons, angiologists, elements through soft tissue and bone. The importance of the
urologists, and endocrinologists, among others. Cleaning observance of aseptic technique and the use of antiseptics
and sterilization of centers of chronic infection should be during the postoperative period should be emphasized. The
included in the preoperative preparation protocol in orthope- patient must be informed of and understand the manipula-
dic pathology. tions that need to be made during the postoperative period
for the resolution of problems of osteosynthesis: compres-
sion, distraction, mutual displacement of the external sup-
port, replacement and reinsertion of the transosseous
L.N. Solomin, M.D., Ph.D.
elements, etc. General guidance should be offered to the
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia patient concerning possible complications and the actions
e-mail: solomin.leonid@gmail.com necessary for their prevention and treatment.
168 L.N. Solomin
The patient, and the doctor, need to be aware that the risk By way of exception, A-P projections should include the
of infectious complications is higher with transosseous oste- proximal joint, and sagittal projections the distal joint.
osynthesis than with internal fixation. However, the damage
to the health of the patient from infectious complications
after external fixation and the time and effort necessary for 6.2.2 Deformities
their treatment are much less than for inflammatory compli-
cations occurring after internal fixation. Accurate imaging of deformities mandates inclusion of the
Before surgery (providing it is not in the context of acute proximal (humeral, hip) and distal (wrist, ankle) joints in
trauma), the patient takes an antiseptic bath. Directly before order to define the mechanical axis of the limb. In special
surgery the operative field is shaved, drenched with Lugol’s cases involving deformities of the leg, the X-ray image
solution or an alcohol solution, and wrapped with a sterile should include the pelvis. In this case, a 130 × 40 cm film
bandage. The patient is then transported to the operating cassette is needed for long radiography (Fig. 6.2).
theatre. If a 130 × 40 cm film cassette is not available, three stan-
The preoperative preparation of patients with orthopedic dard 30 × 40 cm film cassettes fixed to a common base are
pathologies that involve contracture, a “vicious cicatrix,” used (Fig. 6.3a). However, caution must be taken to avoid
etc., is described elsewhere in this book. gaps between the sheets of X-ray film because of the cassette
walls, as this may result in the omission of important ana-
tomic reference points (Fig. 6.3b).
6.2 X-Ray Examination X-ray imaging of the limbs also can be carried out with
two or three sequential radiographs. In this setting, an X-ray
X-ray examination is carried out in two standard projections: contrast mark should be fixed to the skin of the femur next to
frontal (anteroposterior, A-P view) and sagittal (lateral view). the bottom border of the film cassette. First, an X-ray of the
In particular cases, X-ray images must be acquired in addi- hip joint is obtained. Then, without changing the position of
tional projections, at various angles to the frontal and sagittal the radiography tube or the limb, the second cassette is placed
planes. so that its top edge includes the contrast mark. The second
X-ray image is obtained and includes the ankle joint. The two
images are combined oriented by the contrast mark. If the
6.2.1 Fractures length of the second cassette does not allow inclusion of the
ankle joint on the image, then a second contrast mark is fixed
X-ray imaging of fractures should include both joints of the on the skin of the lower leg. In this case, the resulting X-ray
damaged bone. If the length of the film cassette in its stan- image series will consist of three parts. The drawback to this
dard arrangement is not sufficient, it should be placed diago- method is the increase radiation dose to the patient. Also, the
nally (Fig. 6.1). The same mode can be used to examine images will be distorted if during the examination the posi-
patients with deformities of the long bones. tion of either the limb or the radiography tube is changed.
a
b
a
Fig. 6.1 (a, b) X-ray imaging of

the bones and adjacent joints
6 Preoperative Preparation 169
Fig. 6.2 (a) A 130 × 40 cm film a b

cassette and (b) X-ray images:
long radiographs
6.2.3 Imaging of the Lower Limbs the film cassette will be 4–5%. In radiographs made using a
43-cm film cassette at closer distance, the projection increase
During X-ray examination of the lower limbs in an A-P pro- will be 10–20% [102]. This increase can be explained by the
jection, the correct position is when the patella is directed fact that the longer the X-ray beam, the less its divergence
forward, regardless of the position of the foot. Both lower and, hence, less distortion of the image. To measure the pro-
limbs should be in maximal contact. jection increase (as a percent), a ruler with X-ray contrast
If there is an internal or external torsion deformity of the marks is attached to the skin at the level of a bone.
femur or the lower leg, the patella will be oriented inwards or If the patient has a discrepancy in limb length, this can be
outwards. In either case it is necessary to direct the patella compensated by placing blocks underneath the shorter limb
forwards, despite the possibility of placing the lower limb in before the X-ray examination takes place (Fig. 6.5).
the “wrong position.” In the absence of a torsion deformity of the lower limb,
The exception to this rule is a dislocation or subluxation the condition of the hip and ankle joints can be estimated on
of the patella. In such cases, the lower limb should be standard A-P views, centering the X-ray beam to the knee
arranged so that the flexion-extension axis of the knee joint joint. If there is torsion deformity, then an additional image
is either perpendicular to the X-ray beam or parallel to the allowing evaluation of the hip joint is obtained. For this
film cassette. purpose, the femur should be placed in neutral position,
The distance from the film cassette to the radiography tube i.e., between external and internal rotation. To evaluate an
should be 305 cm (Fig. 6.4). Thus, the projection increase at ankle joint, an additional film is taken with the patient
170 L.N. Solomin
Fig. 6.3 (a) X-ray examination

a b
(long radiography) using three
30 × 40 cm film cassette and (b) the
resulting image
a b
Fig. 6.4 Acquisition of an A-P view. (a) Patient positioning; (b) sample image
standing in feet-forward position. The X-ray beam, as at the

standard examination, is centered to the knee joint.
To perform the X-ray examination in the sagittal plane,
the lower limb should be turned 90° relative to the position
used for A-P imaging (Fig. 6.6). If a lateral view is impossi-
ble (for example, due to hip joint fusion), a lateral image of
the femur, including the knee joint, and an axial image of the
proximal femur are acquired.
If there is a deformity of either the hip or the ankle but the
mechanical axis is nonetheless correct, additional X-ray
images should be obtained with centering to the correspond-
ing joint. The X-ray beam is directed onto a projection of the
joint. The size of the film cassette and the distance between
the cassette and the radiography tube should be sufficient to
cover the knee joint (Fig. 6.7).
When the apex of deformity is in the zone of a knee joint,
images obtained as described above will not allow the mutual
relation of the articulating surfaces to be correctly estimated,
such that creating a joint line (Chap. 16) will be complicated. To
avoid this problem, the direction of the X-ray beam is changed:
for an A-P image, the radiography tube is inclined according to
the size of the angular deformity in the sagittal plane (Fig. 6.8).
Similarly, when there is deformity of a knee joint in the
frontal plane, “classical” X-ray examination will result in the
accumulation of the articulating surfaces against each other.
This will likewise prevent a correct joint line (Fig. 6.9a).
Thus, instead, the tube is inclined according to the angular
Fig. 6.5 Limb shortening is compensated before the X-ray examination deformity in the frontal plane (Fig. 6.9b).
a b
Fig. 6.6 Acquisition of a sagittal (lateral) view. (a) Patient positioning; (b) sample image
172 L.N. Solomin
Fig. 6.7 X-ray examination of

deformities of the hip (a) and ankle a
(b) (Adapted from Paley [102])
43 − 91 cm
43 − 91 cm
Fig. 6.8 The A-P X-ray image of a

knee joint with a deformity in the a
sagittal plane. (a) If the X-ray beam is
directed in a horizontal plane, the
articulating surfaces will accumulate
against each other. (b) At an
inclination of the tube according to the
magnitude of the deformity, defined
using the sagittal image, a true picture
of the mutual relations of the
articulating surfaces is obtained
(Adapted from Paley [102])
Level of knee
305 cm
Level of knee
305 cm
Level of knee
305 cm
71 cm
Fig. 6.9 The sagittal X-ray view of a knee joint with a deformity in the frontal plane. (a) If the tube is focused in a horizontal plane, the articulat-
ing surfaces will accumulate against each other
174 L.N. Solomin
Level of knee
305 cm
71 cm
Fig. 6.9 (continued) (b) At an inclination of the tube according to the magnitude of the deformity, determined based on the A-P image, a true
picture of the mutual relations of the articulating surfaces is obtained (Adapted from Paley [102])
In deformities of the hindfoot, it is important to estimate 6.2.4 X-Ray Examination of the Upper Limbs
the arrangement of the heel-bone axis relative to the tibial
axis. This is achieved using a 43 × 30 cm cassette. The tube The same principles as discussed for radiography of the
is arranged at an angle of 45º to the lower leg. The patient lower limb apply. At the A-P examination, correct position-
can be examined in either the standing or prone position ing of the upper limb is defined as placement of the condyle
(Fig. 6.10a,b). However images under loading (standing) of the humeral bone in the frontal plane; the forearm is supi-
conditions are preferred (Fig. 6.10e,f). nated. On sagittal view, the upper limb should be turned to an
In the X-ray examination of an ankle joint in lateral view, angle of 90º. The forearm in this case is in mid-position,
the loaded foot is placed on an X-ray-negative support. The between supination and pronation (Fig. 6.13).
ankle joint should be in neutral (0/0/0) position (Fig. 6.11). Finally, computer tomography can be of essential value as
If any deformity of the foot or ankle is observed, the foot an additional imaging modality in fractures and deformities
should be pressed to the support, simulating the standing of the bones. It is especially important in intra-articular frac-
position. The beam is directed onto the foot, with the film tures and in deformations, when one of the components is
covering the lower leg (Fig. 6.12). torsion.
a b
45°
45°
43 cm
17 − 43 cm
Fig. 6.10 (a–d) Long axial X-ray examination of the heel. (Adapted from Paley [102])
176 L.N. Solomin
e
d
Fig. 6.10 (continued) (e) The X-ray image without loading (patient in the prone position) raises suspicion of a varus position of the calcaneal
bone. (f) The image acquired under loading (same patient, standing) excludes a varus deformity
Fig. 6.11 Lateral view radiograph of

the foot. (Adapted from Paley [102])
305 cm
Film
Fig. 6.12 X-ray examination

of a deformed foot. (Adapted from
Paley [102])
178 L.N. Solomin
Fig. 6.13 X-ray examination of the upper limb. Upper limb position (a) on A-P exam, (b) on sagittal exam
c d
Fig. 6.13 (continued) (c, d) A-P and sagittal images, respectively

Principles of Frame Construction
7
The general algorithm for the assembly of an external device discrete stages over a certain time within the postopera-
includes: tive period. Resolution of the problem presupposes that
1. Identification of the objectives the device will be dismantled after the necessary orienta-
2. Identification of the optimal levels for the insertion of tion of the bone fragments has been achieved (Fig. 7.1).
transosseous elements 2. For bone fragment fixation. the external fixation device is
3. Identification of the optimal transosseous elements on the used only as a fixing device; for example, after open repo-
basis of safe positions and reference positions sitioning of bone fragments and compression arthrodesis
4. Identification of the optimal levels for positioning the (Fig. 7.2).
external supports 3. For the provision of (improved) limb function during
5. Identification of the type and size of external supports, the postoperative period. To ensure limb support and
corresponding to the selected transosseous elements and movement, the external fixation device must fix the
their insertion levels, leaving open the possibility of mod- bone fragments with sufficient rigidity. Furthermore,
ule transformation the transosseous elements must be placed so as to reduce
6. Marking the selected levels and positions on the segment the risk of pin-induced joint stiffness (Fig. 7.3). The
for transosseous elements insertion and external support conditions to meet these requirements are discussed in
placement Chap. 2.
7. Transosseous element insertion, external support installa- In clinical practice, the external fixation device may have
tion, and frame assembly to meet the requirements of a combination of two or more
Steps 1–5 are performed during preoperative planning; identified problems or solve all of them in aggregate.
steps 6 and 7 are operative interventions. The general issues Therefore, a particular clinical situation often demands a
to be considered in carrying out each step are considered in compromise solution (Chap. 3) that ensures the maximum
the following. efficiency of all components of the external device.
7.1 Identification of the Objectives 7.2 Identification of the Optimal Levels

for the Insertion of Transosseous
Osteosynthesis in traumatology and orthopedics is a means Elements
to reach a common aim: recovery (improvement) of the anat-
omy, function, and physiology of an injured limb. The under- This stage of external device assembly must be based on
lying rationale for using an external fixation device can be knowledge of the biomechanics of bone fragment manage-
stated as: ment and fixation rigidity (Chap. 2).
1. To change the spatial layout of the bone fragments. Using In the treatment of fractures, optimal conditions for the
the specific techniques of external fixation, this can be reduction and fixation of bone fragments are provided by an
carried out in a “single-stage” (during surgery) or in external fixation device in which the distance between the
basic and reductionally fixing transosseous elements in the
proximal and distal modules is maximized (Chap. 2). Thus,
basic transosseous elements should be inserted as close as
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia possible to a joint, and the reductionally fixing wires and pins
e-mail: solomin.leonid@gmail.com closer to the fracture site. The requirements to ensure optimal
182 L.N. Solomin
Fig. 7.1 (a–d) Malunited tibial fracture. Bone

fragment dislocation is eliminated within 7 day by a b
using an external fixation device. After locked
nailing is performed, the frame is removed
c d
conditions for both bone repositioning and fixation are Stabilizing transosseous elements, as a rule, are inserted
satisfied by the Ilizarov device. Its assembly involves two between the basic and reductionally fixing transosseous ele-
external supports for each bone fragment. The supports in ments, as close as possible to the basic transosseous elements
each module must be placed as far apart as possible. The (Fig. 7.4b). The maximal distance from reductionally fixing
transosseous elements must be positioned abarticularly and to stabilizing transosseous elements is defined by the ability
at a distance of 1–3 cm from the bone fracture line (Fig. 7.4a). to fix the latter using four-hole posts.
Exceptions are the osteosynthesis of intra-articular or juxta- Insertion of stabilizing half-pins slantwise with respect
articular fractures. to the longitudinal axis of the bone allows an increase in the
7 Principles of Frame Construction 183
a b
Fig. 7.2 (a–c) After removal of the plates, minimal bone fragment mobility is found. As a result external fixation using a arch type frame is
performed
distance between reductionally fixing and stabilizing longer than the example shown in Fig. 7.4a. Moreover, the
transosseous elements (Figs. 7.21b, c, 7.24 and 7.25). The use of stabilizing transosseous elements will increase the
greatest rigidity will be provided by a support to which a rigidity of the osteosynthesis, thus fulfilling one of the major
half-pin inserted slantwise is fixed by means of a four-hole requirements of combined external fixation (Chap. 3).
post. This level is optimal for the insertion of a stabilizing In deformity correction, the need for reductionally fixing
half-pin. transosseous elements and supports in frame assembly is
Figure 7.4d shows that for distal transosseous elements, obviated if the spatial location of the bone fragments is
level VII instead of level VIII is chosen. This choice implies changed by mutually moving the external supports fixing
that the distal bone fragment is long enough, in this case each fragment. To provide the proper rigidity needed for
184 L.N. Solomin
osteosynthesis, the maximum distance should be reached length of the bone fragment does not allow the use of this
between the basic and the stabilizing transosseous elements. type of assembly, then a shorter post must be substituted.
This is achieved by inserting the stabilizing transosseous ele- Depending on the treated segment and the objectives of the
ments slantwise to the longitudinal axis of the bone fragment osteosynthesis, each module can include one or two supports
and then fixing them by means of a four-hole post. If the (Fig. 7.5).
a b
Fig. 7.3 (a, b) An optimal frame configuration for the treatment of knee-joint stiffness
a b c
Fig. 7.4 Identification of the

levels for transosseous element
insertion and for locating the
external supports in the treatment
of fractures. Optimum levels
for the insertion of basic,
reductionally fixing (a, d), and
stabilizing (b, e) transosseous
elements are shown, together with
the optimum levels for locating
the basic and reductionally fixing
supports (c, f). The basic and
reductionally fixing transosseous
elements in each module should
be placed as far apart from one
another as possible. The distance
from reductionally fixing
transosseous to stabilizing
transosseous elements should not
be <4–5 cm (i.e., the length of a
four-hole post)

d e f
a b c
Fig. 7.5 Identification of the

levels of transosseous element
insertion and external support
location in deformity correction.
Optimum levels of insertion
of basic (a, d) and stabilizing
(b, e) transosseous elements are
shown together with the optimum
levels for support arrangement
(c, f). The distance from the
basic to the stabilizing
transosseous elements should not
be <4–5 cm (i.e., the length of a
four hole post)
186 L.N. Solomin
Fig. 7.5 (continued) d e f
7.3 Identification of the Optimal 3, 9) or sagittal (positions 6, 12) planes and perpendicular to
Transosseous Elements on the anatomic axis of the bone fragment, as this will facilitate
the Basis of Safe Positions bone fragment reduction. In the example shown in Fig. 7.4a,
and Reference Positions the levels for the reductionally fixing transosseous elements
are IV and V. At these two levels, positions 3, 9 and 12 are
This objective proceeds from that of the osteosynthesis. The the RPs (Fig. 7.6a, b; Sect. 5.5). Thus, it is expedient to use
atlas in Chap. 5 is consulted. If one of the tasks of using (as a choice) half-pins IV,12,90 and V,12,90 or olive wire
external fixation is to provide (improve) function of the adja- spokes IV,3-9 (or IV,9-3) and V,3-9 (or V,9-3) (Fig. 7.6c, d).
cent joints, only reference positions (RPs) are used, with In the example shown in Fig. 7.4a, the levels for the basic
those located contralateral to the bone being particularly transosseous elements are identified: I and VIII. If possible
important; for example, 2 and 8, 3 and 9, 6 and 12. It is pos- wires should be used as the basic transosseous elements. At
sible to insert a wire in the projection of these positions and level I, the contralateral RPs are 3 and 9 (Fig. 7.7a); at level
to insert a half-pin on the side of any RP. For example, if the VIII they are 2 and 8, 3 and 9, 4 and 10 (Fig. 7.7b). Thus at
RPs at level V of the shoulder are 4 and 10, one can either level I the optimal wire is I,9-3 (Fig. 7.7c) whereas at level
use the wire V.4-10 or the half-pin V,4,90 or V,10,90 (the VIII there is a choice between wires VIII(8-2)8-2, VIII,9-3,
angle of half-pin insertion here is given arbitrarily). If there and VIII,10-4 (Fig. 7.7d). However, in the external fixation
is no contralateral position at this level, it is expedient to use of the lower leg it is necessary to stabilize the distal
half-pins (cantilever wires). tibiofibular syndesmosis, which requires the use of wire
The use of wires is more effective for repositioning bone VIII(8-2)8-2.
fragments in fractures, whereas the use of half-pins increases To increase osteosynthetic rigidity, the reductionally
the rigidity of bone fragment fixation. At the same time it fixing and basic transosseous elements must not be placed in
should be remembered that the use of half-pins is inappropri- the same plane. Therefore, if the basic transosseous elements
ate in the presence of marked osteoporosis. were inserted in the frontal plane (or close to it, at level VIII)
In fracture treatment, the reductionally fixing transosseous then for the reductionally fixing transosseous elements the
element should be inserted strictly in the frontal (positions use of IV,12,90 and V,12,90 is recommended.
a b
10 11 12 1 2 10 11 12 1 2
E39
E
E
9 3
9 3
VB35 B
VB
B Rp7
F
A
A D
8
D 4
8
4 VB36 F
C R
C
V57 V
7 6 5 7 6 5
A B C D A B C D
a.tibialis a.tibialtis v.saphena n.saphenus a.tibialis a.tibialis v.saphena n.saphenus
posterior anterior parva v.saphena posterior anterior parva v.saphena
v.tibialis v.tibialis n.cutaneus magna v.tibialis v.tibialis n.cutaneus magna
posterior anterior surae medialis posterior anterior surae medialis
n.tibialis n.peroneus profundus n.tibialis n.peroneus profundus
V,12,90
IV,12,90
c d
V,3-9
IV,3-9
Fig. 7.6 Selection of reductionally fixing transosseous elements (according to Fig. 7.7a). Reference positions at levels IV (a) and V (b). Optimum
(as a choice) use of reductionally fixing transosseous elements at levels IV (c) and V (d)
In the next step, the optimum positions for the insertion sosseous elements are ideally inserted as follows (Sect.
of stabilizing transosseous elements are chosen. It is 2.3.6, Fig. 2.24):
advisable to use half-pins as stabilizing transosseous ele- • In a plane located at an angle of 60° ± 10° to the plane of
ments. To increase osteosynthetic rigidity and to allow for insertion of a reductionally fixing transosseous element
possible modular transformation the stabilizing tran- (Sect. 2.3.6, Figs. 2.24 and 2.25)
188 L.N. Solomin
a b
11 12 1 11 12 1
2 E41 2
10 10
F4
E
Rp
Rp
9 3 9 3
VB
VB34
F8
8 8
4
4
R10 R3
V60
V40
7 6 5 7 6 5
A B C A B C D
a.tibialis a.tibialis v.saphena v.saphena
a.poplitea a.peroneus n.saphenus
posterior anterior parva magna
v.poplitea communis v.saphena
v.tibialis v.tibialis n.suralis n.saphenus
n.tibialis magna
posterior anterior
n.tibialis n.peroneus profundus
c
d
I,3-9
VIII,3-9
VIII,4-10
(VIII,8-2)VIII,8-2
Fig. 7.7 Choice of basic transosseous elements (according to a). Reference positions at levels IV (a) and V (b). Optimum reductionally fixing
transosseous elements at levels IV (c) and V (d)
• At an angle of 120° ± 10° to the longitudinal axis of the In deformity correction, the displacement of one tran-
proximal bone fragment and 70° ± 10° to the longitudinal sosseous module against the other is used. Thus, the basic
axis of the distal bone fragment and stabilizing transosseous elements should provide the
• At a distance provided by the use of four-hole posts maximal rigidity of osteosynthesis. As noted in Sect. 7.2, the
In the example shown in Fig. 7.4b, there are two levels distance between basic and stabilizing transosseous elements
for stabilizing transosseous elements: II and VII. At level II in each module should be maximized (Fig. 7.5). Generally,
the half-pin II,2,120 fulfills the above-mentioned require- basic transosseous elements are inserted in the frontal or sag-
ments (Fig. 7.8c), and at level VII the half-pin VII,2,70 ittal (or close to them) planes and perpendicular to the longi-
(Fig. 7.8d). tudinal axis of the bone fragment. This allows monitoring of
a b
11 12 1 2 11 12 1
10 10 2
E
E36
F
9 3
9 3
Rp
VB39
VB
Rp9
R8
8
F7 4
8 4
R7
R
7 V55 5
6 V
7 6 5
A B C D E A B C D
a.tibialis n.peroneus a.tibialis v.saphena v.saphena a.tibialis a.tibialis v.saphena v.saphena
posterior superficialis anterior parva magna posterior anterior parva magna
v.tibialis n.peroneus v.tibialis n.cutaneus n.suralis v.tibialis v.tibialis n.suralis n.saphenus
posterior profundus anterior surae medialis posterior anterior
n.tibialis n.tibialis n.peroneus profundus
c d
II,2,120
VII,2,70
Fig. 7.8 Choosing stabilizing transosseous elements (according to Fig. 7.7b). Reference positions at levels II (a) and VII (b). Optimum stabilizing
transosseous elements at levels II (c) and VII (d)
the basic support. The stabilizing transosseous elements • At an angle of 120° ± 10° to the longitudinal axis of the
should be inserted as follows: proximal bone fragment and 70° ± 10° to the longitudinal
• In a plane located at an angle of 60° ± 10° to the insertion axis of the distal bone fragment
plane of the basic transosseous elements (Sect. 2.3.6, The basis for selecting levels for the insertion of tran-
Figs. 2.24 and 2.25) sosseous elements in order to correct a lower leg deformity
190 L.N. Solomin
a b 12 c 12
II,2,120
9 3
9 3
III,3-9
6
6
d 12 e 12 f 12
V,12,120
IV,12,70 VI,4-10
3
9 39 9 3
6
12 6 6
g
VII,2,70
9 3
Fig. 7.9 (a–g) Options for basic (c, f) and stabilizing (b, d, e, g) transosseous elements
is shown in Fig. 7.5c. The apex of the deformity is located proximal bone fragment, and Fig. 7.9e–g for the distal bone
in the middle third of the tibia. Levels II, III, and IV are fragment.
optimum for the proximal bone fragment, and levels V, VI, In the opinion of some authors, situations in which tran-
and VII for the distal bone fragment (Fig. 7.9a). Cross- sosseous elements pass through more than two or three acu-
sectional cuts through the lower leg (Sect. 5.5) show the puncture points on different meridians or cross one meridian
transosseous element options at the corresponding levels. two or three times should be avoided [80, 85, 103]. However,
The above-mentioned conditions define the choice of the use of transosseous elements as stimulators at biologi-
transosseous elements, as shown in Fig. 7.9b–d for the cally active points should not be ruled out [83, 104].
7.4 Identification of the Optimal Levels In deformity correction, the basic support is also located
for Positioning the External Supports in the immediate proximity of the basic transosseous ele-
ments. The distance from a support to the external end of the
The requirements to ensure optimal conditions for bone repo- stabilizing half-pin should be 4–5 cm (length of a four-hole
sitioning and for fixation are satisfied by the Ilizarov device. post) (Figs. 7.5c and 7.11a). If the rigidity of an osteosynthe-
Its assembly involves two external supports for each bone sis must be increased by using additional stabilizing tran-
fragment (one support for a short fragment, as an exception). sosseous elements, inserted at a greater distance from the
In fractures, the basic supports must be located in imme- basic support, then another support, as a stabilizing support,
diate proximity to the basic transosseous elements, with is required (Figs. 1.4, 7.5f and 7.11b).
reductionally fixing supports placed between reductionally Note: For a very long bone fragment it is always possible
fixing and stabilizing transosseous elements (Fig. 7.4c, f). to fix the stabilizing half-pins by means of a four-hole post
In addition, the distance between an external support and placed above and under the support. However, this will not
the external end of the transosseous element should be always provide the osteosynthetic rigidity needed to fulfill
4–5 cm, i.e., equal to the length of a standard four-hole post the requirements for combined (hybrid) external fixation
(Fig. 7.10a). Thus, the maximal length of a bone fragment (Sect. 3.5). These situations necessitate the use of an addi-
for one support is 8–10 cm (Fig. 7.10b). For longer bone tional stabilizing support to which extra stabilizing tran-
fragments it is necessary to use two supports (Fig. 7.10c). sosseous elements can be fixed.
a b
5 cm
>10 cm
10 cm
Fig. 7.10 Determination of the necessary number of supports in frac- with lengths of up to 10 cm, one support can be used (b – distal mod-
tures. Stabilizing transosseous elements must be fixed at a distance of ule). For bone fragments longer than 10 cm, two supports are used
4–5 cm from the reductionally fixing support (a). For bone fragments (a – proximal module, b – both modules)
192 L.N. Solomin
Fig. 7.11 In deformity

correction, the distance from the
a b
basic transosseous elements to
the stabilizing half-pins should
be maximal. If the distance from
a support to the half-pins allows
their fixation by means of a
four-hole post, then one support
is used (a – both modules; b –
distal module only). If this is not
the case, then two supports are
used: one stabilizing and one
basic (b – proximal module)
7.5 Identification of the Type and Size and semicircular supports. Further on, this arrangement can
of the External Supports Corresponding be minimized using modular transformation.
to the Selected Transosseous Elements However, rings often cannot be used, for example at lev-
and Their Insertion Levels While els 0, I, and II of the upper arm and upper leg. It is inappro-
Allowing for Module Transformation priate to use closed basic supports when they mechanically
obstruct movement of the adjacent joint.
If it is necessary to use wires, the support should be circular To enable modular transformation, all transosseous ele-
or semicircular. If only half-pins are fixed, the support can be ments of the given support should be fixed to one part of it
of any type: circular, semicircular, sectorial (arch) or mono- (Fig. 7.13). Figure 7.14 shows the supports intended for
lateral. Figure 7.12 shows the most frequently used closed modular transformation. If the device is intended only for the
and open external supports. fixation of bone fragments, it can initially be semicircular,
To minimize the frame configuration it is advisable to use sectorial, or monolateral.
sectoral, semicircular, and monolateral supports. However The diameter of the external supports is selected taking
there is a direct correlation between the type of support, on into account the circumference of the sector at every inser-
the one hand, and the reduction of the bone fragment and the tion level of the transosseous elements. The choice of the
rigidity of the osteosynthesis, on the other. Use of a closed standard size should allow for both a probable increase in the
(circular) external support provides both optimal conditions circumference by 4–6 cm due to soft-tissue edema and for
for tensing wires and a greater choice of positions and angles soft-tissue displacement relative to the repositioning of the
for half-pin insertion. It also facilitates bone fragment reduc- bone fragments.
tion and increases osteosynthetic rigidity. Therefore if the The minimally recommended distance from the skin to
objective of an osteosynthesis is a two- to three-plane bone the external support is not the same for the different seg-
fragment reduction or deformity correction with the subse- ments and sides of a segment. As a rule, the distance on a
quent fixation of rigid bone fragments, then the initial frame dorsal surface of the segment should be 1.5- to 2-fold greater
configuration should be assembled on the basis of circular than that on a ventral surface.
Fig. 7.12 Main types of external support (From [26])
Due to anatomic and inter-individual variations, the cir- supports of the maximum standard size for the particular sit-
cumference of the segment will differ at every level. Hence, uation. In the former case, the rigidity provided by the struc-
there are differences in the diameter of the supports at every ture is reduced due to the need for connection plates in the
level (Fig. 7.15); alternatively, the device is assembled from completed device, such that its installation becomes more
194 L.N. Solomin
Fig. 7.13 (a) Fixing transosseous

elements to one part of a support
a
allows modular transformation (MT).
(b) In this case MT is impossible, as
the wire is fixed to various parts of a
ring
a b
Fig. 7.14 (a–d) External supports c d

allowing modular transformation
Fig. 7.15 In assembling the

frame using supports of various
diameters, connection plates
should be used. A bend in the
connecting rods is inadmissible
complicated; however, the dimensions of the device are a

reduced. It is easier to assemble the device from supports of
the same standard size as this provides more freedom for
manipulations; however, the device is bulkier. The rigidity of
bone fragment fixation inevitably decreases due to the
increase in the diameter of some of the supports.
Thus, in every situation a reasonable compromise must be
reached based on the priorities of: (a) provision of greater rigid-
ity of the osteosynthesis; (b) minimization of the dimensions of
the external frame; (c) the need for greater freedom for chang-
b
ing the spatial orientation of the fragments; and (d) provision of
maximum possible motion of the joints. For example, in joint
arthrodesis (joint fusion), the possible locations for transosseous
element insertion are extended by using safe positions. In con-
trast, for mobilization of a joint using external fixation tech-
niques, the device should be assembled on the basis of
transosseous elements inserted in the projection of RPs.
It must again be emphasized that the number of tran-
sosseous elements and external supports inserted should pro-
c
vide an adequate rigidity of fixation for each bone fragment.
An external fixation construct-rigidity test is described in
Chap. 36. All frame assemblies for combined external
fixation presented in Part II of this book correspond to this
requirement.
To reduce the surgical intervention time, the external
structure (the frame of the device) should be pre-assem-
bled and then sterilized, either as a whole or in separate
modules, together with any necessary additional
equipment.
7.6 Marking the Selected Levels Fig. 7.16 (a–c) Dividing the femur into eight standard levels to desig-
nate the levels of support placement
and Positions on the Segment
for Transosseous Element Insertion
and External Support Placement
7.7 Transosseous Element Insertion,
The scheme of segment division into levels is shown in Fig. External Support Installation,
4.1. During surgery for this purpose, a special swiveling and Frame Assembly
device and a sterile marker are used (Fig. 7.16). In case of an
acute injury, this stage is carried out after reconstruction of The procedure for transosseous element insertion and the
the limb axis and rough elimination of the displaced frag- specific features of frame assembly depend on the segment
ments by means of skeletal traction on the orthopedic exten- being operated upon, the type of pathology, and the goals of
sion table. osteosynthesis.
196 L.N. Solomin
In fractures skeletal traction or distraction devices should position and vice versa (Fig. 2.3). It is not always possible to
be applied before the external fixation procedure is per- place the limb in the specified position during the insertion of
formed. The algorithm for transosseous element insertion, transosseous elements while operating under conditions of
external support installation, and frame assembly is as fol- skeletal traction on an orthopedic extension table. In such
lows (Figs. 7.26 and 2.4.11): cases, before the wire is inserted through the extension sur-
• Insertion of the basic transosseous elements face of a segment, the skin is displaced (manually or with the
• Frame assembly help of a special hook) towards the adjacent joint. When
• Distraction to form a gap between bone fragments using only RPs for transosseous element insertion, there is no
• Insertion of reductionally fixing transosseous elements need to perform these manipulations.
• Bone fragment reduction For the insertion of wires, discontinuous boring at the
• Insertion of stabilizing transosseous elements to maximum rotational speed of the drill (850 rpm), cooling
increase osteosynthetic rigidity and to enable modular the wire with an alcohol-impregnated gauze tampon, and
transformation regulating (up to 20 N ) the axial pressure on the wire are
• Elimination of the gap between bone fragments advised. After the guiding end of the wire passes the second
In deformity correction, the algorithm is as follows cortical plate, the drill should be disconnected; further inser-
(Fig. 7.34): tion of the wire through the soft tissues is achieved using
• Insertion of basic and stabilizing transosseous elements gentle hammer strikes on the base of the wire. If a wire with
into the proximal bone fragment an olive stop is used, a puncture of 2–3 mm should be made
• Assembly of the proximal transosseous module on the in the skin. The guiding end of the wire should not be pulled
basis of only a basic support or using two supports: basic in an attempt to insert the stop to the bone; rather, the punch-
and stabilizing ing technique is used. To insert a spiral stop as far as the
• Insertion of basic and stabilizing transosseous elements bone, the wire is pulled at the guiding end with simultane-
into the distal bone fragment ous rotation of the curvature in the soft tissue (Fig. 7.17).
• Assembly of the distal transosseous module on the basis For half-pin insertion in a bone, a 0.5 cm incision is made
of only a basic support or using two supports: basic and after a channel has been formed in both cortices by means of a
stabilizing drill. Thermal damage to the bone is prevented by interrupted,
• Connection of the proximal and distal transosseous slow-speed drilling and cooling of the drill in a damp gauze
modules by means of a unified (Sect. 2.2) or universal napkin. The use of a tissue protector sleeve will also help to
(Chap. 17) unit shield the surrounding soft tissue from mechanical damage.
• “Bone” one : osteotomy, bone grafting, etc. (if necessary) Half-pins with a drill on the directing end obviate the need
The features of each stage of mounting an external fixator for a channel for half-pin insertion [2]. They should be used
are discussed in the following. carefully, especially in patients with osteosclerosis. If there
When transosseous elements pass through the flexion sur- is no forward movement of a half-pin when the distant cortex
face of a segment, the adjacent joint is placed in the extension is drilled, then upon rotation within the nearby cortex the
a b
Fig. 7.17 (a) The wire is inserted using a slow-speed drill. (b) Excessive pressure upon a wire and its bend are inadmissible
c d
Fig. 7.17 (continued) (c) Through soft tissue outside the second cor- sharp end with simultaneous rotation. (g) After wire insertion, disc
tex, a wire is inserted using only a hammer. (d) A 2- to 3-mm incision clips for the fixation of gauze napkins are stringed along the device.
is made using a wire with an olive stopper. (e) Pulling sharply to sub- (h) Disc clips on the sides of the wire stopper should have visible dif-
merge the olive stopper until the bone is inadmissible. (f) For an inser- ferences in shape, color, etc. (i) Industrially made disc clips for gauze
tion until a bone corkscrew stopper is reached, a wire is pulled at its napkin fixation
198 L.N. Solomin
Fig. 7.18 (a) Placement of the

drill sleeve on the bone (e.g., at a
position 9) and then changing the
angle in the transversal plane to
approach position 8 is a grave
error. (b) The drill sleeve is
inserted in the projection of
position 8
screw part of the half-pin will destroy the thread previously or 120°). For insertion of a half-pin at any set angle, the spe-
made in the cortex, thus immensely weakening fixation of cial conductor (Table 1.2, Fig. 7.19) is used.
the half-pin in the bone. For insertion of a half-pin at an angle of 90°, the “control-
The insertion of a conical half-pin should be done ling device for bone fragment reduction and support orienta-
fluoroscopically because its partial return following a too tion” (Table 1.2, Figs. 7.20 and 7.33) can be used. The use of
deep insertion into the bone will lead to its destabilization. intraoperative fluoroscopy facilitates this step.
Half-pins with a cortical and spongy thread should be The half-pin should be inserted through both cortical lay-
inserted in the diaphyseal and metaphyseal parts of the bone, ers. The exceptions are when the main vessel or a nerve con-
respectively. The plane in which the half-pin is inserted must tacts the bone. However, in all cases the screw of the half-pin
correspond to the position in which the transosseous element should be hidden within the bone to prevent breakage of the
is to be inserted (Fig. 7.18). half-pin (Fig. 7.21).
Continuing with the tasks of an osteosynthesis, the half- Insertion of a half-pin through the center of the bone’s
pin is inserted perpendicular to the longitudinal axis of the breadth is limited by needles inserted subperiosteally
bone fragment or at an angle distinct from 90° (usually 70° (Fig. 7.22).
a b
Fig. 7.19 A special drill sleeve is used to insert a half-pin at a specified Fig. 7.20 For insertion of a half-pin at an angle of 90° to the longitu-
angle to the longitudinal (anatomic) axis of the bone fragment. (a) A dinal axis of a bone fragment (Table 1.2) both wires of the special
sleeve placed at 90°: in the fixator, the calibrated wire is fixed at the device are immersed until the bone. The half-pin is inserted parallel to
mark indicating the location of the sleeve at the necessary angle. (b) A the wires of the device. If the fragment is short, the length of one of the
sleeve placed at 70°: when drilling is started, the sleeve is inclined until wires is altered according to the diagram and in accordance with the
the calibrated wire leans against the bone bone’s relief
12
a b
9 3
Fig. 7.21 (a) The half-pin should be passed through both cortices. (b) The exceptions are when the main vessel or a nerve contacts the bone
Before inserting a half-pin in metaphyseal bone, a canal is half-pin. In patients with osteoporosis, the diameter of the
made in the nearby cortex using a 3–4 mm awl (Fig. 7.22). canal must be 0.1–0.2 mm less. Use of a surgical drill with a
For insertion of a pin in diaphyseal bone (Figs. 7.23, 7.24, stopper (Table 1.2) requires the addition of a tissue protector
and 7.25), a canal is formed with a diameter corresponding sleeve (Table 1.2). Bayonet drills (Table 1.2) are approxi-
to the standard size of the pin and in relation to the bone tis- mated to the bone by puncturing the soft tissues. Insertion of
sue density. The canal diameter is 2.7 mm for a 4-mm half- a pin without a self-tapping guiding end must be preceded by
pin, 3.8 mm for a 5-mm half-pin, and 4.8 mm for a 6-mm thread formation in the bone using a tap.
200 L.N. Solomin
After the transosseous elements have been inserted, pre- two-plane orientation at an angle of 90º to the longitudinal
sterilized gauze-wad fixators are strung on them using plastic axis of the bone fragment. In addition, the method shown in
or rubber discs 10–15 mm in diameter for wires and Fig. 7.26 can be used.
20–25 mm in diameter for half pins. Fixators placed on the The external supports are oriented relative to the bone in
side of the stopper of the wires must be distinguishable by the horizontal plane (“centering” of the external supports
color, shape, etc. relative to the soft tissues) according to the individual fea-
Mounting of the frame of the device starts with the basic tures of every segment. This information is presented in the
supports. The use of an image intensifier facilitates their respective chapters of this book.
a b
c d
e f
Fig. 7.22 Inserting a half-pin in metaphyseal bone at an angle of 90°. of the controlling device for bone fragment reduction and support ori-
(a) Finding the anterior and posterior cortices. The third wire is inserted entation. (e) Formation of a channel in the nearby cortical plate. The
at a level of the top of the greater trochanter of the femur. (b) A 4–6 mm awl is placed parallel to the wires of the device. (f) Insertion of half-pin
incision is made. (c) Formation of the soft-tissue channel. (d) Placement parallel to the wires of the device
g h
Fig. 7.22 (continued) (g) The half-pin is inserted perpendicularly to the longitudinal axis of the bone. (h, i) A disc clip, either prepared during
the operation (h) or industrially made (see Fig. 7.17i), is put on the half-pin
Wires and, especially, half-pins should not be bent in elements is used intentionally; for example, in the reposi-
fixing either one to the external supports of the device. If tioning of bone fragments or to increase the rigidity of the
the external end of a transosseous element is located at a osteosynthesis.
certain distance from the support, gasket washers or posts If the half-pin is not inserted perpendicular to the ana-
(brackets) should be used (Figs. 7.27 and 7.28). An excep- tomic axis of the bone fragment, it is fixed to the support
tion to this is when elastic deformation of transosseous using two posts, male and female, or two male posts. If two
a b
Fig. 7.23 Inserting a half-pin in diaphyseal bone at an angle of 90°. (a) Finding the anterior and posterior cortices. (b) A 4–6 mm incision is made
202 L.N. Solomin
c d
Fig. 7.23 (continued) (c) Formation of the soft-tissue channel. (d) A first cortex is drilled. (g) After the drill is set against the second cortex,
calibrated wire is fixed in the position providing sleeve placement at an nuts are screwed at a distance from the sleeve equal to the thickness of
angle of 90° (see Fig. 7.19a). (e) Insertion of the tissue protector sleeve the second cortex (2 mm). (h) After channel formation in the second
with a trocar and its disposition such that the calibrated wire rests cortex, the screwed nuts rest against the sleeve, preventing further
against the bone. (f) The trocar is removed, the drill is entered, and the movement of the drill
i j
k l
Fig. 7.23 (continued) (i) Inserting the half-pin through both cortices. bayonet drill parallel to the wires of the device. (l) The half-pin is
(j) The disc clip is placed on the half-pin. (k) Insertion of a half-pin at inserted parallel to the wires of the device, i.e., perpendicular to the
an angle of 90° using the controlling device for bone fragment reduc- longitudinal axis of the bone fragment (see Fig. 7.20)
tion and support orientation. The bone channel is made by focusing a
a b
Fig. 7.24 Inserting a half-pin in diaphyseal bone at an angle of 120° protector sleeve and placing it such that the calibrated wire rests
(as in Fig. 7.19b). (a) A calibrated wire is fixed in the position pro- against a bone
viding sleeve placement at an angle of 120°. (b) Inserting the tissue
204 L.N. Solomin
c d
Fig. 7.24 (continued) Formation of the channel in both cortices (c) Half-pin insertion at an angle of 120° followed by placement of the disc clip (d)
a b
Fig. 7.25 A half-pin is inserted by means of an adapted sleeve (Table After incision of the soft tissues, the bayonet drill is entered into the
1.2) when the support is already mounted. (a) Finding the anterior and bone and a channel in both cortices is formed. (e, j, k) Insertion and
posterior cortices. (b, c) Inserting the adapted sleeve in the hole of the fixation of a half-pin
post. (c, f) Entrance of the bayonet drill into the adapted sleeve. (d, g–i)
e f
g h
i j
51.43

206 L.N. Solomin
a b
c d
Fig. 7.26 Frame assembly in fractures. After the basic transosseous inserted as far as possible into the diaphyseal part of the bone fragment.
elements are inserted, a basic support is mounted, generally perpen- If the fragment is short, the length of one of the wires is altered accord-
dicular to the respective bone fragment. In this case, the controlling ing to the skiagram in accordance with the bone’s relief (a). The support
device for bone fragment reduction and support orientation can be used is placed parallel to the wires of the device: first in the frontal (b) and
(Table 1.2). One of the calibrated wires is removed from the device; the then in the sagittal (c) planes. The specified device also allows control
two remaining wires are withdrawn for an equal distance and then over the orientation of the proximal (d) and distal
e f
Fig. 7.26 (continued) (e) reductionally fixing supports. Proximal and fragment reduction (h). The final step is insertion of the stabilizing tran-
distal modules are connected by threaded rods (f). A 4–6 mm distrac- sosseous elements, elimination of the diastasis, and dismantling of the
tion for diastasis is done (g). Next, the proximal and distal reductionally skeletal traction (i)
fixing elements are inserted followed by consecutive two-plane bone
208 L.N. Solomin
a b
c d
Fig. 7.27 (a) A half-pin is inserted perpendicularly to the anatomic to the anatomic axes of the bone fragment (non-parallel to the device
axes of the bone fragment (parallel to the device support) and close to support) and at some distance from the support. It is fixed with a male
the support. It is fixed with an L-shaped clamp. (b) The half-pin is post and the L-shaped clamp or (d) male and female posts (or two
inserted perpendicularly to the anatomic axes of a bone fragment (par- female posts). Bending of a half-pin to a support is forbidden! If neces-
allel to the device support) and at some distance from the support. It is sary, washers should be used
fixed with a female post. (c) The half-pin is not inserted perpendicularly
a b
Fig. 7.28 (a) A wire is located at a some distance from a support. (b) Wires must not be bent to fix them to the external supports of the device. If
the external end of a transosseous element is located at a certain distance from the support, posts (c) or gasket washers (d) should be used
female posts are used, the half-pin cannot be removed with- inadmissible. In cases in which angular deformity is to be
out dismantling the support. The half-pin can also be fixed eliminated with time, the subsystem includes three hinges:
using an L-shaped clip (Fig. 7.28). two axial and one swivel. Axial hinges are located strictly in
The basic variants of wires tensioning are shown in parallel on the opposite sides of external supports. The axis
Figs. 7.29, 7.30, 7.31, and 7.32. of rotation of a pair of axial hinges is determined according
The protruding ends of the wires are cut off at a distance to the tasks of the osteosynthesis. The swivel hinge is placed
of 30–40 mm from the outer edge of the support and are bent on either the concave or the convex side of a deformity. It is
over. Repeated bending of the free ends of the wires should also possible to place two hinges on the concave side and two
be avoided as subsequent straightening of the wires (to restore hinges on the convex side of a deformity. More detailed
the tensile force for repositioning) may be necessary and the information about Ilizarov and universal hinges is given
wire may fracture at the point of curvature (Fig. 7.29e). in the sections devoted to deformities of the long bones
In deformity correction, transosseous modules fixing the (Chaps. 16 and 17).
proximal and distal bone fragments are not parallel to one After installation of the device is completed, movements
another. Consequently, they are connected by one- or two- in adjacent joints are performed with the maximum possi-
plane hinges (Fig. 7.34). The branches of the hinges must be ble amplitude. If soft-tissue tension is present, the skin and,
coaxial with the respective bone fragments. Skewness and if necessary, the fascia are cut, displaced relative to the
bending of the hinge jaws towards one another are transosseous element, and sutured (Fig. 7.35). If an incision
210 L.N. Solomin
a b
c d
Fig. 7.29 Tensioning wires by means of a standard wire tensioner. (a) is located in the center of the wire tensioner. (d) Otherwise, it will be
Slight fixing of the wire using a wire fixation bolt. (b) The wire is cut difficult to tighten the nut of the wire fixation bolt. (e) After tensioning
off at a distance of 3–4 cm from the fixing bolt of the wire tensioner. (c) and fixings the wire to a support, its free end is bent to the support,
Correct placement of the wire tensioner: the nut of the wire fixation bolt avoiding bending at an angle of 90º
>3 cm is necessary, then the transosseous element should By means of special positioning of the patient in the bed
be reinserted. or through the use of attachments to the external fixation
The frame and skin are carefully cleaned of blood. The skin device, the joints are placed in the position specific for every
where a transosseous element emerges is covered with dressings segment depending on the pathological condition that neces-
of 4–6 cm2 impregnated with 70% ethyl alcohol (Chap. 34). A sitated surgical intervention. The external structure is cov-
control radiograph taken in the operating room is obligatory. ered with a cotton cover (Chap. 34).
a a
c
c
Fig. 7.30 (a) A lever wire tensioner can be substituted for a standard
wire tensioner when use of the latter is complicated or impossible. (b)
Fixing a wire with the lever wire tensioner. The arms of the tensioner
are brought together and the wire is fixed to the support. (c) Removal of
the wire tensioner; the end of the wire is bent to the support
Fig. 7.31 (a) Tensioning a wire by means of turning a post (general

scheme). (b) The post is inclined inwards at an angle of 15–20º and a
wire is fixed to it. (c) The post is held with a flat-nose pliers and the nut
fixing the post is turned. (d) The post is in a vertical position; the wire
is tensed
212 L.N. Solomin
Q = 157 kg Q = 136 kg Q = 91 kg Q = 68 kg
b
a b c d
c
Fig. 7.32 (a) Wire tensioning by turning the wire fixation bolt. (b) The (b, c) or loosen (b, d) the bolt. The maximum tensile force of the wire
maximum possible tensile force on the wire depends on the moment is greater if a wire tensioner is used (b, a, b). [26, 27]. (c) Wire tension-
acting on the bolt and resulting from the wire’s tensile force to tighten ing with the help of a traction clip
a b
Fig. 7.33 To reduce the number of radiographs in a patient undergoing fracture location, the wires are inserted until they touch the bone frag-
fracture reduction, a device to determine the quality of the repositioning ment. The third wire is then inserted until it touches the other fragment
is used (Table 1.2). Neighboring calibrated wires are withdrawn for the (a). If a precise reduction has been achieved, the marks of all the cali-
same distance and fixed on a plate. At the minimum distance from the brated wires will be at the same level (b)
a b c
d e
Fig. 7.34 Frame assembly in deformity correction. Assembly of the supports is in one plane, then one-plane hinges are used. (d, e) If the
proximal (a) and distal (b) transosseous modules. (c) Connection of the angle between supports is in two planes, two-plane or universal hinges
proximal and distal modules by a reductional unit. If the angle between (Table 1.2, item no. 15) are used
214 L.N. Solomin
Fig. 7.34 (continued) (f) for osteotomy

(if it is necessary) modules temporarily f g
should be separated. (g) After osteotomy,
the modules are re-connected
a b
Fig. 7.35 (a) The transosseous element presses on the soft tissues. The skin and fascia are dissected (b), the soft tissues are released (c), and the
wound is closed (d)
7.8 Ilizarov Method of Corticotomy should be made prior to corticotomy. Table 7.1 shows the
positions (Sect. 4.3) optimal for corticotomy execution.
In Part II, methods for the repair of long bone defects and the The positions for the forearm bones are shown for the mid-
correction of deformities are based on Ilizarov corticotomy dle position of a segment: between supination and prona-
together with osteoclasis (Figs. 7.36 and 19.12). For this pur- tion. As noted in the table, when the main vessels and
pose, the rods connecting the device supports proximal and dis- nerves are adjacent to a bone, osteotomy should be done
tal to the contemplated corticotomy area are disassembled, i.e., “openly” (using a surgical approach) in order to avoid their
the modules by which the proximal and distal bone fragments damage.
are to be fixed are separated. Then, through an incision, the adja- An osteotomy of fibular bone is shown in Fig. 15.1. The
cent and lateral cortical plates are dissected with a narrow 5-mm techniques used in the epimalleolar approach, by means of a
osteotome. The proximal and distal modules are rotated and Gigli’s saw, are presented in Sect. 16.8.
flexed manually in opposite directions to fracture the remain- After corticotomy, one or two stitches are placed in the
ing part of the cortical plate. At the Russian Ilizarov Research wound. A cutaneous circular bandage should not be used. To
Center, this type of bone destruction has been shown to result in reduce the hematoma volume, a compression sling-like ban-
the formation of a distraction regenerate. The threaded rods are dage is applied for 1–2 h. Five to eight layers of sterile fabric
reinstalled in the apertures from where they were removed. dressing are used to cover the wound area and are fixed with
If a bone is sclerosed, in order to avoid its splitting, a bandage wrapped tightly on half-pins mounted on the
five or six 2-mm channels arranged like a fan (Fig. 26.2) device (Fig. 7.37).
a b
c d
Fig. 7.36 Ilizarov method of corticotomy. (a) Frame mounting. (b) the lengths of all connecting rods. A small (5–7 mm) incision is made
The proximal and distal modules are separated. The surgeon should for chisel insertion. (c–e) A corticotomy is performed
record the sites of the joining connecting rods and supports as well as
216 L.N. Solomin
f
e
Fig. 7.36 (continued) (f) Osteoclasis is carried out by consecutive flexion in the frontal and sagittal planes. (g) Fluoroscopic control. (h) The
modules are re-connected by rods; the device is stabilized
Table 7.1 Recommended positions for corticotomy of long bones

Levels Bones, positions, notes
Humerus Ulna Radius Femur Tibia
I – 9, 10 – 9, 11, 12 3, 4
Protection of the
n. ulnaris
II 11 4, 5, 6 9, 10 1, 12 3, 4
Protection of
vessels and nerves
III 11 4, 5, 6 1, 11, 12 1 3, 4
Protection of the n. radialis
IV 9, 10 4, 5, 6 1, 12 1 3, 4
Protection of the n. radialis
V 9, 10 4, 5, 6 1, 12 1 3, 4
Protection of the n. radialis Protection of the a.v. tibialis ant.
and n. peroneus profundus
VI 9 4, 5, 6 1, 12 1, 2 4
Protection of the n. radialis and
a. profunda brachii
VII 9 4, 5, 6, 7 1, 12 3, 4 1, 2
Protection of the n. radialis, a. Protection of the a.v. Protection of the a.v. tibialis ant.
collateralis radialis, n. ulnaris poplitea and n. peroneus profundus
and a. collateralis ulnaris
VIII – 4, 5, 6, 7 1 3, 4 1, 2
Protection of the Protection of the a.v. Protection of the a.v. tibialis ant.
vessels and nerves poplitea and n. tibialis and post.
Fig. 7.37 After corticotomy to

reduce the hematoma volume, a
compression sling-like bandage is
applied for 1–2 h. A specially
prepared small elastic sling with
fixing hooks can be used (From
[26])
Features of Reparative Osteogenesis
and the Management of Distraction 8
Osteogenesis in External Fixation
Sergey Aleksandrovich Erofeev

and Elena Andreevna Shchepkina
8.1 Introduction the vascular injury increases; hence, blood continues to

effuse into the area between the bone fragments, leading
Sergey Aleksandrovich Erofeev to hematoma formation. Extensive hematoma is believed to
significantly delay reparative bone formation [113–115].
There are currently two types of bone regeneration, physio- In the body of the adult, bone tissue regeneration depends
logical and reparative. Many authors consider reparative on the osteogenic potential, which is determined by the cells of
regeneration as occurring only in case of traumatic or other the periosteum osteogenic layer [111, 116–118] and endos-
type of pathogenic injury of bone [105–109]. The basis for teum [111, 116, 118–120], the perivascular cells [106, 116,
reparative regeneration is cell division [110]. If following 121–123], and stem cells circulating in the peripheral blood
injury, the differentiated structures are substituted by a dense [106, 124, 125]. All of these cells have been suggested to make
fibrous connective tissue scar, the process is referred to as up the osteoblastic differon, the parent cell of which is a stromal
substitution [109, 110]. stem (mesenchymal) cell [116, 121]. According to numerous
The cellular elements comprising the osseous regenerate observations, by the end of the second day in the proliferative
in the diastasis between bone fragments are responsible for stage of the reparative regeneration process the osteogenic ele-
the synthesis and destruction of the intercellular matrix comments differentiate along osteoblastic, fibroblastic, and chond-
ponents. The functioning of these cells depends on mechani- roblastic lines, together providing the complex structure of the
cal and biological conditions and, in turn, on the local and regenerate [106, 121, 123, 126–129].
systemic factors that determine the metabolism, prolifera- The osteoblastic differon also comprises osteoblasts and
tion, and differentiation of osteogenic cells [106, 111, 112]. osteocytes. The former are found in the periosteum, endos-
During the first stage of regeneration following an injury teum, and osteon channels. A layer of osteoblasts entirely cov-
to bone an inflammatory reaction develops that consists of ers the bone surface. Osteocytes are found in the lacunas, or
three main components: alteration, exudation, and prolifera- bone cavities. According to recent data, these cells are derived
tion. Alteration is characterized by dystrophic and necrotic from osteoblasts [107, 112, 116, 123, 130]. Among the
processes that result in filling of the space between the bone fibroblastic group are fibroblasts, which are the most numer-
fragments. Exudation refers to the presence of hyperemia, ous cells of the fibrous connective tissue, and fibrocytes, which
edema, and infiltration of the site of injury by cellular ele- in response to injury can differentiate into mature, functionally
ments. Organized blood clots, effused blood, and fibrous active fibroblasts [107, 122, 131–133]. In the population of
exudates are replaced with immature connective tissue. cartilage cells there are chondroblasts and chondrocytes.
Depending on the extent of the bone-fragment dislocation, Phagocytizing cell elements in the fracture union area are
macrophages, osteoclasts, and chondroclasts. Following injury
and as part of the inflammatory response, macrophages are
S.A. Erofeev, M.D., Ph.D. (*)
Department of Traumatology and Orthopedics, most commonly observed at the injury site, while osteoclasts
Omsk State Medical Academy, Lenin Str., 12, are needed to remodel the bone regenerate.
Omsk 644043, Russia Active multiplication of the cambial cells of the periosteum
e-mail: esa_rncvto@mail.ru
results in the formation of the periosteal part of the bone regen-
E.A. Shchepkina, M.D., Ph.D. erate [134]. By day 7 post-injury, a marked cuff has formed
ExFix Department,
around the bone fragments of the fracture site. Simultaneous
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia with cell proliferation in the periosteum, blood capillaries from
e-mail: repozition@yandex.ru the endosteum (medullary cavity) grow into the regenerate.
220 S.A. Erofeev and E.A. Shchepkina
Osteogenic cells, located close to the newly forming blood ves- marrow and its ability to produce bone tissue over the short
sels of the periosteum and endosteum, i.e., those with an opti- terms were convincingly proved by Ilizarov et al. [138].
mal oxygen supply, differentiate into osteoblasts, which in turn To study the effects of the different (physical, chemical,
form neogenic bone trabeculae and thus the initial union of the biological, etc.) factors on reparative osteogenesis we con-
bone fragments [113]. Under certain conditions, formation of sider it irrational to focus on the fracture pattern. We agree
the vascular loops is significantly slower than the rapid growth with those authors who believe that the study object should be
of the cell mass. If oxygenation of the regenerate is insufficient, not an experimental fracture but the formation of a distraction
proliferating low-differentiated cells differentiate into regenerate. When the bone or bone fragment is elongated,
fibroblasts or chondrocytes and mediate the formation of the mechanisms of prolonged bone formation come into play.
appropriate tissue, with fracture consolidation achieved by Consequently, a study of the effects of these factors on repar-
reunion of the bone fragments [113]. In this scenario, bone ative osteogenesis during distraction osteogenesis is more
repair dynamics are characterized by a number of consecutive illustrative and the results more convincing [139–142].
phases [135, 136]. As the vessels grow, some areas of the carti-
lage and scar tissue are replaced by neogenic bony tissue. This
is followed by mineralization of the newly formed bone trabe- 8.2 Distraction Osteogenesis
culae and their remodeling into organotypic bone [128, 129].
To create the optimal local and general mechanical and Sergey Aleksandrovich Erofeev
biological conditions for reparative regeneration of the bone
tissue, the following principles must be obeyed: In distraction osteogenesis, damage to the integrity of the
1. Precise, close anatomic reduction of the bone fragments, bone is followed by the process of bone formation, which
with maximum contact between them begins within the first hours after anatomic alignment of the
2. Rigid, constant, and controlled fixation of the bone injured bone margins, such as in fracture union, and occurs in
fragments the diastasis zone between the bone fragments. Some 5–7 days
3. Maximum maintenance of the blood supply after corticotomy of both bone fragments close to the fracture
4. Maximum maintenance of the osteogenic tissues (perios- line, the endosteal reaction begins as small proliferative foci
teum, endosteum, bone marrow) by a conservative of skeletogenous tissue cells, with solitary bone osteoid trabe-
approach during osteosynthesis and after treatment culae extending into the subcortical segment and filling of the
5. Early activation of the patient and restoration of homeo- gap between the bone fragments with fibrin. In addition, fibrin
static balance clot formation is a significant event as is its subsequent retrac-
Among the mechanical factors that define the optimal tion. The distraction tension that is generated along the fibrin
conditions for bone reparative regeneration foremost is a filaments attached to the bone fragment surfaces establishes
stable osteosynthesis. If fixation of the bone fragments is an initial longitudinal orientation that guides the proliferating
rigid and the diastasis between them is minimal, the injured osteogenic cells as well as the collagen fibrils and fibers pro-
bone heals by short-term primary union, without a duced by them. If it is necessary to elongate or thicken the
fibrocartilaginous stage. Improvement of the fixation devices bone, the bone fragments are pulled apart in several stages,
has included the development of various compression-dis- which actually constitutes the distraction procedure. In clini-
traction fixators, among which the Ilizarov external fixator is cal practice, the pace of distraction is 1 mm a day, carried out
the most widely accepted. in four stages (0.25 mm at a time).
Along with the stable fixation of bone fragments, mainte- In the process of further distraction of the bone fragments
nance of the osteogenic elements and blood supply plays an that will lead to the formation of the diastasis regenerate, those
important role. The blood supply defines bone trophism and, areas closer to the bone sections begin to differentiate first,
consequently, the success of reparative osteogenesis. with formation of the first osteoid trabeculae. At the same time,
Disturbance of the bone’s blood supply alters the course of the interlayer of connective fibers, or growth zone, is main-
bone formation processes. Abrupt disturbance of the blood tained in the medial part of the growing regenerate and it
supply in the bone fragments may inhibit the bone’s regenera- retains its size providing that the rhythm, pace, and rigidity of
tive ability. The blood supply to the bone mostly depends on the fixation are optimal. By the end of the first week of distrac-
the integrity of the osteogenic tissues, such as the periosteum tion, bone sections begin to form in the growing regenerate as
and bone marrow [119, 120]. The role of the periosteum as neogenic bone trabeculae [143]. In the growing regenerate,
the source of osteogenesis and thus the obligation to save it there is also profuse tissue vascularization except for a narrow
during surgery are widely known. Analyzing the role of the zone in the connective tissue interlayer in which open blood
periosteum and bone marrow in reparative regeneration, flow persists [112]. Under the effect of the distraction tension
Delloye et al. [137] noted that the periosteum does not com- on the regenerate structure (collagen fibers, osteoid and bone
pensate the absence of the central callus, and the bone mar- trabeculae), blood vessels as well as the cells and even their
row is the main but not the only factor promoting bone tissue organoids become oriented along the direction of the extension
regeneration. The marked osteogenic potential of the bone forces [143]. As distraction proceeds, the maturity or degree of
8 Features of Reparative Osteogenesis and the Management of Distraction Osteogenesis in External Fixation 221
Fig. 8.1 X-ray image of the

dynamics of the distraction
a b
regenerate during its formation
and during fixation: (a) after
surgery; (b) 14 days of distrac-
tion; (c) 28 days distraction;
(d) 58 days of fixation
c d
a b c
d e
Fig. 8.2 Histogram showing the dynamics of distraction regenerate (c) day 28 of distraction; (d) day 60 of distraction; (e) bone 6 months
formation with respect to the stages of limb lengthening and after the after removal of the device
fixation period: (a) day 7 of distraction; (b) day 14 of distraction;
differentiation of the regenerate tissue increases from the their prior tensioning, the reparative process dramatically
growth zone to the margins of the bone fragments, close to slowed and often resulted in the formation of a false joint
which, by the end of the distraction period, the structures of the (neoarthrosis). This classic experiment, well known among
thin cortical plate and medullary cavity will be defined. specialists, once again convincingly proved that stable (rigid)
Symmetric regenerate organization describes the entire period fixation of the bone fragments is of the utmost priority in
of distraction as well as the subsequent one following fixation, traumatology and orthopedics, not only in fracture manage-
when the regenerate rearranges into the typical tubular bone. ment but also in growing bone regenerates.
To form a high-quality regenerate requires stable mainte- However, to date, these findings are essentially qualita-
nance of the organization of its components (stable osteosyn- tive, as there are as yet no quantitative findings concerning
thesis) and thus an optimal distraction regimen; otherwise, osteosynthesis rigidity at each stage of bone injury healing.
in case of dislocation of the bone fragments, e.g., due to
insufficient fixation by the external fixator and poor patient
compliance with the distraction regimen, the rate of regen- 8.3.2 Biological Factors (Maintenance of Blood
eration will be significantly slower, causing the formation of Supply, Bone Marrow and Periosteum)
chondroid tissue and increasing the duration of treatment by
external fixation [144]. A potentially high reparative capacity of bone is achieved if
Maturation of the forming distraction regenerate, i.e., its the paraosseous tissues, periosteum, and medullary cavity
differentiation, occurs at all stages of distraction, continues matter are maximally left intact. The blood supply defines
during the fixation period, and terminates in the rearrange- bone trophism and, consequently, the pattern of reparative
ment of the regenerate as typical mature tubular bone. The osteogenesis. As proof of these statements, in the following
latter occurs after the external fixator has been removed. we present data from experimental trials based on different
The formation of the distraction regenerate, provided by the types of experimental fractures: (a) transverse corticotomy;
action of the mechanical distracting efforts, is distinguished (b) torsion osteoclasia (representative of a spiral fracture);
by the following properties (Figs. 8.1 and 8.2): (c) transverse osteotomy made by a Gigli saw with simulta-
• Internal tensions in the regenerate tissue neous injury of the periosteum, cortical plate, bone marrow,
• Formation and maintenance of polar regenerate structure and intraosseous vessels; and (d) in addition to the above-
in bone sections near the proximal and distal fragments mentioned conditions, a Gigli saw osteotomy in which bone
• Formation and maintenance of the generative zone, i.e., marrow was removed from the fragments along a distance of
the growth zone, during the entire treatment period 10–15 mm.
• Increase in the extent and volume of the bone regenerate Following transverse corticotomy and flexion osteoclasia,
• Differentiation of the regenerate structure the intraosseous vessels were intact. By as early as 10–15 days
• Final complete organotypic rearrangement postoperatively, the endosteum, periosteum, and intermedi-
ary bone union of the bone fragments had formed (Fig. 8.3).
In torsion osteoclasia, after 15 days the line of the spiral
8.3 Features of Osteogenesis in External fracture was indistinct but still visible along its entire course.
Fixation Depending on Various Histology of the bone fragment showed an extensive endos-
Mechanical and Biological Factors teum reaction with the formation of fine-meshed spongy
bone tissue, in the intertrabecular sheets of which fibroreticular
Sergey Aleksandrovich Erofeev bone marrow was observed. The diastasis between the frag-
ments of the cortical plate was mostly filled with loose
8.3.1 Mechanical Factors (Stability fibrous connective tissue. Complete bone union occurred by
of Bone Fragment Fixation) day 30 of fixation. Layers of built-up periosteum surround-
ing the fracture zone were compact and of high optical den-
Experimental studies performed under the supervision of G.A. sity; the intermediary union had formed by compaction of
Ilizarov showed that if the fixation is stable after open osteot- tabular bone (Fig. 8.4).
omy, then despite injury of the nutrient artery the distraction In an osteotomy performed in association with total injury
diastasis will be actively replaced by newly formed bone and by of the osteogenic tissues and supplying artery, after 30 days
the end of the 2-month fixation period a cortical plate will form of fixation bone union was only partial, with a small periosteal
and a medullary cavity will appear in the regenerate [145]. callus at the site of the bone fragments’ junction and the
In trials in which there was limited mobility of the bone frag- remaining line of the osteotomy visible on X-ray.
ments, with each fragment fixated by a pair of K-wires, bone Histological slices showed endosteal, intermediary, and uni-
formation activity during distraction was lower and the dura- lateral periosteal bone union. Complete union was achieved
tion of the normal structure repair increased 1.5- to 2-fold. only after 45–60 days of fixation. X-ray imaging showed the
In marked mobility of the bone fragments, in which fracture line overlapped by shadows of almost the same
fixation of the wires to the ring supports was made without density as the adjacent areas, and a poorly demarcated
a b c
Fig. 8.3 (a) Transversal line of the fracture and intact intraosseous vascular network after transversal corticotomy. Histological slice after 10
(b) and 15 (c) days
periosteal reaction. On histology, the fracture zone contained tical plate and maintenance of the medullary cavity (bone
regenerate bony tissue, mostly of the immature type. The marrow and the main nutritional artery), then experimental
bone marrow was edematous, with marked microcirculation complete union is typically achieved by day 15 of external
disorders. In the cortical plates of the bone fragments, numer- fixation if the injury of the bone structures is minimal. In spiral
ous resorption cavities were observed (Fig. 8.5). fractures with extensive involvement of the cortical plate but
With additional removal of the bone fragments’ medul- minimal injury of other osteogenic tissues, intermediary and
lary cavity content following osteotomy, after 45 days of endosteal bone union occurs by day 30 of external fixation. In
fixation the fissure between the bone fragments was wider osteotomy of the long tubular bones associated with significant
than postoperatively, reflecting significantly marked disor- injury of the periosteum and cortical plate, destruction of the
ders of the microcirculation in the injured zone. The periosteal bone marrow in the bone fragments, and rupture of the main
proliferations overlapped the osteotomy line on one or two nutritional artery, if fixation is stable a partial bone union accom-
sides. Histology showed fibrous connective tissue with carti- panied by marked microcirculation disorders is observed by day
lage inclusions at the fracture level. In the medullary cavity 45 and complete union is achieved by day 60–75 of fixation.
of the bone fragments, there was reticular edematous bone The regenerative potential of injured bone can be used
marrow with numerous microcystic cavities. Following effectively for lengthening if the periosteum and medullary
extensive injury of the osteogenic tissues and blood supply, cavity matter are maximally intact. In experimental length-
union typically occurs after 60–90 days of fixation, at which ening of the tibia and fibula following corticotomy and using
time complete bone union can be defined both clinically and a traditional distraction regimen (1 mm a day in four stages)
on X-ray examination. In this experiment, however, 1 month in the forming diastasis, the regenerate will exhibit the typi-
after the removal of the external fixator, rearrangement of the cal zonal structure and lengthwise striated texture consisting
bony tissue continued in the newly formed bone tissue. Areas of two bone compartments and the connective tissue inter-
of the endosteal regenerate remained in the medullary cavity. layer between them. Under favorable conditions, the regen-
The built-up layers of the periosteum were in the compaction erate’s diameter is greater than that of the adjacent bone
stage and microcirculation disorders continued (Fig. 8.6). fragments. The bone compartments of the regenerate consist
Thus, if the bone fragments are rigidly (stably) fixed follow- of mature spongy bone tissue with reticular bone marrow in
ing corticotomy, with minimal injury of the periosteum and cor- the intertrabecular sheets. The height of the medial zone of
a b c
d e f
Fig. 8.4 (a–c) Day 15 after torsion osteoclasia: (a) X-ray image, (b) histological slice, (c) intermediary fissure filled with fibrous connective tissue
(16 × 10 magnification), (d–f) day 30 fixation: (d) X-ray image, (e) histological slice, (f) intermediary union site (16 × 10 magnification)
the lucid interval should not exceed 5–6 mm and should not space of the regenerate (Fig. 8.9). This arrangement is indica-
account for >20% of the regenerate area (Fig. 8.7). tive of a good basis for the subsequent development of the cor-
The interlayer of the regenerate is formed by immature ele- tical plate during the fixation period.
ments with an abundance of cells; it is profusely vascularized After 30 days of external fixation, the regenerate loses its
with capillaries that have proliferated into it from the bone zonal structure, the diastasis is fully replaced by bony tissue,
compartments parallel to the distraction vector. In the center, a continuous cortical plate forms as well as the medullary
the growth zone is intersected by neogenic bone osteoid trabe- cavity. At the regenerate’s periphery, non-lamellar bone
culae, which can merge to form bone bridges (Fig. 8.8). rearranges into tabular bone, marked by the formation of the
Favorable conditions following osteotomy are confirmed by cortical plate (Fig. 8.10). Based on these X-ray findings of
active rearrangement processes, such as resorption accompanied the distraction regenerate and its advanced morphological
by the new formation of bone tissue, both of which are typical features, the external fixator can be disassembled after posi-
for physiological bone remodeling [146], as well as the pres- tive results of a clinical test.
ence of low-differentiated connective tissue rich in capillaries One month after the external fixator has been disassem-
with newly forming osteoid trabeculae in the intermediary bled, the regenerate, as the result of its rearrangement,
a b c
d e
Fig. 8.5 After osteotomy: (a) X-ray image after 30 days of fixation; (b) histological slice after 30 days of fixation; (c) X-ray after 60 days of
fixation; (d) histological slice after 60 days of fixation; (e) reticular edematous bone marrow in the endosteal regenerate (16 × 10 magnification)
a b c
d e f
Fig. 8.6 After osteotomy with bone marrow removal from the bone 45 days of fixation (magnification 6.3 × 10); (e) X-ray image 1 month
fragments: (a) postoperative X-ray image; (b) X-ray image after 30 days after removal of the external fixator; (f) histological slice 1 month after
of fixation, (c) histological slice after 45 days of fixation; (d) hemosta- disassembly of the external fixator
sis and edema of the bone marrow in the proximal bone fragment after
a b acquires an organotypic structure. In its peripheral parts, the

neogenic tubular bone closely resembles the original bone.
In its center, medullary cavity formation is complete and a
vascular supply is established (Fig. 8.11).
The most unfavorable condition for bone formation dur-
ing limb lengthening is complete transection of the bone,
e.g., either by a chisel or a Gigli saw, since this will injure the
osteogenic tissues, i.e., the periosteum, bone marrow, and
intraosseous blood vessels. In this scenario, the diameter of
the forming bone regenerate is typically smaller than that of
the bone fragment edges. The connective tissue interlayer
exceeds 6 mm in height and may be as high as 10 mm. It may
not be transversed at all by trabecular shadows or it may be
sporadic, thin, and filamentous; its area averages ³30% of
that of the regenerate (Fig. 8.12a). Morphologically, densely
compacted collagen bundles, mostly fibroblastic cells, and
dilated plethoric blood vessels are seen. After 1 month of
external fixation, the zonal structure of the regenerate is still
apparent. The connective tissue interlayer is 1.0–4.0 mm in
height and consists of dense fibrous connective tissue and
Fig. 8.7 Formation of the distraction regenerate following corticotomy cartilage. As a result of the slow formation of bone, there is
(day 28 of distraction): (a) X-ray image; (b) histological slice with van two- to threefold increase in the duration of external fixation
Gieson’s staining using picrofuchsin and in some cases there is false union (Fig. 8.12).
a b
Fig. 8.8 Microphotogram of the regenerate on day 28 of distraction: (a) neogenic bone osteoid trabeculae in the growth zone (magnification 25×);
(b) neogenic capillaries of the growth zone (magnification 63×). H&E staining
a b
Fig. 8.9 Micrograph of the regenerate after 28 days of distraction: (a) resorption and neogenesis of the bone tissue in the regenerate bone com-
partments (magnification 63×); (b) low-differentiated vascularized connective tissue of the growth zone in the intermediary space
a b a b
Fig. 8.11 Thirty days after disassembly of the external fixator (93 days
Fig. 8.10 Day 30 of fixation after 28 days of distraction: (a) X-ray after surgery): (a) X-ray image; (b) histological slice (van Gieson’s
image; (b) histological slice (van Gieson’s staining) staining with picrofuchsin)
Fig. 8.12 Formation of the

distraction regenerate after a b c
“total” osteotomy. (a) X-ray
image after 28 days of distrac-
tion; (b) histological slice after
28 days of distraction (van
Gieson’s staining with picro-
fuchsin); (c, d) after 30 days of
fixation; (e) false union after
150 days of fixation
d e
8.4 Osteogenesis Management The classic approach to limb lengthening, in which the rate
of distraction is 1.0 mm/day in four 0.25-mm stages, results in
Sergey Aleksandrovich Erofeev a more active regeneration. By the end of the lengthening
period, the regenerate diameter is equal to or exceeds the
8.4.1 Optimal Regimens and Distraction Types diameter of the bone fragment edges. The bone compartments
of the regenerate consist of spongy bone that is endoperiosteal
The main stage of the limb lengthening process is the period and periosteal in origin. The regenerate growth zone, which is
of distraction. Indeed, the distraction regenerate forms during 7–8 mm high, is traversed by trabecular shadows and its
limb lengthening. The subsequent rehabilitation period prevailing cell elements are fibroblasts and low-differentiated
largely depends on how the distraction was performed and pre-osteoblasts (osteoprogenitor) cells (Fig. 8.15). The fixation
whether conditions support new bone formation. The period in the classic distraction regimen is 30–70 days (fixation
determining factors in distraction are its rate and pace. The index = 10–23.3 days/cm) (Fig. 8.16).
commonly accepted distraction regimen is typically 1 mm a When the shin is lengthened by 1.0 mm using the 24-hour
day evenly spaced over 4–6 daily stages. However, there are automatic high-frequency distraction regimen, with uniform
also manual devices that allow faster-paced lengthening [147, distraction of the bone fragments by 60 stages a day
148] as well as automatic external fixators with the potential (0.017 mm at a time), the reparative regeneration is more
to increase the distraction pace by tenfold [149–152]. intensive. By the day 28 of distraction, the regenerate exceeds
Single-stage distraction (i.e., distraction of 1 mm/day in the diameter of the bone fragments. The diastasis is almost
one stage) results in a decrease in osteogenesis activity. The completely filled with spongy bone tissue. The connective
characteristically high (up to 13 mm) interlayer of tissue interlayer is 5 mm in height and consists of thin, spo-
connective tissue consists of broad, densely compacted radic, collagen fibers, osteoblasts, low-differentiated cells
bundles of collagen fibers in which fibrocytes prevail. The and fibroblasts. It is traversed by a trabecular system that
presence of old and new hemorrhages in this layer suggests forms the bone bridges. In some areas, the apices of the bone
that the distraction regimen has been traumatic (Fig. 8.13). trabeculae, forming bilaterally from the interlayer, overlap
Constant damage to the newly formed regenerate structure each other, resembling a zipper-like junction (Fig. 8.17).
during the distraction period prevents restoration of the During the fixation period, the regenerate usually loses its
microcirculation and differentiation of osteoblastic cells. zonal structure by day 15. After one month of fixation, the
Hypoxia leads to fibroblast proliferation and intensive regenerate, having completely filled the diastasis, has the
fibrillogenesis, which will in turn prolong the duration of structure of spongy bone. The duration of fixation after auto-
external fixation of the limb to 90–150 days, as determined matic high-frequency distraction is 15–30 days under
under experimental conditions (fixation index = 30–75 days/ experimental conditions (fixation index = 5–10 days/cm), while
cm) (Fig. 8.14). the duration of osteogenesis is only 48–68 days (osteosynthe-
a b c
Fig. 8.13 Formation of the distraction regenerate after 28 days of a showing broad, densely compacted bundles of collagen fibers in the
single-stage distraction regimen of 1 mm/day: (a) X-ray image; (b) his- connective tissue interlayer. H&E staining (16 × 10 magnification)
totopogram (van Gieson’s staining with picrofuchsin); (c) micrograph
a b c
Fig. 8.14 Single-stage distraction (1 mm/day): condition of the regenerate after 30 (a), 60 (b), and 150 (c) days of fixation
a b c
Fig. 8.15 The regenerate after 28 days of distraction under a regimen regenerate, consisting of thin, densely compacted collagen fibers. H&E
of 0.25 mm × 4 times/day: (a) X-ray image; (b) histological slice; (c) staining (6.3 × 10 magnification)
micrograph showing a section of the connective tissue interlayer of the
a b a b
Fig. 8.16 (a, b) Condition of the distraction regenerate after 30 days

of fixation under a regimen of 0.25 mm × 4 times/day: (a) X-ray image;
(b) histological slice Fig. 8.18 Full replacement of the diastasis by bone tissue after 30 days
of 24-h automatic high-frequency distraction: (a) X-ray image; (b)
histological slice
a b c
Fig. 8.17 Distraction osteogenesis after 28 days of 24-h automatic high-frequency distraction: (a) X-ray image; (b) histological slice; (c) micro-
graph. H&E staining (16 × 10 magnification)
sis index = 16–22.6 days/cm) (Fig. 8.18). The active osteogen- with a compensatory increase of the periosteal blood circula-
esis and rapid rearrangement of the regenerate into organotypic tion in response to rupture of the main diaphyseal artery.
bone in high-frequency distraction are promoted by the In clinical practice, the activation of osteogenesis and rear-
rhythmic microstretchings, which stimulate capillary genesis rangement of the bone after rupture of the distraction regenerate
and hence provide a high level of oxygenation. This in turn require approaches that result in the stimulation of osteogenesis.
causes the differentiation of skeletogenous into bony tissue.
8.5 Distraction Osteogenesis Stimulation
8.4.2 Reparative Regeneration of the Bone Sergey Aleksandrovich Erofeev

After Rupture of the Distraction
Regenerate 8.5.1 Dynamic (Compression) Loadings
on the Osteogenesis Area
When new bone formation is active, especially in high-frequency
distraction, there may be premature consolidation of the regener- Techniques to equalize the lengths of the limbs are based on
ate, associated with loss of its ability to grow lengthwise, a condi- restoration of the bone’s anatomy, structure, and function but
tion referred to as regenerate consolidation. According to Paley they are very time-consuming during the fixation stage, as
et al. [153] and Popkov et al. [154], this can lead to serious the formed distraction regenerate must be rearranged into
complications necessitating rupture or osteotomy. Popkov new bone. Hence, in these patients the total treatment period,
et al. [154] suggested that if X-ray examination shows evi- depending on the amount of lengthening, ranges from 4 to
dence of potential regenerate consolidation, associated with 18 months. In recent years, additional approaches to the dis-
replacement of the regenerate growth zone by bone structures, traction of bone formation have been attempted, with the aim
then limb lengthening should be accelerated. of accelerating the consolidation, differentiation, and matu-
Rupture of the distraction regenerate allows a continua- ration of the regenerate and thereby decreasing the treatment
tion of lengthening by significantly slowing down bone for- period as well as accelerating the slow regeneration seen in
mation activity. Based on models in which the formation of a some patients.
distraction regenerate consolidation was followed by its rup- At the Ilizarov Russian Research Center’s Restorative
ture using axial distraction or rotational efforts, it was con- Traumatology and Orthopedics Department, a technique to
cluded that the day of re-distraction should be defined strictly stimulate the bone reparative process [157] has been devel-
individually, considering the level of the rupture, injury to oped and successfully tested. It entails overlengthening of
the intraosseous artery (Fig. 8.19a, b) and the size of the dia- the bone at the height of the regenerate connective tissue
stasis [155]. If the rupture involves the bony part of the layer, followed by a single-stage approach to the bone com-
regenerate, distraction should be started only after 5–7 days. partments of the regenerate such that, by the end of the dis-
If the rupture line is along the connective tissue interlayer, traction period, they have contacted each other (Fig. 8.22).
distraction should be resumed after 7–10 days (Fig. 8.19c, d). Quantitative studies of the growth zone and of the adja-
This period of rest is necessary for the formation of skeletog- cent bone areas of the regenerate by computer densitometry
enous adhesions between the bone fragments [156]. have shown that by the end of the distraction they contain
If the distraction is started soon after the regenerate rupture, non-mineralized and slightly mineralized structures in
then due to the marked circulatory disorders reparative osteo- amounts of 48.3 ± 1.3% and 21.3 ± 0.9%, respectively. After
genesis slows down dramatically; cystic cavities are formed in compression has taken place in the regenerate growth zone,
the regenerate, and a long period of fixation will be required to moderately mineralized structures predominate (54.5 ± 1.5%),
allow the diastasis to fill with bone tissue. In repeated lengthen- with non-mineralized structures accounting for just
ing after a lengthwise rupture of the regenerate from the dis- 17.8 ± 1.2% (Fig. 8.23).
traction, the rate of growth of the bone compartments decreases On the histological slices obtained after regenerate com-
and replacement of the connective tissue interlayer with bone pression, changes in the appearance of the structures making
tissue is slow. During the fixation period, activation of periosteal up the interlayer are seen that are typical only for this
osteogenesis in the regenerate is observed as well as osteoporo- regenerate state, such as disarrangements of the osseous and
sis of the developing bone fragments (Fig. 8.20). At the same osteoid trabeculae, with deformation of their apices and con-
time, after injury (rupture) of the regenerate by torsion, osteo- nective tissue bundles. In some areas, there is occlusion of
genesis remains active such that after 1 month of fixation the regenerate bone; the interlayer structures become
following the repeated distraction the regenerate consists of jammed, accompanied by alterations in their basic initial ori-
spongy bone tissue accompanied from within by the formation entation from a lengthwise to a transversal and wavy pattern.
of a medullary cavity and cortical plate (Fig. 8.21). Activation In addition, transverse zigzag bone structures form in the
of periosteal osteogenesis after regenerate rupture is associated intermediary zone of the regenerate (Fig. 8.24).
Fig. 8.19 (a, b) X-ray images of

the distraction regenerate after its a b
rupture. (a) At the level of the
interlayer, there is injury of the
descending branch of a nutritional
artery after regenerate rupture at
the level of the proximal bone
compartment. (b) After rupture of
the regenerate by torsion, the
nutritional artery is intact.
(c, d) Histological slice instead:
(c) in 5 days after fixing the gap
regenerate at the level of the
proximal bone department;
(d) after 7 days of fixing after the
break regenerate at the level of
connective tissue interlayer
c d
a b a b
Fig. 8.20 (a, b) Day 30 of the distraction regenerate after 30 days of

fixation following re-distraction subsequent to its lengthwise rupture at
the level of the growth zone. The connective tissue interlayer remains Fig. 8.21 (a, b) The distraction regenerate after 30 days fixation fol-
and there is a marked compensatory periosteal response lowing re-distraction due to regenerate injury by torsion, with mainte-
nance of the intraosseous blood vessels. Osteogenesis is active and the
regenerate consists of spongy bone tissue
a b
Fig. 8.22 Compacting of the

distraction regenerate: (a) the
distraction regenerate after
35 days of distraction and
(b) immediately after
compression of the regenerate
Fig. 8.23 Lengthwise recon- a

structions of the distraction
regenerate as seen on CT:
(a) after 35 days of distraction
and (b) 7 days after regenerate
compression
a b c
Fig. 8.24 Micrographs after regenerate compression: (a) groups of trabeculae with zigzag contact; (b) occlusion of the bone trabeculae; (c) defor-
mation of the trabecular apices and the interlayer structure. H&E staining. (a, b) Loupe magnification, (c) 25× magnification
Fig. 8.25 Distraction regener-

ate: (a) day 28 of distraction;
a b c
(b, c) 7 days after autologous
bone marrow grafting into the
medial interlayer
Under experimental conditions, consolidation of the regen- close to the interlayer and on their surface, there is a high
erate occurred after only 19–30 days of fixation (fixation density of osteogenic cellular elements exhibiting highly
index = 6.3–10 days/cm; osteosynthesis index = 19.6– active bone formation (Fig. 8.26).
23.3 days/cm). Thus, in compression of the distraction regen- Activation of cellular biosynthetic processes is evidenced
erate there is more rapid rearrangement, associated with by the activated phenotype of most osteoblasts, with shifting
utilization of the excessively formed desmal elements of the of the nuclei to one of the cell poles, the lighter tint of the
regenerate, which results in more rapid consolidation. nuclei due to the prevalence of euchromatin, the presence of
However, this technique can be applied only if the anatomic 2–3 nucleoli, and an increase in the volume of the vacuo-
and functional condition of the limb to be lengthened is good, lated cytoplasm. At the same time, there is a marked apopto-
since overlengthening (by >20%) can lead to the development sis of the osteogenic cells in association with the activated
of marked contractures in the adjacent joints [158–162]. proliferation of pre-osteoblasts and osteoblasts (Fig. 8.27).
After 28 days of fixation, the regenerate consists of spongy
bone tissue. At its periphery, compacting continues and the
8.5.2 Use of the Bone Marrow cortex forms (Fig. 8.28) [167].
and Growth Factors Thus, stimulation of distraction osteogenesis by autolo-
gous bone marrow is effective and does not require expen-
One aspect of osteogenesis stimulation is use of the bone sive equipment and materials. The dynamics of osteogenesis
marrow, as bone marrow grafting is known to promote the at these stages of fixation indicate progressive replacement
earlier formation of osteoblastic tissue in the regenerate. of the regenerate connective tissue interlayer with bone
Clinically, bone marrow has been used to manage false joints structures. Osteogenesis stimulation likely involves the
and defects, with several positive effects. It should be noted repopulation of osteogenic precursor cells in the local graft-
such methods do not involve a histocompatibility complex ing of low-differentiated pluripotential precursor cells into
antigen response, thus excluding the occurrence of graft- the poorly regenerating area. The grafted precursor cells dif-
versus-host disease [163–165]. ferentiate into pre-osteoblasts and osteoblasts in response to
Hypoplastic regenerate graft stimulation is an experimen- osteogenic stimulation by the local microenvironment. The
tally proven method, in which at the end of the distraction activated phenotype of these cells suggests the activation of
period bone marrow is grafted into the connective tissue biosynthetic processes. The formation and differentiation of
interlayer [166]; after 7 days it is replaced by bone osteoid the regenerate bone osteoid trabeculae has been shown to
trabeculae (Fig. 8.25). The structural features of the connec- occur in association with an elevated density of the osteo-
tive tissue interlayer in this case are fibroblasts with very genic cell elements and osteoblasts.
dense nuclei and the formation of a matrix structure resem- In a study of bone-growth-regulating factors including
bling osteoid. Both in the bone osteoid trabeculae that form those derived from an extract of mineralized bone matrix, the
a a
b b
Fig. 8.26 Micrograph of the regenerate growth zone 7 days after Fig. 8.27 Micrographs of the regenerate growth zone 7 days after
osteogenesis stimulation by the bone marrow: (a) areas of osteoid osteogenesis stimulation by the bone marrow: (a) activation of the
showing a moiré pattern; (b) the high density of cellular elements in the osteogenic elements, with a shift of the nuclei to the poles of the cells
bone osteoid trabeculae and intertrabeculae space. H&E staining and vacuolization of the cytoplasm; (b) apoptosis of the osteogenic cell
elements. H&E staining
protein fraction isolated from bone tissue and from the serum
of animals during active osteogenesis was found to have bio- 8.5.3 Stimulation of Distraction Osteogenesis
logical growth-promoting effects [168, 169]. A stimulating Using Intramedullary Curved Wires
effect on bone formation was observed following the applica-
tion of prefractioned dried blood plasma, obtained from ani- Elastic fixation of the long tubular bones by curved intramed-
mals in the distraction period, into the connective tissue of the ullary wires has been successfully used in fractures occurring
distraction regenerate when the latter was already completed in children. This method of osteosynthesis, besides additional
[171]. After 6 weeks of fixation following the application of fixation of the bone fragment, activates blood circulation in the
plasma components into the regenerate, its diameter was periosteum, promoting periosteal bone formation. The wires
larger or equal to the diameters of the adjacent bone fragments. have no effect on the intramedullary blood circulation and do
The regenerate lost its zonal structure and mostly consisted of not prevent endosteal osteogenesis. In this method of intramed-
neogenic bone tissue. Strong evidence of the stimulating ullary osteosynthesis, circular microdeformities of the regen-
effect was seen CT imaging of the distraction regenerate inter- erate during functional loading promote osteogenesis.
layer after 6 weeks of fixation, which showed replacement of To stimulate osteogenesis, lengthening in combination
the interlayer by neogenic bone tissue that had proliferated with intramedullary reinforcement by curved wires has been
beyond the bone tube, indicating excessive osteogenesis proposed. Experimental studies demonstrated the occurrence
(Fig. 8.29a, d). In the control experiments, in which saline of not only endosteal but also periosteal osteogenesis. During
solution was administered into the regenerate connective tis- the distraction process, it may be necessary to increase the
sue interlayer, after 6 and 12 weeks of fixation the regenerate pace to avoid premature consolidation. Union is achieved by
had maintained its zonal structure (Fig. 8.29c). day 30 of the fixation period (Fig. 8.30a). In this method,
a b
Fig. 8.28 (a) Day 28 of distraction: autologous bone marrow grafting into the medial interlayer; (b) after 30 days of fixation
a b c
a b c
Fig. 8.30 Lengthening over the wires: (a) day 30 of fixation after 28 days of distraction; (b, c) day 30 days after disassembly of the external fixator
disassembly of the external fixator is not followed by second- inconvenience for these patients. To shorten the fixation
ary deformity or bone fracture since the intramedullary wires period various limb lengthening methods have been sug-
are not removed (Fig. 8.30b). Morphologically, the regenerate gested, especially in thigh lengthening, in which an intramed-
consists of spongy bone tissue with a fine-meshed texture and ullary nail is used, either alone or in combination with the
the absence of a connective tissue interlayer. Around the external fixator [172–174]. The periosteum plays a key role
canals of the intramedullary wires, there is a layer of dense in lengthening of the long tubular bones.
connective tissue and newly formed trabeculae (Fig. 8.30c). Successful thigh lengthening over a nail (LON) in combi-
Thus, this method of intraosseous synthesis obeys one of the nation with an external fixator was first mentioned by Paley
most important principles of Ilizarov’s technique: mainte- et al. [175]. As an external fixator they used either Ilizarov’s
nance of the intraosseous blood circulation. fixator or the monolateral OrthoFix fixator. After the neces-
sary lengthening was achieved, the intramedullary nail was
blocked and the external fixator disassembled. The nail was
8.6 Special Features of Distraction removed after complete rearrangement of the bone regener-
Osteogenesis in Lengthening ate. Using this approach, a number of authors reported shorter
Over a Nail periods of consolidation of the bone regenerate, a decreased
incidence of complications, and faster rehabilitation [175–
Sergey Aleksandrovich Erofeev 178]. However, other authors reported slow regeneration, a
high incidence of complications, and contraindications to the
The significant duration of fixation that is characteristic of procedure [179]. Thus far, morphological studies of LON
the use of an external fixator in classic lengthening strategies have been singular and have not yielded extensive insight
often delays the functional repair of the limb, an obvious into the ongoing processes in the regenerate.
Fig. 8.29 Replacement of the regenerate growth zone with bone tissue transverse sections of the distraction regenerate interlayer area; (c)
6 weeks after the administration of blood plasma components into the X-ray image of the saline control experiment, showing maintenance of
regenerate connective tissue interlayer: (a) X-ray image; (b) CT images: the regenerate’s zonal structure and interlayer
a b c
Fig. 8.31 Dynamics of distraction regenerate formation in lengthening of a dog’s foreleg over a nail: (a) day 28 of distraction; (b) 30 days after
fixation; (c) 1 month after nail removal
In a study in Kurgan of experimental LON of the arm bone, appears to be the zone of fibrous connective tissue, with hem-
during lengthening between bone fragments, a bone regener- orrhages and sparse capillaries. Osteoporosis of the cortical
ate formed that was typical for distraction osteosynthesis of plate is accompanied by a massive periosteal layer made up
the tubular bones, associated with adequate growth of the of the spongy bone tissue of the bone fragments (Fig. 8.33b).
respective bone compartments. Active bone formation in the Thus, in lengthening of the bone using the combined
diastasis was mostly periosteal. At the fixation stage, bone method (external fixation and an intraosseous nail), the orga-
regeneration was accompanied by marked cuff-like periosteal notypic rearrangement of the regenerate is still seen a year
layers that built-up along the diaphyseal parts of the bone after nail removal. While this experimental approach cer-
fragments, which afterward became compacted, increasing tainly cannot be fully implemented in the clinic, it points out
the regenerate volume and the diaphysis diameter in general. the advantages and disadvantages of using an intraosseous
At the same time, at the end of the distraction period, at the fixator (Table 8.1).
fixation stage, and after disassembly of the external fixator Clinical guidelines for the method of long-bone LON are
osteoporosis was observed in the distal fragment (Fig. 8.31). covered in Chap. 26.
Morphological studies showed that, in LON, by the end
of distraction there is an extensive zone of fibrosis in place of
the nail. The regenerate consists of bone compartments, i.e., 8.7 Osteogenesis Stimulation
spongy bone tissue of different maturities and a medial inter- by Different Types of Grafts
layer of fibrous connective tissue. A marked periosteal osteo-
genesis was noted both in the regenerate and in the inferior Sergey Aleksandrovich Erofeev
bone compartment (Fig. 8.32).
After 30–45 days of fixation, an extensive zone of fibrosis The course and termination of reparative regeneration are
and part of the canal are seen. Fibrous tissue along the periph- mostly defined by the regenerative course and, primarily,
ery has ossified. The regenerate has rearranged into spongy by the trophic supply, which in turn depends on the blood
bone tissue. Resorption cavities are present in the cortical circulation in the regeneration zone [113, 180]. Omeljanenko
plate of the bone fragments. Of particular interest is the and Slutski [181] subdivides the factors affecting the blood
marked periosteal osteogenesis in the regenerate and in the supply into two groups: angiogenesis stimulators and
inferior bone compartment (Fig. 8.33a). One month after blood-flow stimulators. Stimulators of angiogenesis, and
removal of the nail, the central part of the bone regenerate of osteogenesis, are growth factors. Growth of the vascular
Fig. 8.32 Histological slices

a b
in lengthening over a nail:
(a) the distraction regenerate;
(b) the distal bone fragment.
Maintenance of the canal from the
intramedullary nail, resorption of
the cortex plate, and the build-up
of periosteal layers on the bone
surface are seen
Fig. 8.33 Histological slices of a

the distraction regenerate in b
lengthening over a nail. (a) On
day 45 of fixation, the regenerate
has rearranged into spongy bone
tissues differing in maturity.
(b) One month after pin removal,
the central part of the regenerate
comprises fibrous connective
tissue; there is osteoporosis of
the cortex plate and a build-up of
spongy bone tissue in the
periosteal layer
bed in the area of large diaphyseal defects can be activated constant or varying magnetic fields, low-energy laser radi-
by an adrenal gland extract and by antioxidants. An increase ation, etc.
in the bloodstream requires a more active course. For Nowadays, the most widely used method of reparative
example, local hyperemia in the area of the injured bone and regeneration of the bone tissue is replacement of the defect
an intensified microcirculation have been triggered by ind- using bone alloplasty. However, the replacement with foreign
uctothermy, UHF therapy, ultrasound, electrostimulation, bone to supplement that bone formation in the host occurs
Table 8.1 Combined method of an external fixator and intramedullary One of the most effective ways to overcome the problems
pin in a long tubular bone of bone plastic surgery is the use of synthetic graft materials.
Advantages Disadvantages Synthetic implants contain as their mineral component cal-
1. Improved fixation stability of 1. More traumatic surgical cium phosphoric acid salts mixed with other substances,
the bone fragments intervention such as a mixture of hydroxyapatite (HAP) and calcium
2. Lower risk of developing 2. Risk of deep inflammation of
b-phosphate; calcium phosphate granules in gelatin; HAP
transfixion contractures and the nail canals and spread of
soft-tissue inflammation in the the infection trough the evenly spread on a poly-a-lactide matrix; and ceramics made
area of the transosseous medullary canal from HAP and calcium b-phosphate. According to the char-
element outlet 3. Need for additional surgical acter of their interaction with biological tissues, these mate-
3. Improved patient comfort interventions to block and
rials are subdivided into biodegrading (manufactured on the
during treatment due to earlier remove the nail
disassembly of the external 4. Osteoporosis development basis of collagen, polysaccharides, HAP or biogenic amine
fixator 5. Long-term organotypic salts) and non-biodegrading (metals, plastic, bioceramics).
4. Shorter rehabilitation period rearrangement of the Biodegrading materials are gradually lysed by the host’s
regenerate
cells and replaced by biological tissue. In some cases, dense
fibrous tissue is seen at the site of their insertion instead of
slowly, and the antigenic properties of the allogenic tissue must full-grown bone tissue. Consequently, new, biologically ade-
be taken into account since graft rejection is possible. In addi- quate materials are still needed.
tion, long-term suppurations and fractures at the site of the for- The search for alternative methods has led to the develop-
mer defect can occur. Moreover, the use of allotissues in a ment of biomaterials capable of rearrangement and with
number of countries, including Russia, involves certain osteoconductive and osteoinductive properties. Such materi-
difficulties. For instance, there are still no guidelines that strictly als most often consist of several components and can include
regulate tissue centers with respect to the procurement, prepa- both osteogenic precursor cells and osteoinductive and osteo-
ration, and storage of allogenic grafts. The burning question conductive components of the bone matrix. Experimental
today is the use of biological grafts, given the high incidence of and clinical trials using such biocomposites have proven
viral hepatitis, HIV infections, and tuberculosis, as these dis- their feasibility and adequacy compared with autologous
eases may be transmitted to the recipients of such bioimplants bone.
after bone grafting. In addition, the reagents used in the conser- In recent years, bone pathologies have been treated in
vation and sterilization of biological tissues may cause a toxic maxillofacial surgery, traumatology, and orthopedics using
and immunologic response of the graft recipient. Unfortunately, HAP preparations as well as collagen preparations such as
in Russia, the majority of techniques to conserve and sterilize Colapolum, Ossacol. LitAr, Osteomatrix, OSTIM-100, and
allogenic biological tissues do not meet the international stan- Collapan. Artificial HAP, contained in biocomposition
dards, nor do they satisfy graft safety requirements. preparations, is chemically identical to the HAP comprising
To prevent immune conflicts and to exclude other disad- the main mineral compound of bone tissue and has therefore
vantages of alloplasty, specially prepared bone grafts are been widely used in replacing bone-tissue defects. HAP and
being used, such as bone grafts in which the organic layer materials based on it are capable of resorption and are uti-
has been removed, bioceramic matrix, demineralized bone lized by the body, including in the stimulation of reparative
matrix, and allogenic fetal bone [182–184]. However, these processes in bone. In an isotopic tagging study, it was
are not always of benefit in terms of an active course of observed that artificial HAP crystals in a biological system
regeneration; in fact, correct bone formation is inhibited by undergo metabolic changes in the cells of the body, includ-
the presence of massive grafts in the zone of new bone for- ing their breakdown to calcium and phosphorous ions,
mation. Accordingly, some authors perforate the tubular which later become integrated within the structure of the
demineralized bone matrix or use other physical or chemical regenerating bone tissue. Compared with allogeneic tissues,
methods to alter the allogenic bone. biocomposites have a number of distinct advantages, the
In Russia, due to the deficiencies of modern biological foremost being the absence of rejection risk, allergic reac-
grafts, autologous tissues are widely used in reconstructive tions, and the transmission of HIV and hepatitis virus
surgeries, including in traumatology and orthopedics. Indeed, infections.
bone autoplasty can solve the problem of bone defect replace- According to the most authors, the essential properties of
ment and partially that of bone regeneration stimulation. But a bone graft and biocompatible artificial materials are,
bone autoplasty also has a number of disadvantages: (a) there ideally.
is rather quick lysis of the graft; (b) the possibility of suppura- 1. The ability to enhance regeneration processes, attract
tive inflammatory complications; (c) a graft volume that is inducible osteogenic precursor cells and promote their
insufficient to fill the defect; (d) additional surgical trauma for differentiation into chondroblasts and osteoblasts, and
the patient in obtaining an autologous graft. For these reasons, stimulate DNA synthesis and the proliferation of the
autoplasty has gradually fallen out of favor. determinate osteogenic precursor cells
2. The ability to undergo biological breakdown optimally (cascade) system, the final product of which can be several
timed within bone formation processes biologically active compounds that regulate intra- and extracel-
3. The ability to create a local antibacterial environment lular metabolism [186]. The end result of these growth factor
The aim of ongoing studies is to develop new plastic effects is stimulated osteogenesis. In clinical trials, much atten-
materials having the above-mentioned properties and to tion has been paid to the use of platelet-rich plasma (PRP),
implement their use in combination with traditional methods which is the source of numerous important growth factors, such
of treatment: anatomic reduction, stable fixation of the bone as PDGFaa, PDGFbb, PDGFab, TGF-b1, TGF-b2, EGF, and
fragments, early dynamization, loading, weight-bearing etc. VEGF. PRP and other plasma components containing stimulat-
ing factors are relatively easy to obtain from the patient’s own
blood for use in subsequent surgical treatment.
8.8 Use of the Bone Marrow Cells, Another approach to osteogenesis involves the transplanta-
Morphogenetic Proteins, tion of stromal (mesenchymal) cells, exploiting their potential
and Growth Factors for bone formation. These cells can be used to establish addi-
tional osteogenic foci. The osteogenic potential of bone marrow
Elena Andreevna Shchepkina stromal cells was studied by Fridenshtein and Lalukina [120],
among others. Fibroblast-like stromal cells of the bone marrow
The osteoinductive properties of almost all biocomposition are also referred to as mesenchymal stem cells (MSCs), bone
materials are conferred by either their cells or bioactive compo- marrow stromal cells (BMSCs), and bone marrow mesenchy-
nents. For instance, bone marrow cells, fibroblasts, platelets, mal stem cells (BM-MSCs). The most commonly used term is
morphogenetic proteins, growth factors, hormones, as well as multipotential mesenchymal stromal cells (MMSCs). This cell
other bioactive substances may directly cause osteoinduction population is characterized by a distinct CD-marker phenotype
or stimulate osteogenesis. Fridenshtein and Lalikina [120] and and can be derived from the bone marrow, adipose tissue, bone
Lavrischeva and Onoprienko [106] considered mucopolysac- tissue, or umbilical blood. The peripheral blood also contains a
charides (proteoglycans) to be the inducers of osteogenesis. small number of MMSCs. In cultures of human MMSCs, tar-
Urist and Strates [182] showed that morphogenetic proteins in geted differentiation can be maintained for 8–10 passages [187].
native bone matrix have bone-formation inductive features and Experimental studies of osteogenesis in the area of the bone tis-
that they specifically influence the differentiation of precursor sue defect have examined several different settings for the use of
osteogenic cells in mesenchymal tissue. Nowadays, “osteoin- these cells: following bone marrow transplantation, as cultures
ductive osteogenesis” mainly refers to so-called bone morpho- of both fibroblasts and MMSCs [188], and in the replacement of
genetic proteins (BMPs), which induce phenotypic alterations bone tissue defects with different matrices seeded with MMSCs
in multipotential mesenchymal stromal cells and inducible [189, 190]. In addition, a stimulating effect of bone marrow and
osteoprodromal cells, resulting in their differentiation into cultured fibroblasts injected into the area of the distraction
osteoblasts [181]. Today, 15 different BMPs have been regenerate was reported [191, 192].
identified that are active at different stages in the differentiation In 1986, Fridenshtein proposed the use of a bone myeloid
of inducible osteoprodromal cells into osteoblasts. The com- graft containing demineralized matrix and allogeneic bone and
plex effects of BMPs include: differentiation of multipotential saturated with cells of the autologous bone marrow that had
mesenchymal stromal cells into chondrocytes or osteoblasts, been cultured for several days. The stimulating effect of this
acceleration of the maturation and calcification of bone matrix, automyelogenous explant on bone formation was experimen-
establishment of the differentiation pattern of multipotential tally confirmed and the graft has been used in the clinical setting
mesenchymal cell lines into osteoblastic lines, with the latter with positive results [165]. Autologous bone marrow transplan-
now used in clinical practice. BMPs are administered both as tation in an area of slow union or false union has been clinically
injections and as a compound of biocomposites [185]. implemented. Experimentally, attempts to stimulate reparative
In native bone tissue, growth factors are constantly present osteogenesis have included the use of an embryonic xenotrans-
and they mediate cell proliferation and differentiation, angio- plant consisting of a suspension of chicken embryo cells [193],
genesis, and mineralization in both the physiological and while in clinical trials bone marrow cells, fibroblasts cultured
reparative regeneration of bone tissue. The growth factors that in vitro [194], and the mononuclear fraction of the bone marrow
stimulate bone neogenesis are: transforming growth without pre-culturing [195] have been tested. However, cultured
factor (TGF-b), insulin-like growth factors type I and II MMSCs appear to have a much greater potential than suspen-
(IGF-I, IGF-II), vascular endothelial growth factor (VEGF), sions of bone marrow cells or their mononuclear fraction,
colony-stimulating factor (CDF), platelet-derived growth fac- although MMSCs are found in limited abundances of 2–5 cells
tor (PDGF), epidermal growth factor (EGF), and basic and per 106 mononuclear leukocytes. In clinical trials to stimulate
acidic fibroblast growth factors (bFGF and aFGF). These osteogenesis, cultured MMSCs have been injected into the non-
growth factors bind to the cytoplasmic receptors of target cells union site [196] or the distraction regenerate [188, 197], result-
and thus activate intracellular pathways in a multistage ing in a decrease in the fixation index. MMSC injection into the
a b c
d e
Fig. 8.34 Dynamics of the rearrangement of the distraction regenerate as regenerate, and the lower row the distal regenerate, in which MMSCs
seen on a CT study of patient I, 56 years old, who underwent bilocal were injected at the end of the distraction (a). The results after (b)
replacement of a tibial defect. The upper row shows the control proximal 2.5 months, (c) 3.5 months, (d) 9 months, and (e) after 4 years are shown
distraction regenerate resulted in a more rapid formation of the the bone marrow was used to treat non-union of the long bones
bone cortical layer, a more even bone structure, and a prospec- and as a replacement for bone tissue defects [194, 198, 199]. In
tive observation of the full resemblance of the new bone to the the latter setting, collagen films, combined with adhesion cells
adjacent healthy bone (Figs. 8.34 and 8.35). and vascularized periosteal grafts, have also been investigated
The use of cells immobilized in a matrix is of particular [199]. Compared with the classic rearrangement of the demin-
interest for clinicians. In clinical studies, a demineralized bone eralized bone transplant, in which there is gradual replacement
transplant seeded with fibroblasts and MMSCs derived from by the newly formed bone derived from the bone fragments
Fig. 8.35 X-ray images of the same

patient as in Fig. 8.34, showing the a b
control proximal regenerate and the
distal regenerate (pointed by arrows),
into which MMSCs were injected at
the end of the distraction (a). The
results after 4 years are shown in (b)
Fig. 8.36 Dynamics of a demineralized bone transplant

in a female patient. The images show the CT findings at a
different levels at 1 month (a), 3 months (b), 5 months
(c) and 4 years (d) after surgery
(Fig. 8.36), in the graft-treated defect union occurred mostly were subsequently integrated (Figs. 8.37 and 8.38). A marked
via the graft, inside of which compact bone formation was periosteal callus was absent; along the callus and in the area of
faster. The graft was observed to contain osteogenic foci which the bone graft, the formation of a medullary canal was noted
a b
c d
Fig. 8.37 A 42-year-old female patient diagnosed with atrophic non-union of both lower legs. In the left femur, fracture union with shortening,
and chronic osteomyelitis in remission. (a–d) Before surgery

(e–g) 1 month after surgery e f
performed on both lower legs
using a demineralized bone
transplant seeded with MMSCs
g
Fig. 8.37 (continued) (h–j) 5 years after surgery

h
i j
Fig. 8.38 CT monitoring over the course of treatment of the same patient as in Fig. 8.37: left (a)
Fig. 8.38 (continued) Right (b) lower leg
between 6 months and 4 years after treatment (Fig. 8.39); the fully developed bone tissue is formed (Fig. 8.41). In the stud-
density of the graft in long-term period remained higher than ied grafts, signs of angiogenesis and osteogenesis were
in the adjacent areas of the bone fragments. confirmed 1 and 5 years post-transplant (Figs. 8.42 and 8.43).
In the replacement of bone tissue defects, a demineralized Thus, besides the obvious osteoinductive and osteoconduc-
bone transplant seeded with MMSCs ossifies in 5–8 months tive functions of the transplanted cells, they also exhibit an
(Fig. 8.40); over the long-term, according to CT findings, osteoblastic function.
Fig. 8.40 A 27-year-old male patient with a post-traumatic defect of course of treatment with a demineralized bone transplant seeded with
the left tibia: (a) before plastic surgery of the defect; (b–e) over the autologous MMSCs: 2 and 5 months after plastic surgery
Fig. 8.39 CT scans from the

same patient as in Figs. 8.37 and
8.38 4 years after removal of the
external device
a b c
d e
f g
Fig. 8.40 (continued) (f, g) the result at 1 year

Fig. 8.41 Dynamics of graft

rearrangement as seen on CT in
the same patient as in Fig. 8.40:
(a) immediately after plastic
surgery of the defect; after 3 (b)
and 5 (c) months post-transplant;
(d) after 4 years
a a
b b
Fig. 8.42 Angiogenesis and osteogenesis at the site of bone plastic Fig. 8.43 Angiogenesis and osteogenesis at the site of bone plastic
surgery using a demineralized bone transplant seeded with MMSCs. surgery using a demineralized bone transplant seeded with autologous
The images show the results 1 year after surgery. H&E staining, (a) MMSCs. The images show the results 5 year after surgery. H&E stain-
magnification ×100, (b) magnification ×200 ing, (a) magnification ×100, (b) magnification ×200
External Fixation at the Vreden Russian
Research Institute of Traumatology 9
and Orthopedics
9.1 Introduction The history of transosseous osteosynthesis, as established

and developed at the RISC “RTO” can conventionally be
The Vreden Russian Research Institute of Traumatology and divided into three periods:
Orthopedics, formerly known as the Leningrad Institute of 1. Early experiences in external fixation (1961–1968)
Traumatology and Orthopedics, (LITO), has a long history 2. Consolidation of transosseous osteosynthesis (1968–2001)
in the development of external fixation methods. The Russian 3. The present stage of external fixation (2001–present)
Ilizarov Scientific Center “Restorative Traumatology and
Orthopedics” (RISC “RTO”) was a branch of the LITO until
1971. In 1972, thematic courses in external fixation training 9.2 The Early Experience in External
were organized by the RISC “RTO” on the basis of those Fixation (1961–1968)
previously held by the LITO. Thus, the Institute pioneered
the development of external fixation in the former USSR. The pioneer in external fixation at the Vreden LITO was
The Leningrad-St.Petersburg approach to the development Varvara Semenovna Balakina. On June 21, 1961, she
of external fixation was based on the work of V.S. Balakina, performed a compression arthrodesis of the knee joint
V.K. Rumjantsev, V.M. Demyanov, Z.K. Bashurov, using the Ilizarov device (Fig. 9.2). Her assistants were
V.A. Neverov, I.P. Sobolev, N.V. Kornilov, V.I. Karptsov, Anatoly Dmitrievich Lee, and Vladimir Konstantinovich
Rumjantsev V.K., V.M. Mamayev, P.P. Zhukov, V.I. Kulik, Rumjantsev.
V.M. Mashkov, E.G. Grjaznuhin, V.D. Usikova, By the end of the 1960s, the LITO team had not only mas-
V.V. Dolgopolov, Dadalov M.I., K.A. Novoselov, V.A. Zhirnov, tered the experience of the Kurgan clinic but had also actively
D.V. Nenashev, A.P. Varfolomeyev, I.A. Voronkevich and participated in the analysis of the Ilizarov method, as certified
many other researchers and orthopedic surgeons (Fig. 9.1). in the following document:
The underlying criteria of this approach are the use of The order № 51 from April, 27th, 1965. Danilova Lydia
scientifically proven principles in the organization of external Aleksandrovna, head of the adult orthopedics department and
fixation, i.e., reparative regeneration as the aim of external Eretskaya Mara Fedorovna, senior researcher since May 3rd
fixation, the use of pin and wire (combined, hybrid) device of this year, have been sent to Kurgan for studying and an
assessment of a method of treatment of patients with skeletal
configurations derived from original equipment, and a detailed damages, offered by doctor G.A. Ilizarov. Business trip term–
elaboration of the therapeutic methods for the different ortho- 10 days. The reason: the order of the Deputy Minister of the
pedic pathologies. Following years of work, more than 40 Russian Ministry of Public Health S.V. Sergeev.
copyrights and patents have been granted, accompanied by
more than 1,500 publications and 200 reports at congresses V.S. Balakina’s research was devoted to comparative
and conferences. Within the Institute, seven doctoral and 21 assessments of the various methods of compression osteo-
master’s theses have been awarded, and 13 original scientific synthesis (Ilizarov and Gudushauri devices) in the treatment
studies have been carried out (Tables 9.1, 9.2, and 9.3). of fractures, malunions, and non-unions (1964) and was the
first foray into research in this field at the institute. One of the
first publications regarding external fixation (femoral length-
ening) in the main Russian orthopedic journal of that time
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia Traumatology, Orthopedics and Prosthetics (1966, no. 6)
e-mail: solomin.leonid@gmail.com was that of I.P. Sobolev.
258 L.N. Solomin
a b
d e f
g h i
Fig. 9.1 The Vreden Russian Research Institute of Traumatology and Orthopedics (RNITO) external fixation “Hall of Fame” (a–w)
9 External Fixation at the Vreden Russian Research Institute of Traumatology and Orthopedics 259
j k l
m n o
p q r

260 L.N. Solomin
s t u
v w
Table 9.1 M.D. dissertations

Name Dissertation title Year
Medvedeva N.I. Short-term transosseous osteosynthesis in the treatment of some fractures and dislocations 1968
Zhukov P.P. Treatment of open gun-shot fractures of the long tubular bones 1969
Grjaznuhin E.G. Treatment of patients with multiple fractures of the lower limb bones 1988
Karptsov V.I. Complex regenerative treatment of severe contractures of a knee joint after femoral bone fractures 1989
Kulik V.I. Complex treatment of open shaft lower leg fractures 1992
Faddeev D.I. Early osteosynthesis of multiple and multisystem fractures of the long tubular bones 1992
Kanykin A.J. Complex examination and treatment of patients with delayed consolidation of fractures and non-unions of long 1999
bones of the lower limb
Table 9.2 Ph.D. dissertations

Name Dissertation title Year
Sobolev I.P. Compression-distraction osteosynthesis in the surgical treatment of tuberculous coxitis and its consequences 1969
Kuskov V.D. Condition of the peripheral blood circulation and the neuromuscular device at compression osteosynthesis 1970
Popova A.E. Closed fractures of the humeral bone and their treatment 1972
Bashurov Z.K. Treatment of non-unions of the tibia and fibula bones 1973
Neverov V.A. Influence of distraction and compression on the morphology and shape of the bone 1974
Mashkov V.M. Surgical correction of the longitudinal arch of the foot 1976
Karptsov V.I. Objective quality monitoring at external fixation treatment of lower leg shaft fractures 1975
Kulik V.I. Connection of bones by ultrasound 1977
Lebedeva V.M. The remote consequences of closed shaft fractures of the lower leg after various methods of treatment 1981
Dager N. Modern methods of treatment of closed shaft fractures of the forearm bones 1986
Novosjolov К.A. Substantiation and development of new methods in the operative treatment of closed shaft femur fractures 1988
Nenashev D.V. Comparative estimation of methods in the treatment of closed shaft fractures of lower leg bones 1989
Varfolomeev A.P. Operative treatment of patients with non-unions and traumatic deformities of the femoral bone combined 1992
with knee joint stiffness
Shchepkina E.A. Treatment of femoral shaft fractures in elderly and senile patients 1997
Voronkevich I.A. Surgical treatment of multiple and combined craniocereberal injuries and shaft fractures of the long bones 1998
Lavrentev A.V. The complex method of treatment of complex damage of the lower extremities 1998
Nazarov V.A. Biomechanical principles of module configuration of devices for external fixation of the long bones 2006
Andrianov M.V. Combined external fixation of both fractures and the consequences of fractures of the femoral shaft 2007
(experimental-clinical research)
Mykalo D.A. Combined external fixation both at fractures and consequences of fractures of lower leg shaft 2007
(experimentally-clinical research)
Injushin R.E. Combined external fixation of both fractures and the consequences of fractures of the upper arm shaft 2008
Kulesh P.N. Combined external fixation of both fractures and the consequences of fractures of the forearm shaft 2008
Vilensky V.A. Working out of the basis of new technology in the treatment of patients with shaft damages to the long bones 2009
using a computer-assisted external fixation device (experimental-clinical research)
Tjuljaev N.V. Optimization of the use of a method of external fixation in the damage of long bones under the conditions 2011
of a large city
Table 9.3 Research

Name Research title Year
Balakina V.S. Comparative estimation of various methods of compression osteosynthesis in the treatment of fractures, 1964
malunions and non-unions of long bones
Balakina V.S. The nature of the changes in the vessels and connective tissue in the case of a false joint of the long bones 1973
Zhukov P.P. Treatment of patients with closed shaft fractures of the lower leg bones with the help of a method 1973
of compression-distraction osteosynthesis
Bashurov Z.K. Restorative operations for posttraumatic defects of the long bones 1975
Zhukov P.P. The search for possible application of a current of small force for increasing osteogenesis under conditions of 1977
transosseous osteosynthesis
Tsimidanova N.B. The systematic approach to the planning and forecasting of scientific research into the diagnostics and treatment 1987
of severe trauma on the basis of studying of information materials
Karptsov V.I. Methods of treatment of closed shaft fractures of the long bones combined with a craniocereberal injury 1989
Jushkovskaja Z.O. Reasons for disabilities following closed shaft fractures of the lower leg bones 1981
Voronova M.T. Influence of functional loadings on the biomechanical properties of intact tibial bone at closed shaft fractures 1983
Kulik V.I. Treatment of fractures and their consequences 1995
Yemelyanov V.G. Surgical treatment of the consequences of injures and ankle joint diseases 2000
Solomin L.N. Development of combined external fixation for fractures and the consequences of fractures of the long bones 2004
Lushnikov S.P. Substantiation of optimum methods of graft fixation in the replacement of segmentary defects of the bones 2005
of the shoulder and forearm
Vilensky B.A. Development of an extracortical clamp device for external fixation of periprosthetic fractures of the femoral 2006
bone and substantiation of the application
Shchepkina E.A. Use of autologous mesenchymal stem cells for optimization of regenerative osteogenesis 2007
Mykalo D.A. Improvement in the treatment of patients with diaphysial damage of femoral bone and severe knee joint 2011
stiffness using a software-based external fixation device
262 L.N. Solomin
Fig. 9.2 The report of the first

operation using the Ilizarov
device at the Vreden RRITO
9.3 Consolidation of External Fixation V.I. Kulik, V.M. Mashkov, E.G. Grjaznuhin, K.E. Novoselov,
(1968–2001) D.V. Nenashev, A.P. Varfolomeyev, M.I. Dadalov,
V.K. Rumjantsev, V.V. Dolgopolov, V.A. Zhirnov, I.A. Voronkevich,
Institute staff involved in the further implementation and as well as many other scientists and orthopedic surgeons.
development of the method were V.M. Demyanov, As summarized in Tables 9.1, 9.2, and 9.3, basic scientific
V.S. Balakina, Z.K. Bashurov, V.A. Neverov, I.P. Soboleva, lines of research in the progressive development of external
N.V. Kornilova, V.I. Karptsova, V.M. Mamayev, P.P. Zhukov, fixation were: (1) organizing the use of external fixation,
(2) experimental research, (3) development and actualization the use of external fixation in the reparative regeneration of
of external fixation methods for the treatment of specific ortho- the infected non-union of long bones.
pedic pathologies, and (4) development and actualization. In 1983, A.I. Anisimova and M.T. Voronova discovered
The organizational basis of external fixation was the that, compared with other methods of treatment, the use of
specialty of V.M. Lebedeva (1981), Z.K. Bashurov (1981), an Ilizarov device for the treatment of shaft fractures of the
V.M. Demyanov (1982), K.A. Samojlov (1989), D.V. lower leg bones resulted in faster normalization of the acous-
Nenashev (1989), A.V. Lavrentev (1998), and V.I. Kulik tic and deformation properties of the bone tissue.
(1991–1995). Their work led to an increase in the use of К.A. Novosjolov (1988) and V.I. Karptsov (1989) used
transosseous osteosynthesis from 30.2% (in 1981) to 70% the originally devised frame in carrying out research into the
(in 1987) compared with conservative treatment and internal rigidity of bone fragment fixation at transosseous osteosyn-
fixation. Treatment of open fractures of the lower leg using thesis (Fig. 9.6).
the Ilizarov method increased from 8.8% (in 1965) to 59.5% Particular attention was paid to the development and
in 1979. Moreover, specific recommendations were made improvement of external fixation methods used for specific
regarding the organization of external fixation for isolated nosologies. For example, the work of P.P. Zhukov (1973),
fractures, multiple fractures, and extensive open damage. K.A. Novoselov (1988), and E.A. Shchepkina (1997) was
Principles related to the strict adherence to an osteosynthesis devoted to various aspects in the treatment of closed shaft
method and to the need for sufficient equipment were elabo- damage of the long bones. Improvements in the methods
rated. However, over time the importance of these principles of treatment of complex, open, and gunshot fractures were
was underestimated. the products of research carried out by P.P. Zhukov (1969)
I.P. Sobolev was awarded a bronze medal and certificate and V.I. Kulik (1992, 1995). The latter focused on the pre-
for his complete set of slides on “Compression and vention of infectious complications, namely, the use of the
Distraction” at the first all-USSR festival of medical films, gluing mix Sinergan together with wound “preservation”
“Traumatology and Orthopedics,” in 1974 (Fig. 9.3). One of under a siloxane membrane. Ideas offered by V.I. Kulik
the most significant articles of these years was authored by were later developed in A.V. Lavrentev’s dissertation
A.V. Vorontsov, “Our experience in the application of exter- (1998).
nal fixation for damages and diseases of the skeleton” External fixation in the treatment of patients with multiple
(Grekov Vestnik Khirurgii [709]). fractures and multisystem trauma was developed by
Experimental research played an important role in Grjaznuhin E.G. (1988), K.A. Samojlov, V.I. Karptsov
the development and use of transosseous osteosynthesis. (1989), D.I. Faddeev (1992), and I.A. Voronkevich (1998).
V.S. Balakin and V.V. Rumjantseva (1973) showed that in Their active, minimally invasive, staged surgical approach to
external fixation the nature of the reparative osteogenesis treatment was subsequently referred to as “damage control”
depends on the rigidity of the fixation and the quality of the and involved new device configurations, including combined
adjoining surfaces. Regeneration is accompanied by the (hybrid) approaches.
intense vascularization of bone fragments and soft tissues as The efforts of Z.K. Bashurov (1973, 1975, 1978),
well as an increase in osteoclastic resorption, while bone for- A.I. Anisimov, and G.E. Afinogenov (1978) led to new
mation ranges from desmal to enchondral in type. knowledge in the treatment of delayed consolidation, false
The research team led by V.A. Neverov in 1974 is still joints, and defects in the long bones, including infectious
active today. They experimentally and clinically proved the complications (Fig. 9.7).
possibility of modeling the shape of a bone without osteot- A complete research program was devoted to the use of
omy. This only became a reality with the loadings applied by external fixation in osteosynthesis for the treatment of large-
means of the Ilizarov device (Fig. 9.4). joint pathologies. I.P. Sobolev was a pioneer in this field, begin-
V.I. Karptsov’s research (1975), published as “An objec- ning with his thesis “Compression-distraction osteosynthesis
tive quality monitoring in the course of treatment of bone in surgical treatment of tuberculous coxitis and its conse-
fractures of the lower leg at extrafocal compression osteosyn- quences,” in 1969. Since then, variants of the reconstructive
thesis,” was fundamental in its field. The author used osteom- operation have been developed by the author but the original
etry, sphygmography, and thermometry, and was one of the research has not lost its actuality (Fig. 9.8). Unfortunately, very
first to devise a method in which the mutual displacement of few people are aware that this scientist was the first to demon-
bone fragments could be measured in vivo (Fig. 9.5). strate and use microdistraction.
P.P. Zhukov, A.I. Anisimov, and V.I. Karptsov (1977) V.M. Mashkov (1976) was the first member of the RISC
demonstrated that galvanic electrostimulation at delayed “RTO” to investigate external fixation in the treatment of
union is an effective auxiliary means in the treatment of that complex foot deformities (Fig. 9.9). His methods resulted
pathology by external fixation. in the elimination of the deformity components while
In 1978, Z.K. Bashurov, A.I. Anisimov, G.E. Afinogenov, improving the range of motion in the ankle joint and length-
V.F. Pak, and V.V. Rumjantseva experimentally investigated ening the foot and lower leg at the same time. In addition,
264 L.N. Solomin
Fig. 9.3 Contribution of the

LITO to training in external
fixation
he confirmed that the shorter the length of a segment, the plex treatment of the degenerate-dystrophic diseases in
lower the rate of distraction. which it is involved.
V.I. Karptsov (1989) examined the complex medical reha- The scientific department headed by V.D. Usikov developed
bilitation of patients with severe knee joint stiffness as result of a consecutive method of treatment using external fixation for
femoral bone fractures. His studies were continued by A.P. patients with inveterate and rigid spinal deformities when the
Varfolomeev (1992), who optimized frame assemblies, classified risk of aggravating a neurologic disorder is high (Fig. 9.11).
knee contractures, proposed a treatment algorithm, and proved A specialty branch in the use and development of external
the efficacy of siloxane membrane application (Fig. 9.10). fixation was devoted to hand pathologies. L.N. Brjantseva
V.I. Karptsov and V.G. Emeljanov (2000) confirmed the and M.I. Dadalov developed surgical procedures for shorten-
expediency of arthrodiastasis of the ankle joint in the com- ings, defects, and developmental anomalies of the metacar-
Fig. 9.4 V.A. Neverov’s experiment on the closed correction of the

shape of the bones of the lower leg
pal bones and the phalanxes of the fingers. Their work

included lengthening of the 1st metacarpal, an osteotomy
method in the reconstruction of the thumb using distraction
(Fig. 9.12a), and a method of wire insertion at the stumps of
phalanxes of small length (Fig. 9.12b). The interests of these
researchers are nowadays being pursued in the scientific
microsurgery department headed by L.A. Rodomanova.
The development and improvement of external fixation
equipment is a specialty of the Vreden RISC “RTO”, with
devoted scientific and clinical research (Fig. 9.13). The most
significant developments are described in the following.
Original stiletto-shaped transosseous elements (Fig. 9.14)
were developed by V.I. Karptsov, N.V. Kornilov, E.G.
Grjaznuhin, К.A. Novosjolov, and A.P. Varfolomeev. These
progressive devices led to improved frame configurations.
The original device of I.A. Voronkevich allowed half-pins
to be fixed to the frame quickly and reliably (Fig. 9.15).
To simplify tensioning of the wires fixed on posts in close
proximity to the connecting rods and in other “inconvenient” c
places, V.V. Dolgopolov and I.A. Vronkevich invented “lever
Fig. 9.5 (a–c) V.I. Karptsov’s device for determining the degree of
wire tighteners” (Fig. 9.16). bone fragment mobility
Much effort has gone into the design of original devices
for external fixation (Fig. 9.17).
266 L.N. Solomin
Fig. 9.6 The frame for studying

the rigidity of external fixation
a b
Fig. 9.7 (a–d) Z.K. Bashurov’s

observations (1973)

c d
Fig. 9.8 I.P. Sobolev’s reconstruction of the proximal femur

268 L.N. Solomin
Fig. 9.9 Patients of V.M. Mashkov
a b
Fig. 9.10 (a–d) A patient of

A.P. Varfolomeyev
c d
Fig. 9.11 External fixation in the correction of a spinal deformity

270 L.N. Solomin

Fig. 9.12 (a, b) Innovations in

external fixation of the hand as
developed by L.N. Brjantseva
a
and M.I. Dadalov
272 L.N. Solomin
Fig. 9.13 Vreden RISC “RTO”

patents for new devices and
methods of external fixation
Fig. 9.14 Stiletto-shaped

b
274 L.N. Solomin
Fig. 9.15 A clamp for fixing

half-pins to the frame
Fig. 9.16 Lever-wire tighteners

developed by Dolgopolov (a) and
Voronkevich (b)
a b
276 L.N. Solomin
a c
Fig. 9.17 External fixation devices developed at the RISC “RTO” by (a) Dolgopolov, (b) Kulik, (c) Grjaznukhin
Fig. 9.17 (continued) (d) Karptsov,

Novoselov, and Varfolomeev, (e) d
Shchepkina
e
278 L.N. Solomin
Fig. 9.17 (continued) (f) Kulik, Voronkevich, Lavrentjev, Mamaev, Popov, and Chernetsky
Fig. 9.17 (continued) g

(g) Voronkevich, Samojlov,
and Lavrentjev
280 L.N. Solomin
Fig. 9.17 (continued) (h) Brjantseva and Dadalov, (i) Usikov. Note: (b) and (f) were among the first “pin-less” devices
9.4 Present Stage
In 2001, to improve the quality of treatment of patients with

consequences of traumas and skeletal diseases, Functional
group of external fixation (FGEF) was formed based on the
development as well as on the experimental and theoretical
substantiation of combined external fixation technologies.
The primary goals of the EFD are:
1. Scientific-clinical research related to the use of external
fixation
2. Improved quality of treatment of patients with fractures,
consequences of fractures, and skeletal diseases on the
basis of advances in the technology of combined external
fixation
3. Upgrading effective applications of combined external
fixation
4. Improvement in the organizational basis of training and in
the clinical use of external fixation
In 2011 the FGEF’s core staff are Prof. L.N. Solomin,
Assistant Prof. E.A. Shchepkina, P.N. Kulesh, PhD, V.A.
Vilensky, PhD, and K.L. Korchagin (Fig. 9.18).
Upon the FGEF’s organization, the following criteria
defining the use and development of combined (hybrid,
“wire–half-pin”) external fixation (CEF) (Chap. 3) were
adopted:
1. Use of the method of unified designation of external Fig. 9.18 Functional group of external fixation (FGEF), 2011
fixation (MUDEF)
2. Establishment of reference positions (RPs) for the inser- relative to a bone is minimal, was demonstrated (Fig. 9.20).
tion of transosseous elements RP prevent damage to the main vessels and nerves and
3. Use of different types of external support (closed circular, reduce the risk of pin-induced joint stiffness (Chap. 2).
and open semicircular, sectorial, bilateral or monolateral) Chapter 5 describes the materials presented in the master’s
and transosseous elements (trans-segmental wires and theses of R.E. Injushin, P.N. Kulesh, M.V. Andrianov, and
Steinmann rods, console S-screws, half-pins and console D.A. Mykalo.
wires) based on the specific indications
4. Consideration of the possibility of module transformation Modular transformation (MT), developed at the Vreden
(MT) of the external fixation device RISC “RTO” involves the following:
5. Use of the minimum number of external supports and • Gradually decreasing the quantity of connecting rods and
transosseous elements to provide a quality of reduction transosseous elements
and fixation of bone fragments that is not worse than that • Reducing the quantity of supports without the insertion of
provided by the Ilizarov fixation device additional transosseous element
6. Use of computer navigation in the planning and applica- • Changing the geometry of the external support by dis-
tion of osteosynthesis mantling a part of it
7. Possibility of conversion to internal fixation The use of MT optimizes the conditions for bone frag-
The MUDEF system of designation is analogous to musi- ment union (“regenerate training” in Ilizarov’s terminology),
cal notation. When followed, it allows the precise designa- reduces the risk of transfixion-pin-induced joint stiffness and
tion of any external device, whether in clinical or experimental pin-tract infections, and increases patient comfort by decreas-
use (Fig. 9.19). Chap. 4 is devoted to MUDEF. ing the bulkiness of the frame (Fig. 9.21). These aspects were
The definition of RP is an innovation of the FGEF that is confirmed in the master’s thesis of V.A. Nazarov
based on research initiated at the Irkutsk Orthopedic Institute “Biomechanical bases of module configuration of external
(A.P. Barabash and L.N. Solomin, 1997), in which the expe- fixation devices” (2006), which formulated the concept of
diency of the insertion of transosseous elements (wires, half- MT in transosseous osteosynthesis and explored the possi-
pins) through “safe corridors,” where soft-tissue displacement bility and expediency of this strategy.
282 L.N. Solomin
a b
I,9,90; II,10,90 _ III,10,90; IV,9,90 _ TSF _VI,8,90; VII,3-9; VIII,4,90 (a)
1/3 210 2/3 210 2/3 210
I,4-10; I,2-8 _ II,3-9 _VII,3-9 _ VIII,4-10; VIII,2-8 (b)

70 70 70 70
Fig. 9.19 (a, b) Use of MUDEF in treatment and experimentally
Fig. 9.20 Finding reference positions (RP) at level VII of the femur. (a–c) Research into soft-tissue displacement at level VII of the femur during
knee-joint flexion: skin (a),
Skin
Fascia
Muscles
Fig. 9.20 (continued) fascia (b) and muscle (c) displacements. (d) tissue displacement occurs in a projection of positions 3 and 9; it is
Graphs showing the displacement of soft tissues relative to the femur at slightly higher at positions 8 and 4. There are no main vessels and
a knee-joint flexion of 90/0 at level VII. Due to the relatively remote nerves in the projection of the positions given. Therefore, at level VII
position of level VII with respect to the hip joint, soft-tissue displace- the RP are: VII, 3; VII, 4; VII, 8; VII, 9. See also Supplement 2
ment during hip joint movements can be neglected. The minimum soft-
284 L.N. Solomin
a b c
Fig. 9.21 The basic scheme of module transformation (MT). (a) Initial configuration of the device; (b) the first stage MT: dismantling of the base
supports; (c) second stage MT: partial dismantling of reduction-fixation supports
However, in the absence of knowing the optimum posi- These works resulted in a new external fixation technol-
tions for the insertion of transosseous elements for each of ogy, the main elements of which are presented in Part 2 of
the segments, it was impossible to develop external fixation this manual. All of the device configurations used in a given
device configurations at the various levels of the humerus, technology have been substantiated as being better than their
femur, forearm, and lower leg. It is necessary to take into known analogues. The analysis of Tables 9.4, 9.5, 9.6, 9.7,
consideration that in reaching the goals of MT each of the 9.8, 9.9, 9.10, and 9.11 shows the good and excellent results
frame assemblies should achieve reduction and fixation achieved with the application of this type of combined
qualities equal to or better than those provided by the (hybrid) external fixation.
Ilizarov device. Accordingly, separate scientific-clinical However, it is necessary to mention that until 2006 we
studies were carried out for each of the segments. Similarly, were unable to completely fulfill the sixth point of our mod-
the general principles of nailing must be valid for all ern requirements for external fixation, i.e., the use of com-
designs. However, in the clinic it is impossible to apply puter-based technologies. Indeed, software-based external
these general principles for each patient. Instead, for every fixation devices are a new qualitative level of development in
disease and condition, the correct design must be developed external fixation, by creating an “integrated” trajectory of
and its efficacy along with its range of applications must be moving bone fragments, such as one that permits the elimi-
established. nation of all components of deformation in a single stage.
Having constructed a basis in the form of the general prin- Moreover, the special design of devices like the Taylor
ciples of MT and the determination of the recommended Spatial Frame, Ilizarov hexapod apparatus, and Ortho-SUV
positions, these aspects were further developed in the mas- Frame have vitalized this strategy (Fig. 9.23).
ter’s theses of M.V. Andrianov (2007), D.A. Mykalo (2007), The Russian hexapod Ortho-SUV Frame (Figs. 9.23
R.E. Injushin (2008), and P.N. Kulesh (2008) (Fig. 9.22). and 9.24) was developed by Ortho-SUV Ltd. and tested by
a b c
d e f
Fig. 9.22 (a–k) Configurations of devices for the treatment of fractures of the middle third of bone segments. These assemblies are distinguished
by the possibility to perform MT, the use of RP, and an adequate level of reduction and fixation abilities
286 L.N. Solomin
g h i
j k

Table 9.4 Follow-up results (January Fractures Malunions Non-unions and bone defectsa Deformations Total
2001–February 2007)
Upper arm 23 17 40
Forearm 33 9 21 3 66
Femur 16 11 26 53
Lower leg 68 39 33 38 178
Overall 140 48 82 67 337
a
Eighty seven percent of patients had different types of deformation
Table 9.5 Estimations of fracture healing Femur (%) Lower leg (%)
by LEFS (Lower Extremity Functional
Excellent and good results 97.2 97.5
Scale)
Poor results 2.8 2.5
Table 9.6 Estimations of fracture healing Hip Shin

by using the WHO Handicap Scale 6 months (%) 12 months (%) 6 months (%) 12 months (%)
Physical independence 32.5 82.5 82.5 100
Full mobility 67.5 87.5 82.5 97.5
Employment 40.0 77.5 40.0 90
Social integration 40.0 80.0 37.5 92.5
Table 9.7 Estimations of fracture healing by the Short-Form Health Survey (SF-36)
Upper arm Forearm
End of the fixation Six months after frame End of the fixation period Six months after frame
Parameters period (%) dismantling (%) (%) dismantling (%)
Physical functioning 80.15 100 75 92
Role physical functioning 25.64 100 47 95
Pain 84 100 61 100
General health 62.63 73 76 79
Viability 81 75 81 79
Social functioning 61.5% 75.3 76 82
Role emotional functioning 95.6 100 92 100
Psychological health 80 84.2 82 82
Table 9.8 Estimation of fracture healing by the DASH (Diagnostic Assessment for the Severely Handicapped) scale
Upper arm Forearm
Parameters End of the fixation period Six months after frame dismantling End of the fixation period Six months after frame dismantling
Estimation 25.7 ± 1.4 0.3 ± 1.4 45.2 ± 6.7 15.4 ± 4.8
Table 9.9 Estimations of the consequences of fractures by the SF-36

Upper arm Forearm
End of the fixation Six months after frame End of the fixation Six months after frame
Parameters period (%) dismantling (%) period (%) dismantling (%)
Physical functioning 79.3 90 65 85
Role physical functioning 50.5 100 32 92
Pain 84 100 47 100
General health 57 67.6 72 75
Viability 75.3 80 81 75
Social functioning 65.8 75 72 77
Role emotional functioning 66.7 100 84 100
Psychological health 76 80.2 76 80
288 L.N. Solomin
Table 9.10 Assessment of the consequences of fractures by DASH

Upper arm Forearm
Parameters End of the fixation period Six months after frame dismantling End of the fixation period Six months after frame dismantling
Estimation 38.4 ± 1.1 5.4 ± 1.1 54.2 ± 9.2 22.7 ± 9.6
Table 9.11 Complications

Upper arm (%) Forearm (%) Femur (%) Lower leg (%) Middle value (%)
Pin-tract infection 7.5 7 9.4 5.6 7.4
Wire osteomyelitis 2.5 0.6
Breakage of transosseous element 2.5 3.7 1.6
Non-union 1.9 0.7 0.7
Secondary displacement 2.1 0.5
Overall 12.5 7 15 8.4 10.8
Fig. 9.23 Ortho-SUV Frame (a) and
Fig. 9.24 (a–d) Capabilities of the Ortho-SUV Frame in the correction of a multi-component multi-plane two-level deformation
Fig. 9.23 (continued) a screen shot of the software (b)
a b c
290 L.N. Solomin
pathologies of the long bones, large joints, foot, and pelvis.

These are presented in Chap. 17. The near-term goal is the
creation of a device using an active computer navigation,
as outlined in Fig. 9.25. The device is being developed in
collaboration with scientific research institutes of the
Robotics and Technical Cybernetics (St. Petersburg), as
reported in [200].
The technology required to fulfill the final requirement of
modern external fixation (“possibility of conversion to inter-
nal fixation”) is considered in Chap. 26.
In the following, we list some of the planned directions in
the development of external fixation. The research that, in
our opinion, will continue the long-term evolution of tran-
sosseous osteosynthesis can be summarized as follows:
1. Studying the reparative regeneration of tissues compris-
ing the musculoskeletal locomotor system (based on the
unique opportunities of distraction osteogenesis)
• Research into the features of the reparative regenera-
tion of skeletal tissues under specific conditions
(change in systemic and regional blood circulation,
mechanical models, and compromised immune status
and changes in mineral, carbohydrate, lipid and other
metabolic pathways; in response to pharmacological,
mechanical, immunological, cellular influence,
d reflexotherapy etc.; infection)
• Identifying the features determining the reparative
regeneration of musculoskeletal locomotor system tis-
sues under various climate and geographic conditions
employees of the RISC “RTO” FGEF. In his dissertation, • Research into the influence of pathologies of the vari-
V.A. Vilensky showed that it surpassed comparable devices ous systems of the body on the regeneration of tissues
in terms of hardware and the potential applications (reduc- of the musculoskeletal locomotor system
tion and fixation opportunities) based on features of the • The search for interventions that will directly influence
software. Vilensky’s work laid the cornerstones of this the pathogenic processes that compromise reparative
advanced computer-assisted device application and we are osteogenesis
in the process of developing technologies in which the 2. Improvements in the technology of combined external
Ortho-SUV Frame can be applied in the treatment of fixation of fractures, the consequences of fractures, and
3
1 ADBR structure
1. Any external fixation device that provides the rigid bone fragment fixation.
2. System of positioning (i.e. the device) including 6 degrees of freedom.
2
3. Any type of X-ray device applied in medicine.
4. X-ray image converter.
6 5. Television camera.
4,5
6. Personal computer including the system of video-information input and output for the device
7
control.
7. Control system of the manipulator.
8. Software packing for the construction of 3-D model of bone fragments and securing of their
metrical characteristics.
Fig. 9.25 Schematic diagram of a device working on the basis of active computer navigation
orthopedic pathologies of the long bones, large joints, In addition to the above-mentioned Ortho-SUV Frame, there
pelvis and foot, including in the presence of infection are several potential applications for our extracortical clamp
• Improvement of the organizational basis of the training device. Initially developed for the treatment of peri-prosthetic
and use of external fixation fractures (Fig. 9.28b) ([204, 205]), its effective applications
• Introduction of new effective designs and methods, plan- have been considerably expanded (Fig. 9.28c–f; Chap. 11).
ning and development of external fixation devices, includ- However, applications of the combined strained fixation
ing those involving modern computer technologies (Chap. 20) for fixing free and vascularized bone grafts, the
• Improved CEF technology based on knowledge combined and consecutive use of external and internal
obtained from theoretical research and experiments fixation (Fig. 9.29 and Chap. 26), and arthroscopic control in
• Increasing the efficiency of external fixation by its inte- minimally invasive fixation of articulate fractures (Fig. 9.30)
gration with other orthopedic methods (arthroscopy, require further development.
internal fixation: lengthening over nails, bone transport Between 2001 and 2010, the employees of our FGEF
over nails; consecutive transition from external fixation accounted for more than 200 publications, including over 20
to internal fixation, including arthroplasty and others) original articles, 19 chapters in monographs, and 3 mono-
• Identifying the features determining the use of external graphs, in addition to 12 medical technologies and 21 pat-
fixation in patients of various age groups ents. They presented over 60 reports at conferences and
Some of these directions are in the planning stage, others are congresses. Each year, not less than 120 reconstructive oper-
currently being fulfilled. For example, papers have been pub- ations are carried out at our department. Consequently, it has
lished on the influence of reflexotherapy (Fig. 9.26; [201]), become one of the centers of development, promoting the
Strontium Ranelate (“Bivalos”) therapy [202] and mesenchymal use and teaching of external fixation. However the status of
cells (Fig. 9.27; [197] Chap. 8.8) with respect to the formation “functional group” restrains the further qualitative develop-
and organotypic reorganization of the distraction regenerate. ment of the given direction. In 2008 the first substantiation
Organizational questions regarding the application of for transformation of group to scientific-clinical Limb length-
transosseous osteosynthesis in the conditions of a large city ening and bone reconstruction department was submitted to
are considered in N.V. Tjuljaev’s 2011 dissertational research administration of Institute. Unfortunately, the positive deci-
[203]. Employees of our FGEF have prepared original exter- sion is not resolved till now. More detailed information is
nal fixation training courses (http://rniito.org/solomin). available at www.rniito.org/solomin.
Fig. 9.26 Influence of reflexotherapy on the formation of the distractional regenerate: standard lengthening by Ilizarov (a), traditional reflexotherapy
(b), insertion of wires through acupuncture points (c)
292 L.N. Solomin
Fig. 9.27 Dynamics of bone tissue formation using mesenchymal cells


294 L.N. Solomin
Fig. 9.28 Extracortical clamp device (a) and its application in peri-prosthetic fracture (b)
Fig. 9.28 (continued) severe

c
knee-joint contracture,
subluxation in the presence of a
prosthesis (c)
296 L.N. Solomin
Fig. 9.28 (continued) deformation (shortening, rotation) over a nail (d)

Fig. 9.28 (continued) as an antibacterial spacer (e), and in external-fixation-assisted nailing in deformity correction (f)
298 L.N. Solomin
Fig. 9.29 Hexapod-assisted

a
nailing (a)
Fig. 9.29 (continued) lengthening over

b
a nail (b)
300 L.N. Solomin
Fig. 9.30 In this case of bilateral plateau fractures, arthroscopic control of the reduction was performed
Part II
Specific Aspects of External Fixation
Fractures of the Humerus
10
In external fixation of the humerus according to the Ilizarov To prevent formation of adduction contracture of the
method wires of diameter 1.5 mm are used. The basic wires shoulder joint, the transosseous elements throughout the first
used in CEF are 1.8–2 mm in diameter, and the wires used four levels of the upper arm (0, I, II, III) are placed in the
for reduction are 1.5 mm in diameter. Half-pins of diameter position with the shoulder in abduction at an angle of not less
5 mm are inserted into the diaphyseal part of the humerus than 70°. To prevent pin-induced joint stiffness of the elbow
and 4-mm half-pins or console wires are inserted into the joint following insertion of the transosseous elements through
epicondyle. For patients with bone diameters of 28–30 mm it the front semicircle of the upper arm and through the four
is permissible to use 6-mm threaded half-pins throughout the distal levels of the upper arm (VI, VII, VIII, IX), the fore-
first three levels (0, I, II). The set for fixation must also arms placed in the position of maximum extension. During
include 2-mmconsolewires with a stop at the positions allow- insertion of the transosseous elements through the back
ing various lengths of the wire to be inserted into the bone (5, semicircle of the upper arm the forearm is placed bent at
10, 15 or 20 mm) (Figs. 10.1, 10.2, 10.3, 10.4, 10.5, 10.6, 90°–120°. If it is impossible to change the position in the
10.7, 10.8, 10.9, 10.10, 10.11, 10.12, 10.13, 10.14, 10.15, joints at these angles, the skin is shifted manually or with a
10.16, 10.17, and 10.18). thin hook in the direction of its natural displacement relative
The supports for the first three levels of the upper arm to the bone during movement in the adjacent joint.
(levels 0, I and II) are assembled on the basis of a half-ring In using only reference positions for insertion of tran-
that is “elongated”, if required, on each side by connection sosseous elements, it is not necessary to change the position
plates. The modern basic Ilizarov device set includes special of the joints. However, the skin must be displaced prior to
half-rings with the ends bent up and elongated. At level III of insertion of transosseous elements in elongation of the seg-
the upper arm, two-thirds or three-quarter ring supports are ment, correction of deformities, bilocal fixation and other sit-
used to allow movement of the limb. uations when it is necessary to create a “store” of soft tissue.
As a rule, in external fixation of the upper arm the reduc- Prior to fixation of the wires the external support must be
tionally fixing and distal basic supports have one standard properly oriented relative to the anatomical axis of the bone
size and the proximal basic support, if located at the first fragment and soft tissue (Fig. 10.1). The external supports
three levels (levels 0, I and II), is one or two standard sizes must be located perpendicular to the anatomical (middle dia-
larger. Therefore, to connect the proximal basic support to physeal) axis of the bone fragment to which they are fixed.
the others, connection plates are used. An exception is when the supports are placed preliminarily
The supports used at the three distal levels of the upper in a position of hypercorrection; this is considered below.
arm (levels VII, VIII and IX) are two-thirds or three-quarter The intermediate reductionally fixing supports on the upper
rings to allow bending of the elbow. In fixation of juxtaar- arm are oriented relative to the soft tissue depending on the
ticular and intraarticular fractures (11- and 13-), radiotrans- method to be used to reduce the bone fragments. If the mod-
parent external supports should preferably be used. ules fixing the bone fragments are to be mutually displaced, the
distance between the inner edge of the ring and lateral aspect
of the upper arm (from the inside and outside) must be equal,
and at the back it must be 10–15 cm more than at the front.
L.N. Solomin, M.D., Ph.D. If the position of the bone fragments is to be changed by
R.R. Vreden Russian Research Institute of
means of transosseous elements inserted near the bone
Traumatology and Orthopedics,
8 Baykova Str., St. Petersburg 195427, Russia wound, the ring should be displaced during mounting by the
e-mail: solomin.leonid@gmail.com necessary amount in the direction the bone fragment needs to
304 L.N. Solomin
a b c
Fig. 10.1 (a–c) Supports orientation on the upper arm. (a, b) The distal basic support of the upper arm is generally oriented when it is
proximal basic support on the upper arm is oriented relative to the soft connected to the distal reductionally fixing support. Remember that the
tissue so that the distance between the inner edge of the ring and the thickness of the soft tissue on the posterior aspect of the upper arm in
skin at the front and outside are within in the range 25–35 cm. The the top third of the segment is much greater than in the epicondylar
distance from the skin to the ring along the posterior aspect must be area. Therefore, during mounting of the device, the humerus appears to
10–15 cm more (a – “wire” support; “wire – half-pin support”). (c) The be displaced forward relative to the centre of the distal basic support
move. It is possible to estimate the residual displacement control orientation of the module, it should be supported and
from comparison radiographs. the bending of the wires eliminated by hand.
The ends of the wires and half-pins that are at a distance It is important to note that in all the fixation diagrams pro-
from the support after it is given the necessary spatial orienta- vided, the direction of insertion of reduction transosseous ele-
tion are fixed using posts and/or gasket washers. The half-pins, ments (wires, half-pins), and the locations of the stops on the
unless they are basic or reductionally fixing transosseous ele- wires are given conventionally as examples. In practice, one
ments, are stabilized by external supports only after the neces- should be guided by the actual residual displacement of the
sary spatial orientation of the bone fragments has been achieved. bone fragments. To avoid damage to great vessels and nerves,
If the half-pin is inserted into the bone not parallel to the exter- the safe positions identified in the atlas of the levels recom-
nal support it is fixed to it by two posts, one with a threaded mended for insertion of reductionally fixing transosseous
hole (female) and the other with a threaded end (male). It is elements should be used. The size of the external supports in
possible to fix the half-pin to the sup port or post with L-shaped the diagrams provided is also shown conventionally.
clips in a manner analogous to fixation of wires by wire-fixation For reduction using wires the desired displacement of the
bolts with a lateral slot (Figs. 1.11.27 and 1.11.28). bone fragments is achieved with the help of stops, at the
The following sections describing particular methods of expense of the accurate bending of the wire (Figs. 1.6.11 and
fixation contain phrases similar to: “When the device module 1.6.12). For reduction using half-pins, displacement is
is properly installed its connection rods are located parallel achieved by “pulling” or “pushing”, and for posts with a stop
to the anatomical axis of the bone fragment.” However, it only by “pushing” (Fig. 1.6.10). It is also possible to use any
must be born in mind that when the basic support is fixed technique for reduction that involves mutual displacement of
only with wire(s), its position is likely to change due to bend- external supports (Figs. 1.6.4–1.6.9). Large splinters are
ing of the wires from the weight of the basic ring and the reduced and fixed by means of wires with stops or with the
reductionally fixing ring connected to it. In such cases to help of console wires with stops (Fig. 1.6.13). If there are
10 Fractures of the Humerus 305
a b
Fig. 10.2 (a, b) External fixation of the humerus involves preliminary specially produced. (a) Device developed at the Ilizarov Russian
elimination of the rough displacement of the bone fragments by skeletal Research Center [9]. (b) Structure based on minimum modification of
traction. The equipment generally available on an orthopaedic traction an orthopaedic traction table
table can be used. If a reductionally fixing post is unavailable it must be
great vessels and nerves in the plane of a splinter, it is reduced are taken to achieve “hyperextension” of the damaged seg-
and fixed using a fork-shaped rod (Fig. 1.6.17). ment to 5 mm controlling distraction at the post by compari-
Regional anaesthesia is generally used for external son with the contralateral shoulder. X-ray contrast markers
fixation of the humerus. Transport immobilization is are placed on the skin (injection needles, fragments of wires)
removed on the surgical table after induction of anaesthesia. and radiographs in two standard planes are acquired for com-
A pillow 12–15 cm high is placed under the patient’s head parison, or fluoroscopy is used. Lines are drawn on the skin
and between the scapulas, and the patient is laid so that the of the front and outer aspects of the segment corresponding
shoulder joint projects beyond the edge of the surgical table to the plane of the anatomical axis of each bone fragment.
(Fig. 10.2). Using the special device shown in Fig. 1.8.2, the levels for
In cases of skeletal traction, a wire is inserted through insertion of the transosseous elements are marked. As clini-
the olecranon (olecr., 3–9). It is strained and fixed to the cal experience increases, comparison radiographs during
reductionally fixing post (Fig. 10.3). The recommended skeletal traction are obtained only in cases of juxtaarticular
position of the shoulder during skeletal traction in frac- and intraarticular fractures (11- and 13-). The operative field
tures of the proximal part of the humerus is abduction is treated and covered with drapes.
90°, front deviation 20–30°, and external rotation 20°. In Radiographic confirmation of an accurate reduction on
dislocation fractures (injury 11-B3), abduction of the the surgical table is a rule of external fixation of closed frac-
shoulder should not exceed 50°. In fractures of the dia- tures. The practice of hastily assembling an external fixation
physis (injuries 12-) and the distal humerus (injuries 13-), device in the operating room and performing the reduction
the shoulder is placed at an angle of 90° with a frontal after the patient has been transferred to the outpatient depart-
deviation of 15–20°. ment with daily step-wise radiographic monitoring of the
Instead of skeletal traction on the operation table a special manipulations is an unsatisfactory and discredited method of
distraction device can be used (Fig. 10.3). external fixation. An exception to this rule is when a fixation
Axial traction and manual manipulation improve the loca- device is applied as described below.
tion of the bone fragments. To facilitate reduction, measures
306 L.N. Solomin
c d
Fig. 10.3 (a–c) Using the distraction device. (a) Distraction device sioned and fixed in the distraction device. Distraction is implemented,
consists of two arches or the half rings connected by telescopic rods, (b) (c) the frame is assembled inside distraction devices, (d) after bone
inserting wires. One of them or both can be basic ones. Wires are ten- fragment reduction and fixation the distraction device is removed
10.1 Proximal Humerus (11-) fragment. In this position, wires VII,9-3 and VII,10-4 are
fixed in the distal support after tensioning.
Ilizarov external fixation of fractures of the proximal humerus In fractures 11-A2, 11-A3, 11-B1, and 11-B2 as well as in
(11-) starts with the insertion of two wires through the supra- case of a slipped epiphysis or osteoepiphysis, the method of
condylar area, one in the frontal plane and the other at an Ilizarov et al. [206] is used to eliminate rotational displace-
angle of 30° to it: VII,9-3 and VII,10-4. The markers on the ment. This is achieved by inserting a wire with a stop through
radiograph acquired under conditions of skeletal traction the proximal metaphysis in a plane close to the sagittal plane,
facilitate insertion of the wire perpendicular to the anatomic i.e., I,5-11. The wire is fixed in a half-ring whose standard
axis of the distal bone fragment. size is larger than that of the proximal basic support. With
An intermediate reductionally fixing ring support is the help of this support, the proximal fragment is placed in
installed at level IV of the upper arm, oriented relative to the the position of maximum external rotation. The bone frag-
bone and soft tissue and connected by three threaded rods ment is then rotated inside through an angle of 45–50°. The
with a three-quarter ring as the distal basic support. The con- second wire is inserted in the sagittal plane, i.e., I,12-6. As
nection rods must be parallel to the axis of the distal bone soon as the wire is inserted in the soft tissues of the posterior
semicircle of the upper arm, the proximal fragment is placed

in the position of maximum external rotation. After insertion
of wire I,12-6, the proximal bone fragment is placed again in
the position of internal rotation at 45–50°. Wires I,5-11 and
I,12-6 are fixed to the basic half-ring so that the axis is prop-
erly oriented relative to the soft tissue and is located strictly
perpendicular to the axis of the proximal fragment. The
larger half-ring is then removed.
When the fracture line spreads to level I, the epimetaphyseal
area of the bone can also be used for wire insertion (level 0).
The distal fragment is placed in the medio-physiological
position when the first finger is inserted in the line of the
deltoid-thoracic sulcus. All three supports are connected.
Distraction is applied to create an interfragmentary diastasis
of 4–5 mm if this was not possible by skeletal traction.
Radiographs are obtained in two standard planes or an image
intensifier (fluoroscopy) is used.
A wire is inserted for final reduction of the distal fragment
at the level of the intermediate ring. The direction of its inser-
tion and the location of the stop depend on the displacement
of the proximal end of the distal fragment. To avoid injury to
the great vessels and nerves, only safe positions as specified
in the atlas for level IV of the upper arm are used. As an
example, Fig. 10.4 shows wire IV,4-10.
Figure 10.5 shows the scheme for the combined external
fixation of fracture 11-.
In intra-articular fractures (11-C), the wires are inserted
through the acromion process of the scapula: acr.,7-1 and 3 4 5 1 2
acr.,11-5. After tensioning, they are fixed to the half-ring. I,5-11; I,12-6 – IV,4-10 – VII,9-3; VII,10-4
The device is assembled from three supports, with the inter- 1/2 160 140 3/4 140
mediate ring located at level IV. After distraction, compari-

Fig. 10.4 Ilizarov external fixation device for the fixation of fracture
son radiographs in two planes are obtained. 11-A3.2
Large splinters are reduced and fixed using either
Kirschner wires with stops or console wires with stops. In
turn, these wires are fixed to the proximal support of the humeral head is re-set by traction behind it. In another variant,
device using posts. the wire is arched outwards and fixed to the support using dis-
Distal bone fragments are reduced in a manner similar to traction clips. During tensioning, the wire straightens such that
that described for fractures 11-A2, 11-A3, 11-B1, and 11-B2. the humeral head is brought out of the dislocation condition.
The scheme for Ilizarov fixation of fracture 11-C1 is shown Displacement of the head is accompanied by tension on the soft
in Fig. 10.6. tissues along their dorsal aspect. Therefore, after the manipula-
In dislocation fractures (11-B3), the wires are inserted tion is completed, the soft tissues must be cut as much as neces-
through the acromial process of the scapula: acr.,7-1 and sary, or (more often) wire I,6-12 must be substituted for another
acr.,11-5. After tensioning, they are fixed to the half-ring. transosseous element, for example, half-pin I,9,120.
When manual techniques fail to reset the humeral head, a After reduction and fixation of the humeral head, external
wire with a bayonet-shaped stop is inserted after moderate fixation is performed using a technique similar to that
distraction, on the side of the axillary crease and bypassing described for injuries 11-A2, 11- A3, 11-B1, 11-B2.
the great vessels and nerves. By means of gradual traction of When full-volume external fixation is impossible, for
the wire, the humeral head is re-set [207]. example, in the event of multiple and massive trauma in a
Alternatively, a dislocated humeral head can be re-set as fol- severely injured patient, the “fixed” variant of external
lows: A wire is inserted through the humeral head in the sagit- fixation can be carried out. A wire with a stop is inserted at
tal plane: I,6-12 (in posterior dislocations) or I,12-6 (in anterior levels I and VII. The proximal wire is strained and fixed to
dislocations). This wire is strained in the half-ring and the the half-ring and the distal wire is fixed to a three-quarter
308 L.N. Solomin
a b
c d
Fig. 10.5 (a–k) Combined external fixation device for the fixation of Two-plane roentgenography is performed using X-ray-positive markers.
fracture 11- (a) The traction device is applied on the basis of wires acr., (c) Insertion of proximal basic half-pins I,8,120 and I,11,120.
6-12 and VII,3-9; rough displacement of the bone fragments is elimi- (d) Particular attention must be paid to the orientation of the proximal
nated (below the attachment; not shown). (b) An alternative to the trac- basic support: it should be placed perpendicular to the anatomic axes of
tion device is skeletal traction using wire VII,3-9. At this stage, the proximal bone fragment in two planes
Fig. 10.5 (continued) e

(e) Orientation of the distal
module perpendicular to the axis
of the distal bone fragment and
its fixation on wire VII,3-9.
(f) Connection of the proximal
and distal modules. Distraction
for a diastasis of 3–5 mm.
Two-plane X-ray examination
f
310 L.N. Solomin

(g) Insertion of reductionally g
fixing half-pin III,9,90 and
reduction of the distal bone
fragment. Two-plane X-ray
examination. (h) Insertion of
stabilizing half-pins I,10,120 and
V,10,70
h

(i) Fixation of stabilizing
half-pins, elimination of the
i
diastasis, removal of skeletal
traction. (j) First stage of module
transformation (MT): removal of
the distal basic support
j
312 L.N. Solomin
Fig. 10.5 (continued) (k) Second stage of MT: removal of the medial half ring of the reductionally fixing support. (l) The patient after the second
stage of MT (M) The patient after the second stage of MT
3 4 5 6 7 1 2
acr.,7-1; acr.,11-5; 0,6-12; I,9,80 – IV,4-10 – VII,9-3; VII,10-4
1/2 160 140 3/4 140
Fig. 10.6 External fixation for the fixation of fracture 11-C1
ring support. A moderate distraction force is applied between proximal basic wires through the proximal metaphysis of the
the supports: I,6-12 ↔ VII,3-9. In cases of an intra-articular humerus. One such wire is inserted in the sagittal plane and the
fracture (11-C), the device applied is: acr.,7-1 ↔ VII,3-9. other at an angle of 30° to the first: VII,6-12 and I,11-5.
The “fixed” variant is used as a “lesser of all evils” This is followed by insertion of the distal basic wires: one in the
solution and in cases in which the closed reduction of frontal plane and the other at an angle of 30º to it: VII,9-3 and
complicated intra-articular fractures (11-C3) is unattain- VII,10-4. The proximal support based on an extended half-ring
able and open reduction is contraindicated. The following is oriented relative to the bone and soft tissue and the wires are
device is applied: acr.,7-1; acr.,11-5 ↔ IV,4-10 – VII,9-3; fixed to it after tensioning.
VII,10-4. The intermediate reductionally fixing ring support is then
After final comparison radiographs are obtained, the arm installed at level IV of the upper arm and is connected by
is placed in abduction at an angle of 45–60° by means of a three rods with the three-quarter ring distal support. The
wedge-shaped pillow. Exceptions are cases in which the wires intermediate support is oriented relative to the bone and soft
were inserted through the acromial process of the scapula. tissue. The connection rods must be parallel to the longitudi-
nal axis of the distal bone fragment. After tensioning, wires
VII,9-3 and VII,10-4 are fixed to the distal support, which if
10.2 Diaphyseal Fractures (12-) properly installed is perpendicular to the anatomic axis of the
distal bone fragment.
10.2.1 Proximal Third The proximal basic support is connected by three rods to
the reductionally fixing support. Distraction is applied to cre-
Ilizarov external fixation of fractures of the proximal third of ate an interfragmentary diastasis of 5–7 mm if this was not
the humeral diaphysis (injuries 12-A1.1, 12-A2.1, 12-A3.1, done by skeletal traction. Radiographs are obtained in two
12-B1.1, 12-B2.1, 12-B3.1) starts with the insertion of crossing standard planes or an image intensifier is used.
314 L.N. Solomin
12-B1.2, 12-B10, 12-B3.2) starts with insertion of the cross-

ing wires II,6-12 and II,11-5. If the fracture is located closer
to the proximal third of the diaphysis, proximal basic wires
are placed at level I: I,6-12 and I,11-5. The distal basic wires
VII,9-3 and VII,10-4 are then inserted. If the fracture is
located at the border of the middle and distal thirds of the
diaphysis, distal basic wires are placed at level VIII: VIII,3-9
andVIII,2-8.
After the proximal pair of the wires are strained, they
are fixed in an extended half-ring that is preliminarily ori-
ented relative to the bone and soft tissue as specified in
Sect. 10.
One reductionally fixing support is placed at level III (or
level IV, depending on the fracture site) and another at level
V (or level VI). The reductionally fixing rings and the distal
basic support are two-thirds or three-quarter rings con-
nected to form a single module. The reductionally fixing
rings are oriented relative to the soft tissue, and the module
is installed so that the connection rods are parallel to the
anatomic axis of the distal fragment. Only then are the dis-
tal basic wires strained and fixed to the support. To preserve
the orientation of the reductionally fixing supports relative
to the soft tissue, the module comprising three distal sup-
ports is connected by three rods to the proximal basic sup-
1 2 5 6 3 4
I,6-12; I,11-5; II,11-5 – IV,4-10 – VII,9-3; VII,10-4 port using, if required, connection plates (various diameters
1/2 160 140 3/4 140 of the supports).
Distraction is then applied between the reductionally
Fig. 10.7 The Ilizarov external fixation device for the fixation of frac-
ture 12-A2.1 fixing supports to create an interfragmentary diastasis of
4–5 mm, if this was not previously done by skeletal traction.
To eliminate residual displacement of the proximal bone intensifier is used.
fragment at level II, a reductionally fixing wire is inserted. If To eliminate residual displacement of the proximal bone
the residual displacement is at level IV, a second reduction- fragment, a reduction wire is inserted at level IV (or level III,
ally fixing wire is inserted. The direction of insertion of these depending on the line of the fracture). To eliminate residual
wires and the location of the stop on both of them depend on displacement of the distal fragment, a second reduction wire
the residual displacement of the bone fragments. To avoid is inserted at level V (or level VI). Figure 10.9 shows, as an
injury to the great vessels and nerves, only safe positions as example, wires IV,10-4 and V,4-10.
specified in the atlas for levels II and IV of the upper arm are Figure 10.10 shows the scheme for the combined exter-
used. Figure 10.7 shows an example for wires II,11-5 and nal fixation of fractures of the middle third of the
IV,4-10. humerus.
Figure 10.8 shows the scheme for the combined exter-
nal fixation of fractures of the proximal third of the
humerus. 10.2.3 Distal Third
Ilizarov external fixation of fractures of the distal third

10.2.2 Middle Third of the humeral diaphysis (injuries 12-A1.3, 12-A2.3,
12-A3.3,12-B1.3, 12-B2.3, 12-B3.3) starts with insertion
Ilizarov external fixation of fractures of the middle third of of the intercrossing proximal basic wires III,6-12 and III,1-
the humeral diaphysis (injuries 12-A1.2, 12-A10, 12-A3.2, 7. The distal basic wires VIII,9-3 and VIII,8-2 are then
a b
Fig. 10.8 (a–j) Combined external fixation for the fixation of frac- attention must be paid to the orientation of the proximal basic support,
tures of the proximal third of the humerus. (a) Application of skeletal which should be placed perpendicular to the anatomic axes of the
traction using wire VIII,3-9. Division of the lower leg into levels. proximal bone fragment in two planes. (c) Orientation of the distal
Two-plane X-ray examination with X-ray contrast markers. (b) module perpendicular to the axis of the distal bone fragment and its
Insertion of proximal basic half-pins I,10,120 and II,8,90. Particular fixation on wire VII,3-9
316 L.N. Solomin
Fig. 10.8 (continued) (d)

Connection of the proximal and d
distal modules, distraction for a
diastasis of 3–5 mm. Two-plane
X-ray examination. (e) Insertion
of half-pin IV, 9,90 and its
fixation with the help of a
reduction device to a reduction-
ally fixing support
e
Fig. 10.8 (continued) (f) Distal

bone fragment reduction in two f
planes. Two-plane X-ray examina-
tion. (g) Fixation of stabilizing
half-pins II,11,90 and VI,8,70.
Elimination of the diastasis and the
removal of skeletal traction
g
318 L.N. Solomin
Fig. 10.8 (continued) (h) First

stage of module transformation
(MT): removal of the distal basic h
support. (i) Second stage of MT:
removal of the reductionally fixing
support
i
Fig. 10.8 (continued) (j) The patient after the second stage of MT
inserted. The proximal support is a two-thirds ring placed

at level III of the upper arm and oriented relative to the
bone and soft tissues as described in Sect. 10. After ten-
sioning, wires III,6-12 and III,1-7 are fixed to the proximal
basic support.
At level V, an intermediate reductionally fixing ring is
installed and oriented relative to the soft tissue. The interme-
diate ring is connected by three rods to the proximal basic
support. To achieve proper orientation of the supports, the
connection rods must be parallel to the anatomic axis of the
proximal bone fragment.
The distal basic support is a three-quarter ring oriented
perpendicular to the anatomic axis of the distal bone frag-
ment; it is connected by three rods to the intermediate sup-
port. In this position, wires VIII,9-3 and VIII,8-2 are fixed to
the distal supports after tensioning.
Distraction is applied to create a 4–5 mm diastasis between
the fragments, if this was not done previously by skeletal
traction. Radiographs are obtained in two standard planes or
an image intensifier is used.
To eliminate residual displacement of the proximal bone
fragment, a reduction wire is inserted at level V. If the elimi-
nate residual displacement involves the distal fragment, at
level VII, a second reduction wire is inserted. Figure 10.11
1 2 5 6 3 4 shows, as an example, wires V,4-10 and VII,9-3.
II,6-12; II,11-5 – IV,10-4 V,4-10 – VII,9-3; VII,10-4 Figure 10.12 provides the scheme for the Combined exter-
1/2 160 140 140 3/4 140
nal fixation device for the fixation of segmentary fractures is
Fig. 10.9 Ilizarov external fixation device for the fixation of fracture presented on Fig. 10.13.
12-A3.2
320 L.N. Solomin
a b
Fig. 10.10 (a–l) Combined external fixation device for the fixation of An alternative to the traction device is skeletal traction using wire
fractures of the middle third of the humerus. (a) The traction device is olecr.,3-9 or VIII,3-9. Wire VIII,3-9 will be the basic one. At this stage
applied on the basis of wires II,5-11 and VIII, 3-9. Rough displacement Two-plane roentgenography with X-ray contrast markers. (c) Insertion
of the bone fragments is eliminated. These wires will be basic ones. (b) of basic wires II,5-11 and VIII,3-9
Fig. 10.10 (continued) (d) Orientation and fixation of the proximal basic support. (e) Orientation of the distal module perpendicular to the axis
of the distal bone fragment and its fixation on wire VIII,3-9. The hand simulates the soft-tissue distribution on the dorsal surface of a shoulder
322 L.N. Solomin
g h
Fig. 10.10 (continued) (f) The basic wires are tensioned only after the examination. (g) Insertion of reductionally fixing half-pin IV, 9,90 and
proximal and distal transosseous modules have been connected (if they its dynamic fixation to the reductionally fixing support. (h) Insertion of
have not been tensioned as wires of the traction device or during skel- reductionally fixing half-pin V, 10,90 and its dynamic fixation to the
etal extension). Distraction for a diastasis of 3–5 mm. Two-plane X-ray distal reductionally fixing support

(i) Subsequent two-plane bone i
fragment reduction. Two-plane
X-ray examination. Static fixation of
the reductionally fixing half-pins. (j)
Insertion and fixation of proximal
and distal stabilizing half-pins
II,8,120 and VII,8,70. Elimination of
the diastasis
j
324 L.N. Solomin
Fig. 10.10 (continued) (k) First

stage of module transformation (MT): k
removal of the basic supports. (l)
Second stage of MT: removal of the
medial half rings of the reductionally
fixing supports
l
Fig. 10.10 (continued) (m) The patient after the second stage of MT
10.2.4 Radial Nerve Injury
A quite frequent complication of diaphyseal fractures of

the humerus is injury to the radial nerve. When clinical and
laboratory examinations confirm functional nerve injury
and immediate recovery is not possible, the method of
Shved et al. is used. After precise reduction and stable
external fixation of the humeral fragments, a diastasis of
5–8 mm is created between the bone fragments. This results
in moderate tension on the radial nerve, which prevents it
from becoming trapped and compressed between bone
fragments. After formation of the primary bone commis-
sure, step-wise coaptation of the bone fragments is carried
out (0.25 mm 4× per day). A complete course of simultane-
ous treatment is prescribed to recover the function of the
nerve.
When full-volume external fixation of diaphyseal frac-
tures of the upper arm is not possible, for example in the
event of multiple and massive trauma, the “fixation” variant
of external fixation can be performed. Wires I,5-11 and
VII,3-9 are inserted in the case of fracture of the proximal
third of the humeral diaphysis. The proximal wire is ten-
sioned and fixed to the half-ring while the distal wire is fixed
to a three-quarter ring support. Moderate distraction is cre-
ated between the supports: I,5-11 ↔ VII,3-9.
1 2 5 7 6 3 4 For temporary fixation of fractures of the middle and dis-
III,6-12; III,1-7 – V,4-10; VI,8,75 – VII,9-3; VIII,9-3; VIII,8-2 tal thirds of the humeral diaphysis, the following devices are
2/3 150 140 3/4 140
used: II,5-11 ↔ VII,3-9 and III,6-12 ↔ VIII,3-9, respec-
Fig. 10.11 Ilizarov external fixation device for the fixation of fracture tively (Fig. 10.14).
12-B2.3
326 L.N. Solomin
Fig. 10.12 (a–k) Combined

a b
external fixation device for the
fixation of segmentary fractures
is presented on Fig. 10.13.
(a) Application of skeletal
traction using wire olecr.,3-9. If a
traction device was used
(Fig. 10.10a), wire II,7-1 is the
proximal basic one. Two-plane
radiological control. (b) Insertion
of distal basic half-pins
VIII,4,120 and VIII,8,120.
(c) Orientation and fixation of the
distal basic support perpendicular
to the anatomic axes of the distal
bone fragment in two planes
c
d e
Fig. 10.12 (continued) (d) Insertion of proximal basic wire II,7-1. reductionally fixing half-pin V, 10,90 and its dynamic fixation to the
Assembly and orientation of the proximal basic support. (e) Assembly support
of the frame; distraction to achieve a 3–5 mm diastasis. (f) Insertion of
328 L.N. Solomin
Fig. 10.12 (continued) (g) Insertion of g

distal reductionally fixing wire VII,3-9
with subsequent two-plane bone fragment
reduction. Two-plane X-ray examination.
Static fixation of the reductionally fixing
transosseous elements. (h) Insertion and
fixation of proximal stabilizing half-pin
III,9,120. Elimination of the diastasis
h
Fig. 10.12 (continued) (i) First stage of

module transformation (MT): removal of
i
proximal basic support VII,3-9. (j) Second
stage of MT: removal of the medial half
rings of the reductionally fixing support
j
330 L.N. Solomin
Fig. 10.12 (continued) (k) The patient after MT

a b
Fig. 10.13 (a, b) Combined external fixation device for the fixation of segmentary fractures 12-C2.1. It is crucial to ensure that the proximal and
distal basic supports are installed perpendicular to the anatomic axis of the bone fragments to which they are fixed
Fig. 10.14 “Fixation” device

for fractures of the humeral bone
shaft. Joining of the telescopic
rods with the support by means
of connection plates facilitates
the installation of reductionally
fixing supports at the next stage
332 L.N. Solomin
The “fixation” variant of external fixation has advantages

over skeletal traction: it is less bulky, the patient is more
mobile, and reduction may be achieved using both skeletal
traction (elastic traction) and external fixation, which enables
dismantling of the device.
After the final radiographs have been obtained to confirm
the positions of the fragments, the arm is placed in abduction
at an angle of 45–60° using a wedge-shaped pillow and the
patient is transported to the ward.
10.3 Distal Humerus (13-)
Ilizarov external fixation of fractures 13 starts with

insertion of the intercrossing proximal basic wires into
the upper third of the humerus. One wire is inserted in the
sagittal plane and the other wire at an angle of 30° to it:
III,6-12 and III,1-7. The proximal basic support is a two-
thirds ring placed at level III of the upper arm and ori-
ented relative to the bone and soft tissue. After tensioning,
wires III,6-12 and III,1-7 are fixed to the proximal basic
support. At level V, an intermediate ring is installed and
connected by three rods to the proximal basic ring. When
the proximal basic support is properly installed, the
connection rods are parallel to the axis of the proximal
bone fragment.
In cases of extra-articular fractures (13-A2, 13-A3) or a
1 2 5 6 3 4
slipped epiphysis or osteoepiphysis, two wires are inserted III,6-12; III,1-7 – V,4-10 – VII,9-3; VIII,3-9; VIII,8-2
through the distal fragment strictly perpendicular to its lon- 2/3 150 150 3/4 150
gitudinal axis. One is inserted in the frontal plane and the

other at an angle of 30° to it: VIII,3-9 and VIII,8-2. After
13-A3.1
tensioning, the wires are fixed to a three-quarter ring external
support. The distal basic support is connected to the interme-
diate ring by three rods. Figure 10.16 shows the scheme for the combined external
Distraction is then applied to create an interfragment diafixation of extra-articular fractures of the distal part of the
stasis of 4–5 mm, if this was not previously done by skeletal humerus.
traction. Radiographs in two standard planes are obtained or It is also beneficial to perform external fixation of intra-
an image intensifier is used. articular fractures of the distal humerus (injuries 13-B and
To eliminate residual displacement of the proximal frag- 13-C) under conditions of skeletal traction on the orthopedic
ment, a reductionally fixing wire is inserted at the level of the traction table. However, it should be kept in mind that ten-
intermediate ring. To avoid injury to the great vessels and sion to the collateral ligaments of the elbow as a result of
nerves, only safe positions as specified in the atlas for level excessive traction can aggravate displacement of the
IV of the upper arm are used. Figure 10.15 shows, as an fragments.
example, wire V,4-10. In fractures 13-B and 13-C, closed external fixation can
The distal fragment is reduced using a stop and/or arched only be performed when it is possible to recover joint con-
bending of the wire. If required, reduction is achieved by gruity by moderate skeletal traction or by manual techniques
displacement of the external supports. Large splinters are (including the use of a thin hook or an awl). Fluoroscopy
fixed using either Kirschner wires with stops or console considerably facilitates the manipulation. If closed reduction
wires with stops. fails, then open reduction becomes necessary.
a b
Fig. 10.16 (a–g) Combined external fixation device for the fixation of (b) Insertion of basic wires II,5-11 and VIII,3-9. Assembly and align-
extra-articular fractures of the distal part of the humerus. Module trans- ment of distal reductionally fixing and basic supports. (c) Frame mount-
formation of the device for fractures of the distal part of the humerus is ing, tensioning and fixation of the wires, and distraction for a 3–5 mm
shown in Fig. 10.18. (a) Application of skeletal traction, division of the diastasis. Two-plane X-ray examination
segment into levels. Two-plane X-ray examination using radiopaque.
334 L.N. Solomin
Fig. 10.16 (continued) (d) Insertion of

d
reductionally fixing transosseous elements
V,10,90 and VII,9-3, followed by their
dynamic fixation to the supports. (e) Reduction
of the bone fragments in two planes, static
fixation of the reductionally fixing transosseous
elements. Two-plane X-ray examination
e
Fig. 10.16 (continued) (f) Insertion and fixation to supports of stabilizing half-pins III,9,120 and VIII,8,120. Elimination of the diastasis.
Dismantling of skeletal traction. (g) Patient after module transformation
336 L.N. Solomin
After the fragments of the humeral condyle have been

properly put together, they are fixed by wires with stops
inserted head to head. To eliminate residual displacement of
the proximal fragment and to ensure its stable fixation, a
reduction wire is inserted at the level of the intermediate
ring. Figure 10.17 shows, as an example, wire V,10-4.
In intra-articular fractures accompanied by injury to the
collateral ligaments, with apparent hemarthrosis, as well as
in open fractures, the elbow joint must be temporarily immo-
bilized after open reduction. This a achieved by applying a
single-support module to the forearm and connecting the
module to the main device by three hinges as shown in
Fig. 10.18.
When it is impossible to perform full external fixation, for
example in the event of multiple and massive trauma, the
fracture can be immobilized by a “fixation” device. This type
of external fixation can be used when an open reduction is
temporarily precluded. Wire IV,4-10 is tensioned and fixed
to the ring support. A second wire is inserted through the
base of the olecranon: olecr.,9-3. This wire is fixed after ten-
1 2 5 3 4
III,6-12; III,1-7 – V,10-4 – VIII,3-9; VIII,8-2 sioning to a three-quarter ring support. The forearm is placed
2/3 150 150 3/4 150 in flexion at an angle of 90–100° and fixed in this position
with a sling. Moderate distraction is applied between the
13-C10
a b
Fig. 10.18 (a) General configuration of the device used in the osteo- (b) First stage of module transformation (MT): removal of both the
synthesis of an intra-articular fractures of the distal part of the humerus. proximal basic support and the forearm support
Fig. 10.18 (continued) (c) Second stage of MT: c

partial removal of the reductionally fixing support
1 6 3 4 2 5 7 8
II,5-11_ III,9,120; V,10,90 _ VII,3,90; VIII,3-9; VIII,8,120 --o-- III,3-9; IV,6,70 (a)
1/2 150 140 3/4 140 3/4 130
III,9,120; V,10,90 _ VII,3,90; VIII,3-9; VIII,8,120 (b)

140 3/4 140
III,9,120; V,10,90 _ VII,3,90; VIII,3-9; VIII,8,120 (c)
1/2 140 3/4 140
supports: IV,4-10 ↔ olecr.,9-3. Later, the device can be con- soft tissue can be more readily prepared for open
verted to a full assembly. intervention.
The “fixation” variant of external fixation has advantages After the final radiographs have been obtained, the patient
over skeletal traction: it is less bulky and the patient is more is transported to the ward.
mobile. Compared to the use of plaster immobilization, injured
Fractures of the Forearm
11
In Ilizarov external fixation of the forearm (Table 1.2), wires bilocal osteosynthesis, and in other settings in which it is
with a diameter of 1.5 mm are used. In combined external necessary to create a “store” of soft tissue.
fixation, the basic wires have a diameter of 1.8–2 mm and the Before fixation of the wires, the external support must be
half-pins a diameter of 4 mm. The osteosynthesis set must appropriately oriented relative to the anatomic axis of the
also include 2-mm console wires with a stop set at various bone fragment and soft tissue (Fig.11.1). In external fixation,
lengths corresponding to the part to be inserted into the bone the external supports must be placed perpendicular to the
(5, 10, 15, and 20 mm). anatomic (mid-diaphyseal) axis of the bone fragment to
As a rule, in external fixation of the forearm, the device is which they are fixed. An exception is when the supports are
assembled from supports of the same diameter. In order to intentionally placed in a position of hypercorrection (dis-
allow flexion of the elbow, the supports placed at levels 0, I, cussed below).
and II of the forearm must be open (i.e., two-thirds or three- The intermediate reductionally fixing supports on the
quarter rings). In external fixation of juxta-articular and intra- forearm are oriented relative to the soft tissue depending on
articular fractures (21- and 23-) the use of radiotransparent the how the bone fragments are to be reduced. If the approach
external supports is recommended. involves mutual displacement of the modules fixing the bone
The insertion of transosseous elements at the first four fragments, the distance between the inner edge of the ring
levels of the forearm, through its ventral semicircle, and the dorsal aspect of the forearm must be equal.
requires that the forearm is extended, while insertion When the positions of the bone fragments need to be
through the rear semicircle is done with the forearm flexed changed using transosseous elements inserted near the bone
at 90–120°. The insertion of wires and half-pins through wound, during frame assembly, the ring should be displaced
the ventral aspect of the forearm at the four distal levels the necessary distance in the direction of the required dis-
requires placement of the hand in dorsiflexion at 40°; for placement of the bone fragment. The residual displacement
insertions through the dorsal aspect of the forearm, the can be evaluated on comparison radiographs. This method of
hand is placed in ventriflexion at 40°. When it is not pos- device assembly is more often used when the fragments are
sible to change the articular position to these angles, the to be reduced over a certain time during the postoperative
skin is displaced either manually or using a thin hook in the period (e.g., in traumatic deformities or in deformities arising
direction of its natural displacement relative to the bone from an orthopedic pathology) rather than in a single stage
during movement of the adjacent joint. When only refer- on the surgical table.
ence positions are used for the insertion of transosseous If the ends of the wires and half-pins located at a certain
elements, there is no need to change the articular position. distance from the support, which has been placed in the nec-
However, preliminary skin displacement (prior to the inser- essary spatial orientation, are to be fixed using posts and/or
tion of transosseous elements) must be used in the elonga- gasket washers, the half-pins (unless they are basic or reduc-
tion of the segment, in the correction of deformities, in tionally fixing transosseous elements) are fixed in the external
support only after the necessary spatial orientation of the bone
fragments has been achieved. If a half-pin is inserted in the
L.N. Solomin, M.D., Ph.D. () • P.N. Kulesh, M.D., Ph.D. bone not parallel to the external support, it is fixed to the sup-
Department of Traumatology and Orthopedics, port using two posts, one with a threaded hole (female) and
R.R. Vreden Russian Research Institute
the other with a threaded end (male). A half-pin can be fixed
of Traumatology and Orthopedics, 8 Baykova Str.,
St. Petersburg 195427, Russia to a support or post using an L-shaped clip in a similar manner
e-mail: solomin.leonid@gmail.com to the fixation of a wire using a threaded slotted clamp.
340 L.N. Solomin and P.N. Kulesh
a 11 12 The following sections describe particular methods of

1
fixation and contain phrases noting that when the device
15 mm
module is properly installed, its connection rods are parallel
10
2 to the anatomic axis of the bone fragment. However, when
the basic support is fixed only to wires, its position is likely
to change (i.e., it is likely to warp) due to bending of the
wires from the weight of the basic ring and the reductionally
fixing ring connected to it. In such cases, the orientation of
9 3 the module can be controlled by manually supporting it in
order to prevent bending of the wires.
It should be noted that in the diagrams illustrating osteo-
synthesis, the direction of the insertion of reductionally fixing
elements (wires, half-pins), and the positions of the stops of
8 the wires are conventionally stated, as examples. In practice,
4
one should be guided by the actual residual displacement of
7 5 the bone fragments. To avoid injury to the great vessels and
6
nerves, the safe positions given in the atlas of Part 1 should
b 12 be used to guide the insertion of reductionally fixing tran-
11 1
sosseous elements. The size of the external supports in the
diagrams is also shown conventionally.
In a reduction using wires, displacement of the bone
fragments is controlled by means of a stop; however, due to
the flexibility of the wires (Fig. 2.10), half-pins are more
2 often used for a reduction achieved by “pushing” or “pull-
10 ing;” if posts with a stop are used, the reduction can only be
achieved by “pushing” (Figs. 2.11 and 2.12). In addition,
any technique can be used when the reduction is via mutual
displacement of the external supports (Figs. 2.4, 2.5, 2.6,
2.7, 2.8, and 2.9). Large splinters are reduced and fixed by
9 3
wires with stops or by a hinge (cantilever) with stops (Fig.
2.16). If the splinter is located in the interosseous space or
there are great vessels and nerves in its path, a fork pin is
used. In contrast to the fork pin shown in Fig. 2.17, the fork
pin appropriate for the forearm is based on a 2-mm wire.
8
4 Regional anesthesia is generally preferred for external
7 6 5 fixation of the forearm. Before external fixation of isolated
fractures of the ulna, except fractures of its proximal and dis-
Fig. 11.1 The proximal basic support on the forearm (a) is installed tal parts, the bone fragments are roughly reduced by skeletal
perpendicular to the anatomic axis of the proximal fragment of the ulna. traction. This can be carried out using the standard devices
An exception is when there is an old injury to the ulna restricted to an
angular deformity. The proximal basic support is oriented relative to the available with the orthopedic traction table. When the neces-
soft tissue of the forearm, with a minimal amount of distance between sary structure is not available, a reductionally fixing post
the inner edge of the ring and the skin along the anteroexternal aspect must be specially produced (Fig. 11.2).
of the segment (plane of position 11 of the radius). The standard size of Transport immobilization is removed on the surgical table
the support must ensure the distance here is within 15 mm. The distance
from the ulna to the support along the outer aspect (position 9) and after the involved region has been anesthetized. When the
along the posterior aspect (position 6) must be equal: A–A1 = B–B1; Sysenko device and its analogues are used, wire olecr.,3-9 is
C–C1 = D–D1. The distal basic support on the forearm (b) in isolated inserted through the olecranon. The wire is tensioned and
fractures of the radius is installed perpendicular to the anatomic axis of fixed to the proximal support of the reductionally fixing post.
the distal fragment of the radius. In fractures of the ulna and in those of
both bones of the forearm, the distal basic support is installed perpen- A second wire is inserted through metacarpals II and V:
dicular to the anatomic axis of the distal fragment of the ulna. In all m-carpII–mcarpV. This wire is tensioned and fixed to the
cases, at the level of the basic supports the distance from the rear sur- distal support of the post. When the modified device described
face of the ulna (plane of position 6) to the support must be equal
11 Fractures of the Forearm 341
by Demjanov is used, only one wire is inserted through the X-ray contrast markers (injection needles, wire fragments)
metacarpals. are placed on the skin and comparison radiographs are
Irrespective of the fracture level, the forearm is placed obtained in two standard planes, or fluoroscopy is used. On
in the mid-position between supination and pronation. the basis of the data obtained, additional correction to the
Distraction is applied sufficient to eliminate the longitudinal positions of the bone fragments in the reductionally fixing
displacement of the fragments. To facilitate the elimination post may be required. Lines corresponding to the anatomic
of lateral and angular displacements, a diastasis of 3–4 mm is axis of each bone fragment are drawn on the skin of the ven-
created. tral and dorsal aspects of the segment. The special device
b c
Fig. 11.2 Reduction posts for the forearm. (a) The post developed by the Russian Ilizarov Research Center and (b) by K.U. Kudzaev; (c) the
modified device of V.M. Demjanov
Fig. 11.2 (continued) (d) the

distraction-reduction module. Note d
that the basic frame mount is inside
the module, after preliminary
reduction. Thus, the proximal wire
of the module will be the proximal
basic wire of the frame, and the
distal wire of the module the distal
basic wire of the frame in cases of
fractures of the distal part of the
forearm bones
shown in Table 1.2 and Chap. 4 is used to mark the insertion The aim of the external fixation of closed fractures is to
levels of the transosseous elements. achieve accurate radiographically confirmed reduction of the
When sufficient clinical experience has been obtained, bone fragments with the patient still on the surgical table. The
comparison radiographs during skeletal traction are needed fixation device should be assembled carefully in the operating
only in cases of juxta-articular and intra-articular fractures of room whenever possible. A hastily assembled device not assem-
the distal part of the forearm (23-). bled in the operating room may result in a poor outcome. In some
At this stage of the procedure, the surgical field is treated rare cases, the patient may need daily treatment as an outpatient,
and draped. with radiographically monitored stepwise manipulations. The
exceptions are patients treated with the variant “fixation” device; Fig. 11.3 Ilizarov external fixation in
the indications for its use are discussed below. fractures 21-B1.1
Importantly, after external fixation of fractures of the
radius and of both bones of the forearm, it is not advisable to
strive for complete rotation of the forearm during the fixation
period. However, during this phase there are positions that
allow partial restoration of rotational function (Table 5.1).
That is why reference positions designated in the atlas of Part
1 by → and — symbols are used for the external fixation of
the radius and of both bones of the forearm.
11.1 Proximal Forearm (21-)
In juxta-articular fractures of the proximal metaphysis of the

ulna (21-A1) and of the olecranon (21-B1), the choice of
external fixation method is largely dependent on the nature of
the fracture surface. Before fixation, the forearm is placed in
the position of maximum extension to relax the triceps mus-
cle of the upper arm.
II,4-10; III,10-4
If an end stop between the fragments is suspected (damage 1/2 120
21-A1.2 and 21-B1.1) and the fracture line is directed proxi-
mally, the olecranon is fixed with a thin hook and a wire is
inserted through its top, with the guiding end of the wire ori-
ented towards the dorsal aspect of the ulna. The wire usually is given in parentheses. If the wire is inserted through
perforates the skin at level II or III of the forearm (pos. II,6 or both bones simultaneously, it is designated in accordance
III,6 of the ulna). A bending spiral-shaped stop is formed on the with the priority with which the guiding end of the wire is
central end of the wire. Rotation of the tensioning end of the inserted through the ulna and radius. For example, the
wire results in insertion of the stop to the bone. Comparison designation VIII,6-12(VIII,6-12) is a wire with a stop
radiographs are obtained in two standard planes. After the reduc- inserted from the side of the ulna. The designation
tion has been confirmed, the wire is moved slightly proximally, (VIII,12-6)VIII,12-6 is a wire without a stop inserted
cut off at the external edge of the stop, and reinserted as far as through both bones of the forearm from the side of the
the bone. Two wires with stops (II,4-10 and III,10-4) are then radius.
inserted through the ulna in the opposite direction in a plane One of the wires is fixed after tensioning directly in the
close to the frontal plane. Both wires are strained in the half-ring support and the second with the help of posts: III,4-10; IV,6-
that is oriented parallel to the plane of emergence of the com- 12(IV,6-12). The support can be hybrid, as shown in
pressing wire. After stabilization of the basic support, the com- Fig. 11.5.
pressing wire is tensioned using a traction clip (Fig. 11.3). Ilizarov external fixation of a splinter fracture of the ole-
If the fracture line is located in a horizontal plane, the pro- cranon (21-A1.3, 21-B1.2, 21-B1.3) starts with the insertion
cedure is carried out according to the algorithm presented in of the basic wires, one of which is inserted through both
Fig. 11.4 (see also Chap. 20). bones: III,4-10 and IV,6-12(IV,6-12). The ring support is ori-
If the line of the fracture of the olecranon travels downwards ented perpendicular to the anatomic axis of the forearm. The
and backwards, the emergence of the compressing wire is ori- proximal wire is strained and fixed directly to the support.
ented to the ventral aspect of the ulna. In this case it is strained Wire IV,6-12(IV,6-12) is fixed to the ring using posts. Instead
in the ring support on the basis of two wires, one inserted through of wire III,4-10, half-pin (V,10,70) can be used. The forearm
the ulna and the other through both bones of the forearm. is placed in the position of maximum extension and the ole-
Note: According to MUDEF, the indication for tran- cranon is temporarily stabilized with a thin hook. A wire
sosseous elements to be inserted through the radial bone with a stop to be inserted as far as the bone is inserted through
a b c d
Fig. 11.4 (a–e) Variant of osteosynthesis in a fracture of the olecranon. Closed or open (using a minimal approach) reduction. (b) Wire insertion
(a) Formation in a projection of a position 6 level IV channel with a through the olecranon. (c) Formation of a wire stop. (d) Insertion of half-
diameter of 2.5 mm. The channel should be located at an angle of 150° pin V,6,120 and tensioning of the axial compression wire with the help
to an axis of a bone fragment. Insertion into the channel of a 2-mm wire. of a traction clip. (e) The patient after olecranon fixation
the olecranon into the ulna medullary canal. Mutually cross- involves immobilization of the elbow. A wire module is
ing wires are inserted through the olecranon, one located in applied to the upper arm using a two-thirds ring for the distal
the frontal plane and the second at an angle of 30° to the first: support: IV,10-4; IV,8-2 — VII,3-9. Instead of a wire module
olecr.,3-9 and olecr.,4-10. After tensioning, these wires are based on two supports, a hybrid (wire–pin) module can be
fixed to a two-thirds ring. The wire inserted in the intramed- used based on a two-thirds ring: VI,7,120; VII,3-9.
ullary canal is bent at a distance of 20 mm from the skin and In fractures of the head and neck of the radius (21-A2,
its end is fixed to the proximal support (Fig. 11.6). After 21-B2), a wire is inserted through the top third of the diaphy-
2–3 weeks the wire can be removed. sis: (IV,5-11). It is strained and fixed in the ring support. The
External fixation of isolated fractures of the proximal part basic supports of the upper arm and forearm are connected by
of the radius (21-A2, 21-B2) and of fractures of the proximal hinges with the elbow bent at 90–100° and moderate distrac-
parts of both bones of the forearm (21-A3, 21-B3, 21-C) tion is applied. A comparison radiograph is obtained and the
a b c d
Fig. 11.5 (a–d) Variant device for the external fixation of fracture sion wire. (c) Cutting the wire behind a wire stop. In osteoporosis, a
21-B1.1. (a) Note that the fracture line is directed distally. (b) Closed or curved wire stop is expedient. (d) Tensioning of the compression wire
open (using a minimal approach) reduction. Insertion of the compres- in the transosseous module IV,6-12 (IV,6-12); (V,10,70)
Fig. 11.6 External fixation device for fixation of fracture 21-B1.3

Fig. 11.7 External fixation

device for fixation of fracture
21-C2.2
problem of inserting the reductionally fixing wire, for example

the post wire with a stop (II,9,90), is resolved by fixing it to the
distal basic support using a post. The operation is completed
by insertion of the second basic wire (III,3-9) through the
radius. The wire is also fixed to the basic support using posts.
In fractures of the proximal parts of both bones of the
forearm (21-A3, 21-B3, 21-C), after the support is mounted
on the upper arm, the second support is mounted on the ulna
and radius: III,4-10; IV,6-12(IV,6-12).
Then the fracture of the olecranon is fixed in the manner
described above. The two modules are connected by hinges
with the elbow bent at 90–100° and moderate distraction is
applied. Reductionally fixing wires for the radius are inserted.
In Fig. 11.7 this is wire (0,9,120).
If it is not possible, for various reasons, to perform the full
external fixation, the alternative is the “fixation” variant. An
external support is mounted on the upper arm and on the
forearm. They are connected by three hinges and moderate
distraction is applied. A possible variant assembly is:
VI,7,120; VII,3-9 ← o → III,4-10; IV,6-12(IV,6-12).
If an external module is not applied on the upper arm, the
arm is fixed with a sling with the elbow flexed at 90–100°,
after which the patient is transported to the ward.
11.2 Diaphyseal Fractures (22-)
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh 1 2 4 5 3 6

I,2-8; I,5-11(I,5-11); II,10-4 – III,3-9 – VII,4-10; VII,6-12(VII,6-12)
3/4 130 130 130
11.2.1 Ulnar Diaphysis
Fig. 11.8 Ilizarov external fixation of isolated fractures of the proxi-
11.2.1.1 Proximal Third mal third of the ulnar diaphysis
Ilizarov external fixation of isolated fractures of the proximal
third of the ulnar diaphysis (injuries 22-A1.1, 22-A1.2, metaphysis. One is inserted through the ulna in a plane close
22-B1.1, 22-B1.2, 22-C1.1) starts with insertion of two inter- to the frontal plane and the other through both bones: I,2-8
crossing proximal basic wires at the level of the proximal and I,5-11(I,5-11). A distal basic wire (VII,4-10) is then
inserted through the ulna at the level of the distal metaphysis tions of their stops depend on the residual displacement of
in a plane close to the frontal plane. The proximal basic sup- the bone fragments. To avoid damage to the great vessels
port, a three-quarter ring, is oriented relative to the anatomic and nerves, only the safe positions identified in the atlas of
axis of the ulna relative to the soft tissue. The wires are ten- Part 1 for levels II and IV of the forearm (relative to the ulna)
sioned and fixed to the support. are used. As an example, Fig. 11.8 shows wires II,10-4 and
An intermediate reductionally fixing ring support is then III,3-9. Wire II,10-4 is fixed to the proximal support using
installed at level IV of the forearm and connected by three posts.
rods to the proximal support. The intermediate support is By displacement of the bone fragment with the help of a
connected by three rods to the distal basic support. The nuts stop, or arched bending of the wire, the proximal and distal
of the connection rods at the intermediate support are not bone fragments are reduced successively. It is also possible to
tightened. The distal basic support is installed so that it is use any reduction technique together with mutual displacement
perpendicular to the anatomic axis of the distal bone frag- of the external supports. After elimination of the lateral and
ment. The distances between the posterior aspect of the ulna angular displacement of the fragments, the supports are
and the supports at the levels of the basic support locations brought closer to each other in order to eliminate the
must be equal. After tensioning, wire VII,4-10 is fixed to the diastasis.
distal basic support installed in this way. The nuts are tight- If it is possible to ensure axial compression (transverse or
ened at the intermediate support, with distraction then applied short oblique fracture line), a second basic wire VII,5-11 is
to create an interfragmentary diastasis of 3–4 mm. Two stan- inserted through the ulna. If head cross-compression (oblique,
dard radiographs are obtained or an image intensifier is spiral fractures) or neutral osteosynthesis (splintered destruc-
used. tion) is deemed necessary, a second distal basic wire
To eliminate residual displacement of the proximal bone is inserted through both bones of the forearm: VII,6-
fragment at level II, a reductionally fixing wire is inserted. 12(VII,6-12). Large splinters are reduced and fixed using
Residual displacement of the distal fragment at level IV is wires with stops or console wires with stops.
eliminated by the insertion of a second reductionally fixing Figure 11.9 shows the scheme for the combined external
wire. The direction of insertion of these wires and the loca- fixation of fractures of the proximal third of the ulna.
a b
Fig. 11.9 Combined external

fixation device for the fixation of
fractures of the proximal third of
ulna. Wire VIII,5-11 is removed
on the surgical table immediately
after radiographic confirmation
of fragment reduction. (a)
Transosseous element
I,5,90(I,5,90) is a 2–3-mm wire
inserted from the front cortical
plate of the radius through both
bones only as far as the outlet of
its guiding end. (b) This wire is
tightened 2–3 weeks after surgery
so that it stays only in the ulna.
At the same time, the distal
support is removed. The front
half-rings are dismantled at the
intermediate and distal basic
rings
1 3 4 5 7 2 6
I,4-10; I,5,90(I,5,90); II,6,90 _ III,6,90; V,7,120 _ VII,5-11; (VII,12-6)VII,12-6 (a)
2/3 130 130 130
I,4-10; I,5,90; II,6,90 _ III,6,90; V,7,120 (b)
2/3 130 1/2 130
Fig. 11.9 (continued) (c) At this time, recovery of the rotational movements of the forearm can be initiated
11.2.1.2 Middle Third At level III (or level IV, depending on the fracture loca-
Ilizarov external fixation of fractures of the middle third of tion), an intermediate (reductionally fixing) support is
the ulnar diaphysis (injuries 22-A1.1, 22-A1.2, 22-B1.1, installed; it is connected by three rods to the proximal
22-B1.2, 22-C1.1) starts with the insertion of intercrossing basic support. For proper orientation of the supports, the
proximal basic wires, one of which is inserted through both connection rods must be parallel to the anatomic axis of
bones of the forearm: I,2-8 and I,5-11(I,5-11). The distal the proximal bone fragment. At level V (or level VI,
basic wire is then inserted through the ulna:VIII,5-11. depending on the fracture location), the second reduction-
The proximal support, a three-quarter ring, is oriented ally fixing ring support is installed, connected by three
relative to the anatomic axis of the ulna, with respect to the rods to the proximal reductionally fixing support and by
soft tissues. The proximal basic wires are then tensioned pre- three rods to the distal basic support. The nuts of the con-
liminarily and fixed to the support. nection rods at the second reductionally fixing support are
inserted at level V (or at level VI). Figure 11.10 shows, as an

example, wires IV,10-4 and V,4-10.
Using a stop or the arched bending of the wire, the proxi-
mal and then the distal bone fragments are reduced succes-
sively. Alternatively, any reduction technique together with
mutual displacement of the external supports can be used.
The diastasis between the fragments is then eliminated.
If it is possible to ensure axial interfragmentary compression
(transverse or short oblique fracture line), a second basic wire
VII,4-10 can be inserted through the ulna and fixed to the distal
support using posts. If head cross-compression (oblique, spiral
fractures) or neutral osteosynthesis (splintered destruction) is
deemed necessary, a second distal basic wire is inserted through
both bones of the forearm: VIII,6-12(VIII,6-12).
Figure 11.11 shows the scheme for the combined external
fixation of fractures of the middle third of the ulna.
11.2.1.3 Distal Third

Ilizarov external fixation of fractures of the distal third of the
ulnar diaphysis (injuries 22-A1.1, 22-A1.2, 22-B1.1, 22-B1.2,
22-C1.1) starts with insertion of intercrossing proximal basic
wires through the ulna: II,2-8 and II,4-10. The distal basic
wire VIII,5-11 is then inserted through the ulna. The proximal
support, a three-quarter ring, is oriented relative to the ana-
tomic axis of the ulna, with respect to the soft tissues. The
proximal basic wires are then tensioned preliminarily and
fixed to the support.
The reductionally fixing ring support is then installed at
1 2 4 5
I,2-8; I,5-11(I,5-11) – III,9-3 – V,4-10 – level V of the forearm and connected by three rods to the
3/4 130 130 130 proximal support. The connection rods must be parallel to
3 6 the axis of the proximal fragment of the ulna. The intermedi-
– VIII,5-11; VIII,6-12(VIII,6-12)
ate support is then connected to the distal basic support. At
130
the levels of the basic supports, the distances from the poste-
Fig. 11.10 Ilizarov external fixation of fractures of the middle third of rior aspect of the ulna to the supports must be equal. After
the ulnar diaphysis orientation of the distal basic support relative to the anatomic
axis of the distal fragment of the ulnar bone, wire VIII,5-11
is tensioned and fixed to it.
not tightened. The distal basic support is installed so that it Distraction is applied to produce an interfragmentary dia-
is perpendicular to the anatomic axis of the distal bone stasis of 3–4 mm if this could not be achieved by skeletal
fragment. The distances from the posterior aspect of the traction. Radiographs are obtained in two standard planes or
ulnar bone to the support at the levels of the basic supports an image intensifier is used.
must be equal. After tensioning, wire VIII,5-11 is fixed to To eliminate residual displacement of the proximal bone
the distal basic support installed in the previously described fragment at level V, a reductionally fixing wire is inserted.
manner. Residual displacement of the distal fragment at level VI is
The device is stabilized and distraction is applied to pro- eliminated by the insertion of a second reductionally fixing
duce an interfragmentary diastasis of 3–4 mm. Radiographs wire. The direction of the insertion of these wires and the
are obtained in two standard planes or an image intensifier is location of their stops depend on the residual displacement of
used. the bone fragments. To avoid damage to the great vessels and
To eliminate residual displacement of the proximal bone nerves, only the safe positions identified in the atlas of Part 1
fragment, a reduction wire is inserted at level IV (or level III, for levels V and VII of the forearm (relative to the ulna) are
depending on the line of fracture). To eliminate residual dis- used. As an example, Fig. 11.12 shows wires VI,4-10 and
placement of the distal fragment, a second reduction wire is VII,10-4. Wire VII,10-4 is fixed to the distal support using
Fig. 11.11 (a) Combined a b

external fixation variant of a
fracture of the middle third of the
ulna. (b) At 3–4 weeks postop-
eratively, wire I,5,90(I,5,90) is
tightened so that it stays only in
the ulnar bone: I,5,90. At the
same time the distal ring is
removed. The front semi-rings of
the reductionally fixed and distal
basic rings are dismantled. At
this time, gradual recovery of the
rotational movements of the
forearm can be initiated
1 3 4 8 5 9 6 7
I,4-10; I,5,90(I,5,90) _ II,8,110; IV,6,90 _ V,6,90; VII,7,80 _ VIII,5-11; (VIII,12-6)VIII,12-6 (a)
2/3 130 130 130 130
II,8,110; IV,6,90 _ V,6,90; VII,7,80 (b)

1/3 130 1/3 130
posts. After elimination of the lateral and angular displace- the unbent forearm, pronating it and moving it at the elbow,
ment of the fragments, the proximal and distal supports are and with the other hand presses upon the head of the radius
brought closer to each other in order to eliminate the in an inwards and backwards direction. After re-setting, the
diastasis. forearm is placed in extreme supination. The head of the
If it is possible to ensure axial compression (transverse or radius is fixed to the radial bones by a wire with a stop:
short oblique fracture line), the second distal basic wire is not (I,11-5)I,11-5. On completion of the operation, to reduce the
inserted through the ulnar bone. If it is expedient to apply risk of pin-tract infection and elbow stiffness, wire (I,11-5)
head cross-compression (oblique, spiral fractures) or neutral I,11-5 with post or half-pin (I,9,90) should be replaced
osteosynthesis (splintered destruction), the second distal (Fig. 11.12). If re-setting of the head of the radius is
basic wire is inserted through both bones of the forearm: confirmed radiographically, external fixation is performed
VIII,6-12(VIII,6-12). Wire VIII,5-11 can be removed. following a method similar to those described for isolated
Figure 11.13 shows the scheme for the combined external ulnar fractures.
fixation of fractures of the distal third of the ulna. If the head of the radius cannot be re-set manually, skeletal
traction is applied by means of a reductionally fixing post
11.2.1.4 Monteggia Fractures (Fig. 11.2), and an anteroposterior radiograph is assessed. If
External fixation of Monteggia fractures (22-A1.3, 22-B1.3, the interrelationships of the distal radial joint are not impaired,
22-C1.1) is preceded by an attempt to re-set the head of wire VIII,6-12(VIII,6-12) is inserted through both bones of
the radius. With an assistant holding the patient’s shoul- the forearm in the sagittal plane. When the ulnar fracture is
der, the surgeon uses one hand to exert traction while holding located in the upper third of the diaphysis, the distal basic
proximal basic support and the reductionally fixing support is

increased by an amount sufficient to pull the head of the
radius through the resulting space.
For final re-setting and fixation of the head of the radius, a
wire with a stop (I,11-5)I,11-5 is inserted through both bones
of the forearm. If lateral displacement is present, the use of
wire (I,3-9) or (I,9-3) is recommended. With the use of the
stop, lateral displacement of the proximal part of the radius is
eliminated. The wire is then bent backwards and inwards.
The dislocation is eliminated by simultaneous traction at
both ends of the wire. After the manipulation, wire (I,3-9) is
replaced by wire (I,11-5)I,11-5 or half-pin I,9,90.
The ulnar fragments are then reduced and fixed using one
of the above methods. If the second variant of the device
assembly (solid rods between the supports) is used, elimina-
tion of longitudinal displacement of the ulnar fragments is
achieved by distraction between the intermediate and distal
basic supports. In the distal support a strained wire must be
inserted only through the ulnar bone, for example VIII,5-11
(Fig. 11.14a).
Figure 11.14b–f presents the stages of external fixation
according to Puseva et al. [208].
After comparison radiographs have been obtained, the
skeletal traction device is dismantled. The arm is fixed by
means of a sling with the elbow flexed at 90–100°. Two pins
fixed to the distal support with a gauze sling between them
ensure the mid-physiological position of the hand.
1 2 4
II,2-8; II,4-10 _ VI,4-10 –
3/4 130 130 11.2.2 Radial Diaphysis
5 3 6
_ VII,10-4; VIII,5-11; VIII,6-12(VIII,6-12)
130 Irrespective of the level of the radial diaphysis fracture before
external fixation, the forearm in skeletal traction is placed in
Fig. 11.12 Ilizarov external fixation of fractures of the distal third of the mid-physiological position: the forearm is maximally
the ulnar diaphysis
supinated and then internally rotated to 65–70°.
External fixation of fractures of the proximal third of the
radial diaphysis (injuries 22-A2.1, 22-A2.2, 22-B2.1, 22-B2.2,
wire is inserted at level VII: VII,6-12(VII,6-12). The proxi- 22-C2.1) starts with insertion of the proximal basic wire I,2-8
mal basic wire is inserted only through the ulnar bone: I,4-10. through the ulna at the level of the proximal metaphysis in a
The device is assembled with three supports for fractures of plane close to the frontal plane. The distal basic wire (VII,1-
the proximal or distal thirds of the ulnar diaphysis, and with 7) is then inserted through the radius at the level of the distal
four external supports (two basic and two reductionally fixing) metadiaphysis in a plane close to the sagittal plane. The prox-
for fractures of the middle third of the ulnar diaphysis. imal support, a three-quarter ring, is installed perpendicular
After the device has been assembled, distraction sufficient to the anatomic axis of the ulna; the support is oriented rela-
to place the head of the radius exactly opposite the radial tive to the soft tissues, tensioned, and the wire is fixed in it.
incisure is applied. The end-point may be recovery of the The intermediate reductionally fixing support is then
anatomic length of the ulna. installed at level IV of the forearm and connected by three
If comparison radiographs reveal impaired inter-relation- rods to the proximal basic support. The intermediate support
ships of the distal radial joint as well, the assembly of the is connected by three rods to the distal basic support. The
external fixation device has certain requirements: All sup- nuts of the connection rods at the intermediate support are
ports of the device are connected by solid rods. Wire (V,2-8) not tightened. The distal basic support is installed so that it is
is inserted through the radius and fixed after tensioning to the perpendicular to the anatomic axis of the distal bone frag-
intermediate support using posts. The distance between the ment. The distance from the posterior aspect of the ulna (line
Fig. 11.13 The combined

a b
external fixation of fractures of
the distal third of the ulna. (a)
Wire VIII,4-10 is removed on the
surgical table after reduction of
the bone fragments. The
transosseous element
II,6,90(II,6,90) is a 2-mm wire
inserted through both bones only
as far as the outlet of its guiding
end from the front cortical plate
of the radial bone. (b) At
3–4 weeks postoperatively, wire
VIII,12-6(VIII,12-6) is removed.
The front semi-rings at the
intermediate and distal basic
rings are dismantled. At this
time, recovery of the rotational
movements of the forearm can be
initiated
1 3 6 4 5 2 7
II,4-10; II,6,90(II,6,90) _ IV,7,100; VI,6,90 _ VII,6,90; VIII,6,80; (VIII,12-6)VIII,12-6 (a)
2/3 130 130 130
IV,7,100; VI,6,90 _ VII,6,90; VIII,6,80 (b)

1/3 130 1/3 130
of position 6) to the support at the levels of the basic supports inserted through both bones of the forearm: (I,11-5)I,11-5.
must be equal. After tensioning, wire (VII,1-7) is fixed to the The wire is tensioned and fixed to the proximal support.
distal support installed as described. The device is stabilized The console wire lever is removed. Radiographs are obtained
by tightening the nuts at the rods. in two standard planes or an imaging intensifier is used.
Distraction is applied to create an interfragmentary dia- To eliminate residual displacement of the proximal bone
stasis of 4–5 mm, if this was not possible by skeletal trac- fragment by the Ilizarov method, a reductionally fixing wire
tion. Rotational displacement of the proximal fragment of is inserted at level II. Insertion of Kirschner wires through
the radial bone is then eliminated according to the method the radial bone at this level is dangerous due to the possibil-
of Ilizarov et al. [209]. A 2-mm console wire II,10,90 is ity of damaging the great vessels and nerves. Therefore, it is
inserted in the proximal fragment of the radial bone at a best to use a console wire with a stop or a 4-mm half-wire.
distance of 20–25 mm proximal from the fracture level Figure 11.15 shows, as an example, console wire II,9,90,
through both cortical layers. Using this wire as a lever, the which is fixed to the proximal support using a post. To elimi-
proximal splinter is rotated first toward the outside up to the nate residual displacement of the distal fragment at level III
stop and then 90° towards the inside. In this position in or IV, a second reductionally fixing wire is inserted. Possible
Ilizarov external fixation, the second proximal basic wire is variants of the wire insertion are selected on the basis of the
residual displacement of the distal bone fragment using the By repositioning the bone fragment using a stop together
safe positions of the atlas in Part 1 for level II of the forearm with arched bending of the wire, the proximal and then the
(relative to the radius). Figure 11.15 shows wire (III,11-5) as distal bone fragments are successively reduced. Alternatively,
a possible variant. any reduction technique can be used together with mutual
a b
c d
Fig. 11.14 (a–g) External

fixation devices for the fixation
of Monteggia fractures (22-
A1.3). (b) Insertion of half-pins
I,6,90 and II,6,90 in the proximal
bone fragment. Insertion of
half-pins V,6,90 and VII,6,90 in
the distal fragment. Frame
assembly. (c) Elbow bone-frag-
ment reduction: one-stage or
gradually (at malunion). (d)
Insertion of half-pin (VI,12,100)
and its fixation to the distal
device support. Connection of the
supports. Distraction to lower the
head of the radius
e f
1 4 5 6 3 2
I,4-10; (I,9,90); II,10-4 – IV,6,90; (V,2-8) – VIII,5-11 (a)
3/4 130 130 130
Fig. 11.14 (continued) (e) Insertion of half-pin (II,9,90) and its fixation in a reductionally fixing unit. After the head of the radius has been
lowered, the distal support can be dismantled. (f) Elimination of a subluxation of the head of the radius
basic wire through the ulnar bone: I,4-10. A distal basic wire
is then inserted through the radial bone: (VIII,1-7). The prox-
imal basic support, a three-quarter ring, is oriented relative to
the anatomic axis of the ulnar bone, with respect to the soft
tissues, and then the tensioned wire is fixed to it.
At level III (or level IV, depending on the location of the
fracture), an intermediate (reductionally fixing) support is
installed and connected by three rods to the proximal basic
support. At level V (or level VI, depending on the location
of the fracture), a second reductionally fixing ring support
is installed and connected by three rods to the proximal
reductionally fixing support and by three rods to the distal
basic support. The nuts of the connection rods at the second
reductionally fixing support are not tightened. The distal
basic support is installed so that it is perpendicular to the
anatomic axis of the distal bone fragment. The distances from
the posterior aspect of the ulna to the supports at the levels of
the basic supports must be equal. After tensioning, wire
(VIII,1-7) is fixed to the distal basic support, installed as
described.
The device is stabilized and distraction is applied to create
an interfragmentary diastasis of 3–4 mm. Rotational dis-
placement of the proximal fragment of the radial bone is then
eliminated according to the method of Ilizarov et al. [209]
and wire (I,11-5)I,11-5 is inserted through both bones.
intensifier is used.
1 3 4 5 To eliminate residual displacement of the proximal bone
I,2-8; (I,11-5)I,11-5; (II,9,90) – (III,5-11) – fragment at level IV (or, depending on the fracture line, level
3/4 130 130 III), a reduction wire is inserted. Residual displacement of
6 2 the distal fragment at level V (or level VI) is eliminated by
– VII,6-12(VII,6-12); (VII,1-7)
inserting a second reduction wire. Figure 11.17 shows, as an
130
example, wires IV,1-7 and V,9-3.
Fig. 11.15 Ilizarov external fixation of isolated fractures of the proxi- Using known techniques (repositioning using a stop or
mal third of the radial diaphysis bending of the wire), the proximal and then the distal bone
fragments are successively reduced. Alternatively, any reduc-
displacement of the external supports. After the lateral tion technique can be used together with mutual displace-
angular displacement of the fragments has been eliminated, ment of the modules fixing the bone fragments. After that,
the proximal and distal supports are approximated to elimi- the diastasis is eliminated.
nate the diastasis, together with moderate compression in If the line of the fracture allows compression of the frag-
transverse and short oblique fractures. ments axially (transverse or short oblique fractures), the sec-
If head cross-compression (oblique, spiral fractures) or ond distal basic wire VIII,1-7 can be inserted through the
neutral osteosynthesis (splintered destruction) is deemed radius. If head cross-compression (oblique, spiral fractures)
necessary, a second distal basic wire VII,6-12(VII,6-12) is or neutral osteosynthesis (splintered destruction) is deemed
inserted through both bones of the forearm in the sagittal necessary, a second distal basic wire is inserted through both
plane. Large splinters are reduced and fixed using wires with bones of the forearm: VIII,6-12(VIII,6-12). Large splinters
stops or console wires with stops. are fixed using wires with stops or console wires with
Figure 11.16 shows the scheme for the combined external stops.
fixation of fractures of the proximal third of the radius. Figure 11.18 shows the scheme for the combined external
Ilizarov external fixation of fractures of the middle third of fixation of fractures of the middle third of the radius.
the diaphysis of the radial bone (injuries 22-A2.1, 22-A2.2, Ilizarov external fixation of fractures of the distal third of
22-B2.1, 22-B2.2, 22-C2.1) starts with insertion of a proximal the radial diaphysis (injuries 22-A2.1, 22-A2.2, 22-B2.1,
a b
1 3 7 4 5 8 2 6
I,4-10; I,5,90(I,5,90); (I,8,90); (II,8,90) _ (III,9,90); (V,12,90) _ (VII,1-7); VII,6-12(VII,6-12) (a)
2/3 130 130 130
(I,8,90); (II,8,90) _ (III,9,90); (V,12,90) (b)

2/3 130 1/2 130
Fig. 11.16 (a) Combined external fixation variant of a fracture of the proximal third of the radius. (b) At 2–3 weeks postoperatively, the distal
ring is removed. (c) At this time, gradual recovery of the rotational movements of the forearm can be initiated
Distraction is applied to create an interfragmentary diasta-

sis of 3–4 mm. The rotational displacement of the proximal
fragment of the radius is then eliminated according to the
method of Ilizarov et al. [209]. The second proximal basic
wire is then inserted through both bones of the forearm:
(I,11-5)I,11-5. After tensioning, the wire is fixed to the proxi-
mal support. Radiographs are obtained in two standard planes
or an image intensifier is used.
fragment at level V, a reductionally fixing wire is inserted.
Residual displacement of the fragment at level VII is elimi-
nated by inserting a second reductionally fixing wire.
Figure 11.19 shows as an example wires VI,2-8 and VII,4-
10. Wire VII,4-10 is fixed to the distal support using
posts.
The proximal and then the distal bone fragments are suc-
cessively reduced. After reduction of the fragments, with the
displacement edgewise and at an angle, the proximal and dis-
tal supports are brought closer to eliminate the diastasis, with
moderate compression used in transverse and short oblique
fractures.
If head cross-compression (oblique, spiral fractures) or
neutral osteosynthesis (splintered destructions) is deemed
necessary, a second distal basic wire is inserted through both
bones of the forearm: VII,6-12(VII,6-12).
1 3 4 5 Figure 11.20 shows the scheme for the combined external
I,4-10; (I,11-5)I,11-5 _ (IV,1- 7) _ (V,9-3) –
3/4 130 130 130
fixation of fractures of the distal third of the radius.
2 6 In Galeazzi’s injury (22-A11, 22-B11, 22-C2.1), there is
_ (VIII,1-7); VIII,6-12(VIII,6-12) rupture of the ligaments of the distal radioulnar joint with
130
displacement of the distal fragment of the radius together
Fig. 11.17 Ilizarov external fixation of fractures of the middle third of with the hand towards the palmar or dorsal sides but the spa-
the radial bone diaphysis tial location of the ulna does not change. Therefore, in the
closed reduction that must precede external fixation, the dis-
tal fragment of the radius is brought closer to the ulna and not
22-B2.2, 22-C2.1) starts with insertion of the proximal basic vice versa. The same principle is followed for correction of
wire I,4-10 through the ulna. The distal basic wire (VIII,1-7) the dislocation with the help of the device.
is then inserted through the radius. The proximal support, a For skeletal traction, the proximal basic support is
three-quarter ring, is oriented relative to the anatomic axis of mounted on a three-quarter ring: I,4-10; I,5,90(I,5,90). In the
the ulna, with respect to the soft tissues, and the preliminarily flexion variant of Galeazzi’s injury, wire (VIII,1-7) is inserted
tensioned wire is fixed to the support. through the radius; in the extension variant, wire (VIII,7-1) is
The intermediate ring support is then installed at level V of inserted. Depending on the level of the radial fracture, the
the forearm and connected by three rods to the proximal sup- device is assembled on the basis of three or four external
port. The connection rods between the intermediate and prox- supports.
imal basic supports must be parallel to the axis of the ulna. Distraction is applied to create an interfragmentary diasta-
The intermediate support is then connected by three rods to sis of 3–4 mm. In the same manner as was described for
the distal support. At the level of placement of the basic sup- external fixation of isolated diaphyseal fractures of the radius,
ports, the distance from the posterior aspect of the ulna to the the bone fragments are reduced. The interfragmentary diasta-
support must be equal. During tensioning of the wire in the sis is eliminated and comparison radiographs obtained in two
distal basic support, the support must be located perpendicu- standard planes are evaluated. If the interrelationships in the
lar to the anatomic axis of the distal fragment of the radial distal radioulnar joint have not been restored, console wire
bone. VII,9,90 is inserted in the ulna in the flexion variant or wire
a b
Fig. 11.18 (a) Combined external fixation variant of the middle third of the radius. (b) At 2–3 weeks postoperatively, the proximal and distal
supports are removed. (c) At this time, gradual recovery of the rotational movements of the forearm can be initiated
1 3 5 3 4 6 2 7
I,4-10; I,5,90(I,5,90) _ (II,8,100); (IV,12,90) _ (V,12,90); (VII,10,80) _ (VIII,1-7); VIII,6-12(VIII,6-12) (a)
2/3 130 130 130 130
(II,8,100); (IV,12,90) _ (V,12,90); (VII,10,80) (b)

1/3 130 1/3 130
VII,4,90 in the extension variant. Wire (VIII,1-7) or (VIII,7-1)

can be bent in an arc, which will restore the proper interrela-
tions in the distal radioulnar joint. Wire VIII,6-12(VIII,6-12)
is then inserted through both bones of the forearm. Only then
is the distraction force provided by the reductionally fixing
post removed. The operation is completed by removal of the
console wire at level VII.
device for skeletal traction is dismantled. The arm is fixed
with a cravat bandage with the elbow flexed at 90–100°. Two
pins with a gauze sling between them, to ensure the mid-
physiological position of the hand, are fixed to the distal sup-
port of the device.
11.2.3 Diaphysis of the Radius and Ulna
Irrespective of the level of radial diaphysis fracture before

external fixation, the forearm in skeletal traction is placed in
the mid-physiological position: the forearm is maximally
supinated and then internally rotated 90°. The rotational dis-
placement of the proximal fragment is eliminated by the
method of Ilizarov et al. [209]. The algorithm for the meth-
od’s implementation is described Sect. 11.2.2.
Ilizarov external fixation of fractures of both bones of the
forearm (injuries 22-A3, 22-B3, 22-C1.2, 22-C1.3, 22-C2.2,
22-C11, 22-C3) starts with insertion of the proximal basic
1 3 4
wire I,4-10 through the proximal metaphysis of the ulna in a
II,2-8; (II,12-6)II,12-6 – (VI,2-8) – plane close to the frontal plane. The proximal support, a
130 130 three-quarter ring, is oriented relative to the anatomic axis of
5 2 6 the ulna, with respect to the soft tissues. The wire is then
– (VII,4-10); (VIII,1-7); VIII,6-12(VIII,6-12) tensioned and fixed to the external support. If the radiographs
130
obtained in skeletal traction show that the relations in the dis-
Fig. 11.19 Ilizarov external fixation of fractures of the distal third of tal radioulnar joint are not disturbed, the distal basic
the radial bone diaphysis wireVIII,6-12(VIII,6-12) is inserted through both bones. A
second distal basic wire (VIII,1-7) is then inserted through port must be equal. With the distal basic support in this posi-
the radius. tion, the wires are tensioned and fixed to it.
Depending on the levels of the fractures of the ulna and Distraction is applied to create an interfragmentary dia-
radius, the device assembly includes up to three reduction- stasis of 3–4 mm. Rotational displacement of the proximal
ally fixing rings. It should be remembered that an additional fragment of the radius is then eliminated using the method of
support considerably simplifies reduction of bone fragments. Ilizarov et al. [209]. The manipulation is completed by the
The reductionally fixing support(s) is (are) connected by insertion of a wire through the proximal metaphysis of both
three rods to the proximal basic support. For the device to be bones of the forearm: I,5-11(I,5-11). After tensioning, the
properly centered, the connection rods must be parallel to wire is fixed to the proximal support. Radiographs are
the anatomic axis of the proximal fragment of the ulna. The obtained in two standard planes or an image intensifier is
intermediate supports are then connected by three rods to the used.
distal basic support. The distal basic support must be installed The residual displacements of the proximal and distal
perpendicular to the anatomic axis of the distal fragment of bone fragments of the ulna and radius are successively
the radius. At the levels of the basic supports, the distance eliminated. The reduction wires are inserted at a distance of
from the posterior aspect of the ulna (position 6) to the sup- 20–30 mm from the fracture. To exclude damage to the great
a b
Fig. 11.20 (a) Combined external fixation

variant of the middle third of the radius. (b)
At 2–3 weeks postoperatively, the proximal
support is removed
1 3 4 5 2 6 7
II,4-10; II,6,90(II,6,90) _ (V,12,100); (VI,9,90) _ (VII,12,90); (VIII,1,90); VIII,6-12(VIII,6-12) (a)
2/3 130 130 130
(V,12,100); (VI,9,90) _ (VII,12,90); (VIII,1,90) (b)

1/3 130 1/3 130
Fig. 11.20 (continued) (c) At this time, gradual recovery of the rotational movements of the forearm can be initiated
vessels and nerves, only the safe positions identified in the

atlas in Part 1 for the insertion of transosseous elements at
the relevant levels of the forearm are used. Large splinters
are reduced and fixed using wires with stops or console wires
with stops.
If the comparison radiographs in skeletal traction show
that the fragments of the ulna and radius need different
amounts of distraction (compression), the device assembly
must allow the possibility of separate reduction of the fore-
arm bones. As an example, Fig. 11.21 shows a diagram of the
external fixation of fracture 22-A3.3 according to the method
of Ilizarov et al. [209].
It follows from Figs. 11.21 and 11.22b that to allow sepa-
rate reduction the reductionally fixing and distal basic sup-
ports of the device must be connected by rods. Both the distal
basic and distal reductionally fixing wires through the distal
fragment of the ulna are fixed to the intermediate support;
those through the radius are fixed to the distal support. Thus
separate axial displacement of the fragments of the forearm
bones is possible.
Figure 11.23 shows the scheme of the separate external
fixation of the forearm bones that allows forearm rotation to
be carried out during the fixation period.
In fractures of the lower third of the diaphysis of the
forearm bones, two- or three-hole posts are used. In fracture
of the forearm bones at different levels, the distal fragment
of bone fractured at the lower level is fixed to the distal
ring.
1 4 5 6
I,4-10; I,5-11(1,5-11) III,9-3; (IV,11-5) – device for skeletal traction is dismantled. The arm is fixed
–
3/4 120 120 with a cravat bandage with the elbow flexed at 90–100°. Two
7 2 8 3
rods with a gauze hammock strung between them are fixed to
VI,10-4; VII,4-10 (VII,1-7); (VIII,7-1)
–
120
–
120
the distal support of the device to place the hand in the mid-
physiological position.
Fig. 11.21 External fixation device of Ilizarov et al. [209] for the
fixation of fracture 22-A3.3
Fig. 11.22 Combined external fixation a b

devices for the fixation of fractures
22-C2.2 (a) and 22-A3.3 (b). The
proximal basic wire must have a stop:
I,4-10. The second proximal basic wire
is a console wire; it is inserted through
both bones: I,5,90(I,5,90). In segmen-
tary fractures (a), before the tran-
sosseous elements can be inserted
through the intermediate fragment of the
radius, the latter is temporarily fixed
with a towel clip. (b) The variant
according to Ilizarov et al. [209]:
combined external fixation with separate
reduction of the ulna and radius
1 3 4 6 10
I,4-10; I,5,90(I,5,90) __ III,7,90; (IV,10,90); IV,6,80 __
3/4 130 130
5 8 9 7 2
__ V,4-10; (V,12,110); (VI,1-7) __ (VII,10,90); VIII,6-12(VIII,6-12) (a)
130 130
1 4 5 6 7 2 8 3
I,4-10; I,5,90(I,5,90) __ III,9-3; (IV,1,70) __ V,7,90; VII,4-10 __ (VII,1-7); (VIII,7-1) (b)
3/4 120 120 120 120
Fig. 11.23 (a–l) Separate

external fixation of the forearm
a b
bones. (a) Skeletal traction is
applied, the forearm is divided
into levels, and radiographs are
obtained with the forearm
marked with roentgen-positive
markers. (b) Basic wire I,4-10 is
inserted through the proximal
metaphysis of the ulna and wire
(VIII,1-7) through the distal
metaphysis of the radius. Distal
basic supports are installed
followed by wire tensioning and
fixation to the supports. (c)
Assembly of the external fixation
device frame and the application
of distraction to create an
interfragmentary diastasis of
3–4 mm while achieving the
correct correlations in the distal
radioulnar joint. Wire VIII,6-
12(VIII,6-12) fixation. X-ray
examination
c

(d) Insertion of reduction d
half-pins IV,6,90 and V,6,90 in
the ulnar fragments. (e)
Dynamic fixing of half-pins to
the intermediate supports
e

(f) Reduction of the ulnar f
fragments. X-ray examination
g

(i) Reduction of radial bone h
fragments. X-ray examination
i

(j) Stabilizing half-pins II,9,100, j
VII,7,80, (II,8,100) and
(VII,1,80) are inserted and then
fixed to the intermediate supports.
(k) Module transformation to
separate external fixation can be
realized: removal of the basic
supports and the conversion
of ring supports to sectorial
supports
k
Fig. 11.23 (continued) l

(l) Example of the combined
external fixation of both
bones of the forearm
1 3 9 10 7 8
I,4-10; I,5,90(I,5,90) _ II,9,100; (II,8,100); IV,6,90; (IV,12,90) _
130 130
5 6 11 12 2 4
_ V,6,90; (V,12,90); VII,7,80; (VII,1,80) _ (VIII,1-7); VIII,6-12(VIII,6-12) (j)
130 130
II,9,100; IV,6,90 _ V,6,90; VII,7,80 _ (II,8,100); (IV,12,90) _ (V,12,90); (VII,1,80) (k)

1/3 130 1/3 130 1/3 130 1/3 130
11.3 Distal Forearm (23-) oriented relative to the soft tissues so that the forearm at level
V is in the center of the ring support. The wire is strained and
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh fixed to the ring.
An intermediate support is installed at level VIII of the
The operation is preceded by a closed manual reduction of forearm. The device is assembled such that the metacarpal
the bone fragments. Wire m/carpII–m-carpV is then inserted bones are located in the same plane as the forearm bones,
through metacarpal bones II and V (bypassing metacarpal parallel to the connection rods. After the external supports
bones III and IV). The wire is tensioned and fixed to a half- have been mounted, a distraction force is applied. On the
ring or to a two-thirds ring support. The wire can be inserted basis of comparison radiographs, reductionally fixing
through metacarpal bones II, III, IV, and V only after they wires, for example VI,4-10 and VIII,11-5, are inserted
have been forced into one plane. If the wire inserted through through the ulnar fragments. The diastasis between the
metacarpal bones II, III, IV, and V is not removed at the end fragments is eliminated. In oblique or splintered fractures,
of the operation, it will cause pain and will negatively affect a wire is then inserted through both bones of the forearm:
the function of the fingers. A support based on the two wires VIII,6-12(VIII,6-12). If the fracture line allows axial com-
m/carpII–m/carpIV; m/carpIII–m/carpV will provide firm pression, a half-pin or a 2-mm console wire VIII,8,110 is
fixation of the hand. inserted.
For the external fixation of isolated juxta-articular frac- External fixation of injury 23-A1.2 is shown in Fig. 11.24.
tures of the ulna (23-A1), a proximal basic wire with a stop is In transverse fractures, the operation is completed by
inserted through both forearm bones in the sagittal plane:V,6- removal of the support from the hand. In splintered fractures
12(V,6-12). The ring support is placed perpendicular to the with marked soft-tissue edema of the carpal joint area, the
anatomic axis of the proximal fragment of the ulna and support is removed in 2–2.5 weeks.
usually wires (VI,2-8) and (VIII,7-1), and in Smith’s frac-

tures wires (VI,8-2) and (VIII,1-7). The wire at level VIII
must be strictly perpendicular to the anatomic axis of the dis-
tal fragment of the radius. Using stops, the wires are bent in
an arc and the fracture is finally reduced. The diastasis
between the fragments is then eliminated.
In oblique or splintered fractures, a wire is inserted
through both bones of the forearm: VIII,6-12(VIII,6-12). If
the fracture line allows axial compression, and the relation-
ships in the distal radioulnar joint are not interrupted, a half-
pin or a 2-mm wire (VIII,11,110) is inserted.
Figures 11.25 and 11.26 show the variants of external
fixation of injuries of the distal part of the radius.
In transverse fractures the operation is completed by
removal of the support from the hand. In splintered fractures,
this is done after 2–2.5 weeks.
External fixation of intra-articular fractures of the distal
part of the forearm bones (23-B, 23-C) is carried out simi-
larly. Intermediate supports should not be located in the
joint space plane as they will hinder radiographic evalua-
tion. An alternative solution is to use an X-ray-transparent
support.
After distraction, restoration of the congruence of the
articular surfaces is determined radiographically. The posi-
2 3 4 5 tion of the bone fragments can be improved using wires with
V,6-12(V,6-12); VI,4-10 – VIII,11-5; VIII,6-12(VIII,6-12) – stops and posts with a stop. If closed reduction fails, reduc-
120 120
1
tion can be achieved with an external fixation device, with
– m/carpV–m/carpII the minimum surgical approach controlling only the position
1/2 120 of the bone splinters. Osteoautoplasty can also be used if
indicated.
Fig. 11.24 External fixation device for the fixation of fracture 23-A1.2
In fragmented, splintered, open infected fractures, tran-
sosseous elements through the distal part of the forearm
bones are not used.
In the external fixation of extra-articular fractures of the When full-volume external fixation is not possible, for
distal radius (23-A2, 23-A3), a proximal basic wire is example in the event of multiple and massive trauma, and if
inserted through both bones of the forearm: V,6-12(V,6-12). the patient’s condition is grave, the fracture can be
The ring support is located perpendicular to the anatomic immobilized using a device with two supports. The same
axis of the proximal fragment of the radial bone and oriented external fixation variant can be used when it is not immedi-
relative to the soft tissues so that the forearm at level V is in ately possible to perform the necessary open reduction of the
the center of the ring support. Wire V,6-12(V,6-12) is ten- bone fragments.
sioned and fixed to it. An intermediate support is installed at Wire V,6-12(V,6-12) is tensioned and fixed to the ring
level VIII of the forearm and connected by three rods to the support. The second wire is inserted through the metacarpal
basic ring. bones: m/carpV–m/carpII. This wire is fixed after tensioning
In Colles’ fractures (23-A2.2), the support fixed to the to a half-ring or to a two-thirds ring. A moderate distraction
hand is installed so that it is located parallel to the proximal force is applied between the supports: V,6-12(V,6-12) ↔ m/
basic and intermediate supports but it is displaced dorsally carpV–m/carpII. Later, the device can be converted to a full
so that the hand is in palmar flexion at 25–30°. In Smith’s assembly.
fractures (23-A11), the hand is placed in dorsiflexion at After comparison radiographs have been obtained, the
25–30°. arm is fixed with a cravat bandage with the elbow flexed at
After the external supports of the device has been mounted, 90–100°. If the support was assembled on the hand, two rods
a distraction force is applied. On the basis of comparison are connected to the device, with a gauze sling stretched
radiographs, reductionally fixing wires are inserted through between them for temporary immobilization of the bone in
the fragments of the radius. In Colles’ fractures these are the mid-physiological position.
a b c
Fig. 11.25 (a–h) Combined external device for the fixation of fractures wire VI,3-9. (b) Frame assembly. Note: since the distal basic wire was
of the distal part of the radius. (a) Skeletal traction is applied using wire not inserted perpendicular to the anatomic axis of the ulna, it is fixed to
m/carpV-m/carpII. Division of a segment into levels. X-ray examination a support by means of posts. (c) Distraction, insertion of the
in two projections with contrasting markers. Insertion of proximal basic reductionally-fixing half-pin (VII,12,90) and wire (VIII,1-7)
d e
f g
Fig. 11.25 (continued) (d) Reduction of the bone fragments. (e) proximal fragment in the frontal plane. Note: Do not forget to discon-
Elimination of the interfragmentary diastasis. Insertion of stabilizing nect (VII,12,90) during reduction! (f) Dismantling of skeletal traction.
half-pins (V,9,90) and (VIII,11,90). If the fracture is both splintered and (g) Module transformation: removal of the distal basic support, partial
intra-articular, additional reductionally-fixing K-wires and console dismantling of the proximal support
wires are inserted. Half-pin (V,9,90) can be used in the reduction of the
Fig. 11.25 (continued) (h) An example of external fixation of fractures of the distal part of the forearm bones
1 3 5 4 2
(V,9,90); (VII,12,90) _ (VIII,1,90); (VIII,11,90) _ m/carpII,11,90
1/4 120 1/4 120 1/4 120
Fig. 11.26 This version of the external fixation of fractures of the dis-
tal part of radial bone has limited reduction possibilities. (VIII,1,90);
console wire for fixation of a bone splinter; (VIII,11,90): stabilizing
half-pin. If insertion of half-pin (VIII,11,90) is not possible, an addi-
tional half-pin is placed into the second metacarpal bone
Fractures of the Femur
12
Leonid Nikolaevich Solomin and Viktor Alexandrovich Vilensky
In femoral osteosynthesis, wires 1.8–2 mm in diameter are angles cannot be achieved, the skin is displaced manually or
used. In combined external fixation, these wires are supple- by using a thin hook in the direction of its natural movement
mented by half-pins 5 and 6 mm in diameter. The external relative to the bone with movement in the adjacent joint.
fixation set must also include 2-mm console wires with a When only reference positions are used to insert the tran-
stop that can be set at various lengths, allowing variable sosseous elements, it is not necessary to change the position of
insertion into the bone (5, 10, 15 and 20 mm). the joint. However, preliminary (prior to insertion of the tran-
In Ilizarov external fixation of the femur, at levels 0, I, and sosseous elements) displacement of the skin must be carried out
II, one-third or one-quarter sector or radius bar external sup- in segment lengthening, deformities correction, bilocal osteo-
ports are used. The half-pins used in combined external synthesis, and other situations calling for a stock of soft tissue.
fixation in the proximal part of the femur are fixed to these Prior to fixation of the transosseous elements, the external
supports. The supports are one third or one-quarter rings support must be appropriately oriented relative to the ana-
(Fig. 12.1). At levels III and IV of the femur, two-thirds or tomic axis of the bone fragment and the soft tissue. In exter-
three-quarter rings are used. They are mounted with the open nal fixation, the external supports must be perpendicular to
part facing inwards so that the patient can adduct the limb. the anatomic (mid-diaphyseal) axis of the bone fragment to
In external fixation of the femur, the external supports at which they are fixed. As the distal epidiaphyseal angle of the
the first six levels (levels 0–V) must be two or three standard femur is about 81° (Fig. 16.30), the supports on the femur
sizes larger than the supports in the distal third of the femur. should not be placed parallel to the knee joint space.
Therefore, the modules forming the proximal and distal bone Exceptions are in the osteosynthesis of intra-articular frac-
fragments are connected by connection plates. tures of the distal part of the femur and in cases in which the
The supports located at the distal three levels of the femur supports are intentionally placed in a position of hypercor-
(levels VII–IX) are two-thirds or three-quarter rings to allow rection, as described below.
flexion of the knee. In external fixation of juxta-articular and If the device assembly includes a reductionally fixing sup-
intra-articular fractures (33-), the use of radiotransparent port between levels III and V of the proximal fragment of the
external supports is recommended. femur, it is positioned as follows. The distance between the
To prevent knee stiffness, the transosseous elements at the inner edge of the ring (notionally extrapolated in the case of an
four distal levels of the femur (VI–IX) are inserted through open support) and the lateral aspects of the femur must be
the soft tissue of the anterior semicircle of the femur with the equal. The distance from the skin to the support at the back
lower leg bent to an angle of 90–120°. Transosseous ele- must be 2.5–4 cm greater than at the front. To connect this ring
ments through the posterior semicircle of the femur are by rods to the proximal basic support, due to the different diam-
inserted with the lower leg extended. When the necessary eters of the supports, connection plates are additionally used.
When the device assembly requires the use of two exter-
nal supports of different diameters (distal reductionally
L.N. Solomin, M.D., Ph.D. (*) fixing and distal basic supports) for the distal bone fragment,
R.R. Vreden Russian Research Institute of Traumatology they are preliminarily connected by a single rod along the
and Orthopedics, 8 Baykova Str., St Petersburg 195427, Russia
anterior surface. In this case, the distal basic support appears
to be displaced forwards relative to the reductionally fixing
V.A. Vilensky, M.D., Ph.D.
support. At this stage the supports are not fixed to the
Department of Orthopedics, R.R. Vreden Russian Research Institute
of Traumatology and Orthopedics, 8 Baykova Str., transosseous elements. The rod connecting the supports is
St. Petersburg 195427, Russia installed parallel to the anatomic axis of the distal bone
376 L.N. Solomin and V.A. Vilensky
a b
Fig. 12.1 Orientation of the proximal basic supports in Ilizarov exter- 3–4 cm (a). When half-ring (sector) are used, the distance between the
nal fixation of the femur. The proximal (basic) support is oriented rela- surface of the skin and the support along the anterior external surfaces
tive to the soft tissue so that the distance between the internal edge of of the femur is constant (3–4 cm). Also, the size of the support is such
the support and the skin anteriorly and laterally is 3–4 cm. The distance that its internal edge corresponds to the plane of position 1 and the
from the skin to the support along the posterior aspect is an additional posterior external edge – to the plane of position 8 (b)
Fig. 12.2 Installation of distal reductionally fixing and basic supports on the femur
fragment. The distal reductionally fixing support is then washers (Fig. 7.28). The half-pins, unless they are basic or
oriented relative to the soft tissues so that the distance from reductionally fixing transosseous elements, are stabilized in
the skin to the support at the back is 2.5–4 cm greater than at the external supports only after the necessary spatial orienta-
the front, while the distances from the inner edge of the ring tion of the bone fragments has been achieved.
and the lateral aspects of the femur are equal. Then, with If a half-pin inserted in the bone is not parallel to the
axial rotation on the connection rod of the distal basic sup- external support, it is fixed to the support using two posts,
port, it is oriented relative to the soft tissues. Only then are one female and the other male. The half-pin can be fixed to
the transosseous elements that have been inserted at the level the support or post using an L-shaped clip, similar to the use
of the distal basic support fixed. Finally, the remaining two of a laterally slotted wire clamp (Fig. 19.27).
or three connection rods are mounted using connection plates The following sections describe particular external
(Fig. 12.2). fixation methods. In the text, it is often noted that when the
The ends of the wires and half-pins, which are at some device modules are properly installed, the connection rods
distance from the support after it has been given the neces- will be parallel to the anatomic axis of the bone fragment.
sary spatial orientation, are fixed using posts and/or spacer However, it should be taken into account that the position of
12 Fractures of the Femur 377
Fig. 12.3 Skeletal traction in a

diaphyseal fracture of the femur.
The uninjured limb is fixed in the
foot-support of the orthopedic
traction table and the necessary
traction force is applied to
prevent pelvic warping. The
panels of the table located under
the pelvis and femur are lowered.
The specific features of the
external fixation of the various
parts of the femur are described
in the respective sections
a basic support fixed only on wire(s) is likely to change due by skeletal traction. The patient is placed on the orthopedic
to bending of the wires as a result of their weight and that of traction table with a pelvic stand and a perineal radiotrans-
the connection rods. In such cases, to control the orientation parent rest. Wire VIII,3-9 is inserted through the condyles of
of the external fixation module it should be supported by the femur and tensioned in the half-ring of the traction unit of
hand, thus neutralizing the bending flexure of the wires. the orthopedic traction table. In low fractures, wire I,3-9 for
Reduction by wires is achieved by displacement of the skeletal traction is inserted through the proximal metaphysis
bone fragment with the help of a stop and the bending of the of the tibia.
wire (Fig. 2.10). Reduction with half-pins more often requires In combined external fixation, skeletal traction on the
“pushing” or “pulling,” and with console wires with a stop orthopedic traction table is performed using a wire that will
only “pushing” (Figs. 2.10 and 2.11). Alternatively, any be further employed in the device as the distal basic wire:
reduction technique can be used together with mutual dis- VIII,3-9 or VII,3-9 or VI,3-9 depending on the device assem-
placement of the external supports (Figs. 2.4, 2.5, 2.6, 2.7, bly. The size of the fixture (half-ring) for skeletal traction
2.8, and 2.9). Large splinters are reduced and fixed using must be sufficient to allow placement of the distal basic sup-
wires with stops or console wires with stops (Fig. 2.16). port of the device inside it (Fig. 12.3).
When there are great vessels and nerves in the plane of the The positions of the bone fragments are improved by
splinter, its reduction and fixation are performed using a fork axial traction and manual manipulation. To facilitate reduc-
device (Fig. 2.17). tion, the injured segment is overtensioned by up to 5–8 mm,
It should be noted that in all the external fixation dia- monitoring distraction in the attachment by comparison with
grams, the direction of insertion of reduction transosseous the non-injured femur. X-ray contrast markers (injection
elements (wires, half-pins) and the locations of the stops on needles, wire fragments) are placed on the skin and com-
the wires are given as examples. In practice, however, one parison radiographs are obtained in two standard planes, or
should be guided by the actual residual displacement of the an image intensifier is used. Lines are drawn on the skin of
bone fragments. To avoid injury to the great vessels and the anterior and external aspect of the femur corresponding
nerves, safe positions at the levels recommended in the atlas to the plane of the anatomic axis of each bone fragment.
of Part 1 for the insertion of reductionally fixing transosseous Using the special device shown in Table 1.3, the levels for
elements are used. The sizes of the external supports in the insertion of the transosseous elements are marked. With
diagrams are also provided only as examples. accumulating clinical experience in the external fixation of
For external fixation of the femur, anesthesia is generally diaphyseal fractures, the need for comparison radiographs
regional. The transportation immobilization is removed during skeletal traction is reduced. The operative site is
on the operating table after the surgical field has been treated and draped.
anesthetized. An invariable rule for external fixation of closed fractures
External fixation of the femur requires a rough prelimi- is radiographic confirmation of the precise reduction on the
nary elimination of the displacement of the bone fragments operating table. First, the principal large splinters are reduced
12.1 Proximal Femur (31-)
The specific features pertaining to the insertion of tran-

sosseous elements in the external fixation of proximal
fractures of the femur are based on the assumption that
axial compression of only the bone fragments will be pos-
a
sible. Therefore, special attention should be paid to the
precision of the preliminary reduction. To improve visual-
ization of the procedure, it is necessary to use an image
intensifier.
In femoral neck fractures (31-B2), closed reduction of
bone fragments is performed using one of the established
methods. The leg is then slightly abducted (20–30°),
rotated maximally inward (up to 45–60°), and fixed in this
position in the attachment of the orthopedic traction table.
The uninjured leg is flexed at an angle of 90° at the hip
and knee and is placed on the attachment of the orthope-
dic traction table so that it will not hinder radiography in
the axial plane. If counter-extension by the unaffected leg
is necessary, it is lowered above or below the injured
limb.
In pertrochanteric fractures of the femur (31-A1, 31-A2),
the femur is abducted on the orthopedic traction table to
an angle of 15–20° and flexed at an angle of 15–25°. In elderly
debilitated patients, reduction is performed without the
b
hip abduction and flexion. In intertrochanteric fractures
(31-A3), it is necessary to abduct and flex the hip by the
Fig. 12.4 A trolley (a) and a bed (b) with a recess to accommodate the
frame are required after Ilizarov external fixation of the femur amount of displacement of the proximal fragment, usually
up to 30–40°. In undisplaced fractures, only “disciplinary”
traction is applied on the orthopedic traction table, without
and fixed with Kirschner wires with stops, or with periosteally abduction of the limb.
inserted wires or console wires with stops. In the plane of the inguinal ligament, a connection plate
The practice of hastily assembling an external fixation from the Ilizarov set is placed and fixed to the skin, further
device and performing the reduction after transferring the serving as a landmark. To mark the femoral neck, an injec-
patient to a clinical department, with daily stepwise radio- tion needle is inserted at the upper and lower boundaries.
graphic monitoring of the manipulations performed, is an Comparison radiographs are obtained in two planes, or an
unsatisfactory and discredited method of external fixation. image intensifier is used. If reduction is confirmed, external
An exception to this rule is when a fixation device is applied fixation is initiated.
as described below. After external fixation it is necessary to Ilizarov external fixation of fractures of the femoral neck
check the passive movements of the joints adjacent to the seg- (31-B2) starts with the insertion of a wire in the subtrochan-
ment operated upon. Tension in the soft tissues as a result of teric region 8–9 cm from the top of the greater trochanter,
insertion of the transosseous elements must be eliminated by along the lateral external surface of the femur in the direction
releasing the skin and, if required, the fascia and muscles. of the upper pole of the femoral head. A second wire is
After Ilizarov external fixation, a special trolley with an inserted in the same plane 4.5–5 cm from the top of the
opening for the device and a bed with a similar opening greater trochanter in the direction of the lower pole of the
(Fig. 12.4) are required for transportation of the patient. femoral head. Thus, these two wires form a cross in a plane
Patients must be warned that during fixation they will not be close to the frontal plane [210]. A wire is then inserted from
able to use a normal bed and/or sit. After external fixation with the anteroexternal surface of the femur at a distance of 5.5–
a hybrid or pin device a normal trolley and bed can be used. 6.5 cm from the top of the trochanter in the direction of the
a b
Fig. 12.5 (a, b) Ilizarov external fixation device for the fixation of fracture 31-B2.1
posterior surface of the femoral head. A fourth wire is For insertion of the half-pin at level I, a canal made with an
inserted at the same level from the posteroexternal surface in awl in the adjacent cortical plate suffices. Starting from
the direction of the anterior surface of the femoral head. A level II and distally, where the cortical plate is more marked,
third and fourth wire form a cross at 45–65° in the sagittal the canal should be made with a borer for insertion of the
plane. A mandatory condition is the subchondral location of half-pins. Non-observance of this rule may result in splin-
the guiding ends of all four wires, which is monitored tering of the bone, which will considerably complicate
radiographically. external fixation and worsen the prognosis. To ensure later
The device configuration for tension of the diafixation interfragmentary compression, the spongy thread should be
wires depends on the length of the splinter levers, and the located more medially than the fracture zone. All half-pins
degree of muscle tissue development on the number of should be inserted as far as the subchondral layer of the
external supports. With a relatively short femur and shal- femoral head. Two or three 6-mm half-pins can also be used
low soft tissues, a ring of diameter 180–195 mm should as basic transosseous elements. Less stable fractures,
be used with wires IV,1-7;V,1-7;V,2-8; VI,3-9 (Fig. 12.5a). heavier patients, and the greater need for early loading are
Figure 12.5b shows the configuration of the device on the indications to increase the number of fixation and basic
basis of two external supports: IV,1-7; IV,6-12 – VI,2- half-pins.
8;VI,3-9. The diafixation wires are fixed to a threaded bar Figures 12.6 and 12.7 shows the scheme for the combined
to enable separate repositioning along it during tension- external fixation of fractures of the proximal part of the
ing of each pair of wires. The wires can also be fixed femur.
using a monolateral support and half-pins: III,9,90; After comparison radiographs have been obtained, the
IV,9,90. skeletal traction is dismantled and the patient is trans-
When a half-pin-based device for external fixation after ported to the ward. During transportation, a soft cushion
reduction is used, two or three 6-mm half-pins with a must be placed under the involved knee to ensure flexion
spongy thread are inserted in parallel in the femoral neck. of 60–45°.
a b
c d
Fig. 12.6 (a–d) External fixation of pertrochanteric fractures. (a) I,9,120 and II,9,120. (c) Insertion of basic half-pins IV,9,90 and V,9,90.
Closed bone fragment reduction using the orthopedic table. Two-plane (d) Installation and stabilization of the monolateral support
X-ray examination with sterile skin markers. (b) Insertion of half-pins
a b
Fig. 12.7 (a–l) Combined external fixation device for the fixation of distal basic wire VI,3-9. (c) Insertion of proximal basic half-pins I,11,90
fractures of the proximal part of the femur. (a) Closed bone fragment and I,8,110. (d) Alignment of the proximal basic support and fixation of
reduction using the orthopedic table. Division of the femur into levels. the basic half-pins
Two-plane X-ray examination with sterile skin markers. (b) Insertion of
e f
g h
Fig. 12.7 (continued) (e) Alignment of the distal basic support. (f) bone fragment. Static fixation of half-pin III,9,90. Insertion of proximal
Frame assembly, distraction 3–5 mm. Two-plane X-ray examination. stabilizing half-pin I,9,120. Insertion and fixation of proximal stabiliz-
(g) Insertion of half-pin III,9,90 and its dynamic fixation, aided by the ing half-pins V,8,70 and VII,8,70. Two-plane X-ray examination
reduction device, to the support. (h) Two-plane reduction of the distal
i
j
Fig. 12.7 (continued) (i) Elimination of the diastasis. Dismantling of skeletal traction. (j) First stage of modular transformation (MT): removal
of wire VI,3-9; partial removal of reductionally fixing and distal basic supports. (k) Second stage of MT: removal of the distal support
Fig. 12.7 (continued) (l) Clinical

example l
12.2 Diaphyseal Fractures (32-)
In skeletal traction, the distal fragment is placed in the mid-

position between external and internal rotation. The rota-
tional displacement of the proximal fragment is eliminated
after fixation of both bone fragments by the modules of the
device. This is carried out by manually holding the tran-
sosseous module fixing the proximal bone fragment and
placing it maximum external rotation. It is then rotated maxi-
mally inwards and then again outwards by 30–40° to place it
in the neutral position. In this position, the proximal and dis-
tal transosseous modules are connected by modules. If the
mobility of the hips is limited by the presence of pathology,
then during the preoperative period the amplitude of rota-
tional movements in the intact limb should be determined.
12.2.1 Proximal Third
In fractures of the proximal third of the femoral diaphysis (inju-

ries 32-A1.1, 32-A2.1, 32-A3.1, 32-B1.1, 32-B2.1, 32-B3.1,
32-C), skeletal traction is applied on the orthopedic traction
table with the hip abducted at 30–45°. The more proximal the
fracture, the greater the abduction angle. In subtrochanteric
fractures, the hip must be additionally flexed to 40–50°.
The Ilizarov operation starts with the insertion of crossing
proximal basic wires through the proximal metaphysis of the
femur. Before insertion of the first wire, pulsation of the fem-
oral artery should be confirmed by palpation in Scarpa’s tri-
angle. The wire is then inserted 15–20 mm from the artery
towards the outside. The second wire is inserted at an angle 1 2 5 7 6 8 3 4
of 30° to the first. In Fig. 12.8, these wires are designated as I,6-12; I,11-5; II,11-5; II,6-12 æ V,8-2; V,1-7 æ VII,2-8; VII,4-10
arc 250 195 180
I,6-12 and I,11-5.
In some cases it is technically complicated to insert the Fig. 12.8 Ilizarov external fixation device for fixation of fracture 32-A1.1
wire with a stop I,6-12. If this is the case, wire I,12-6 is
inserted and embedded in the soft tissue until its tail protrudes
30–40 mm. A flexural stop (corrugated or spit-like) is then fixing) sectorial support is installed, connected by three rods
formed on the opposite side: at the clunis (breech). By push- to the proximal basic support.
ing the end, the rest of the wire is inserted as far as the bone, The reductionally fixing support for the distal fragment is
and thus wire I,12-6 becomes I,6-12. It should be emphasized then installed at level V of the femur. It is connected by three
that a wire with such a flexural rest must not be tensioned rods to the distal basic ring. The reductionally fixing support is
with a force >400 N. Therefore, to ensure sufficient rigidity oriented relative to the bone and soft tissues. Wires VII,2-8 and
of the external fixation, it is necessary to insert either an addi- VII,4-10 are then tensioned and fixed to the distal support, either
tional wire or console wire I,9,90, as the Russian Ilizarov directly to the ring or, if offset, using posts. When the distal
Research Center recommends. In the supracondylar region, module of the device is properly installed, its connection rods
the distal basic wires VII,2-8 and VII,4-10 are then inserted are parallel to the anatomic axis of the distal bone fragment.
perpendicular to the anatomic axis of the distal fragment. The rotational displacement of the proximal fragment is
For the proximal support, the femoral sectorial support is eliminated and the proximal basic support then connected by
oriented relative to the anatomic axis of the proximal bone three rods to the reductionally fixing support. A distraction force
fragment, with respect to the soft tissues, and the wires are is applied to create an interfragmentary diastasis of 5–7 mm, if
fixed to it after tensioning. If the length of the proximal bone this was not possible during skeletal traction. Radiographs are
fragment exceeds 110–120 mm, an additional (reductionally obtained in two standard planes or an image intensifier is used.
To eliminate residual displacement of the proximal bone tures in muscular and/or overweight patients, additional
fragment at level II (or III), a reductionally fixing wire is transosseous elements, for example II,6-12 or V,1-7, can be
inserted. Residual displacement of the distal fragment at inserted to increase the rigidity of the external fixation.
level V is eliminated by the insertion of a second wire. The Figure 12.9 shows the scheme for the combined external
direction of insertion of these wires and the location of their fixation of fractures of the proximal third of the femur.
stops depend on the residual displacement of the bone frag-
ments. To avoid injury to the great vessels and nerves, only
the safe positions identified in the atlas of Part 1 for levels II 12.2.2 Middle Third
and V of the femur are used. Figure 12.6 shows, as an exam-
ple, wires II,11-5 and V,8-2. In fractures of the middle third of the diaphysis of the femur
Following established techniques (repositioning the bone (injuries 32-A1.2, 32-A2.2, 32-A3.1, 32-B1.2, 32-B2.2,
fragment using a stop together with bending of the wire), the 32-B3.2, 32-C1, 32-C3), skeletal traction on the orthopedic
proximal and then the distal bone fragments are reduced. traction table is applied with the hip abducted 15–30°. The more
Alternatively, any reduction technique can be used together proximal the fracture location, the greater the abduction must
with mutual displacement of the external supports (Figs. 2.4, be. In fractures at the boundary of the middle and lower thirds
2.5, 2.6, 2.7, 2.8, and 2.9). For unstable splintered frac- of the diaphysis, traction is performed without hip abduction.
Fig. 12.9 (a–k) Combined external fixation device for the fixation of fractures of the proximal third of the femur. (a) Skeletal traction is applied
using wire VI,3-9. The lower leg is divided into levels. Two-plane X-ray examination with X-ray contrast markers
Fig. 12.9 (continued) (b) Insertion of

proximal basic half-pins I,9,90 and
II,11,90. The control of their perpendicu-
lar insertion is achieved with aid of the
special device shown in Table 1.3.
(c) Alignment of the proximal basic
support and fixation of the basic
half-pins
c
d e
f g
Fig. 12.9 (continued) (d) Alignment of the module comprising the tion. (f) Insertion of proximal reductionally fixing half-pin II,9,90 and
distal basic and reductionally fixing supports. Fixation of this module its dynamic fixation to the proximal support. (g) Insertion of distal
to the distal basic wire. (e) Connection of the proximal and distal mod- reductionally fixing half-pin IV,9,90 and its dynamic fixation to the
ules. Distraction for a diastasis of 4–6 mm. Two-plane X-ray examina- reductionally fixing support with the help of the reduction device
h i
j k
Fig. 12.9 (continued) (h) Two-plane reduction of bone fragments; V,8,70 and VII,8,70. Elimination of the diastasis. Dismantling of skel-
static fixation of reductionally fixing half-pins II,9,90 and IV,9,90. etal traction. (j) First stage of module transformation (MT): removal of
Two-plane X-ray examination. (i) Insertion and fixation to the support wire spokes VI,3-9. (k) Second stage of MT: partial dismantling of the
of proximal stabilizing half-pin II,10,90 and distal stabilizing half-pin reductionally fixing and distal basic supports
At level V or level VI, a distal reductionally fixing support

(a ring of the appropriate size) is installed and then connected
by rods to the distal basic ring. The distal reductionally fixing
support is oriented relative to the bone and soft tissues. It is
important to note that, as the distal epidiaphyseal angle in the
frontal plane is on average 81° (Fig. 16.30), the distal sup-
ports are not placed parallel to the knee joint space but rather
at an angle of 7–11° to it. Only then are the wires VII,8-2 and
VII,10-4 tensioned and fixed to the distal basic support.
When the distal module of the device is properly installed, its
connection rods are parallel to the anatomic axis of the distal
bone fragment.
The rotational displacement of the proximal fragment is
eliminated and the proximal basic support is then connected
by rods to the reductionally fixing support. A distraction
force is applied to create an interfragmentary diastasis of
5–7 mm, if this was not possible by skeletal traction.
Radiographs are obtained in two standard planes, or an image
intensifier is used.
fragment at level III or level IV, a reduction wire is inserted.
Residual displacement of the distal fragment at level V (or
level IV) is eliminated by inserting a second reduction wire.
Figure 12.9 shows, as an example, wires III,1-7 and V,2-8.
Using established techniques (repositioning by bending
of the wire with a stop), the proximal and then the distal bone
fragments are reduced. Alternatively, any reduction tech-
nique can be used together with mutual displacement of the
external supports. For fragmented fractures in muscular and/
or overweight patients, an additional wire can be inserted to
increase the rigidity of the external fixation at the level of the
reductionally fixing supports.
1 2 5 7 6 8 3 4
I,1-7; I,6-12 –– III,1-7; III,6-12 –– V,2-8; V,1-7 –– VII,2-8; VII,4-10 Figure 12.11 shows the scheme for the combined external
arc 250 arc 250 180 180
fixation of fractures of the middle third of the femur.
32-C3.2
12.2.3 Distal Third
Ilizarov external fixation starts with the insertion of pairs In fractures of the distal third of the femoral diaphysis (inju-
of proximal and distal basic wires: I,6-12; I,11-5 and VII,2-8; ries 32-A1.3, 32-A2.3, 32-A3.3, 32-B1.3, 32-B2.3, 32-B3.3,
VII,4-10 (Fig. 12.10). The specific features of wire insertion 32-C1, 32-C3) skeletal traction on the orthopedic traction
were noted above in the description of the fixation of femoral table is applied without abduction of the segment. To avoid
fractures of the proximal third of the diaphysis. backward tilting of the distal fragment, the knee must be
The femoral arc support is placed perpendicular to the flexed in skeletal traction at an angle of no less than 60–90°.
axis of the proximal bone fragment and oriented relative to Ilizarov external fixation (Fig. 12.12) starts with insertion
the soft tissues, after which the proximal basic wires are ten- of two proximal basic wires: III,6-12 and III,1-7. Distal basic
sioned and fixed to the support. wires VIII,2-8 and VIII,4-10 are then inserted. The proximal
At level III or level IV (depending on the fracture loca- basic ring is oriented relative to the bone and soft tissues and
tion), the proximal reductionally fixing support is installed. wires III,6-12 and III,1-7 are fixed to it after tensioning. Instead
This is a two-thirds or three-quarter arc or sectorial support of a ring, it is possible to use a femoral sectorial support com-
that is oriented relative to the bone and soft tissues. The prising a two-thirds or three-quarter ring. A reductionally
proximal basic and reductionally fixing supports are then fixing ring is then installed at level V, oriented relative to the
connected by three or four rods. When properly oriented, the soft tissues and connected by three rods to the proximal basic
connection rods are parallel to the anatomic axis of the prox- support. When properly installed, the connection rods are par-
imal bone fragment. allel to the axis of the proximal bone fragment.
Fig. 12.11 (a–o) Combined external fixation device for the fixation of plane of the knee joint line but perpendicular to the anatomic axis of the
fractures of the middle third of the femur. (a) Skeletal traction is applied distal bone fragment. Two-plane X-ray examination using radio-opaque
using wire VIII,3-9. Note that the wire is inserted not in parallel to the markers. (b) Insertion of proximal basic half-pins I,9,90 and II,11,90

(c) Alignment of the
and the fixation to it of
basic half-pins.
(d) Alignment of the
proximal reductionally
fixing support and its
connection with the
d

(e) Alignment of the module
including the distal basic and
Fixation of the module to the distal
basic wire. (f) Connection of the
proximal and distal modules.
Distraction for a 4–6 mm diastasis.
f
g h
i j
Fig. 12.11 (continued) (g) Insertion of proximal reductionally fixing reduction and static fixation of reductionally fixing half-pins IV,9,90
half-pin IV,9,90 and its dynamic fixation to the proximal reductionally and V,9,90. Two-plane X-ray examination. (j) Insertion of stabilizing
fixing support. (h) Insertion of distal reductionally fixing half-pin half-pins III,10,120, VI,8,90 and VII,8,70 and their static fixation to
V,9,90 and its dynamic fixation to the support with the aid of the the appropriate supports. Elimination of the diastasis
reductionally fixing device. (i) Consecutive two-plane bone fragment
k l
m n
Fig. 12.11 (continued) (k) Dismantling of skeletal traction. (l) First ally fixing supports. (n) Third stage of MT: removal of half-pin I,9,90;
stage of module transformation (MT): dismantling of the distal basic “changing” of half-pin II,11,90 on the proximal reductionally fixing
support. (m) Second stage of MT: partial dismantling of the reduction- support
Fig. 12.11 (continued) o

(o) Clinical example
If the comparison radiographs show that the backward After the proximal and distal modules of the device have
tilt of the distal fragment has not been fully eliminated, the been mounted, the rotational displacement of the proximal
distal support is installed with 7–10° of hypercorrection. fragment is eliminated and the modules are connected by
Furthermore, in relation to the frontal projection, the ring must three or four rods. A distraction force is applied to create an
be located at an angle that opens inwards by about 9° rela- interfragmentary diastasis of 5 mm, if this was not possible
tive to the knee joint space. This is because the epidiaphyseal by skeletal traction. Radiographs are obtained in two stan-
angle in the frontal plane is 79–83° (Fig. 16.30). In this posi- dard planes, or an image intensifier is used.
tion wires VIII,2-8 and VIII,4-10 are tensioned and fixed to To eliminate residual displacement of the proximal bone
the support. If the length of the distal bone fragment exceeds fragment, wire V,2-8 (or V,8-2) is inserted and fixed to the
110–120 mm, a second reductionally fixing ring should be reductionally fixing ring after tensioning. Residual displace-
installed connected to the distal basic support by three rods. ment of the distal fragment is eliminated using wire VII,3-9
support. Two crossing wires are inserted through the distal

metaphysis of the femur and tensioned in a three-quarter ring
support. Moderate distraction is applied between the sup-
ports: I,8,90; II,11,90 ↔ VII,3-9;VII,2-8 (Fig. 12.16). In
fractures of the distal third of the femur, the distal support is
placed at level VIII: I,8,90; II,11,90 ↔ VIII,3-9;VIII,2-8.
Figure 12.17 shows another variant for the temporary
fixation of femoral fragments. Two half-pins are inserted in
each bone fragment in the frontal plane (or close to it). After
rough elimination of the displacement of the fragments, all
half-pins are fixed to a long plate, for example I,9,90;
III,10,120; V,9,90; VII,8,90.
The “fixation” variant of external fixation undoubtedly
has advantages over skeletal traction: less bulkiness, greater
mobility of the patient, and the possibility of reduction using
both skeletal traction and reductionally fixing transosseous
elements during assembly of the device.
skeletal traction is removed and the patient is transported to
1 2 5 7 6 3 4
III,6-12; III,1-7 æ V,2-8; VI,9,90 æ VII,9-3; VIII,2-8; VIII,4-10
195 195 180
32-B2.3
or VII,9-3. For fragmented fractures in muscular and/or

overweight patients, additional transosseous elements, for
example V,1-7 and VII,2-8, can be inserted to increase the
rigidity of the external fixation.
Figures 12.13 and 12.14 show the schemes for the com-
bined external fixation of fractures of the distal third of the
femur. Figure 12.15 shows combined external fixation device a
for the fixation of segmental fracture.
When full-volume external fixation of diaphyseal femoral Fig. 12.13 (a–k) Combined external fixation device for the fixation of
fractures is not possible, for example in the event of multiple fractures of the distal third of the femur. (a) Skeletal traction is applied
using wire VIII,3-9. Note that the wire is inserted not in parallel to the
and massive trauma, the “fixation” variant of external fixation plane of the knee joint line but perpendicular to the anatomic axis of the
can be performed. Two half-pins are inserted in the proximal distal bone fragment. Two-plane X-ray examination using radio-opaque
metaphysis of the femur and fixed to a one-third sectorial markers

(b) Assembly, alignment, and
fixation of the proximal basic and
(c) Installation of the frame of the
device and distraction for a
diastasis of 4–6 mm. Two-plane
X-ray examination. (d) Insertion
of proximal reductionally fixing
half-pin V,9,90 and its dynamic
fixation with the aid of the
reductionally fixing device.
(e) Insertion of reductionally
fixing wire VII,9-3. Stage-by-
stage reduction of the proximal
and distal bone fragments. Static
fixation of the reductionally
fixing transosseous elements to
the supports. Two-plane X-ray b
examination. (f) Insertion of
stabilizing half-pins III,10,120,
IV,8,90 and VII, 8,80 and their
fixation to the supports
c d
e f
i j
Fig. 12.13 (continued) (g) Elimination of the diastasis. (h) Dismantling of skeletal traction. (i) First stage of module transformation (MT): dis-
mantling of the proximal basic support. (j) Second stage of MT: partial dismantling of the reductionally fixing support
Fig. 12.13 (continued) (k) Clinical example

a b
2 3 6 4 5 1
I,8,90; II,11,90 − V,9,90 →← VII,4,120; VIII,8,90; VIII,3-9 (a)
1/3 225 195 3/4 180
I,8,90; II,11,90 − V,9,90 →←VII,4,90; VIII,8,90 (b)

1/3 225 1/3 195 3/4 180
Fig. 12.14 Combined external fixation device for the fixation of frac- traction reveal the proper location of the distal fragment, the distal basic
ture 32-A3.3. In patients with overdeveloped muscles and/or who are support is assembled based on a wire and two half-pins: VII,4,120;
overweight, the proximal basic support is based on two half-pins: I,8,90 VIII,8,90; VIII,3-9 (a). The internal part of the reductionally fixing
and II,11,90. For final reduction of the proximal bone fragment, half-pin support and wire VIII,3-9 can be removed after 6–8 weeks (b)
V,8,90 or V,9,90 can be used. If radiographs obtained during skeletal
a b
Fig. 12.15 (a–c) Combined external fixation device for the fixation of support can be removed after 10–12 weeks. This results in “dynamiza-
segmental fracture 32-C2.2. (a) Half-pin IV,8,90 and wire V,8-2 are tion” of the device and a reduction in its size
used to reduce and fix the intermediate fragment. (b) The distal basic
2 3 4 6 7 5 8 1
I,8,120; II,11,90; III,9,70 →← IV,9,90; V,8-2 — VI,3-9; VII,8,120 — VIII,3-9 (a)
1/3 225 195 180 3/4 180
I,8,120; II,11,90; III,9,70 →← IV,9,90; V,8-2 — VI,3-9; VII,8,120 (b)

1/3 225 195 3/4 180

Fig. 12.16 (a–c) “Fixing”

a b
device. (a) Insertion of half-pins
I,9,90 and II,11,90. (b) Insertion
of wires VII,9-3 and VII,4-10.
(c) Frame assembly and
distraction for a 3–5 mm
diastasis
c
tomic axis. If comparison radiographs obtained during skele-

tal traction show that the backward tilt of the distal fragment
has not been eliminated, the ring is installed with 7–10° of
hypercorrection. The wires are then tensioned and fixed to it.
Next, the distal and reductionally fixing rings are con-
nected by three rods and a distraction force is applied to
create an interfragmentary diastasis of 4–5 mm, if this was
not possible by skeletal traction. Radiographs are obtained in
two standard planes, or an image intensifier is used.
To eliminate residual displacement of the proximal fragment
at the level of the reductionally fixing support, a wire with a
stop is inserted: VI,3-9 or VI,9-3. If the distal fragment is small,
a wire cannot be used for its final reduction. To increase the
rigidity of the external fixation, wire VIII,3-9 can be inserted.
Any residual displacement is eliminated by displacement of the
distal support relative to the transosseous module fixing the
proximal fragment (Figs. 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9).
If the ligaments of the knee are injured, in the presence of
marked edema of the soft tissues and hemosynovitis, or if the
knee requires fixation for other reasons, the support II,2-8;
II,4-10 is applied to the lower leg. Alternatively, a hybrid
Fig. 12.17 Device for the temporary fixation of femoral fragments wire-pin support II,9-3; III,1,120 connected by hinges to the
[211] basic device can be used. After insertion of the half-pin
V,8,120 and its fixation to the support, the proximal support
can be dismantled.
the ward. During transportation, a soft cushion must be Figure 12.18 shows the scheme for the combined external
placed under the patient’s knee to ensure flexion of 45–60°. fixation of extra-articular fractures of the distal femur.
Ilizarov external fixation of isolated fractures of the femo-
ral condyle (injuries 33-B) starts with the insertion of two
12.3 Distal Femur (33-) crossing wires in the lower third of the femur. After tension-
ing, the wires are fixed to the ring support: VI,3-9;VI,2-8.
Leonid Nikolaevich Solomin The support must be located perpendicular to the biome-
chanical axis of the limb, i.e., at an angle of 7–10° to the
In fractures of the distal part of the femur, skeletal traction on anatomic axis of the femur (Fig. 16.30). If the condyle is
the orthopedic table is applied only in cases of extra-articular considerably displaced, the basic support should be installed
injuries (33-A). This is achieved using a wire inserted through with 7–10° of hypercorrection rather than perpendicular to
the proximal metaphysis of the tibia: I,3-9. The knee must be the anatomic axis of the femur, by inclining the ring towards
flexed at 60–70°. In intra-articular fractures (33-B, 33-C), to the injury. The second ring, preferably made of a radiotrans-
facilitate the application of the basic device supports “disci- parent material, is installed at the level of the femoral con-
plinary” traction at the foot is applied or the lower leg is dyles and connected by three rods to the basic support.
placed on cushions. If indicated, the knee joint is punctured Crossing wires are then inserted through the proximal
for the aspiration of blood and effusion fluid. metaphysis of the tibia. After tensioning, they are fixed to the
In extra-articular fractures (33-A1.2, 33-A1.3, 33-A2, ring support II,2-8; II,4-10. The support is preferably installed
33-A3) as well as in slipped epiphyses and osteoepiphyses, at an angle of 7–10° to the fracture, rather than perpendicular
the device assembly is similar to that used in fractures of the to the anatomic axis of the tibia. The distal basic support of
distal third of femoral diaphysis (Fig. 12.12). the femur is connected to the lower leg support by three or
Ilizarov external fixation starts with the installation of the four hinges. After the device has been mounted, a distraction
basic support on the femur: IV,6-12; IV,1-7. A reductionally force is applied mostly on the injured side between the distal
fixing ring is installed at level VI and fixed by three rods to the support of the femur and the support applied to the lower leg.
proximal basic support. When the device is properly mounted, Preliminary placement of the basic supports in positions of
the connection rods are located parallel to the anatomic axis of hypercorrection facilitates the parallel positioning of all ring
the femur. Two crossing wires VIII,2-8 and VIII,4-10 are then supports after distraction. Radiographs are obtained, or an
inserted through the distal fragment perpendicular to its ana- image intensifier is used.
a b
Fig. 12.18 (a–l) Combined external fixation device for the fixation of of the distal bone fragment. Also note the 90° flexion of the lower leg.
extra-articular fractures of the distal femur. (a) Skeletal traction is Two-plane X-ray examination using radio-opaque markers. (b) Insertion
applied using wire VIII,3-9. Note that the wire is inserted not in parallel of proximal basic half-pin III,9,90
to the plane of the knee joint line but perpendicular to the anatomic axis

c
(c) Assembly, alignment, and
fixation of the module, including
the proximal basic and
(d) Alignment and fixation of the
distal basic support. Note that the
support should be assembled in a
5–7º position of hypercorrection.
Since the distal wire was inserted
in the frontal plane and not
perpendicular to the anatomic
axis of the distal bone fragment,
correct alignment of the support
was achieved by using a post
d
Fig. 12.18 (continued) (e) Insertion

e
and fixation of distal basic half-pins
VII,8,90 and VIII,8,90. Special
attention should be paid to the correct
alignment of the distal support.
(f) Connection of the proximal and
distal modules. In urgent (not older than
1 week) fractures, module connection,
distraction and X-ray examination can
be done at this stage
f
Fig. 12.18 (continued) In malunions, the

g
procedure described in g should be
followed. (g) Insertion and fixation of
half-pin IV,10,120. Distraction for a
4–6 mm diastasis. Two-plane X-ray
examination. (h) Insertion of distal
reductionally fixing half-pin VI,9,90 and
its dynamic fixation to the support with the
aid of the reduction unit
h
Fig. 12.18 (continued) (i) Two-

i
plane bone fragment reduction. If the
displacement of the bone fragments
exceeded 1/3 to 1/4 of the diameters
of the bone, basic half-pins III,9,90
and IV,10,120 should be re-installed
after reduction (Fig. 2.14). Two-plane
X-ray examination. (j) Elimination of
the diastasis. Dismantling of skeletal
traction
j
k l
Fig. 12.18 (continued) (k) First stage of module transformation (MT): partial dismantling of the reductionally fixing support. (l) Second stage
of MT: partial dismantling of the distal basic support
If no reduction is achieved by ligamentotaxis and addi- axis of the limb, i.e., at an angle of about 10° to the anatomic
tional lowering of the condyle is required, a wire with a stop axis of the femur (Fig. 16.30). If one of the condyles has a
is inserted through it in a plane close to the sagittal plane. greater displacement, the support is installed with 10–15° of
The location of the stop depends on whether the condyle is to hypercorrection towards the condyle, with more displacement
be displaced forwards or backwards. The wire is tensioned in in the proximal direction. The distance between the inner
the support installed at level VIII of the femur. A distraction edge of the support and the skin in front and outside must be
force, uniform at all the pins, is then applied between two 30–45 mm. The distance from the skin to the support along
proximal supports of the device (Fig. 12.19a). If comparison the posterior surface must be an additional 25–35 mm. After
radiographs confirm that the condyle has been lowered by orientation of the support, the tensioned wires are fixed to it.
the necessary amount, a wire with a stop is inserted in the The reductionally fixing ring is installed at level VI, the
frontal plane: VIII,3-9 in fractures of the internal condyle distal (radiotransparent) basic ring of the same diameter is
and VIII,9-3 in fractures of the external condyle. Then, at a installed at level VIII. These two rings are connected by three
distance of 15–20 mm from the exit point of this wire, another rods and the reductionally fixing ring is oriented relative to
wire is inserted in the opposite direction. If osteoporosis is the soft tissues. A unit of two rings is then connected by three
present, wires with curved spiral stops are recommended. rods to the proximal basic support. As the proximal support
The wire inserted in the sagittal plane is removed. usually has a larger standard size, connection plates are used
Additional rigidity of the external fixation is provided by for the connection. When the proximal basic support is prop-
insertion of an additional wire through the injured condyle. erly installed, the connection bars are parallel to the anatomic
Afterwards, unless there are special indications for knee joint axis of the femur.
fixation, the support can be removed from the lower leg Support II,2-8; II,4-10 is mounted on the upper third of
(Fig. 12.19b). the shin and connected by three or four hinges to the basic
Ilizarov external fixation of both condyles (33-C) starts support of the femur. After the device has been mounted
with the insertion of two crossing proximal basic wires at the between the distal support of the femur and the support
level of the central third of the segment. One is inserted in the applied to the lower leg, a distraction force is applied
sagittal plane and the other at an angle of 30° to it: IV,6-12 mostly on the side of the greater displacement of the con-
and IV,1-7. With uniform displacement of the condyles, the dyle. Radiographs are obtained, or an image intensifier is
ring support is oriented perpendicular to the biomechanical used.
Fig. 12.19 (a, b) Ilizarov

a b
fixation of fracture 33-B2.1
1 2 5 3 4
VI,3-9; VI,2-8 ←→ VIII,5-1 ←o→ II,2-8; II,4-10 (a)
180 180 150
VI,3-9; VI,2-8 — VIII,3-9; III,9-3; VIII,4-10 (b)

180 180
To eliminate residual displacement of the proximal frag- It should be noted that “closed” external fixation of
ment, the wire with a stop VI,3-9 or VI,9-3 is inserted at the fractures 33-B and 33-C is not always feasible. The use
level of the reductionally fixing ring. If no reduction is of an image intensifier and arthroscopic monitoring con-
achieved by ligamentotaxis and a condyle needs to be low- siderably facilitate reduction. Moreover, arthroscopic
ered further, this is accomplished using a wire inserted in the cleansing of the joint, with removal of small bone splin-
sagittal plane, as shown in Fig. 12.19a. After congruence of ters and cartilage fragments, is a significant component
the articular surfaces has been achieved, two wires with in the prevention of traumatic deforming arthrosis.
stops, VIII,3-9 and VIII,9-3, are inserted from the opposite However, in the case of failure, open apposition of the
directions. Additional rigidity of external fixation is provided fragments is necessary. If considered appropriate, bone
by wires VIII,2-8 and VIII,4-10. Afterwards, unless there are autoplasty is used.
special indications for knee joint fixation, the support can be When a full-volume external fixation is not possible, the
removed from the lower leg. fracture can be immobilized by a fixation device based on
Following the insertion and fixation of wire VI,2-8, the two supports. The proximal support is installed at level VI
proximal support can be removed. This assembly (two sup- of the femur and the distal support at level II of the lower
ports on the femur) can be used as the initial one in cases in leg. The device assembly can be of the wire type
which sufficient experience in the application of external VI,3-9;VI,2-8← ◦ → II,2-8; II,4-10 or of the hybrid wire-pin
fixation allows assembly of the device, avoiding the need for type V,8,120; VI,3-9 ← ◦ → II,9–3; III,1,70 or V,10,120;
additional reduction of the proximal fragment. VI,8,70 ← ◦ → II,3-9; III,12,70.
Figure 12.20 shows the scheme for the combined external After the final radiographs have been obtained, the patient
fixation of intra-articular fractures of the distal part of the femur. is transported to the ward.
a b c
Fig. 12.20 (a–o) Combined external fixation of intra-articular frac- proximal basic support. In the sagittal planes, the alignment should be
tures of the distal part of the femur. (a) Defining the levels. (b) Insertion perpendicular to the anatomic axis of the bone fragment; in the frontal
of basic wires IV,7-1 (femur) and II,9-3 (tibia). (c) Assembly of the planes, perpendicular to the mechanical axis of the femur
d e f
g h
Fig. 12.20 (continued) (d) Assembly and alignment of the distal mod- device. Tensioning and fixation of the wires. (f) Distraction for a diasta-
ule (distal basic support of the femur and reductionally fixing support) sis of 4–6 mm. Two-plane X-ray examination. (g) Insertion of reduc-
and its connection with the proximal basic support. Connecting rods tionally fixing wire VI,3-9 (or VI,9-3) and two-plane reduction of the
should be parallel to the mechanical axis of the lower limb. (e) Insertion proximal bone fragment. Two-plane X-ray examination. (h) Insertion of
of a basic half-pin III,1,70 (tibia). Assembly of the “frame” of the a reductionally fixing wire in the sagittal plane: cond.lat.,6-12
i j
k l
Fig. 12.20 (continued) (i) Reduction of the external condyle by means tling of the distal reductionally fixing support. Two-plane X-ray exami-
of wire cond.lat.,6-12. Two-plane X-ray examination. (j) Insertion of nation. (l) Insertion of proximal stabilizing half-pin V,8,120. Elimination
reductionally fixing wires VIII,9-3 and VIII,3-9. (k) Insertion of wires of the diastasis
VIII,8-2 and VIII,4-10. Removal of wire cond.lat.,6-12. Partial disman-
m n
Fig. 12.20 (continued) (m) First stage of module transformation them to console wires VIII,8,90 and VIII,4,90. (o) If instead of wire
(MT): removal of the proximal basic support. (n) Second stage of MT: VI,3-9 half-pin VI,9,90 was inserted, partial dismantling of the reduc-
removal of the distal basic support. Wires VIII,8-2 and VIII,4-10 should tionally fixing support is possible
be cut intracutaneously on a forward surface. This trick “transforms”
12.4 Patella (91.1-)
The operation is performed with the knee in maximum exten-

sion, achieved by placing a cushion under the heel.
Osteosynthesis must be preceded by puncture of the knee
joint to remove blood and effusion fluid.
The proximal fragment is lowered into contact with the
distal fragment using a single-tooth hook. The reduction
moment is determined by the disappearance of the diastasis
on palpation. To avoid displacement of the proximal frag-
ment upwards, it is temporarily fixed to the femur by a wire
inserted in the sagittal plane. a
For transverse and short oblique fractures, wires with a
stop are then inserted through the proximal and distal frag-
ments in the frontal plane in the opposite direction. During
wire insertion through the proximal fragment, the skin is
maximally displaced downwards. The wires must be located
in the splinters in one horizontal plane to avoid tilt during
compression. Therefore, before insertion of the wires, the
anterior and posterior edges of the bone must be marked with
needles.
The tensioned wires are fixed in half-rings connected by
two or three rods. A comparison radiograph is obtained in
two planes, or an image intensifier is used. The reduction is
facilitated by the use of arthroscopic monitoring.
If lateral displacement of the fragments in two planes has
been eliminated, the wire fixing the proximal fragment to the
femur is removed. By bringing the half-rings closer on the b
half-pins, compression is created at the junction of the frag-
ments (Fig. 12.21a). If comparison radiographs show the Fig. 12.21 (a, b) External fixation devices for fixation of the patella
need for further reduction, the fragments are additionally sta-
bilized. A 2-mm console wire in inserted in each fragment in
the sagittal plane or 3-mm half-pins are used. The console a diafixing wire with a stop is inserted through them (two
wires are fixed to the half-rings. This stabilization of the wires in splintered fractures). Both ends of this wire are bent
proximal fragments can be performed using a diafixing wire, and fixed at the ends of the connection rod, thus functioning
the guiding end of which is removed from the femur. in this case as an external support. The free ends of the
Final reduction is performed by mutual displacement of console wires are also fixed to this rod. The design of the
the supports by the necessary amount. If, subsequently, the mini-device allows a compression force to be applied at the
openings of the half-rings do not coincide (warping of the junction of the fragments. Figure 12.22 shows the various
half-pins is impossible!), connection plates are additionally arrangements for the insertion of the transosseous elements
used. If one or both half-rings are not perpendicular to the in external fixation of the patella.
anatomic axis of the fragment, hinges must be used to con- With a small distal fragment, or the need for restoration of
nect the supports (Fig. 12.21b). the patellar ligament (for example, after removal of the distal
Shved and Sysenko [11] developed the method of exter- pole), a two-thirds or three-quarter ring support is applied to
nal fixation of the patella based on an Ilizarov mini-device. the lower leg: I,2-8; I,4-10; II,3-9 or I,9-3; II,1,70 and con-
Console wires of diameter 1.8–2 mm are used as transosseous nected to the basic device. This technique avoids immobili-
elements. At least two crossing console wires are inserted in zation of the knee joint.
each bone fragment. They are used as levers in the reduction. For transportation of the patient to the ward, a cushion is
After the displacement of the fragments has been eliminated, placed under the knee to ensure 30–45° flexion.
At malunited fractures of the patella, the strategy depends

on the length of the interfragmental gap and the rigidity of the
soft tissues. If the cranial displacement of the proximal bone
fragment is £ 2–3 cm and a one-stage distal movement of up to
1–1.5 cm is possible, osteosynthesis, as depicted in Fig. 12.21,
can be done. At 2–3 days postoperatively, a proximal frag-
ment of the patella can be moved at a rate of 2–4 mm/day.
Docking of the bone fragments is followed by their open adap-
tation, thus exchanging an external for an internal fixation.
With a diastasis > 3–5 cm, the insertion of wires in the
frontal plane and the absence of fixing of a knee joint will
increase the danger of pin-tract infection. Therefore, on the
femur and lower leg transosseous modules are applied. Both
a modules are connected by three rods: VI,8,120; VII,3-9 —
III,9-3; IV,12,90. Oblique-wire distal bone fragment trans-
port is used (Fig. 12.23c).
If over 3–5 months have passed from the moment of frac-
ture and there is considerable diastasis, open mobilization
of the proximal bone fragment and muscles release should
be done (Fig. 12.23b). The second stage is oblique-wire dis-
tal bone fragment transport (Fig. 12.23e, f). The third stage
includes open adaptation and internal fixation (Fig. 12.23g).
If stabile osteosynthesis could not be provided, for example,
due to an osteoporosis, the frame is not removed. At stable
internal fixation, the frame can be used to increase the range
of movement of the knee joint (see Chap. 23).
b
12.5 External Fixation for the Treatment
of Periprosthetic Fractures
of the Femur

The use of plating techniques for periprosthetic fractures has

a number of serious disadvantages. A bone fragment, already
deprived of intramedullary blood supply, now is being par-
tially deprived of the periosteal circulation as well; or its vol-
ume, when plate constructions are used, is substantially
c diminished. Moreover, the rigidity of plate osteosynthesis
and therefore the effectiveness of functional treatment
Fig. 12.22 (a–c) Locations of the wires for the external fixation of the
patella (From Shved and Sysenko 1999) depends directly upon the size of the selected plate, with
a larger plate implying more extensive operative trauma.
a b
Fig. 12.23 (a–g) Stages of repair in a malunion of the patella


f g

Fig. 12.24 Extracortical clamp

a
device for diaphyseal fixation.
(a) General view in two planes;
(b) fixator disassembled: 1
hook-shaped tab, 2 tail-piece, 3
pointed clamping rod, 4 wrench
head. (c) The mounting handle of
the fixator is separate and is fixed
to the ECD
As ar as revision arthroplasty with a long-stem endoprosthe- and the bone, and the outside part, which connects to the
sis is concerned, plating techniques are not efficient for the basic support of the frame. The inside part has one or two
treatment of Vancouver type B1 and type C fractures. hook-shaped tabs (Fig. 12.24, 1) each of which, via chisel-
Traditional external fixation techniques may in these situ- like teeth, grasps an area of bone fragment that is greater
ations be used only limitedly since the presence of a foreign than a semi-circumference. Through their bases, these tabs
body in the intramedullary cavity precludes the insertion of are connected rigidly to the tail-piece (Fig. 12.24, 2), which
regular external fixation elements such as wires and half-pins consists of an internally threaded hollow rod that clamps to
through the bone. the outside part of the ECD. A narrower, pointed rod (Fig.
Alternatively, extracortical clamp devices (ECDs) may be 12.24, 3) screws into the hollow rod and is fitted at the base
used for the treatment of periprosthesis fractures. These are with a wrench head (Fig. 12.24, 4). Correct spatial position-
special devices designed for the fixation of bone fragments ing of the pointed rod (eccentric relatively to the axis of the
containing a massive foreign body, whether a nail or the stem tab) together with the grip ensured by the chisel teeth ensures
of a joint prosthesis, to the basic support. There are two ECD a sufficiently rigid fixation.
variants: for diaphyseal (Fig. 12.24) and for supracondylar
(Fig. 12.25) fixation. The ECD for supracondylar fixation
may also be used for diaphysis; for instance, in the presence 12.5.2 ECD Placement Technique
of osteoporosis.
The site of ECD placement is chosen by referring to the
X-ray image and as described in the chapter “Reference
12.5.1 ECD Design Positions for the Insertion of Transosseous Elements.” The
ECD dimensions (sizes of the tabs and the tail-piece) are
The two main parts of an ECD are the inside (submersible) selected and the device is then connected with the mounting
part, which serves to provide a contact between the fixator handle (Fig. 12.24).
Fig. 12.25 Extracortical clamp

device for supracondylar fixation. a
(a) General two-plane view;
(b) fixator disassembled: 1
hook-shaped tab, 2 tail-piece,
3 pointed clamping rod, 4 wrench
head
Then, under aseptic conditions, a longitudinal 2- to 2.5- is necessary to press the concave part of the tab onto the
cm incision (if a diaphyseal fixation clamp is used) or a 3- to bone. The mounting handle is removed and the tail-piece is
4-cm incision (if a supracondylar fixation clamp is used) is fastened to the frame’s external support by an L-shaped
made, splitting the soft tissues by a slit-like canal down to the fixator.
bone. A narrow curved rasp is used to disengage the area of The fragment containing the hip component of the endo-
bone intended for ECD fixation from the soft tissues. If this prosthesis is fixed using two ECDs adjusted to the basic sup-
step is omitted, the tabs of the clamp will hold muscle and ports. If transosseous elements can be inserted below the
there will be no rigid bone-metal adhesion. stem of the endoprosthesis (type C fractures), this is done
The inside (submersible) part of the ECD is inserted into using one ECD and two traditional transosseous elements
the canal. The mounting handle is manipulated like a joy- (wires, half-pins).
stick to orient this part of the ECD such that contact between The second bone fragment, if there is a foreign body pres-
the bone and the inner surfaces of the tabs is achieved. To ent within its medullary cavity, is fixed using one or two
insert a diaphyseal fixator, the plain surface of a tab should extracortical clamps. If there is no foreign body within the
be positioned frontally (parallel to the long axis of the bone). fragment, it is fixed by wires or half-pins; the latter, in turn,
When the tab reaches the point where it is just above the are fastened to the frame’s external support(s) (Figs. 12.26,
central axis of the bone, the fixator is turned 90° using the 12.27). The fracture is reduced using external fixation tech-
mounting handle. The pointed rod is then screwed into place, niques, stabilizing the fragment with an external fixation
i.e., until it is located against the bone, continuing until the device until consolidation is achieved. During the consolida-
bone is firmly grasped by the tab (tabs) from one side and the tion period, the ECD must be continuously stabilized, by
pointed end of the rod from the other. During this process it screwing the pointed rod 0.5–1 mm further once a week.
a b
Fig. 12.26 Variants of ECD placement for the treatment of periprosthetic fractures (a), (c) fixing of the bone fragment having foreign
body with help of ECD only (b) hybrid fixation
Fig. 12.27 (a–e) ECD

a
placement for the treatment of a
periprosthetic fracture
b
c

d
e
12.5.3 Other Indications fixation is indicated but there are limits to the insertion of
wires and half-pins (Figs. 12.28–12.32). Additional informa-
In addition to the treatment of periprosthetic fractures, ECDs tion is available in Chapters 2.16 and 2.18.
can be used in other situations, i.e., whenever external
Fig. 12.28 Upon placement of

an oncological knee joint
prosthesis, the position of the
lower leg was incorrect, i.e.,
flexion with posterior sublux-
ation. Use of the Ortho-SUV
device with an ECD as one of its
components allowed a gradual
correction
Fig. 12.29 A nailing failure caused displacement of the fragments for tion of the displaced fragment. The nail was then locked again and the
the second time (shortening 5 cm, outside rotation 55°). After the nail frame removed
was unlocked, the Ilizarov frame was applied, allowing gradual correc-
Fig. 12.30 Use of an ECD in

the treatment of osteomyelitis
enables the bony fragments to be
firmly stabilized and the spacer
inserted, with antibiotics, in the
intramedullary cavity
Fig. 12.31 Deformity correc-

tion using an ECD. (a–d)
Step-by-step correction with the
Ortho-SUV Frame
b
d e
Fig. 12.31 (continued) (e) Acute deformity correction

Fig. 12.32 Clinical example of an ECD used as part of an arthrodesis in a female patient with severe deforming arthrosis of the right knee joint
and a history of an earlier revision of a hip arthroplasty with a Wagner femoral component
Fractures of the Tibia and Fibula
13
Leonid Nikolaevich Solomin and Tracy J. Watson
Osteosynthesis of the tibia and fibula (Figs. 13.1, 13.2, 13.3, 220–240 mm ring supports connected by three telescopic rods
13.4, 13.5, 13.6, 13.7, 13.8, 13.9, 13.10, 13.11, 13.12, 13.13, can be used [212] (Fig. 13.2).
13.14, 13.15, 13.16, 13.17, 13.18, 13.19, 13.20, 13.21, 13.22, The location of the bone fragments is improved by axial
13.23, 13.24, 13.25, 13.26, 13.27, and 13.28) is performed traction and manual manipulation. To facilitate reduction,
with wires 1.8–2 mm in diameter. In combined external the injured segment is “overtractioned” by up to 7–10 mm,
fixation, half-pins 5 and 6 mm in diameter are used together with monitoring of the distraction force in the attachment by
with wires. The osteosynthesis set must also include 2-mm comparison with the contralateral lower leg. Radio-opaque
console wires with stops of various lengths (5, 10, 15 and markers (injection needles, fragments of wires) are fixed on
20 mm) for variable bone insertion. the skin and comparison radiographs are obtained in two
External fixation of the bones of the lower leg is generally standard planes, or an image intensifier is used. Lines corre-
carried out with external supports of the same standard size, sponding to the anatomic axis of every bone fragment are
but if the difference in circumference between the upper and drawn on the skin of the anterior and external aspects of the
lower thirds of the segment is more than 5–6 cm then exter- segment. The levels for the transosseous elements insertion
nal supports of two standard sizes can be used. are marked using the special device shown in Table 1.3 and
To ensure knee-joint flexion, the supports placed at the first Chap. 4. With accumulating clinical experience in the exter-
three levels of the lower leg (levels 0, I, and II) must be open, nal fixation of diaphyseal fractures, the need for comparison
i.e., two-thirds or three-quarter rings. In osteosynthesis of the radiographs during skeletal traction is reduced. The opera-
juxta-articular and intra-articular fractures (41-, 43-, and 44-) tive field is treated and covered with a cloth.
the use of radiotransparent external supports is recommended. For the insertion of transosseous elements through the
External fixation of the tibia is generally done with the soft tissues of the anterior semicircle of the lower leg at the
patient receiving regional anesthesia. Transportation immo- first four levels (0–III), the knee is placed in 90–120º flexion.
bilization is removed on the surgical table after anesthesia To insert wires through the posterior semicircle of the lower
induction. leg, the knee joint is placed in the neutral (0/0/0) position.
External fixation of diaphyseal fractures of the bones of the To prevent pin-induced stiffness of the ankle following
lower leg and of extra-articular fractures of the proximal and the insertion of wires and half-pins through the anterior
distal parts of the tibia requires preliminary rough elimination aspect of the lower leg at the four distal levels, the foot is
of the displaced bone fragments by skeletal traction (Fig. 13.1). placed in 40º plantar flexion. For the insertion of tran-
Alternatively, a special distraction device assembled from two sosseous elements through the posterior aspect of the lower
leg, the foot is placed in maximum dorsal flexion (Fig. 2.2).
When it is not possible to change the position of the joints
by the required amount, the skin is displaced manually or by
L.N. Solomin, M.D., Ph.D. (*) using a thin hook in the direction of its natural reposition
R.R. Vreden Russian Research Institute of Traumatology relative to the bone during movements in the adjacent joint.
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia When only reference positions are used for transosseous
element insertion, there is no need to change the position of the
T.J. Watson, M.D. joints. However, preliminary skin repositioning (prior to inser-
Division of Orthopedic Traumatology, Saint Louis University
tion of the transosseous elements) is necessary in segment elon-
Health Science Center, 3635 Vista Avenue, Seventh Floor,
St. Louis, MO 63110-0250, USA gation, deformity correction, bilocal osteosynthesis, and other
Saint Louis University School of Medicine, St. Louis, MO, USA situations in which a “stock” of soft tissue must be created.
434 L.N. Solomin and T.J. Watson
Fig. 13.1 Skeletal traction in a

diaphyseal fractures of the tibia
and fibula. The patient is placed
on the orthopedic traction table
and a regular attachment to the
table is installed under the distal
third of the femur, ensuring
flexion of the knee of 40–50°. If
a soft cushion is used instead of
the attachment, it should be
provided with a rest located on
the inner surface of the knee.
A wire is inserted through the
heel bone and fixed under tension
in the half-ring of the table’s
traction angle (a). To reduce
fragment displacement at an
angle opening outwards, traction
is performed at an angle of b
30–40° opening inwards rather
than along the axis of the
segment [213] (b). To eliminate
rotational displacement, the foot
is oriented such that the first web
space of the toes and the middle
of the patella (the tibial ridge of
the proximal fragment) are
aligned
a b
Fig. 13.2 Use of the distraction device. (a) Basic wires are inserted without removing the transportation splint. (b) Basic wires are strained in the
distraction device
13 Fractures of the Tibia and Fibula 435
c d
Fig. 13.2 (continued) (c, d) The Ilizarov frame is assembled within the distraction device. (e) The distraction device is removed after reduction
and stabilization of the bone fragments
Prior to fixation of the transosseous elements, the external the bone is not parallel to the external support it is fixed by
support must be appropriately oriented relative to the anatomic two posts, female and male. The half-pin can be fixed to the
axis of the bone fragment and the soft tissue (Fig. 13.3). The support or to the post using an L-shaped clip, similar to the
external supports must be located perpendicular to the ana- use of the laterally slotted wire fixator (Table 1.2).
tomic (central diaphyseal) axis of the bone fragment to which In the following sections describing particular methods of
they are fixed, except when they are intentionally placed in the fixation, it is often noted that when the device module is
positions of hypercorrection, as discussed below. properly installed its connection rods are parallel to the ana-
In combined external fixation, the device is assembled so tomic axis of the bone fragment. However, when the basic
that the junctions of the intermediate reductionally fixing support is fixed only on wires (wire) its position can change
supports and the distal basic support are located in the frontal due to bending of the wires from the weight of the rings and
plane. This allows the posterior half-rings to be disconnected connection rods. In these situations, to control its orientation
during the fixation period using the techniques of modular the module should be held while the wires are straightened.
transformation. The proximal support, a three-quarter ring, Reduction by wires is performed by relocation of the bone
can be disconnected from the device assembled in this man- fragment with the help of a stop and with arched bending of
ner and the entire structure sent for sterilization. the wire. Reduction with half-pins is mostly achieved by
The ends of the wires and half-pins, located at a given pushing or pulling, and with console wires with a stop only
distance from the support after it is placed in the necessary by pushing. Alternatively, any reduction technique can be
spatial orientation, are fixed using posts and/or spacing wash- used together with mutual displacement of the external sup-
ers. Unless the half-pins are basic or reductionally fixing ports. Large splinters are reduced and fixed using wires with
transosseous elements, they are stabilized in the external stops or console wires with stops. When the splinter is located
supports only after the necessary spatial orientation of the between the tibia and fibula, reduction is achieved using a
bone fragments has been achieved. If a half-pin inserted in fork device (Chaps. 1.4 (Table 1.2, 30), 2, and 7).
a b
b b
a a
Fig. 13.3 Orientation of the basic supports for the external fixation of are an additional 1.5–2 cm. The distance from the inner edge of the
fractures of the lower leg. (a, b) The markedly eccentric position of the distal basic support to the tibial axis in the plane of positions 3 and 12
tibia relative to the soft tissues determines the orientation of the sup- should be the same as the distance for the proximal basic support. These
ports. The distances from the proximal basic support to the skin of the distances are calculated from radiographs. In simplified terms, the dis-
anterior and inner aspects of the segment (planes of positions 12 and 3) tances from the bone to the basic supports in the plane of positions 3
are 1.5–2 cm in an osteosynthesis of fractures of the proximal and mid- and 12 are the same [10]. (c) Note that because of differences in soft-
dle third of the tibial diaphysis and 2–2.5 cm in an osteosynthesis of the tissue thickness, the distance from the skin surface up to a ring at levels
distal third and distal part of the tibia and fibula. The distances from the I and VIII should be different
proximal basic support to the skin of the posterior aspect of the segment
In all of the osteosynthesis schemes illustrated in the and recommended for the insertion of reductionally fixing
figures, the direction of insertion of the reductional tran- transosseous elements. The sizes of the external supports in
sosseous elements (wires, half-pins) and the positions of the schemes illustrated in the figures are also the conven-
the stops on the wires are conventional and shown only as tional ones.
examples. In practice, one should be guided by the actual Radiographic confirmation of an accurate reduction on
residual displacement of the bone fragments. To avoid the surgical table is a rule in the external fixation of closed
injury to the great vessels and nerves, one should use the fractures. The practice of hastily assembling an external
safe positions at the levels identified in the atlas in Part 1 fixation device in the operating room and performing the
reduction after the patient has been transferred to the clinical joint. Only then are the two wires fixed and tensioned to the
department, with daily stepwise radiographic monitoring of proximal ring.
the manipulations, is an unsatisfactory and discredited Establishment of the proximal ring is followed by a distal
method of external fixation. An exception to this rule is when ring, located at the level of the distal metaphysis of the tibia.
a fixation device is applied as described below. The basic distal wires cross in orientation, much like the
After the osteosynthesis has been performed, it is neces- proximal wires. (VII,2-8 and VII,4-10 are inserted.) A “mod-
sary to check passive movements in the joints adjacent to the ule” (two-ring block) is then mounted on the lower leg that
segment operated upon. Tension in the soft tissues as a result includes a mid-tibial reductionally fixing (“float“) ring
of the insertion of the transosseous elements must be elimi- located at level III and the distal ring located at level VII.
nated by releasing the skin and, if necessary, the fascia and This midtibial ring will be used as the reduction ring for
muscles. additional fixation to slowly dial-in the shaft reduction. The
distal two-ring module is connected by three rods to the
proximal ring without tightening the nuts on the rods so they
13.1 Proximal Tibia and Fibula (41-) can be moved in the holes of the proximal ring. The distal
ring is adjusted relative to the soft tissues and applied such
Leonid Nikolaevich Solomin and Tracy J. Watson that it is also oriented perpendicular to the anatomic axis of
the tibia. Once the distal ring block is attached to the proxi-
In fractures of the proximal lower leg, skeletal traction is mal ring, the connecting rods between the mid ring and the
applied in extra-articular injuries (41-A). As has been pointed proximal ring should be attached but not tightened. This will
out, this is done using a wire inserted through the calcaneal achieve a preliminary reduction of the tibial shaft as the con-
tuberosity. For intra-articular fractures (41-B, 41-C), “tem- necting rods will be parallel to the bone’s anatomic axis.
porary traveling” traction is applied to achieve a temporary Only then are the distal wires attached and tensioned to the
ligamentotaxis reduction. Accordingly, a simple external distal ring. It is important to build the ring up or down to the
fixator is used to span the knee. With the immediate distrac- distal wire by using a post or wire support.
tion along its length, the fracture achieves a degree of initial The threaded connecting rods are then tightened between
reduction. The metaphyseal fracture components will reduce the proximal basic and intercalary reductionally fixing ring.
as well as the shaft extension. Intra-articular impaction and A distraction force of 4–5 mm is then applied between the
joint comminution usually do not reduce with traction force float ring and the proximal ring to effect a shaft reduction.
alone. Thus the surgical tactic should be planned to elevate Application of a distraction force should result in the joints
these remaining unreduced joint fragments. Occasionally, aligning themselves and a realignment of the anatomic axis
the knee joint can be aspirated to remove an intra-articular as all connecting rods are tightened. The reduction should be
hematoma. This allows for decompression of the joint and confirmed by plain radiographs or monitored continuously if
will assist in the recovery of the traumatized soft tissues using fluoroscopy.
around the knee by reducing capsular distension. Once the If there is residual shaft displacement, the “float” or reduc-
soft tissues have recovered, a limited surgical approach can tion mid-ring can be used to correct any residual displace-
be carried out, if necessary, to elevate the impacted articular ment. This is accomplished by the addition of a reduction
segments. olive wire applied at level III,3-9 or III,9-3 and used to trans-
For extra-articular fractures (41-A2, 41-A3) as well as late the fracture in either direction. To achieve additional
physeal or epiphyseal injuries, device assembly is similar to construct stability, wire I,3-9 is inserted to increase the rigid-
that used for extra-articular fractures of the proximal third ity of the osteosynthesis. Additionally, the reduction can also
of the tibial shaft (Figs. 13.12 and 13.13). Ilizarov frame be fine tuned—and any residual displacement of the frag-
mounting begins with the insertion of two crossing wires ments eliminated—by moving the distal ring module relative
(0,2-8 and 0,4-10) at the level of the proximal metaphysis of to the proximal support.
the tibia. These wires should diverge by at least 30–60° to If the ligaments of the knee are injured, or in the pres-
prevent translation along a potential single-wire axis. The ence of significant soft-tissue compromise, or in other situ-
proximal (two-thirds or three-quarter) ring is oriented to ations in which fixation of the knee joint is recommended,
allow for significant soft-tissue clearance. This is done to such as severe articular damage when joint comminution
avoid impingement of the soft tissues on the ring, which precludes early weight-bearing, it is advantageous to span
may occur if the diameters of the rings are too small or if the knee to maintain some degree of residual joint stability.
they are positioned too close to the proximal tibia relative to A support based on the wires VII,2-8; VII,4-10 is applied
the soft tissues, as described in the beginning of the chapter. to the femur, or the combined support VI,8,120; VII,3-9 is
It is important that the proximal ring is applied at right used.
angles to the anatomic axis of the proximal fragment as it Figure 13.4 provides an example of a combined or hybrid
ensures that the proximal ring is applied parallel to the knee external fixation of fracture 41-A2.
a b
Fig. 13.4 (a–j) Combined external fixation of fracture 41-A2.3. (a) placed parallel to the joint line. (c) The proximal ring block is com-
Skeletal traction is applied and the leg is divided into the various pleted by the insertion of two proximal half-pins, I,2,90 and I,10,90. The
segments using radio-opaque markers. The levels are marked on the leg proximal ring is then attached, taking care to align the ring parallel to the
using a sterile skin marker. (b) Insertion of proximal basic wire 0,9-3, knee joint and perpendicular to the anatomic axis of the tibia
d e f
g h
Fig. 13.4 (continued) (d) Insertion of distal basic wire VII,9-3, placed Additionally, the reduction can be further manipulated with the help of
parallel to the ankle joint and perpendicular to the anatomic axis of the a reduction device attached to the reductionally fixing (“float”) ring. (g)
tibia. (e) The distal ring block with the “float” reduction ring is assem- Two-plane reduction of the distal bone fragment. Two-plane roentgen-
bled and loosely attached to the proximal ring, achieving a preliminary ography. (h) After insertion of the stabilizing half-pins V,2,70. The
reduction. Distraction across the fracture is used to create an interfrag- reduction is fine tuned with the reduction construct attached to the
mental diastasis of 3–5 mm as well as a preliminary reduction. reductionally fixing ring. The diastasis is compressed at this point to
Radiographic exam confirms the initial reduction. (f) The reduction can achieve a more stable construct at the fracture site
be fine tuned by the introduction of various half-pins III,12,90.
i j
Fig. 13.4 (continued) (i) The distal ring is removed in the first stage of modular transformation (MT). (j) The second stage of MT: removal of the
posterior portion of the intercalary reductionally fixing (“float”) ring
Ilizarov external fixation of isolated fractures of the tibial tensioned. Preliminary orientation of the distal femoral and
condyles (41-B) begins with insertion of two crossing wires distal tibial rings in a position of hypercorrection facilitates
in the lower third of the femur; after tensioning, the wires are parallel positioning of all the rings following application of
fixed to a distal femoral ring support: VII,2-8; VII,4-10. The the main distraction force. Comparison radiographs are
distal femoral ring is positioned parallel to the joint surface obtained (an image intensifier is used) or the reduction is
of the femoral condyles. If the condyle is considerably dis- visualized arthroscopically.
placed, the basic support should be installed with 7–10º of If an inadequate reduction is achieved via ligamentotaxis,
hypercorrection, with the ring inclined towards the injury. an additional reduction maneuver or elevation of the condyle
A tibial ring block is then attached to the distal femoral ring. is required. This is accomplished with an olive wire inserted
The proximal articular ring of the lower leg, which is prefer- relative to the sagittal plane of the fracture fragment. The
ably radiolucent, is oriented relative to the soft tissues and exact orientation of the olive wire is dependent upon whether
connected by three or four hinges to the ring on the distal the condyle is displaced forwards or backwards. The wire is
femur. This articular ring is located at the level of the fibular attached and tensioned to the radiolucent articular ring placed
head. at the level of the condyles (fibular head) of the lower leg.
Crossing wires IV,3-9 and IV,4-10 are then inserted A uniform distraction force is then applied to all the connect-
through the tibia at the level of its middle third. The distal ing rods between the rings on the lower leg (Fig. 13.5a). If
ring is then positioned at level IV. This ring should be ori- the reduction radiographs confirm elevation of the condyle
ented perpendicular to the anatomic axis of the tibia and con- by the required amount, an olive wire is inserted in the fron-
nected by three rods to the proximal articular ring of the tal plane: 0,3-9 in fractures of the medial tibial condyle or
lower leg without tightening the nuts on the connection rods. 0,9-3 in fractures of the lateral tibial condyle. Then, at a dis-
The distal ring is oriented so that it is inclined 7–10º towards tance of 15–20 mm from the exit point of the first wire, a
the injury; only then are the wires attached to the ring and second olive wire is inserted from the opposite direction.
Fig. 13.5 Ilizarov external fixation devices for the a b

fixation of fracture 41-B1.2
1 2 5 3 4
VII,2-8; VII,4-10 –o– I,5-1 ←→ IV,3-9; IV,4-10 (a)

180 150 150
0,3-9; 0,9-3; I,4-10 — IV,3-9; IV,4-10 (b)
150 150
This wire is also attached and tensioned to the proximal nected by three or four hinges to the distal femoral ring. The
articular tibial ring. In the presence of osteoporosis, it is best distal ring block consists of two rings, a “float” or reduction
to use wires with stops bent in the form of a corkscrew. The ring connected to a distal tibial reference ring. The “float” or
wire inserted in the sagittal plane is removed once the reduc- reduction ring is located at level IV and is connected to the
tion has been achieved. distal tibial reference ring by three threaded rods. The distal
If additional stability of the condyle is required, then tibial reference ring is positioned at level VII. The connec-
another wire can be placed through the injured condyle. At tion rods of this module must be parallel to the anatomic axis
this point, unless there are additional indications for span- of the tibial shaft, with the rings oriented perpendicular to the
ning the knee joint, the distal femoral ring can be removed anatomic axis. This distal tibial ring block is then attached to
from the femur (Fig. 13.5b). the proximal tibial articular ring using additional threaded
Ilizarov external fixation of both condyles (41-C AO/) rods. At this point, wires VII,2-8 and VII,4-10 are inserted in
begins with the insertion of two crossing wires in the lower the plane of the distal tibial reference ring, attached and ten-
third of the femur. These are attached and tensioned to the sioned to the distal ring.
distal femoral ring: VII,2-8; VII,4-10. In the case of sym- After the device has been mounted, a distraction force is
metric displacement of the condyles, the distal femoral ring applied between the distal femoral ring and the proximal
must be located parallel to the joint surface of the femoral tibial articular ring of the lower leg. Eccentric distraction
condyles. The proximal tibial articular ring of the lower leg, may be utilized to effect a concentric reduction, with more
which is preferably radiolucent, is placed at the level of the force on the side of the condyle with greater displacement.
condyles and oriented relative to the soft tissues. It is con- Following reduction, a comparison radiograph is obtained
(fluoroscopy) or arthroscopic monitoring is used. To elimi- located on the proximal tibia (at level II of the lower leg).
nate residual displacement of the proximal fragment at the Simple distraction is carried out between the two rings to
level of the proximal articular ring, an olive wire is inserted: effect a simple ligamentotaxis reduction. The device is
IV,3-9 or IV,9-3. applied using wires (1) type or hybrid (2) type:
If an inadequate reduction was achieved by ligamento- VII,2-8; VII,4-10 ←o→ IV,3-9; IV,4-10 (1)
taxis, additional elevation of a condyle(s) may be required. VI,8,120; VII,3-9 ←o→ IV,3-9; V,12,70 (2)
A reduction wire is inserted in the sagittal plane as shown in After the final X-rays, the patient is transferred to the
Fig. 13.5a. If necessary, both condyles are consecutively ward.
reduced using this technique. After congruity of the joint
surfaces has been achieved, two olive wires are inserted in
opposing directions: 0,3-9 and 0,9-3. Additional stability of 13.1.1 Surgical Technique for Limited Internal
the construct can be conferred by the insertion of wires I,2-8 Fixation with Spanning External Fixation
and I,4-10. Unless there are indications to span the knee of Tibial Plateau Fractures
joint, the distal femoral ring can be removed from the
femur. The technique of “hybrid” external fixator application relies
Wire IV,4-10 is then inserted, attached, and tensioned to heavily on the principles of ligamentotaxis to achieve a meta-
the reductionally fixing (“float”) ring. The distal tibial ring physeal reduction. These techniques will usually not reduce
can now be dismantled. This type of assembly (two supports the impacted articular surfaces. Merely “pulling on it” is not
on the lower leg) can be used as the initial one in cases in indicated where there are large areas of articular depression
which the device can be assembled in such a way that no and comminution. Instead, these areas must be addressed
additional reduction of the distal fragment is required. through limited incisions accompanied by fluoroscopic or
Figure 13.6 depicts the algorithm of combined external arthroscopic guidance to re-establish congruent articular
fixation of fracture 41-C1.3. surfaces.
It should be noted that either the use of an image intensifier Application of a circular or hybrid external fixator involves
or arthroscopic monitoring considerably facilitates reduc- positioning the patient on a fracture table or a radiolucent
tion. Thorough arthroscopic or syringe joint lavage to remove table with calcaneal pin or distal tibial pin traction.
small bone and cartilage fragments is a significant factor in Alternatively, in poly-trauma patients or in patients with
the prevention of post-traumatic arthrosis secondary to wear severe plateau injuries in concert with severely contused and
debris from foreign intra-articular bodies. compromised soft tissues, a temporary knee-spanning exter-
Closed reduction of these fractures using these methods nal fixator is used to obtain a preliminary ligamentotaxis
of external fixation is possible when there is no articular reduction of the larger metaphyseal fragments as well as to
impaction (impression), comminution, or articular surface realign the areas of shaft comminution (Fig. 13.7).
defects (fractures 41-B1, 41-C1 and, partly 41-C2). However, Careful preoperative planning based on distraction com-
in fractures 41-B2 and 41-C3, closed reduction is often puted tomography (CT) scan data is of tremendous value.
unsuccessful. In these cases, it is necessary to perform a lim- The scans will localize areas of impacted articular fragments
ited open reduction with the surgical approach directed pre- and identify the extent of articular comminution. They also
cisely at the site of articular impaction. This is done to limit point out the condylar fracture line orientation and aid in the
soft-tissue dissection to a minimum in order to avoid planning of potential olive wire placement to stabilize the
significant soft-tissue compromise, which can occur in these metaphyseal fragments. No universal wire formula for these
significant skeletal injuries. Following open reduction of the fractures is used. The placement and direction of the olive
joint, the shaft and the remaining condylar components can wire fixation and cannulated screws are determined with the
be stabilized by using the external fixation technique as aid of fluoroscopy, following the surgical plan as established
described above. In the presence of indications of a bone by the preoperative CT study. The areas of identified joint
defect, replacement with a free graft is warranted. Thus, impaction will not reduce with ligamentotaxis alone and will
external fixation techniques and the variability of the frame require direct elevation and repositioning. Percutaneous or
constructs can be used with all types of fractures of the tibial limited open incisions may be used to reduce displaced meta-
plateau. Closed reduction with the help of the frame is pos- physeal and articular fragments in conjunction with lag
sible in specific fracture patterns. screws or small plates (Fig. 13.8). This is accomplished
If it is not possible to perform a complete osteosynthesis, through small incisions directed precisely at the areas of
the fracture can be spanned and immobilized by a simple involvement. Following articular elevation, the residual sub-
fixation device. The frame is based on two rings. The proxi- chondral void must be grafted in order to avoid late articular
mal ring is applied just above the femoral condyles on the collapse. At this point, the metaphyseal fragments can be
distal femur (at level VII of the femur); the distal ring is reduced in either an open or a closed fashion (Fig. 13.9).
a b c d
Fig. 13.6 (a–q) Combined external fixation of fracture 41-C1.3. (a) femoral ring placement. (c) Additional proximal half-pin VII,8,120
Skeletal traction is applied, the femur and tibia are divided, and the skin insertion with application of the distal femoral ring, which should be
is marked into segmental levels Two-plane X-ray confirms ligamento- oriented perpendicular to the mechanical axis of the lower limb and par-
taxis reduction. (b) Insertion of proximal basic wire VII,3-9 for distal allel to the knee-joint line. (d) Insertion of distal ring basic wire VII,9-3
f g
Fig. 13.6 (continued) (e) Application of the frame with a distraction adjustments can be achieved with the help of a reduction device attached
of 1.5–2 cm to achieve ligamentotaxis reduction. Two-plane X-ray to the reduction ring. (g) The construct allows for two-plane reduction,
examination to confirm the reduction. (f) Half-pin III,12,90 insertion confirmed with A/P and lateral radiographs
attached onto the “float” reductionally fixing ring. Additional reduction
h i
j k
Fig. 13.6 (continued) (h) To facilitate medial condylar reduction, Condylar reduction is achieved by the insertion and fixation of wires
additional fixation through the medial condyle is performed: m.cond.,6- 0,3-9; 0,9-3 and the removal of wire m.cond.,6-12. (k) This is followed
12. (i) A reduction maneuver of the medial condyle is accomplished by the insertion and tensioning of additional neutralization wires I,2-8
using wire m.cond.,6-12. Reduction of the lateral condyle is achieved and I,10-4
using a similar wire technique. Two-plane X-ray examination. (j)
l m
n o
Fig. 13.6 (continued) (l) Additional stabilization of the shaft fixation elements I,2,90 and I,10,90. This allows for increased range of
component is accomplished with the insertion of an additional half-pin motion at the knee joint. (o) This hybrid assembly is smaller due to the
V,2,70 and its attachment to the intercalary reductionally fixing “float” use of a monolateral support to which the basic half-pins are attached
ring; Counter compression of the rings allows for elimination of the for fixation of the shaft component of the fracture. However, this assem-
diastasis between the condyles and distal shaft component. Two-plane bly has limited reduction ability and is not recommended for highly
X-ray examination confirms the reduction. (m) First stage of modular comminuted fractures. The eccentric location of the long connecting
transformation (MT): removal of the distal ring. (n) Second stage of struts allows for cantilever loading along the entire length of the shaft
MT: partial removal of the intercalary reduction and articular rings. and, as such, can induce mechanical instability in the construct, which
Under aseptic conditions, the reduction wires I,2-8 and I,10-4 are can lead to delayed or nonunion. Additionally, the distraction ability of
transected at the posterior surface, after the soft tissues have been this construct is limited by the location of the struts along the anterior
maximally displaced towards the bone. Thus, the wires become solitary and lateral surfaces of the segment
Fig. 13.6 (continued) (p) A clinical example

Fig. 13.6 (continued) (q) A clinical example (continuation)
a b c d
Fig. 13.7 (a, b) Injury views of a plateau fracture with significant shaft comminution and articular extension. (c, d) Temporary spanning of an
external fixation to achieve a preliminary ligamentotaxis reduction and to place the soft tissues at rest
a b
c d
Fig. 13.8 (a) Distraction CT scan demonstrates comminution of the Following proximal and distal ring fixation, intercalary fixation is
lateral cortex and articular impaction in this region. A small incision applied (reduction ring). Directional olive wires are used to reduce the
directed to the affected area is used to elevate the impacted surface and extensive shaft comminution, with the olive wires serving as “push/
disrupted cortex. (b) A small cortical substitution plate is positioned in pull” devices to reduce the shaft component
this area to maintain the cortical rim and subchondral elevation. (c–f)
e f
g h i j
Fig. 13.8 (continued) (g, h) Final external fixation components prior obtain cortical contact. (i, j) Final views demonstrating complete shaft
to frame removal. Counter ring compression can be performed between healing, with maintenance of articular continuity
the intercalary rings to compress small areas of comminution and to
a b
Fig. 13.9 (a) Severe injury with articular impaction and shaft demonstrates displacement of the medial articular surface as well as the
extension. (b) Preliminary ligamentotaxis reduction achieved with a detachment of the tibial tubercle (white arrows)
temporary knee-spanning external fixator. (c) Distraction CT scan
d e
f g
Fig. 13.9 (continued) (d, e) The joint is reduced and the tubercle construct. (g, h) The proximal ring is attached using opposing “olive”
reattached via small incisions using cannulated screws and a small hook wires to achieve maximal interfragmentary compression between the
plate. Reduction is accomplished with large percutaneous reduction condyles. The reductionally fixing ring is attached using olive wires to
forceps. The subchondral void is filled with bone graft substitute. (f) reduce the shaft comminution
Following articular reduction, the frame is applied to neutralize the
h i
Fig. 13.9 (continued) (i, j) Final X-rays following frame removal, with complete articular maintenance and shaft healing
In some fractures, the tibial tubercle is fractured as a sepa- be used as the main reference wire. Following articular reduc-
rate fragment in conjunction with posterior cortical commi- tion, a preassembled frame consisting of three or four appro-
nution. Because of the anatomic constraints and inherent priately sized rings is placed around the limb. The proximal
dangers of placing front to back transfixion wires, this tuber- ring is temporarily placed at the level of the fibular head, and
cle fragment is stabilized with an anterior hook plate the main reference wire is attached and tensioned to the prox-
(Fig. 13.9). This allows rigid fixation of the tubercle fragment imal ring. Following attachment of the proximal ring, the
with distally directed screws which are able to purchase intact remainder of the proximal wire fixation can be attached and
posterior cortex at a site distal to the tubercle fragment. tensioned to the proximal ring (Figs. 13.8 and 13.9).
Additional reduction of the condylar components is The distal ring is attached to the bone using 5–6 mm half-
achieved using a large, percutaneously placed reduction for- pins (in some cases of extensive shaft comminution,
ceps (Fig. 13.9). Percutaneous K-wires can also function as transfixion wires) (Fig. 13.8). The distal ring must be placed
“joysticks” and aid in the manipulation of these large condy- parallel to the ankle joint line and perpendicular to the ana-
lar fragments. After reduction of the condyles, olive wires are tomic axis of the leg. The proximal, intercalary (reduction
used to achieve interfragmentary compression of the condylar ring) and distal rings are connected to each other with fully
articular surface. Three to four olive wires are usually required adjustable components to allow for the appropriate correc-
to stabilize the condylar and metaphyseal fragments. These tion and alignment of the overall mechanical axis.
wires should be applied in such a way that they perpendicu- Once the proximal and distal rings have been attached,
larly cross the major fracture lines, similar to the placement of distraction across the intercalary (reduction ring) helps to
a lag screw (Figs. 13.8 and 13.9). This is done in order to reduce the shaft component. Any proximal shaft comminu-
achieve maximal condylar compression. The ability to main- tion or axial deviation can then be corrected using olive wires
tain the condylar reduction depends on the presence of com- inserted from the appropriate direction and used as a reduc-
pressive forces on either side of the fracture lines—accomplished tion wire to correct any axial malalignment of the shaft com-
by placing opposing olive wires through the fragments, i.e., ponent (Figs. 13.8 and 13.9). Following the reduction, theses
coming from opposite sides of the major condylar fracture wires are attached and tensioned appropriately to the interca-
line. If this wire orientation (i.e., front to back transfixion lary (reduction) ring.
wires) cannot be placed to achieve interfragmentary compres- Serial X-rays should be obtained for any deviation of the
sion due to anatomic constraints, cannulated screws will mechanical axis during treatment in the external fixator. If
instead accomplish this function. Another option is to substi- needed, adjustments may be made gradually to realign the
tute cannulated screws for olive wires if the metaphyseal frag- extremity and to add compression to small areas of bony
ments are large enough and not extensively comminuted. comminution (Fig. 13.10). This maneuver establishes bone
The fracture lines dictate the location where these wires on bone contact and thus a more stable fracture configuration.
are placed as well as the direction of the olive. The proximal As fracture consolidation progresses, these frames allow full,
articular fixation must consist of at least three tensioned unrestricted weight-bearing. After consolidation is complete,
wires. Four opposing olive wires are comparable to medial the connections between the proximal and distal rings are
and lateral dual plates in terms of interfragmentary condylar loosened (frame dynamization) so that the pin-bone stresses
stability for a bicondylar fracture. One of the condylar fixation are decreased and the weight-bearing forces are transmitted
wires should be placed parallel to the knee joint line; it will by the bone instead of by the external fixator.
Fig. 13.10 (a, b) Injury films

a b
demonstrating sever articular
disruption; and shaft
comminution. (c, d) Articular
reduction is accomplished
through a CT-directed incision
and the use of “joysticks.”
Articular reduction is stabilized
with small cannulated screws
c d
e f
Fig. 13.10 (continued) (e) The shaft reduction is compressed and the mechanical axis is manipulated using “spatial” struts. (f, g) Complete
healing of articular surfaces and shaft comminution following frame removal
13.1.2 Arthroscopy and Fracture Management cannulated drill is used to produce the metaphyseal cortical
window and to drill through the impacted metaphyseal bone
In select fractures, arthroscopically aided reduction can be to the level of the impacted articular surface. The resulting
helpful to avoid extensive open exposure. The technique tunnel must be of sufficient size to allow grafting and eleva-
requires direct visualization of the joint by arthroscopy tion of the fragment from below. A curved bone impactor
following distraction of the fracture, with either traction or and bone graft material is then used to elevate the depressed
a spanning external fixator. A 2–3 cm portion of the stan- segment. The bone graft is incrementally placed through
dard lateral surgical exposure is developed over the lateral the cortical window into the metaphyseal defect and packed
metaphyseal region of the fracture (Fig. 13.11). CT or under the fragment, gradually elevating it. The adequacy of
magnetic resonance imaging (MRI) is extremely helpful to reduction is visualized either arthroscopically or using an
specifically determine the location, depth, and orientation image intensifier.
of the articular depression. This is crucial when contem- After the articular surface of the joint has been restored
plating the location of the subcondylar window through and confirmed arthroscopically, the graft can be stabilized by
which the impacted articular surface will be elevated. the percutaneous placement of cannulated screws under the
Occasionally, a medially tilted lateral articular surface may subchondral compact bone, or by the use of CT-directed sub-
be approached through a medially based subcondylar win- chondrally tensioned wires.
dow (Fig. 13.11). Arthroscopically assisted fixation not only allows treat-
Exposure is needed only for access to the subcondylar ment of meniscal lesions but also provides valuable diagnos-
flare in order to develop a small metaphyseal cortical win- tic information regarding the cruciate ligaments and adjacent
dow. This is accomplished using an anterior cruciate liga- articular surfaces. However, among the adverse outcomes
ment reconstruction drill guide or equivalent device. A reported are infection, deep vein thrombosis, pulmonary
small guide wire is passed through this metaphyseal region embolism, and peroneal nerve palsy. Fluid extravasation into
directly to the area of joint impaction, as confirmed the soft tissues leading to compartment syndrome can be
arthroscopically. After placement of the guide wire, a small avoided by avoiding irrigation under pressure.
a b
Fig. 13.11 (a) Preoperative CT scan to identify the orientation of the advanced directly into the visualized defect under arthroscopic control.
impacted articular surface (arrow). In this particular case, a medial A cannulated reamer is then used to drill an open tract directly under
subchondral window is used to disimpact and elevate the surface. the impacted surface. Next, an impactor is used in concert with graft
(b–d) Through the small medial subchondral exposure a guide wire is material to disimpact and elevate the surface
c d
Fig. 13.11 (continued) (e) Impacted surface (top image) and the reduced joint following reduction (bottom image)
13.2 Diaphyseal Fractures (42-) applied to create an interfragmental diastasis of 4–5 mm if this
was not achieved by skeletal traction. Radiographs are obtained
Leonid Nikolaevich Solomin in two standard planes or an image intensifier is used.
13.2.1 Proximal Third fragment at level II, a wire is inserted in the frontal plane, for
example, II,3-9 or II,9-3. To eliminate residual displacement
Ilizarov external fixation of fractures of the proximal third of of the distal fragment, a second reductionally fixing wire is
the tibial diaphysis (42-A1.1, 42-A2.1, 42-A3.1, 42-B1.1, inserted at the level of the intermediate support: IV,3-9 or
42-B2.1, 42-B3.1, 42-C1, 42-C3) starts with the insertion of IV,9-3. Following known techniques (relocation of the bone
two crossing proximal basic wires at the level of the tibial fragment using a stop and arched bending of the wire), the
tuberosity. One is inserted only through the tibial bone and proximal and then the distal bone fragments are reduced.
the other through the head of the fibula and the tibial meta- Reduction must be confirmed radiographically. Large splin-
physis: I,4-10 and (I,8-2)I,8-2.2. ters are fixed by console wires, paraosseously inserted wires,
Note: According to MUDEF, the transosseous elements or wires with stops, as shown in Fig. 13.12.
to be inserted through the fibula are indicated in parentheses. Figure 13.13 presents the scheme for the combined exter-
If the wire is simultaneously inserted through both bones, it nal fixation of fractures of the proximal third of the tibia.
is designated in accordance with the priority with which the
guiding end of the wire was inserted through the fibula and
tibia. For example, the notation (I,8-2)I,8-2 designates a wire 13.2.2 Middle Third
with a stop that was inserted from the side of the fibular head
and then through the tibia. The notation I,8-2 designates a Ilizarov external fixation of fractures of the middle third of
wire inserted through the tibia slightly in front of the fibular the tibial diaphysis (42-A1.2, 42-A2.2, 42-A3.2, 42-B1.2,
head. The notation (III,6-12) designates a wire inserted at 42-B2.2, 42-B3.2, 42-C1, 42-C3) starts with the insertion of
level III in the sagittal plane only through the fibula. two crossing proximal basic wires at the level of the tibial
The distal basic wires (VIII,8-2)VIII,8-2 and VIII,4-10 tuberosity. One is inserted only through the tibial bone and
are then inserted at the level of the distal metaphysis. the other through the head of the fibula and the metaphysis of
The bolts connecting the half-rings at one side are removed the tibia: I,4-10 and (I,8-2)I,8-2. Two distal basic wires,
from the preliminarily assembled device. The device is (VIII,8-2)VIII,8-2 and VIII,4-10, are then inserted at the
opened, placed under the shin, and the half-rings recon- level of the distal metaphysis.
nected. The proximal basic ring is installed perpendicular to The proximal reductionally fixing ring must be located
the anatomic axis of the proximal fragment oriented relative at level III or level IV, depending on the level of the frac-
to the soft tissues, as described at the beginning of the chap- ture. The distal reductionally fixing ring must be at level V
ter, and the tensioned wires are fixed to it. (or level VI). If the device was preliminarily assembled, it
The nuts of the connection rods are retracted 3–4 mm is opened by removal of the bolts connecting the half-rings
from the reductionally fixing ring installed at level IV. The at one side. The structure is placed under the shin, installed
distal basic ring is oriented relative to the anatomic axis of perpendicular to the anatomic axis of the proximal frag-
the distal fragment and soft tissues, and the distal basic wires ment, oriented relative to the soft tissues, as explained at
are fixed to it after tensioning. If the wires are not perpen- the beginning of this chapter, and the tensioned wires are
dicular to the anatomic axis of the distal fragment, they are fixed to it.
fixed to the ring using console posts. The nuts on the connection rods are retracted 3–4 mm
The reductionally fixing support is then restabilized by tight- from the reductionally fixing supports. The distal basic ring
ening the nuts of the connection rods. A distraction force is is then oriented relative to the anatomic axis of the distal
Fig. 13.12 Ilizarov external fixation device for the fixation

of fracture 42-B2.1
1 2 5 7 6 3 4
(I,8-2)I,8-2; I,4-10; II,3-9 — III,9-3; IV,3-9 — (VIII,8-2)VIII,8-2; VIII,4-10
150 150 150
fragment and soft tissues and the distal basic wires are fixed residual displacement of the distal fragment, a second reduc-
to it after tensioning. If the wires were not inserted perpen- tionally fixing wire is inserted at the level of the second inter-
dicular to the anatomic axis of the distal fragment, they are mediate ring, for example V,3-9. Based on established
fixed to the ring using console posts. The reductionally fixing techniques (relocation of the bone fragment using a stop
supports are then stabilized and a distraction force is applied together with arched bending of the wire), the proximal and
to create an interfragmental diastasis of 4–5 mm if this could then the distal bone fragments are consecutively reduced.
not be achieved by skeletal traction. Radiographs are obtained Reduction must be confirmed radiographically. Large splin-
in two standard planes or an image intensifier is used. ters are fixed by console wires, paraosseously inserted wires,
To eliminate residual displacement of the proximal bone or wires with a stop, as shown in Fig. 13.14.
fragment, a wire is inserted at the level of the proximal Figure 13.15 provides the scheme for the combined exter-
reductionally fixing ring, for example III,3-9. To eliminate nal fixation of fractures of the middle third of the tibia.
Fig. 13.13 (a–m) Combined external

a b
fixation device for the fixation of fractures
of the proximal third of the tibia.
(a) Skeletal traction is applied using wire
calc.,3-9 (not shown), followed by division
of the lower leg into levels. Two-plane X-ray
examination with X-ray contrast markers.
The variant of skeletal traction using wire
VII(8-2)8-2 is possible. In this case, this
wire-in-frame assembly will be the distal
basic wire. (b) Insertion of proximal and
distal basic wires I,9-3 and VII(8-2)8-2.
(c) Alignment of the module, which
includes proximal basic and reductionally
fixing supports. Particular attention is paid
to the orientation of proximal basic support,
which should be located perpendicular to the
anatomic axes of the proximal bone
fragment in two planes
c

(d) Assembly of the distal basic d
support and its connection with
the reductionally fixing support.
(e) For alignment of the frame
with respect to the axes of bone
fragments and soft tissues, the
basic wires can be temporarily
disconnected from the supports
e
Fig. 13.13 (continued) (f) Tensioning

of the basic wires and distraction for a 3–5 f
mm diastasis. X-ray examination in two
planes. (g) Consecutive insertion of
reductionally fixing wire II,3-9 and half-pin
IV,12,90 and their dynamic fixation to the
supports
g
Fig. 13.13 (continued) (h) Consecutive

two-plane bone-fragment reduction. Static h
fixation of reductionally fixing transosseous
elements to the supports. Two-plane X-ray
examination. (i) Insertion and static fixation
of stabilizing half-pins I,1,90 and VI,2,70
i
Fig. 13.13 (continued) (j) Elimination

of the diastasis and the dismantling of j
skeletal traction. (k) First stage of modular
transformation (MT): removal of the distal
base support
k
Fig. 13.13 (continued) (l) Second stage of MT: partial dismantling of the reductionally fixing support. (m) The patient after the second stage of MT
Fig. 13.14 Osteosynthesis of fracture 42-B2.2, according

to G.A. Ilizarov
1 2 5 7 6 3 4
(I,8-2)I,8-2; I,4-10 –– III,3-9; IV,9-3 –– V,3-9 –– (VIII,8-2)VIII,8-2; VIII,4-10
150 150 150 150
Fig. 13.15 (a–l) Combined a b

fixation of fractures of the middle
third of the tibia. (a) Skeletal
traction is applied using wire
calc.,3-9 (not shown) followed
by division of the lower leg into
levels. Two-plane X-ray
examination with X-ray contrast
markers. The variant of skeletal
traction using wire VIII(8–2)8-2 is
possible, in which case the wire in
the frame assembly will be the
distal basic wire. (b) Insertion of
proximal basic wires I,9-3 and
VIII(8–2)8-2. (c) Installing the
preassembled frame
c
Fig. 13.15 (continued) (d) Particular attention should be paid to the (e) Tensioning the basic wires and distraction for a diastasis of 3–5 mm.
orientation of the basic supports: they must be located perpendicularly Radiological control in two planes
to the anatomic axes of the proximal bone fragment in two planes.
Fig. 13.15 (continued) (f) Insertion of

half-pins IV,12,90 and IV,12,90 and their f
dynamic fixation, with the help of
reduction devices, to the reductionally
fixing supports. (g) Consecutive two-plane
bone fragment reduction. Static fixation of
reductionally fixing half-pins to the
supports. Radiological control in two
planes
g
Fig. 13.15 (continued) (h) Insertion

and static fixation of stabilizing half-pins h
II,2,120 and VII,2,70. (i) Elimination of
the diastasis is followed by dismantling
of the skeletal traction
i
Fig. 13.15 (continued) (j) First stage of

modular transformation (MT): removal of the j
basic supports. (k) Second stage of MT: partial
removal of the reductionally fixing supports
k
Fig. 13.15 (continued) (l) Clinical example

13.2.3 Distal Third are fixed to it after tensioning. If the wires were not inserted
perpendicular to the anatomic axis of the distal fragment,
Ilizarov external fixation of fractures of the distal third of they are fixed to the ring using posts.
the tibial diaphysis (42-A1.3, 42-A2.3, 42-A3.3, 42-B1.3, The reductionally fixing support is then restabilized and a
42-B2.3, 42-B3.3, 42-C1, 42-C3) starts with the insertion of distraction force is applied to create an interfragmental dia-
two crossing proximal basic wires at the level of the tibial stasis of 5 mm if this could not be achieved by skeletal trac-
tuberosity. One is inserted only through the tibial bone and tion. Radiographs are obtained in two standard planes or an
the other through the head of the fibula and the metaphysis of image intensifier is used.
the tibial bone: I,4-10 and (I,8-2)I,8-2. The distal basic wires To eliminate residual displacement of the proximal
(VIII,8-2)VIII,8-2 and VIII,4-10 are then inserted at the level bone fragment at level V, a reductionally fixing wire is
of the distal metaphysis. inserted in the frontal plane, for example V,3-9. To elimi-
The bolts connecting the half-rings at one side are removed nate residual displacement of the distal fragment, a second
from the preliminarily assembled device. The device is reductionally fixing wire is inserted, for example VII,3-9.
opened, placed under the lower leg and the half-rings recon- Based on established techniques (relocation of the bone
nected. The proximal basic ring is installed perpendicular to fragment using a stop together with bending of the wire),
the anatomic axis of the proximal fragment, oriented relative the proximal and then the distal bone fragments are
to the soft tissues as described in beginning of this chapter, reduced. Reduction must be confirmed radiographically.
and the tensioned wires are fixed to it. Large splinters are fixed using console wires with stops,
The nuts of the connection rods are retracted 3–4 mm paraosseously inserted wires, or console wires, as shown
from the reductionally fixing ring installed at level V. The in Fig. 13.16.
distal basic ring is oriented relative to the anatomic axis of Figure 13.17 shows the scheme for the combined external
the distal fragment’s soft tissues and the distal basic wires fixation of fractures of the distal third of the tibia. On figure
1 2 5 7 6 3 4
Fig. 13.16 Osteosynthesis of the fracture 42-B2.3, (I,8-2)I,8-2; I,4-10 — V,3-9; VI,3,90 –– VII,9-3; (VIII,8-2)VIII,8-2; VIII,4-10
according to G.A. Ilizarov 150 150 150
Fig. 13.17 (a–k) Combined external fixation

device for the fixation of fractures of the distal
a b
third of the tibia. (a) Skeletal traction is applied
using wire calc.,3-9 (not shown) followed by
division of lower leg into levels. Two-plane
X-ray examination with X-ray contrast markers.
The variant of skeletal traction using wire
VIII(8–2)8-2 is possible, in which case this
wire-in-frame assembly will be the distal basic
wire. (b) Insertion of proximal basic wires
II,9-3 and VIII(8–2)8-2. (c) Alignment of the
proximal module (proximal basic and
reductionally fixing supports). Particular
attention must be paid to the orientation of the
proximal basic support: it must be perpendicular
to the anatomic axes of the proximal bone
fragment in two planes
d e
Fig. 13.17 (continued) (d) Wires should be tensioned after the complete assembly of the frame of the device, with its orientation with respect to
the bone fragments and soft tissues. (e) Stabilization of the device and distraction for a diastasis of 3–5 mm
Fig. 13.17 (continued) (f) Consecutive insertion

of reductionally fixing half-pin V,12,90 and wire f
VII,3-9. Consecutive two-plane reduction of bone
fragments. Two-plane X-ray examination.
(g) Insertion and static fixation of stabilizing
half-pins III,2,120 and VII,1,100. Elimination
of the diastasis and the dismantling of skeletal
traction
g
Fig. 13.17 (continued) (h) First stage of

module transformation (MT): removal of the h
proximal basic support. (i) Second stage of MT:
partial dismantling of the reductionally fixing
support
i
Fig. 13.17 (continued) (j) A clinical example

Fig. 13.17 (continued) (k) A clinical example

13.18 Combined external fixation device for double tibia If distal tibiofibular syndesmosis separation is a possibility,
fracture is presented. wire VIII (8-2)8-2 is inserted after reduction of the bone
In patients with injuries to both lower extremities or in fragments.
overweight patients in whom supports of diameter more than When full-volume external fixation of diaphyseal frac-
160 mm are required, the rigidity of bone fragment fixation tures of the lower leg is not possible, for example, in the
must be increased. In such cases, osteosynthesis involves the event of massive severe casualties upon admission, a
insertion of additional wires at the level of the reductionally “fixation” variant of external fixation is an option. One
fixing supports and in the case of combined external fixation (Fig. 13.19) or two wires are inserted through the proximal
at the level of the basic supports. and distal metaphyses of the bones of the lower leg and then
External fixation of both lower legs complicates walking: fixed under tension in two ring supports. A moderate distrac-
the parts of the supports that are between the legs catch on one tion force is applied between the supports: I,8-2; I,4-10 ↔
another. Device configurations that allow circumvention of this (VIII,8-2)VIII,8-2; VIII,4-10.
disadvantage of external fixation are presented in Chap. 18. The “fixation” variant of external fixation has indisput-
In cases of isolated injury of the tibial bone, wire, I,8-2, able advantages over skeletal traction: less bulkiness, greater
inserted before the head of the fibula, is used instead of wire patient mobility, and the possibility of reduction by both
(I,8-2)VIII,8-2. In these cases, wire VIII,3-9 replaces wire skeletal traction (elastic energy) and the insertion of reduc-
(VIII,8-2)VIII,8-2. If there is a threat of distal tibiofibular tionally fixing transosseous elements during final assembly
syndesmosis separation, wire (VIII,8-2)VIII,8-2 is inserted of the device.
after reduction of the bone fragments. After final radiography, skeletal traction is dismantled
In cases of isolated injury of the tibia, wire I,8-2, inserted and the patient is transferred to the ward. During transporta-
before the head of the fibula, is used instead of wire I(8-2) tion a soft cushion must be placed under the patient’s knee
8-2. In these cases, wire VIII,3-9 replaces wire VIII(8-2)8-2. joint to ensure flexion at 30–40°.
a b
Fig. 13.18 (a–c) Combined

fixation of fracture 42-C2.2.
Half-pin IV,1,90 is used for the
reduction of the distal end of the
intermediate fragment and its
further fixation. Console wire with
a stop V,10,110 fixes the large
splinter of the bone after reduction
(a). The distal support is removed
1–1.5 months and the posterior 1 3 8 5 6 7 4 9 2
half-rings of the reductionally I,9-3; II,3-9; II,1,90 →← III,3-9; IV,1,90 ⎯ V,10,110; VI,3-9; VII,1,70 ⎯ (VIII,8-2)VIII,8-2 (a)
fixing supports 2–3 weeks (b) prior 3/4 160 160 160 160
to the planned date of fixation I,9-3; II,3-9; II,1,90 →← III,3-9; IV,1,90 –– V,10,110; VI,3-9; VII,1,70 (b)
completion 3/4 160 1/2 160 1/2 160

a b
Fig. 13.19 (a–c) Application of a “fixation” device (a) Insertion of supports and their tension. Note that telescopic rods are connected to
wires I,9-3 and (VIII,8-2)VIII,8-2. These wires must be inserted per- the supports with the aid of plates. This facilitates the installation of
pendicular to the axis of the bone fragments. (b) Alignment of the reductionally fixing supports (if necessary). (c) Distraction for a diasta-
device, taking into account the soft tissues. Fixation of wires to sis of 3–5 mm
13.3 Distal Tibia and Fibula (43-) Figure 13.20 provides the scheme for the combined exter-
nal fixation of fractures of the distal part of the tibia.
Leonid Nikolaevich Solomin Ilizarov external fixation of intra-articular fractures of the
distal part of the bones of the lower leg (injuries 43-B, 43-C;
Ilizarov external fixation of fractures in group 43-starts with pylon or plafond fractures) also starts with the mounting of a
the insertion of two crossing proximal basic wires at the module based on two supports: the proximal basic support
level of the proximal tibiofibular joint. One wire is inserted and the reductionally fixing support. The ring support, which
through both bones. The proximal basic ring is installed per- preferably is radiotransparent, is fixed to the module. The
pendicular to the anatomic axis of the tibia, oriented relative support must be located at level VIII of the lower leg. The
to the soft tissues, and the tensioned wires I,4-10; (I,8-2)I,8- support on the foot is then mounted (Fig. 13.21).
2 are fixed to it. A reductionally fixing ring is installed at The support is grasped and an attempt is made to reduce
level VI of the lower leg and connected by three telescopic the bone splinters manually. The distal support is then
rods to the basic support, thus forming a proximal tran- connected by three or four rods to the basic device and a
sosseous module. distraction force is applied. Comparison radiographs are
External fixation of extra-articular fractures (43-A) and of obtained or an image intensifier is used. Wire VI,3-9 (or
epiphysiolyses and osteoepiphysiolyses is generally similar VI,9-3) is then inserted at the level of the reductionally fixing
to the intervention for fractures of the distal third of the tibial ring. This wire helps to correct the position of the proximal
bone (Figs. 13.11 and 13.12). fragment and to stabilize it.
After the proximal transosseous module has been mounted If reduction was not achieved by ligamentotaxis, the dis-
at the level of the epimetaphysis of the distal fragment, per- placed fragments are brought together using a thin awl,
pendicular to its anatomic axis, two crossing wires are inserted: used as a lever, with monitoring using an image intensifier
(IX,8-2)IX,8-2 and IX,4-10. The proximal transosseous mod- or arthroscopically. It should be noted that the latter does
ule is connected to the distal basic support by three or four not simplify reduction. Cleansing of the joint by the removal
rods. The nuts of the reductionally fixing support are not tight- of small bone splinters and cartilage fragments is an impor-
ened, thus allowing movement of the rods in the holes of the tant component in the prevention of traumatic arthrosis.
ring. The distal basic ring is oriented relative to the soft tissues If congruity of the joint surfaces cannot be restored, open
and installed so that the connecting rods are parallel to the reduction is performed. The advantages of external fixation
anatomic axis of the distal fragment. Only then are the distal in this case are the reduced danger of devitalization of the
basic wires tensioned and fixed to the ring. The reductionally splinters that is offered by a minimized surgical intervention
fixing support is stabilized by tightening the nuts. (required only for monitoring the reduction) and the unload-
A distraction force is then applied to create an interfrag- ing of the joint surfaces.
mental diastasis of 4–5 mm if this could not be achieved by Before the first incision is made, the ring support at level
skeletal traction. Radiographs are obtained in two standard VIII is raised on rods to the level of the reductionally fixing
planes or an image intensifier is used. support, and the connection rods hindering the manipulation
To eliminate residual displacement of the proximal frag- are removed. If the surgical approach is impeded due to soft-
ment at the level of the reductionally fixing ring, a wire with tissue tension, the distraction force is removed.
a stop is inserted: VI,3-9 or VI,9-3. A small distal fragment Standard pairs of wires are used: (VIII,8-2)VIII,8-2 and
cannot be reduced using a wire. However, in order to increase VIII,4-10 or (IX,8-2)IX,8-2 and IX,4-10 after reduction by a
the rigidity of the osteosynthesis, wire VIII,3-9 can be standard method. Additional transosseous elements (wires
inserted. Residual displacement is eliminated by mutual dis- with a stop, console wires) are inserted according to the loca-
placement of the external supports (Figs. 2.4, 2.5, 2.6, 2.7, tion of the splinters. In patients with osteoporosis, stops bent
2.8, and 2.9). in the form of a corkscrew are used. Bone autoplasty is per-
If fixation of the distal fragment is unstable, for example, formed if considered appropriate.
due to osteoporosis, the ankle joint is temporarily fixed. Two Figure 13.22 shows three device assemblies for the oste-
wires are inserted through the heel bone, tensioned in the osynthesis of pylon fractures. The smaller dimensions of
elongated support and connected to the distal basic support the hybrid assembly shown in Fig. 13.22c are due to the use
of the device. of a monolateral support for fixation of the long fragment of
To make the structure less bulky, the “wire” device can be the diaphysis, the basic half-pins being fixed to the support.
transformed into a “wire-pin” one. After half-pin V,12,120 is However, one should consider the limited reduction possi-
inserted and fixed to the reduction-fixation support, the prox- bilities of this structure, as distraction is possible only along
imal support can be dismantled. If the device was mounted the anterior and partly the lateral aspects of the segment.
with the junctions of the half-rings oriented in the frontal Figure 13.23 provides the scheme for the combined exter-
plane, the posterior half-ring of the wire-pin support is dis- nal fixation of intra-articular fractures of the distal part of the
mantled within 2–3 weeks. tibia and fibula.
a b
c d
Fig. 13.20 (a–j) Combined external fixation device for the fixation of attention must be paid to ensure that the distal basic support is oriented
fractures of the distal part of the tibia. (a) Skeletal traction is applied perpendicular to the anatomic axes of the distal bone fragment in two
using wire calc,3-9 (not shown), followed by division of the lower leg planes. (c) Insertion of proximal basic wire II,9-3. Assembly, alignment
into levels. Two-plane X-ray examination using radio-opaque markers. of the proximal basic support, and its connection with the reductionally
Alternatively, the variant of skeletal traction using wire VIII(8–2)8-2, fixing support. (d) Wires should be tensioned only after the frame of the
which will then be the distal basic wire, can be performed. (b) Insertion device has been completely assembled and correctly oriented with
of distal basic wires VIII,4-10 and VIII(8–2)8-2. Alignment of the respect to the bone fragments and soft tissues. Stabilization of the
module includes reductionally fixing (not shown) and distal basic sup- device, distraction to create a diastasis of 3–5 mm. Two-plane X-ray
ports relative to the distal bone fragment and soft tissues. Particular examination
e f
g h
Fig. 13.20 (continued) (e) Insertion and dynamic fixation of reduc- fragment has been incorrectly positioned, the distal transosseous mod-
tionally fixing half-pin V,12,90. (f) Two-plane reduction of the proxi- ule should be made the relative proximal module (Figs. 2.4, 2.5, 2.6,
mal bone fragment and static fixation of half-pin V,12,90. Insertion and 2.7, 2.8, and 2.9). (g) Elimination of the diastasis and the dismantling of
fixation of stabilizing half-pin III,2,120 to the reductionally fixing sup- skeletal traction. (h) First stage of module transformation (MT):
port. Insertion of stabilizing half-pin VIII,1,90 and its fixation to the removal of the proximal basic support
distal basic support. Two-plane X-ray examination. If the distal bone
Fig. 13.20 (continued) (i) Second stage of MT: partial dismantling of the reductionally fixing support. (j) A clinical example
Fig. 13.21 (a, b) External

a b
fixation supports for mounting
on the foot
Calc.,5–m/tars.V; calc.,7–m/tars.I calc.,2-8; calc.,4-10; m/tars.IV–m/tars.I
a b c
Fig. 13.22 (a–c) External fixation devices for the fixation of fractures 43-B and 43-C
Fig. 13.23 (a–l) Combined external fixation

of intra-articular fractures of the distal part of a
the tibia and fibula. (a) Skeletal traction is
applied using wire calc,3-9. The half-ring for
skeletal traction should have a “large”
diameter. Division of the lower leg into levels.
Two-plane X-ray examination using
radio-opaque markers. (b) Closed or open
reduction and wire fixation in a fibular
fracture
b
c d
e f
Fig. 13.23 (continued) (c) Insertion of proximal basic wire II,9-3 and for example, IX,3,100, IX,9,100, VII,1,80. Console wire VII,1,80 is
assembly of the frame. Wire calc,3-9 is used as the distal basic wire. made by cutting before stopper wire IX,7-VII,1. (f) Insertion of wire
The distal basic support is placed “inside” the half-ring for skeletal trac- VIII(8-2)8-2. To increase osteosynthesis stability, wire calc.,10-4 can
tion. Distraction 7–10 mm. Two-plane X-ray examination. (d) Insertion be inserted. Fixation to a support of the wire fixing the fibular frag-
of half-pin VI,12,90 and two-plane reduction of the proximal bone ments. Insertion of stabilizing half-pin IV,2,120 and the dismantling of
fragment. (e) Closed (using C-arm or arthroscopy control) or open skeletal traction Two-plane X-ray examination
reduction and fixation of large splinters with the aid of console wires,
g h
Fig. 13.23 (continued) (g) First stage of module transformation (MT): fibula. (i) Third stage of MT: partial dismantling of the reductionally
removal of the proximal basic support. (h) Second stage of MT: dis- fixing support
mantling of the distal basic support, removal of the spoke from the
Fig. 13.23 (continued) (j) The patient after the second stage of MT. (k) A clinical example

l
(l) A clinical example
Fig. 13.24 “Fixing” variant of external fixation
If full-volume osteosynthesis is not possible, the frac- weakened patients with poorly controlled weight-bearing)
ture can be immobilized using a “fixation” device based two wires are used in each support: VI,8-2;VI,4-10 ←→
on two supports instead of skeletal traction (Fig. 13.24). ←→ calc.,2-8; calc.,4-10.
If the rigidity of the osteosynthesis must be increased After final radiography, the patient is transferred to the
(e.g., patients weighing > 90 kg, “muscular” types, or ward.
13.4 Ankle Injuries (44-) a b
Surgery must be preceded by closed manual reduction of

the bone fragments. Classical Ilizarov external fixation of
complicated fractures of the ankle joint starts with the
insertion of two crossing proximal basic wires at the level
of the proximal tibiofibular joint, with one wire inserted
through both bones: I,4-10 and (I,8-2)I,8-2. The proximal
basic ring is installed perpendicular to the anatomic (medio-
diaphyseal) axis of the tibial bone and oriented relative to
the soft tissues, so that the distance between its inner edge
and the skin along the anterior and inner aspects is no less
than 3–3.5 cm. The tensioned wires are then fixed to the
ring. An intermediate ring is installed at level V of the
lower leg and connected by three telescopic rods to the
basic support. When the device module is properly installed,
the connection rods will be parallel to the anatomic axis of
the tibial bone.
The distal basic ring, preferably radiotransparent, is
installed at the level of the distal tibiofibular joint (level VIII)
Fig. 13.25 (a, b) External fixation device for reduction and fixation of
and connected to the intermediate ring by three rods. If a
fractures of the lateral malleolus
metal ring is used, it is placed somewhat higher—closer to
level VII—to avoid problems in reading the radiographs. In
this case, the wires are fixed to the support with posts.
The sequence used to restore the anatomic arrangement of end of the wire with a wire tensioner or a distraction clip will
the ankle joint must be as follows: eliminate the lateral displacement of the fragments, and
1. Reduction and fixation of the fibular fragments (lateral simultaneous pulling at both ends the downward displace-
malleolus). ment of the malleolus.
2. Elimination of the tibiofibular diastasis. If the comparison radiograph does not confirm reduction,
3. Reduction and fixation of the anteroinferior part of the longitudinal displacement is eliminated by a distraction force
tibial bone. This reduction is recommended when > 25% applied between the intermediate and distal basic rings
of the joint surface is involved. (Fig. 13.25a). Displacement in the anteroposterior direction
Stages 1, 2, and 3 are aimed at eliminating or consider- is eliminated by a stop with traction at the anterior end of the
ably decreasing the dislocation of the foot. wire (Fig. 13.20b). If required, the wire can be bent further
4. Reduction and fixation of the medial malleolus, which inwards (outwards), with its subsequent tensioning. Special
eliminates the dislocation of the foot. attention should be paid to the accurate reconstruction of the
In fractures of the fibula, a wire with a stop (VIII,5-11) is fibula as it is the key to the ankle joint.
inserted through its distal fragment at the level of the distal To eliminate a tibiofibular diastasis, the wire with a stop
tibiofibular syndesmosis and perpendicular to the intermal- VIII,3-9 is inserted through the tibia. The ends of the wire
leolar line. If the fibula is broken at the level of the syndes- inserted through the lateral malleolus (VIII,5-11) are bent
mosis, the wire is inserted directly under the fracture: inwards and tensioned at the same time (Figs. 13.21b and
(IX,5-11). The ends of the wire are bent downwards and 13.26a). If the fibula was sound and the wire (VIII,5-11) was
inwards in external incomplete dislocations of the foot or not inserted through the fibula, two wires are inserted: VIII,2-
downwards and outwards in internal incomplete disloca- 8(VIII,2-8) and (VIII,8-2)VIII,8-2. The distance between
tions. The amount of bending is determined by the degree of these wires, which are inserted parallel in opposite direc-
displacement of the lateral malleolus. The ends of the wire tions, must be 5–7 mm (Fig. 13.26b). It is important to ensure
are then fixed to the distal basic ring. In fibular fractures at that mutual compression of the third metatarsal in the syn-
the level of or below the distal tibiofibular syndesmosis, the desmosis area should not exceed 80–100 N [214]. It can be
end of the wire is fixed to the ring using posts. This preserves controlled by the mobility of the ankle joint with an ampli-
the orientation of the ring at level VIII. Pulling the anterior tude of not less than 30/0/0.
Fig. 13.26 (a, b) Ilizarov a b

external fixation device for
the fixation of pronation
fracture-dislocations of the ankle
The posteroinferior (anteroinferior) part of the tibia can a b

be reduced by directed pulling at the foot. In fractures of the
posteroinferior part, a wire is inserted through the calcaneal
tuberosity, and in fractures of the anteroinferior part through
the tarsal bones. The wire is tensioned in a half-ring con-
nected to the device by threaded rods and axial distraction is
applied.
If reduction has not been achieved by ligamentotaxis, the
reduction is similar to that used in a reduction of the lateral
malleolus. A wire is inserted through the splinter parallel to
the fracture plane. Its ends are bent downwards and fixed in
the ring of the device. If required, console posts can be used.
The splinter is abducted by uniform tension on the ends of the
wire. Figure 13.27 shows a variant of reduction wire fixation:
directly into the basic support of the device. After radio-
graphic confirmation of the reduction, final reduction and
fixation of the splinter are performed using a wire with a stop,
which is inserted outwards from the Achilles tendon through
the splinter and the tibial bone. In fractures of the posterior
part, the wire is inserted from the back to the front and at an
upward angle: IX,7-VIII,1. In fractures of the anteroinferior Fig. 13.27 (a, b) External fixation device for the reduction and fixation
part of the tibial bone, wire IX,1-VIII,7 is inserted. The wire of the posteroinferior tibia (rear view)
is used to abduct the splinter, which is then removed.
The medial malleolus is adjusted using a thin awl or a sin- The ends of the wires are fixed in a two-thirds or three-quar-
gle hook, which in either case is passed through the skin and ter ring support. A half-pin is inserted at the higher level and
brought to its top. Sometimes, complete alignment of the frac- fixed to the support. The wires are then tensioned in the
ture is hindered by the soft tissues. If this occurs, open reduc- opposite direction to eliminate the tibiofibular diastasis. The
tion using a minimum approach is needed. The ankle is fixed MUDEF designation of the device is VII,12,120; (VIII,8-2)
by a wire with a stop, inserted from the side of the top of the VIII,8-2; VIII,2-8(VIII,2-8).
ankle perpendicular to the fracture plane. The exit of the guid- Another algorithm can be used for external fixation of the
ing end of the wire is usually on the posteroexternal aspect of ankle joint. The first stage involves open reduction of the
the lower leg, at the border of its middle and lower thirds. The internal malleolus and its fixation by a wire with a stop or by
wire is tensioned at this end and fixed with a traction clip to a console wire. The minimum approach is used in this case,
the middle ring of the device (Fig. 13.26a). The internal aspect with only visual control and the possibility of tissue removal.
of the ankle can be fixed using a console wire with a stop. This stage generally results in elimination of the incomplete
Comparison radiographs showing residual incomplete dislocation of the foot outwards (inwards) and a better loca-
dislocation of the foot outwards (inwards) are indicative of tion of the fibular fragments. In addition, creation of an inter-
the failure to anatomically restore the ankle joint fork. Wire nal rest for the ankle bone prevents conversion of the external
calc.,9-3 (or calc.,3-9) is inserted through the heel in the fron- incomplete dislocation of the foot into an internal dislocation,
tal plane. In the plane of the inserted wire, a half-ring support which sometimes happens with the “traditional” method of
is installed, connected by three rods to the distal basic sup- reduction. Wire talus,9-3 with a stop is inserted through the
port of the lower leg. A diastasis of 2–3 mm is created between ankle bone, parallel to the space of the ankle joint. The wire
the joint surfaces. Pulling at the guiding end of the wire will is inserted slightly to the front of the top of the external ankle
eliminate the dislocation of the foot outwards (inwards); the and tensioned in the basic support of the device using posts.
orientation of the fragments of the external (internal) ankle is The next stage involves the reduction and fixation of the
improved, and the tibiofibular diastasis is eliminated. anteroinferior part of the tibia. Radiographic monitoring of
If the foot is incompletely dislocated forwards or back- the degree of abduction of the splinter identifies both whether
wards, wire calc.,3-9 without a stop is inserted. The ends of the incomplete dislocation of the foot has been eliminated
the wire are bent backwards or forwards in accordance with and the nature of the displacement of the fibular fragments.
the foot displacement. Uniform tension on the ends of the Residual displacement of the foot is eliminated by pulling
wire results in transfer of the foot by the designated amount the guiding end of the wire and/or its arched bend forwards
and elimination of the dislocation. In the case of a combined or backwards. If displacement of the fibular fragments
incomplete dislocation outwards and backwards, the foot is remains, it is eliminated as described above.
first moved inwards by means of a wire with a stop. The ends Figure 13.29 provides the scheme for the combined exter-
of the wire are then bent forwards and the residual incom- nal fixation of ankle injuries.
plete dislocation is eliminated. It should be noted that the use of arthroscopy consider-
Temporary immobilization of the ankle joint by means of ably facilitates the reduction. Cleansing of the joint with
an additional support on the heel bone is necessary in cases removal of small bone splinters and cartilage fragments is an
of injury to a deltoid or talofibular ligament, and in cases of important component in the prevention of traumatic deform-
incomplete dislocation of the foot forwards or backwards ing arthrosis. If the operation involves the use of arthroscopic
without fracture of the anteroinferior parts of the tibia. In devices, a device support is installed on the foot for all types
other cases, it is sufficient to use an elastic foot support fixed of injuries and a distraction force is applied in order to
to the device. increase the spacing of the ankle joint.
Figure 13.28 shows the fixation device variants that can External fixation in injuries of the ankle joint is com-
likewise be used for injuries of the ankle. In the device shown pleted by fixation of the anterior part of the foot by means
in Fig. 13.28a, instead of the proximal hybrid support of a foot support (Chap. 34). The foot is fixed for 3–4 weeks,
V,12,120; VI,3-9 a support based on wires V,9-3; VI,2-8; after which the wires are removed from the ankle (heel)
VI,4-10 is used. However, this assembly based on one sup- bones.
port (Fig. 13.28b) has limited capabilities. If full-volume osteosynthesis is not possible, the fracture
In the case of an isolated rupture of the distal tibiofibular can be immobilized using a “fixation” device based on two
syndesmosis at level VIII, two wires with bending cork- supports instead of skeletal traction (Fig. 13.30): II,9-3 –
screw-type stops are inserted from opposite directions. calc.,9-3.
Fig. 13.28 (a–c) Combined

external devices for the fixation a b
of fractures of the ankle
c
Fig. 13.29 (a–m) Combined

external fixation for the fixation a b
of ankle fractures. (a) Skeletal
traction is applied using wire
calc,3-9 or calc., 9-3. The wire
stopper should be located on the
side in which displacement of the
foot occurred. The wire is
tensioned in an arc (half-ring)
whose diameter accommodates
the distal base support of the
frame within it. Closed manual
reduction is attempted. Division
of the lower leg into levels.
with X-ray contrast markers.
(b) Insertion of proximal basic
wire II,9-3. (c) Assembly and
orientation of the module from
the distal basic and reductionally
fixing supports. It is important to
note the direction that the distal
part of the lower leg will move
during the elimination of a foot
dislocation
c
d e
f g h
Fig. 13.29 (continued) (d) Frame assembly followed by wire tension- malleolus by console wire IX,3,140. (g) Reduction of the lateral malleo-
ing and a 7–10 mm distraction. Two plane X-ray examination. (e) lus, which can be accomplished using the method shown in Fig. 13.20.
Insertion of half-pin VII,12,90. Elimination of the foot dislocation with To fix the lateral malleolus, wire (IX,8-2)IX,8-VIII,2 or a 4-mm half-
the aid of a reduction device. The dislocation is eliminated not by the pin (IX,9,90) is used. (h) Reduction of the posterior-inferior part of the
movement of the foot (it remains immobile), but by the two-plane (in tibia, which can be accomplished using the method shown in Fig. 13.22
the necessary direction) movement of the distal part of the tibia by and wire ix,7–viii,1
means of half-pin VII,12,90. (f) Reduction and fixation of the medial
i j
k l
Fig. 13.29 (continued) (i) Before the wire support of wire IX,7–VIII,1 of the osteosynthesis, wire calc.,10-4 can be inserted. (k) First stage of
is placed under the skin, the latter is cut in front of it, such that wire module transformation (MT): removal of the proximal basic support.
IX,7–VIII,1 becomes console wire VIII,1,80 and thus avoids Achilles (l) Second stage of MT: removal of the distal basic support
tendon fixation. (j) Removal of skeletal traction. To increase the rigidity
Fig. 13.29 (continued) (m) A clinical example
Fig. 13.30 “Fixation” device

13.5 Chronic Ankle Injuries The wire inserted through the heel bone is tensioned and
fixed to the three-quarter support. As the wires inserted
Leonid Nikolaevich Solomin through the ankle and heel bones are located one above the
other, a slotted washer placed under the post is used for the
In the opinion of Oganesyan et al. [103], injuries of the ankle fixation of each end of wire calc.,3-9. The wire inserted
joint can be considered as “chronic” when 2–6 weeks have through the ankle bone is fixed via posts. The guiding end of
passed since the injury, i.e., until primary union of the frag- the wire must be provided with a distraction clip. Thus, the
ments by membranous reticulated tissue. With external fixation wires inserted through the ankle and heel bones are fixed to
methods, restoration (or improvement) of the ankle joint anat- the distal support of the device. Wire talus,9-3 is left unten-
omy is possible by at least 4–6 months post-injury. It should be sioned at this stage.
noted that even if the decision was made to perform a recon- Over a period of 3–5 min, a distraction force is gradually
structive operation (arthrodesis, arthroplasty), the use of exter- applied to increase the spacing of the ankle joint by 4–6 mm.
nal fixation techniques can restore the mechanical axis of the Only then is wire VIII,3-9 inserted through the tibia and
lower extremity as the first stage, with minimal trauma. fixed under tension to the support; in cases of internal incom-
The operation starts with the installation onto the lower plete dislocation of the foot, wire VIII,9-3 is inserted.
leg of a basic transosseous module based on two wire Incomplete dislocation of the foot is eliminated by traction
supports, I,2-8; I,4-10 – VI,2-8; VI,4-10, or on a combined on the wire with a stop inserted through the ankle bone. The
one, V,12,120; VI,9-3. wire inserted through the heel bone has a dual function: a
Special attention must be paid to the orientation of the guiding role and maintenance of the diastasis between the
supports relative to the soft tissues. The module is placed per- joint surfaces (Fig. 13.31a). During setting, the foot is manip-
pendicular to the anatomic axis of the tibia so that the lower ulated manually, with elimination of the incomplete disloca-
leg is in the center of the support located at level VI. In the tion usually taking 5–10 min of gradually increasing
case of a chronic incomplete dislocation of the foot outwards, manipulations.
the ring is placed inwards by the amount of the dislocation In cases of incomplete dislocation of the foot forwards or
plus 2–3 cm. (Analogous methods are applied for other vari- backwards in the sagittal plane, the distal support is displaced
ants of foot displacement.) Only then are the transosseous in the necessary direction relative to the basic device (Figs.
elements fixed to the support(s). Next, osteotomy of the ankle 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9).
at the height of the deformity is performed with the minimum The described procedure allows for the single-step elimi-
number of incisions. The line of the osteotomy of the lateral nation of incomplete dislocations of the foot that occurred
ankle must be made in the oblique direction for subsequent 3–4 or more months previously. Residual dislocation, seen
restoration of the length of the fibula, as its reconstruction is on comparison radiographs, is gradually eliminated during
obligatory. An apposition suture is applied to the wounds. the postoperative period. In this case, the manipulations
In the case of chronic rupture of the distal tibiofibular syn- described below are performed during the second stage of
desmosis, which may further prevent elimination of the dia- setting of the foot. If elimination of the incomplete disloca-
stasis, the fibrous material is removed via a 5-mm incision tion of the foot is confirmed, open adaptation of the medial
with a Volkmann curette. The assistant then fixes the lower malleolus is performed, with fixation by a wire having a
leg and the surgeon moves the foot in order to set it. corkscrew-like stop. An anteroposterior radiograph is
A ring support is installed at level VIII and connected by obtained to determine whether the lateral malleolus is short-
three rods to the ring mounted at level VI. The foot is placed ened. If this is the case, and “sliding” along the oblique
in position 0/0/ and a wire with a corkscrew-like stop of osteotomy line does not correct the length, free bone plasty
diameter 5–8 mm is inserted through the center of the ankle of the diastasis is necessary. The proximal fragment of the
bone unit, parallel to its joint surface in the frontal plane. The fibula is fixed by a wire inserted through both bones of the
more marked the osteoporosis, the larger the diameter of the lower leg: (VIII,8-2)VIII,8-2. The tibiofibular diastasis is
stop. In cases of incomplete dislocation of the foot outwards, eliminated by tensioning the wire. The ankle is stabilized by
wire talus,9-3 is used. a wire inserted in a plane close to the sagittal plane:
Wire calc.,3-9 is then inserted through the heel bone per- (IX,5-11). The lateral malleolus can be fixed by a console
pendicular to its anatomic axis. The wire must be located wire with a stop (or by a 4-mm half pin) inserted in the fron-
parallel to wire talus,9-3. A three-quarter ring support is tal plane: (IX,9,90) (Fig. 13.31b).
installed in the plane of the wire inserted through the heel If not more than 6–8 weeks have passed since the injury,
bone; it is connected by three rods to the support above. The the location of the splinter of the anteroinferior or posteroin-
distance from the internal edge of the distal three-quarter ferior parts of the joint surface of the tibia is usually improved
support on the heel must be sufficient to allow unhindered after setting of the foot. Residual displacement is eliminated
movement of the foot during setting of the dislocation. by means of an arched bent wire, as described in the section
a b
2 1 5 4 3
V,1,120; VI,9-3 – VIII,3-9 ←→ talus,9-3; calc.,3-9 (a)
150 150 3/4 150
2 1 5 6 7 4 3
V,1,120; VI,9-3 – VIII,3-9; (VIII,8-2)VIII,8-2; (IX,9,90) ←→ talus,9-3; calc.,3-9 (b)
150 150 3/4 150
Fig. 13.31 (a–c) External fixation for the fixation of chronic injuries to the ankle joint (dislocation setting “inside the device”)
Fig. 13.32 Diagram of the external fixation device in the case of a

chronic injury of the ankle joint (setting of the dislocation at the
expense of mutual transposition of the transosseous modules)
1 2 3 4 8 9
VI,2-8; VI,10-4 –– VIII,3-9; VIII,4-10; (VIII,11-5); (IX,5-11) ←o→
150 150
5 6 7
←o→ calc.,2-8; calc.,4-10; m/tars.,V–m/tars.,I
oval 150
on the treatment of ankle fractures. After the reduction has After the dislocation has been set, reduction and osteosyn-
been confirmed radiographically, the splinter is fixed by a thesis of the ankle are performed following a method similar
wire with a stop, inserted outside the Achilles tendon through to that described above. Figure 13.20 shows, as an example,
the splinter and the tibia. In a fracture of the posteroinferior the method for eliminating a tibiofibular diastasis facilitated
part of the tibial bone, wire IX,7-VIII,1 is inserted; in a frac- by the arched bending of wire (VIII,11-5), and reduction and
ture of the anteroinferior part, wire IX,1-VIII,7 is inserted. fixation of the lateral malleolus by wire (IX,5-11).
The wire used for abduction of the splinter is removed. If the Nowadays, the preferred method of treatment of inveter-
fragment has already fused in the wrong position, osteotomy, ate damage to the ankle joint is similar to that shown in
open reduction, and fixation are needed. Fig. 13.29. It features, unlike the approach used in urgent
For a chronic injury of the ankle joint, mutual displace- trauma (Fig. 13.33), two wires in basic supports, followed by
ment of the transosseous modules fixing the lower leg and osteotomy of the medial and lateral malleolus; and, if neces-
the foot can be used (Fig. 13.32). At the beginning of the sary, ankle joint release and removal of scars from the area of
operation, the basic device is mounted on the lower leg: the distal tibiofibular syndesmosis.
VI,2-8;VI,10-4 – VIII,3-9;VIII,4-10. A support is then If the residual subluxation of the foot cannot be elimi-
installed on the lower leg. Osteotomy of the ankles is per- nated in one stage (typically 4 months post-injury), the post-
formed with the minimal number of incisions along the line osteotomy wounds are sutured. After the wounds have healed,
of the former fractures. A unit is mounted between the distal distraction is used to increase the ankle joint gap to 0.5–
support of the lower leg and the support on the foot, allowing 0.7 mm. A reduction device with half-pin VIII,12,90 is then
a distraction force to be applied to move the foot in the nec- used to gradually eliminate residual subluxation of the foot.
essary direction (Figs. 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9). peпoзициoнную a prefix with a core a screw дoзиpoвaннo in
Fig. 13.33 Variant external a b

fixation devices for the fixation of
injuries to the ankle. Fixation of
half-pin VIII,12,90 to the support
using the device shown in Fig.
2.12 allows easy elimination of
the incomplete dislocation of
the foot both in the frontal and
sagittal planes (a). After
reduction, the proximal support
can be removed (b)
1 2 5 3 4
II,8-2; II,4-10 – VIII,12,90 ←→ calc,8-3; calc.,4-10
150 150 3/4 150
1 2 5 3 4
VI,2,120; VIII,12,90; (IX,9,90) ←→ calc,8-3; calc.,4-10
1/2 150 3/4 150
time eliminate(erase,remove) a foot incomplete dislocation. deltoid ligament is performed. In case if osteosynthesis
The patient then undergoes the second stage of treatment: according to Fig. 13.23 is done, a week prior to the plasty of
adaptation and fixation of the medial and lateral malleolus. the deltoid ligament the wire from the talus should be
External fixation is completed by fixation of the anterior removed. To stabilize the foot, an additional wire with a stop
part of the foot with a foot support (Chap. 34). is simultaneously inserted through the heel bone: calc.,10-4.
If the medial malleolus has set 3–4 weeks after elimina- Analogous methods are used in cases of chronic injury of the
tion of the incomplete dislocation of the foot, plasty of the ankle-fibula ligaments.
Open Fractures
14
Alexander A. Lerner and Leonid Nikolaevich Solomin
Generally, the principles underlying the treatment of patients ultimately determine the long-term results and final
with open fractures involving the limbs are similar to those outcome.
discussed in Chaps. 2, 3, and 7. Therefore, in this chapter we There are a number of criteria underlying the selection of
consider only the most important, fundamental aspects of the optimal external fixation technique for the treatment of
external fixation in the management of open limb fractures. complex open fractures, including those caused by gunshot
The assemblies of the external fixation devices comprise wounds. Among them, the most important is the degree of
only the basic frames, as was the case for the fixation frames skin damage according to the IO scale, the degree of muscle
described in Chaps. 10, 11, 12, and 13. Nevertheless, it must be and tendon damage according to the MT scale, the degree of
kept in mind that detailed, precise, and careful preoperative neurovascular damage according to the NV scale, and the
planning together with optimal external fixation frame extent of the bone damage (types A–C) according to the AO/
configurations is the keystone of successful treatment. The ASIF classification [1] The degree of contamination and
number of constructional elements, their localization according infection of the traumatic wound must also be determined. In
to the fixed bone fragments, and the general assembly of the addition, the Gustilo-Anderson index, based on the size of
frame should meet the specific needs of the patient and his or the wound and the amount of soft-tissue injury, is a very use-
her clinical situation. The injured limb should not be condemned ful in dealing with open fractures [215, 216].
to the “Procrustean bed” of the standard fixation frame! In open fractures with skin perforation from the inside
(IO1) or a laceration of the arm, forearm, or thigh up to
3–5 cm in size (IO2) with limited damage to a single muscle
14.1 Fixation Methods in the Treatment group (MT2), and in the absence of neurovascular damage
of Open Limb Fractures (NV1), the bone fragments usually need not be isolated dur-
ing primary surgical treatment. These types of injuries cor-
The type of bone damage, even in patients suffering from respond to IA–IB compound fractures according to the
severe bone comminution and/or bone loss, is not the most Kaplan-Markova classification [217] and Gustilo types 1 and
important factor in choosing the optimal treatment method. 2. The bone fragments are repositioned and fixed as in simple
Rather, the condition of the soft tissues and the degree, depth, fractures following drainage and suturing of the wound.
and extent of the damage are the basic defining factors that In the treatment of gunshot-induced fractures, primary sur-
gical debridement of multiple point wounds that do not con-
tain foreign bodies and are not accompanied by a growing
hematoma or a disorder of the peripheral circulation is not
A.A. Lerner, M.D., Ph.D. (*)
Faculty of Medicine in Galilee, indicated [218, 219]. However, a different approach is required:
Bar-Ilan University, Zefat, Israel in skin wounds longer than 5 cm, if there are nonviable areas
Department of Orthopedic Surgery, (IO3), if there is considerable contusion through the whole
Ziv Medical Center, Rambam Str. 1, thickness of the skin, in graze wounds or if there are skin
Zefat 13100, Israel defects (IO4), if there is considerable damage to the muscles
e-mail: alex_lerner@yahoo.com
(MT3), if there are muscle defects or rupture of the tendons, or
L.N. Solomin, M.D., Ph.D. if there is extensive muscle contusion (MT4). These types of
R.R. Vreden Russian Research Institute of
damage, according to the classification of Kaplan and Markova,
Traumatology and Orthopedics, 8 Baykova Str.,
St. Petersburg 195427, Russia correspond to compound fractures IIA, IIB, IIIA, and IIIB. In
e-mail: solomin.leonid@gmail.com the Gustilo classification, these are type 3 fractures.
508 A.A. Lerner and L.N. Solomin
a treatment of open high-energy fractures characterized by

extensive and complex soft-tissue damage.
14.2 Debridement and Primary Bone

Fixation Using Unilateral External
Fixation Frames
External fixation frames types I and II (Table 1.1) provide an

effective method of fracture stabilization, permitting
sufficiency control of the wound, vascular repair, and subse-
quent plastic-surgery coverage (Fig. 14.2).
Unilateral external fixation frames provide primary
fracture stabilization either “in situ” (e.g., when the frac-
b
ture is immediately stabilized without reduction in critical
general condition of patient) or after re-alignment of the
bone fragments during operative manipulation. This
approach is largely analogous to the fixation method used
in osteosynthesis.
In the acute trauma setting, unilateral external fixation pro-
vides a rapid, efficient, and relatively simple method of fracture
stabilization, retaining the distance between bone fragments
and preventing contracture of the muscles, thus allowing post-
operative mobilization and facilitating patient discharge. The
Fig. 14.1 Severe complications due to irrational primary internal average time required to place a tubular external fixator is
fixation in the treatment of open complex high-energy fractures. (a) 20–30 min [220, 221]. In addition, early mobilization of the
Extensive skin and soft-tissue post-necrotic defects with an uncovered injured limb is possible, greatly simplifying the post-operative
internal fixator after primary open reduction and internal fixation in the
nursing care of the multiple-trauma patient (Fig. 14.3).
treatment of a blast injury to the right lower limb. (b) Skin necrosis with
fixation-plate denudation after primary internal fixation of an open Bone fragment fixation achieved using external frames
high-energy ulnar fracture with severe soft-tissue damage also allows primary fracture stabilization to the extent that the
patient can be discharged from the hospital relatively soon
after treatment, with early functional mobilization of adjacent
Thus, internal fixation methods, including intramedullary unfixed joints. This modular and versatile treatment strategy
nailing and plating, can be applied in the treatment of open may be employed for fractures of almost any configuration,
low-energy limb fractures with relatively limited soft-tissue severity, and location and in the presence of various skin and
damage (Gustilo types 1 and 2). In the management of open
limb fractures accompanied by severe and extensive soft-tis-
sue damage (high-energy Gustilo 3 fractures), the preferred
treatment approach is based on the sparing principles of min-
imally invasive methods of bone stabilization. However, the
immediate reduction of open bone fragments and the surgical
implantation of the internal fixation devices can lead to addi-
tional soft-tissue trauma, increasing the likelihood of wound
healing problems and septic complications. Indeed, the
implanted internal fixator can become a massive foreign
body, supporting local septic processes. This is especially the
case in the treatment of patients with significant soft-tissue
loss and insufficient fracture site coverage (Fig. 14.1).
External fixation provides bone stabilization without the
need for an additional surgical incision, thus avoiding soft-
tissue trauma, bone stripping, and blood loss, and without
the presence of massive additional foreign bodies (internal
Fig. 14.2 Unilateral external stabilization of an open femoral fracture
fixators) in the fracture zone. Thus, minimally invasive exter- demonstrating the possibility of an adequate surgical approach around
nal fixation is an effective and preferred method in the initial the injured limb segment
14 Open Fractures 509
Fig. 14.3 (a, b) Primary fracture stabilization using unilateral external fixation frames, allowing “damage control” in the treatment of patients
with complex and multiple trauma
a b
d
c
Fig. 14.4 External fracture fixation using the AO tubular external frames (a, b) and OrthoFix device (c, d)
soft-tissue conditions or even loss. The main difficulties and especially likely in patients with high-energy gunshot
disadvantages associated with unilateral external fixation wounds, blast injuries, and severe crush injuries.
frames are discussed in Chap. 2. The entrance and exit sites of the gunshot wound should be
Thus, the main indication for unilateral external fixation excised and widely dissected. Skin margins are excised as eco-
frames is open high-energy fractures with extensive and nomically as possible. The wound canal and wound pockets are
complex soft-tissue damage and loss (Gustilo 3 fractures). revised, with excision of all devitalized tissues. For patients
These multiple trauma patients, including those who are with vascular injuries (Gustilo 3C fractures) or when crush
hemodynamically unstable and with complex pelvic frac- damage to a limb is significant, prophylactic fasciotomy should
tures, require minimally invasive and rapid fracture stabili- be performed to prevent compartment syndrome. Connections
zation. For such cases, many different tubular external between bone fragments and the surrounding soft tissue should
fixation systems have been developed, such as the devices be preserved. Denuded and comminuted bone fragments with
of AO, Hoffmann, Orthofix, Dinafix, and EBI-fixators questionable viability must be removed, avoiding devascular-
(Fig. 14.4). ization of the fracture zone. Large free bone fragments can
Our fixator of choice for primary stabilization of open often be saved after their massive irrigation.
limb fractures is the AO tubular external frame (Synthes The presence of an open fracture and related wound does
AG, Chur, Switzerland), used in a single-plane unilateral not prevent the extremity from the complication of compart-
configuration [222]. This is a rapid, modular, and simple ment syndrome, as an open fracture does not automatically
method of stable primary fracture stabilization after severe relieve the compartment of the injured limb. Consequently,
complex trauma. A minimal number of basic frame compo- even these patients can develop compartment syndrome.
nents can be tailored to address specific surgical problems Thus, fasciotomy should be performed during the primary
and anatomic sites. Figure 14.5 shows the basic frame com- debridement procedure by longitudinal widening of the post-
ponents of the AO tubular external fixator (Synthes). traumatic fascial defects.
Copious, massive, repeated irrigation is an essential step Surgical gloves and all surgical tools must be changed
in primary wound management during debridement. High- after copious massive irrigation, primary radical debride-
pressure pulsatile lavage (HPPL) may further damage the ment of the wound, and the removal of foreign bodies are
soft tissue by driving contaminants deeper into tissue already completed. The injured limb is re-prepared with antiseptics
compromised by trauma, rather than removing them. This is and re-draped according to basic surgical rules. It is desirable
to leave the distal parts of the injured limb exposed for ongo- possible to fully expose the operated limb, freeing it from the
ing visual inspection of the fingers or toes, including color, surgical drapes. The adjoining proximal and distal joints
capillary filling, palpation of peripheral pulses, and instru- must be observed during surgery to avoid unintentional mal-
mental control of peripheral perfusion and oxygenation. positioning (usually malrotation) of the bone fragments dur-
The non-standard conditions posed by severe and coming the bone fixation procedure.
plex injuries frequently necessitate significant expansion of Prior to the half-pin insertion procedure, all potentially
the surgical access anywhere along the limb. Moreover, the dangerous zones, including the locations of the major ves-
introduction of additional external fixation elements away sels, nerves, and musculo-tendinous units, as well as large
from the zone of injury may be required. Thus, it must be bone fragments and pertinent skeletal landmarks, should be
b c
Fig. 14.5 Basic frame components of the AO tubular external fixator (Synthes): (a) threaded Schanz screws (5-mm diameter); (b) stainless steel
tubes; (c) adjustable clamps tube-to-Schanz; (d) adjustable clamps tube-to-tube
Fig. 14.5 (continued) (e) triple

e
trocar: trocar 3.5 mm, drill sleeve
3.5 mm, drill sleeve 5.0 mm, and
drill bits; (f) universal chuck with
T handle, socket wrench, and
combination wrench (11 mm)
marked on the skin using a marker pen. The potential for A thin Kirschner wire, used as a probe, is a helpful tool to
non-anatomic localization of important structures due to dis- determine the position of the displaced fragments and to
placement of the bone ends and surrounding soft tissues must identify the correct site and optimal direction for subsequent
be kept in mind. A preoperative marking procedure can con- half-pin insertion into the bone.
siderably facilitate the operation, reducing its duration and In unilateral external fracture fixation, a pair of 5.0–
the probability of iatrogenic complications. 6.0 mm threaded half-pins is introduced into each of the
Considering the significant damage to the bone and soft main bone fragments (proximal and distal) of the tibia,
tissues due to open high-energy trauma, the choice of lev- humerus, and forearm bones (Fig. 14.5a–c). In large and/or
els and positions for the introduction of the fixation ele- obese patients with oblique fracture configurations or in
ments to the bone may be substantially limited. Therefore, patients with severe comminution of the bone fragments, as
except for the “reference positions” other localizations, well as in the stabilization of femoral shaft fractures, three or
with the exclusion only of zones containing the main neu- even more half-pins should be introduced into the proximal
rovascular structures (“safe positions”), can be more and distal main fragments (Fig. 14.6d). External fixation of
widely used. Exceptionally, the temporary insertion of femoral and tibial fractures is performed using 5–6 mm
half-pins into the uncovered bone can be carried out. Then, screws. In external fixation of the humerus 5 mm screws are
after stabilization of the patient’s general condition and used, and in the forearm, foot, and hand bones 3.5–2.7 mm
improvement of the local soft-tissue status, these half-pins screws.
should be re-inserted at more suitable sites along the Short femoral or tibial bone fragments should be fixed
injured limb segment, i.e., the “recommended positions” with three half-pins in order to avoid trans-articular
(Sects. 14.3 and 14.4). bridging.
Fig. 14.6 External fixation of

the humerus (a) and forearm a b
bones (b) with introduction of a
pair of screws into the proximal
and distal bone fragments. In
external fixation of the tibia (c)
and femur (d), two or three
screws are inserted into the
proximal and distal bone
fragments
c d
In the fracture reduction procedure, the wide base of the ments. The most proximal and distal half-pins are introduced
external fixation frame is particularly stable—an additional into the bone near the metaphyseal zone. The degree of sta-
benefit over a prolonged fixation period. Half-pins are bility can be increased by the non-parallel multi-scheduled
inserted into the bone fragments close to the fracture zone at introduction of bone-fixing elements (70–120° to the bone
a distance of 4–5 cm from the ends of the main bone frag- axis) (Figs. 2.24 and 2.25).
Fig. 14.8 External fixation of a tibial fracture using the AO tubular

external fixation frame
achieved by inserting a pair of additional half-pins into the

bone from the opposite side of the fixed joint. The external
Fig. 14.7 External fixation of a tibial bone fracture ends of these half-pins are fixed to each other and then to
the primary external fixation frame using two longitudinal
tubes, thereby increasing the stability of the fracture fixation
Half-pins should be introduced into the bone using versa- itself (Fig. 14.9).
tile projections of the different positions, for example, posi- Temporary trans-articular bridging is particularly useful
tion 8 at level I and position 10 at level IV. in patients scheduled to undergo conversion to internal frac-
Reduction of the distance between a bone and a tube of ture fixation, as it protects the planned surgical approach
the external fixation device also increases the stability of from possible pin-tract infection around the screws of the
fracture fixation. During the fracture fixation procedure, primary tubular external fixator.
all Schanz screws are usually inserted into the proximal Surgical fixation in the treatment of severely injured,
and distal femoral bone fragments from the lateral side hemodynamically unstable patients should be rapid and min-
(positions 8, 9, 10). The approach for screws introduced imally traumatic in order to avoid further aggravation of the
into the tibial bone at each level is wider: positions 3–9 patient’s general condition and the local condition of the
(anterior hemisphere of the segment), except for the con- damaged limb. The gross displacement of bone fragments
tra-indicated positions at levels VI, VII, and VIII. For the and local pressure on the skin and nearby neurovascular
stabilization of ulnar bone fractures, it is advisable to use structures should be eliminated in the context of primary
between positions 5–9 in the insertion of the fixation fracture fixation (Fig. 14.10).
screws. The insertion of half-pins into the humeral or radial In the treatment of patients with extensive wounds and
bones due to complex anatomic features of these segments, exposed bone fragments, fixation using external frames is
must be performed according to the recommendations, carried out, as a rule, at the final stage of primary surgical
given in Chap. 5. debridement. The technical difficulties of a fracture reduc-
The external ends of half-pins inserted into the proximal tion procedure performed during the acute phase of treatment
and distal bone fragments are fixed to the corresponding are usually insignificant, especially under open wound con-
short longitudinal tubes using special tube-to-screw connec- ditions involving an exposed fracture zone and bone frag-
tors. The tubes of each of these proximal and distal blocks ments. In such cases, fracture reduction under direct visual
are then connected using universal tube-to-tube clamps. and manual control is relatively easy.
Manual alignment and reduction are stabilized by tightening Particular attention should be paid to the final position of
the clamps after clinical and radiological control of the frac- the bone fragments achieved as a result of primary operative
ture’s reduction (Figs. 14.7 and 14.8). stabilization, especially when the condition of both the
Temporary trans-articular bridging of the injured limb is patient and the injured limb is relatively stable. Accurate
indicated in complex peri-articular and intra-articular frac- positioning of the bone fragments during primary fixation is
tures, extensive osteo-ligamentous injuries, or intra-articu- important, given that conversion from the primary external
lar penetrating injuries, and in the presence of severe fixation frame to the final definitive internal fixation may be
damage to the capsule and ligamentary complex of adjoin- significantly delayed or even impossible in some severely
ing joints. In addition, temporary trans-articular bridging injured patients [223]. This procedure, naturally, should be
fixation is an effective method to increase stability in minimally traumatic.
patients with very short para-articular bone fragments. Severe high-energy traumas usually result in extensive
Technically, this type of trans-articular fixation can be and deep tissue damage, and even tissue loss. Immediate
restoration of the length and shape of the damaged limb is even minimal, trauma in patients with severe high-energy
inexpedient and in some cases even dangerous. Early cover- injuries and extensive tissue loss, especially in those who
age of the exposed bone fragments poses a surgical challenge are in critical condition, either generally or with respect to
and frequently results in additional trauma. Significant the injured limb. Temporary fixation of atypical bone frag-
wound defects demand the use of local and distant soft-tissue ments in positions of acute shortening, acute angulation,
flaps. However, severe high-energy trauma causes extensive acute rotation, or a combination thereof create optimal
damage not only to the zone enclosing the wound itself but conditions for the closure and healing of soft-tissue
also to surrounding tissues. Thus, a precise definition of the wounds, without additional morbidity to local or distant
extent and depth of the tissue damage is not possible during tissue flaps, and for free microsurgical tissue transfers.
the early stages of treatment. Consequently, wound coverage Care must be taken to avoid malpositioning of the bone
using local or distant tissue flaps may become complicated fragments and possible neurovascular complications due to
by partial or even full necrosis of the flaps (Fig. 14.11). severe angulation and twisting of the main vessels and
Wound coverage using the microsurgical transfer of free nerves. Therefore, estimating the level of the peripheral
tissue requires highly skilled specialist interventions and circulation is necessary after any “acute malpositioning”
equipment but also imposes additional trauma to the donor procedure (Fig. 14.12).
site and a considerable lengthening of the operation time. Cutting of the bone fragments is not obligatory in a
Thus, in the severely traumatized patient this complex sur- significant acute limb shortening procedure. In some
gical approach cannot be reconciled with the vital princi- patients, especially those with femoral and humeral bones
ples of damage control. Instead, limb salvage using only fractures, limb shortening is an option, with temporary
the remaining tissues is advised to avoid any additional, superposition (duplication) of the bone ends. However,
b c
Fig 14.9 (a–e) Trans-articular bridging fixation of the upper and lower limbs

d
resection of the bone ends is necessary in temporary tibial ment according to the Ilizarov method is possible. This treat-
shortening, due to the tibia’s exocentric position with respect ment strategy allows preservation and restoration of the
to the surrounding soft tissues. If the intact fibula interferes critically damaged limb using only minimally invasive meth-
with shortening and re-positing of the tibial bone fragments, ods of treatment and without causing additional local (dam-
fibular osteotomy or even its segmental resection are aged limb) and general (donor site) morbidity.
mandated. In addition, temporary acute limb shortening can be
An atypical position of the bone fragments, achieved at especially beneficial in the treatment of open complex frac-
the final stage of the debridement procedure, allows the tures with vascular damage (Gustilo 3 C) and in limb frac-
edges of the wound to be pulled together and thereby consid- tures with complicated damage to peripheral nerves. Urgent
erably reduces the extent of the post-traumatic soft-tissue vascular repair can be carried out without the need for graft-
defect. Thus, radical surgical debridement with temporary ing; the same is true for the nerves, as limb shortening allows
acute shortening, angulation, and malrotation of the bone the restoration of damaged vessels and nerves by a relatively
fragments has been recommended in the treatment of severe simple end-to-end suture without tensioning. The results of
open fractures with extensive soft-tissue loss, e.g., due to this type of restoration, as a rule, surpass those achieved
combat injuries, high-energy traffic accidents, and industrial with restoration based on an interpositional grafting
trauma. technique.
After complete soft-tissue wound healing (sometimes The surgical procedure is finished by repeated copious
requiring an additional free skin graft on a relatively small irrigation of the wound with antiseptic solution, followed, if
area), graduated length restoration of the injured limb seg- indicated, by establishment of a drainage system.
Fig. 14.10 (a, b) X-ray images

obtained after primary fixation of
a b
the comminuted femoral and
tibial bones demonstrate axial
realignment of the bone
fragments
14.3 Final Bone Reconstruction Using

Circular and Hybrid External
Fixation Frames
Despite the above-mentioned advantages of unilateral tubular

external fixators, these devices are limited with respect to their
active influence on bone fragment positioning and the complex
processes involved in bone callous formation and fracture heal-
ing. Indeed, unilateral tubular external fixation devices, as a
definitive method of skeletal stabilization, have been associated
with a high rate of non-union [224–226]. In most cases, as their
Fig. 14.11 Tissue necrosis after a local rotating flap was used for cov-
name implies, these are only external stabilizing devices, yield-
erage following extensive tissue loss resulting from a blast injury to the ing the same result as achieved by manual repositioning.
lower limb Alternatively, various methods of final fracture fixation
are available. Conversion to internal fixation, including plat-
In patients with high-energy injuries, especially combat- ing or intramedullary nailing, is the method of choice for the
related gunshot and blast trauma, and in those with crush treatment of low-energy fractures. However, in patients with
injuries, primary closure of the wounds must be avoided significant and extensive soft-tissue damage, any surgical
because of the high risk of contamination and the retention intervention involving open repositioning and internal
of necrotic tissues. Instead, standard care for the manage- fixation of the displaced bone fragments will result in addi-
ment of complex high-energy open fractures is initial surgi- tional trauma to the injured tissues and disturb local blood
cal debridement, with the open wound covered with a supply. Internal fracture fixation in patients with problematic
traditional wet-to-dry dressing on the first day of treatment. coverage of the bone fragments and the fracture site may
Separate approximating sutures are allowed only for cover- considerably increase the probability of septic complica-
age of the exposed bone fragments using the surrounding tions, especially in the presence of additional metal foreign
muscular tissue (Fig. 14.13). bodies, i.e., the implanted internal fixation device. This is
Fig. 14.13 High-velocity gunshot injury to the elbow joint. Trans-

articular bridging fixation using a tubular external fixator. The open
post-debridement wounds are seen
b Increased fracture stabilization with an external fixation

frame is possible even if the position of the bone fragments
is unsatisfactory. A final, precise fracture reduction proce-
dure should be carried out only after soft-tissue wound
healing.
Additional preoperative imaging of the damaged limb
segment, including the adjacent joints, is mandatory to iden-
tify the position of the bone fragments, the proximal or distal
extension of the fracture, missed fractures, and foreign bod-
ies. Meticulous preoperative planning of the surgical proce-
dure and the appropriate optimal fixation frame configuration
offer the best chance of successful treatment.
The external fixation frame can be assembled by a variety
Fig. 14.12 Stabilization of an open humeral bone fracture in which of methods: (1) preliminary mounting of the frame prior to
there is extensive bone and soft-tissue defects and vascular damage the operation, (2) mounting the fixation frame around the
(Gustilo 3C). (a) Radical debridement with temporary bone stabiliza-
fixed limb segment during the operation, and (3) separate
tion using a unilateral external fixation frame. The 6-cm defect of the
humeral bone is seen. (b) Fracture fixation using a unilateral external mounting of the proximal and distal fixation blocks followed
fixator with the bone ends in a position of temporary shortening; reduc- by their joining together in the position in which the main
tion of the soft-tissue defect; and the establishment of conditions for bone fragments are to be re-aligned. We recommend prelimi-
wound coverage and vascular suture
nary assembly of the circular fixation frame, with stabiliza-
tion of the tibia, forearm bones, and humerus. For the fixation
especially relevant in the treatment of patients with combat of femoral bone fractures, we use the 2nd and 3rd options.
trauma and victims of a terrorist attack. Continued treatment The number of rings, thin wires, and half-pins of the
in both cases dictates the use of minimally invasive methods fixation frame varies depending on the type and configuration
of external fracture stabilization using circular or hybrid of the fracture, the condition of the soft tissues, and planned
external fixation devices. subsequent operative interventions. Temporarily bridged
When good fracture reduction was achieved in the primary adjusted joints should be released during the conversion
operation, final fixation of the bone fragments should be per- procedure.
formed as early as possible after the patient’s general condi- Usually, the recommended distance between the internal
tion and that of the wound site have stabilized. In most cases, part of the rings and the skin of the fixed limb should be
final fixation is possible 5–7 days after the trauma has within the limits of 2–3 cm. In the treatment of patients in
occurred. It is usually combined with wound revision (second whom severe post-traumatic swelling of the injured site is
look) and with final coverage using plastic surgery methods. likely, and when additional operative interventions are
a transosseous elements should be avoided, if possible, accord-

ing to the recommended positions (Chap. 5).
14.3.1 Conversion from Primary Unilateral

External Fixation Devices with Half-Pin
Preservation
In conversion procedures, it is desirable to preserve and use

the Shanz screws of the primary frame, assuming there are
no signs of local pin-tract infection, as they are well-fixed to
the bone and situated in the recommended positions. These
Shanz screws do not transfix either the muscles and tendons
or the joint capsule. Screws located over tendon-muscle
units, resulting in restricted joint motions, must be removed.
In most patients, circular Ilizarov devices or their ana-
logues allow closed repositioning without the need for open-
ing the fracture zone. Access to the bone fragments through a
wound can facilitate fracture repositioning in patients in
whom the closed reduction attempt was unsuccessful due to
soft-tissue interposition. Open reduction is performed in these
cases through the wound and maintained with clamps, or by
applying thin wires through the reduced bone fragments for
temporary fixation to maintain the fragments in the aligned
position. The clamps and wires of the temporary fixation can
b be removed once stable fixation of the fragments in the circu-
lar/hybrid external fixation frame has been achieved.
During the conversion from the unilateral tubular external
fixation frame to the circular Ilizarov external fixation device,
it is important to preserve the good bone fragment reduction
achieved during primary skeletal stabilization. For this pur-
pose we recommend the following conversion technique:
The tube of the double unilateral tubular frame that is more
distant from the limb must be moved even further towards
the outer ends of the half-pins and then firmly reattached.
Then, the tube nearer the injured limb segment can be
removed. These two steps provide adequate space for mount-
ing a circular external fixation frame around the still fixed
Fig. 14.14 (a, b) An Ilizarov large-ring external fixator is used to sta- segment, preserving the previously achieved alignment of
bilize an open high-energy fracture with extensive soft-tissue damage the bone fragments. The Shanz screws of the primary tubular
external fixator are then firmly attached to the Ilizarov circu-
planned (plastic coverage procedures), this distance should lar frame by fixing them to the corresponding rings.
be increased, especially on the posterior surface of the fixed Additional thin wires and half-pins are introduced into the
injured segment. High-energy injuries are frequently associ- main bone fragments and included in the fixation frame.
ated with severe post-traumatic swelling of the injured limb. Then, while the stability of the fracture fixation is main-
This dictates the need to use rings with a diameter larger than tained, the remaining tube of the primary unilateral fixation
that usually recommended for the assembly of a circular frame is removed (Fig. 14.15). Following this sequence
frame in standard situations (Fig. 14.14). However, increas- reduces both the hazard of secondary fracture displacement
ing the ring diameter reduces the frame’s stability (Chaps. 2 during conversion and additional trauma to the soft tissues,
and 3). To improve the rigidity of the fracture fixation, we while shortening the operative procedure and minimizing
recommend installing additional stabilizing elements in the both the patient’s and the surgical staff’s intra-operative
frame and increasing the distance between the levels at which radiation exposure. Moreover, part of this procedure (mount-
the half-pins and thin wires are inserted into the bone frag- ing the Ilizarov frame using the available half-pins of the
ments. Moreover, single-plane orientation of the stabilizing primary fixation device) can be performed directly on the
Fig. 14.15 Conversion from a unilateral to a circular external fixation

device. (a) External unilateral fixation of a high-energy tibial fracture;
(b) conversion to the Ilizarov device with an additional foot ring to cor-
rect an equinus ankle deformity
Fig. 14.16 Fixation of bilateral femoral fractures using hybrid exter-
hospital ward and without anesthesia. This considerably nal fixation frames
reduces demand on the operation room, which can be impor-
tant in mass casualty situations such as war-related conflicts, as proximal tibial fractures. The circular part of the hybrid
natural catastrophes, and industrial accidents. device is placed above the metaphyseal zone, and the unilat-
eral part above the diaphyseal zone (Fig. 14.16).
These standard hybrid frames, with one ring or a 5/8 ring
14.3.2 Hybrid External Fixation Devices above the metaphyseal zone, have a low rate of reposition-
ing. This is advantageous because elimination of a secondary
The simultaneous use of components from different external displacement or the continued correction of the bone frag-
fixation (unilateral and circular) systems provides various ments’ position requires additional anesthesia and repeated
options for external stabilization, exploiting the relative manipulation of the injury in the operation room. The inclu-
advantages of each type of external frame. The merits of uni- sion of an additional ring improves the repositioning capa-
lateral external fixation devices include the simplicity of bilities of the hybrid external frame (Fig. 14.17). Threaded
their design and their ease of use, their provision of sufficient rods, located between these two rings, will allow, if neces-
access to the soft tissues of the injured limb segment, and the sary, bone lengthening by distractional osteogenesis, while
reduced inconvenience to the patient, especially in the threaded rods with hinges facilitate the repair of angular
fixation of proximal femoral and humeral fractures. Circular deformities, should they arise.
external fixators, on the other hand, provide reliable fixation,
are suitable for full weight-bearing, and allow ongoing cor-
rection throughout the external fixation period as well as the 14.4 The Ilizarov Device as a Basic Frame
reconstruction of large bone defects according to the Ilizarov
method. In a stage-by-stage treatment strategy, the conversion from a
The use of hybrid external fixation frames expedites the simple monolateral device to a circular one is not always
fixation not only of diaphyseal but also of intra- and para- necessary; rather, in some cases the Ilizarov device can be
articular distal femoral, tibial, and humeral fractures, as well used for primary stabilization aimed at achieving damage
Fig. 14.17 Various a

configurations of hybrid external b
fixation devices. (a) The standard
configuration has only fixation
properties. (b) The two-ring
frame allows dynamic influence
of the fracture site
control. Unlike the installation of a monolateral frame, this It should be emphasized that these frame assemblies are
variant of osteosynthesis should be performed by a specialist suitable only for patients with Gustilo 1 and Gustilo 2 dam-
skilled in the Ilizarov technique. However, it is important age and for those with (multiple) closed fractures. In other
that the same surgeon be involved directly throughout treat- cases, i.e., significant damage of the soft-tissue cover, the
ment of the patient. initial configuration should provide stable fixation of the
The frame is originally mounted according to a mini- bone fragments.
mum fixing scheme, based on only two supports, each of If external fixation is to be later converted to nailing, wires
which is fixed using one or two transosseous elements and half-pins are inserted such that they will not block the
(Fig. 14.18). Further information on the fixing variants of insertion of the nai (Chap. 26). Accordingly, in a femoral
the Ilizarov device configurations is provided in Chaps. 10, osteosynthesis it is expedient to use extracortical clamp
11, 12, and 13. devices (Table 1.2, Chaps. 12.5 and 26).
After the device has been installed, moderate distraction During the primary operation, final bone fragment reduc-
should be applied to increase the rigidity of the osteosynthe- tion and stabilization using the Ilizarov apparatus can be car-
sis and reduce the pressure exerted by the ends of the dis- ried out as long as the patient’s condition allows (damage
placed bone fragments on the soft tissues. In this context, the control) and the necessary organizational facilities are avail-
fixation device is simple, convenient, and allows quick and able, i.e., a qualified team and the required time in the operat-
effective primary stabilization of the fracture. Later, once the ing room. The operation starts with the installation of the
patient’s condition has improved, final reduction of the dis- basic supports. In injuries to the proximal or distal bone seg-
placed bone fragments and their stable fixation are carried ments, the basic supports are mounted only on the longer
out. This requires changing the primary configuration of the bone fragment. If the fixation of a joint is contemplated, the
device by the inclusion of reductionally fixing supports and transosseous module is superimposed onto the adjacent seg-
transosseous elements. ment. The exit sites of the transosseous elements are covered
In addition to the above variant, a pre-assembled standard with a sterile drape and/or bandage.
three- or four-ring device with one or two reductionally Using the basic supports as “bone-holders,” the length
fixing rings can be used. Thus, at the first stage (during dam- and axis of the segment are restored without the reposition-
age control) only basic transosseous elements are inserted. ing or fixation of the bone fragments. This is necessary in
This method of frame installation facilitates the final reduc- order to determine the repair potential of the damaged major
tion and fixation of the bone fragments. For this purpose it is vessels (if not, the defect should be replaced with an autolo-
sufficient to insert only the reductionally fixing transosseous gous vein graft), nerves, muscles and tendons, with
elements. simultaneous preservation of the anatomic length of the
segment. If repair is possible, then the next stage involves If arterial injury has led to non-compensated ischemia of
restoration of the damaged soft-tissue structure. During this the extremity, the main blood flow should first be restored.
stage of surgery, the basic supports are temporarily con- Then, in compliance with the biomechanical require-
nected to two telescopic rods, and/or the main bone fragments of the external fixation, the intermediate reduction-
ments are connected with the aid of diafixation using ally fixing supports are installed, with the number determined
wires. as needed. Under visual control, the main bone fragments
Fig. 14.18 (a–d) “Fixing”

configurations of the Ilizarov
device in shaft fractures. Note
that the support and telescopic
rods are connected with the aid of
plates. This trick facilitates
subsequent installation of the
reductionally fixing supports
These frame assemblies should
be used only in patients with
Gustilo 1 and Gustilo 2 damage
and for those with (multiple)
closed fractures

c
I,5-11 VII,3-9 (a)

I,4-10 VIII,6-12(VIII,6-12) (b)
I,8,90; II,11,90 VII,3-9; VII,2-8 (c)
I,8-2; I,4-10 (VIII,8-2)VIII,8-2; VIII,4-10 (d)
and splinters are repositioned and then stabilized in the and secures the skin without tension. The combination of
device by insertion of the reductionally fixing transosseous fixation of the adjacent joint in the desired position and ren-
elements. In splinter fixation, besides conventional wires dering the fragments in an atypical position will reduce the
console wires with a stop can be used. degree of deformity of the damaged segment.
As discussed above, the levels and positions available for When, during debridement, bone defects occur in a seg-
the insertion of transosseous elements are limited in com- ment, the assembly of the transosseous device must provide
pound fractures. Therefore, in addition to the reference posi- for the possibility of restoring the lost tissue. In such cases,
tions, safe positions, which avoid damage only to the main monolocal and bilocal methods of external fixation can be
vessels and nerves, may be used more widely. Furthermore, used [228, 229]. During debridement, the ends of the frag-
to provide freedom of movement in the joints, some tran- ments must be processed for their adaptation, if need be.
sosseous elements are best removed and replaced by new In monolocal distraction osteosynthesis, the proximal and
ones inserted according to the reference positions. distal bone fragments are simultaneously approximated until
In a number of cases, in order to restore the soft-tissue they are in close contact. Within 14–18 days, the bone fragments
structure without tension, including on vessels and nerves, the are gradually separated at a mean rate of 0.25 mm three or four
adjacent joint should be placed in a position that can be main- times a day until the segment length is restored (Fig. 14.19b, c).
tained during the postoperative period and will allow for the If the fibula hinders the approximation of the femoral fragments,
later removal of the soft tissues, for example with the lower fibular osteotomy or segment removal is warranted. In the fore-
leg bent. This can be achieved by installing a transosseous arm, the monolocal method of distraction osteosynthesis can be
module in the adjacent segment based on one or two external used only if the two bones show similar defects.
supports. This module, installed with the aid of hinges in In some cases, simultaneous approximation of the main
compliance with the rotational axis of the knee or ankle joint, bone fragments is not possible. This is particularly likely if
is connected with the basic device fixing the bone fragments there is evident crimping of the soft tissues, resulting in
(Chap. 23). After the vessels and nerves have been repaired trophic disorders and hindering wound suturing. In these
under microscopic control, the joint is gradually moved to the cases, monolocal successive compression-distraction osteo-
zero position. The hinges are stabilized after slight tensioning synthesis is used. The bone fragments are gradually approxi-
or “straightening” has been achieved [227]. Between days 14 mated after the skin wound has healed. However, the rate of
and 21, graded movement is started in the joint in the direc- approximation is limited by the neurotrophic disorder and
tion that will cause tensioning of the sutured soft-tissue struc- usually does not exceed 3–5 mm/day in four to six sessions.
tures. The distraction force applied with the aid of the swivel After the bone fragments have been approximated, they are
hinged section is selected such that vessel and nerve stretch- compressed axially or laterally depending on the plane of the
ing does not exceed 0.75–1 mm/day (3–4 times × 0.25 mm). bone wound. Within 14–18 days, the bone fragments are
Later, the hinge subsystem is used, when necessary, for the gradually separated at a mean rate 0.25 mm two or three times
passive-active development of movement in the joint. a day until the segment length is restored (Fig. 14.19a–c).
The above procedure generally enables the repair of dam- If by the end of the distraction period there are signs of
aged soft tissues, providing the defect is less than 50–55 mm. soft-tissue tension that can be attributed to the tension caused
If modeling of both the length and segment axis restoration by the transosseous elements fixed in the reductionally fixing
indicates that the diastasis will remain or considerable ten- supports, those elements should be replaced. For example, in
sion on the damaged soft tissues is required, or if there is Fig. 14.19, half-pin V,8,90 is replaced with wire VI,9-3.
wide segmented damage to the vessels and nerves (NV4) In the case of a marginal, triangularly shaped defect, the seg-
without the possibility of plastic repair of the defect, the ment is given an angular deformity until the fragment wound
above-discussed method of acute shortening (translation, surfaces are in contact. The transosseous modules fixing each
angulation, torsion) can be used. Initially, the bone fragments bone fragment are connected with two axial and one swivel
are repositioned and stabilized in the device supports. The hinge. On postoperative day 7–10, gradual distraction is started
positions of the external supports and transosseous elements in order to form a triangular regenerate. For simultaneous elon-
by which repositioning was achieved are documented in the gation, a trapezoidal regenerate is formed. Further details on the
medical records and photographically. The fragments are formation of wedge-shaped distraction regenerates are pre-
then given an “atypical” position to allow suturing of the soft sented in the sections of this book dedicated to traumatic defor-
tissues without tension. The possibility that a trophic disor- mities and the transosseous osteosynthesis of pseudoarthroses.
der will ensue as a result of crimping or excessive bending of If the bone needs to be moved a greater distance, then dur-
the major vessels should be borne in mind. The modules of ing the debridement an axial wire or flexible pulls should be
the proximal and distal bone fragments are stabilized in the inserted (Chap. 19). When the relocating support has reached
newly achieved position. This technique enables either suture its limit of movement, the transosseous elements fixed in it
repair or plastic repair of the damaged soft-tissue structures are removed. Further relocation of the fragment is performed
a b c
Fig. 14.19 (a–c) Examples of open monofocal distraction (b, c) and alternating compression-distraction (a → b → c) for external fixation in the
treatment of a segmental defect of the femur
with the axial wire (or flexible pulls). Traction-guiding wires injuries are usually associated with massive soft-tissue dam-
are inserted immediately prior to the removal of the tran- age as well as ligament and capsular tears [232]. Reliable sta-
sosseous elements of the intermediate support. The magni- bilization of the bone fragments using hinged external fixation
tude of the traction to be applied to the traction-guiding wires frames that enable simultaneous early motion optimizes the
to enable linear relocation of the intermediate bone fragment functional outcome of these complex injuries. Generally, the
by 1 mm is determined by calculations based on radiographic stabilization of open articular fractures is carried out accord-
information [9, 25, 230]. ing to the principles stated in Chaps. 2, 7, 10, 11, 12, and 13.
More detailed information on bilocal compression-dis- The joint’s stability should be examined during the final
traction osteosynthesis is presented in Chap. 19. stage of the fracture fixation procedure. If articular instabil-
Figure 14.20 shows an example of tibial bone defect replace- ity is noted, the external fixation frames from the different
ment after an open (Gustilo 3b) fracture of the right lower leg. sites of the joint should be connected using axial hinges.
When the bone fragments are covered by muscles but The specific features of articular hinge installation for the
there is an extensive skin defect, the method of choice is that different joints are described in Chap. 23. Improper setting
of Ilizarov, which involves replacing the skin of the defect. of the hinges and discrepancies with the rotational axis of the
At each wound margin, a Kirschner wire is inserted and then fixed joint will result in displacing forces during movements,
fixed with pulling and distraction clamps to the device sup- causing damage to the cartilage, articular capsule, and liga-
ports (Fig. 14.21). In the postoperative period, the wound mentary complex as well as secondary bone fragment dis-
margins are gradually approximated (0.25 mm × 3–4 times a placement and even subluxation of the fixed joint.
day) until they can be stitched together. The setting procedure at the axial hinge should start from
one side of the injured joint (internal or external), without
firm attachment of the hinge to the corresponding proximal
14.4.1 Special Features of the Ilizarov and distal rings of the external device. If control movements
Circular Device in the Treatment at the joint result in hinge displacement, then the location of
of Open Peri-articular Fractures the hinge must be changed, moving it to the next set of aper-
tures on the rings, with this dynamic test then repeated. Only
Severe trauma to the major joints, especially the knee and after the hinge is firmly fixed to the corresponding proximal
elbow, is common in combat injuries [231]. These high-energy and distal rings is the same procedure repeated on the
Fig. 14.20 (a–h) Acute shortening

a b
in the treatment of a tibial and
soft-tissue defect. (a) Initial
radiological image. (b) Initial view
of the lower leg. (c) After
debridement, external fixation and
acute shortening
c
d e
f g
Fig. 14.20 (continued) (d) A corticotomy was performed on day 12. (e) 6 cm lengthening. (f) During the fixation period. (g) The index of
fixation was 35 days/cm.
Fig. 14.20 (continued) (h) Two h

weeks after frame removal
Fig. 14.21 Ilizarov method in the

replacement of a skin defect. (a) The
surgical strategy
Fig. 14.21 (continued) (b) S.I. Swed’s clinical images
opposite side of the trans-fixed joint. The use of either radi- sive damage to peri-articular soft-tissues, including the
ography with contrast labels or intra-operative fluoroscopy articular capsule and ligamentary complex, dictate a delay
facilitates this technically demanding procedure. in the early mobilization of the injured join. Restoration of
Articular distraction resulting in a diastasis of 2–4 mm is the maximal possible range of movement following com-
needed to prevent the articular surfaces from damaging plex intra- and peri-articular fractures requires significant
each other by axial compression of the bone fragments. effort and time, both during the external fixation period and
Stable fixation in the device with correctly located axial after removal of the device. Trans-fixation of the soft tis-
hinges allows early active and passive movements in the sues in the external fixation frame leads to some restriction
joint, providing partial axial loading on the damaged limb. of movement in the adjacent joints, which will remain until
The range of these early active and passive movements the transfixing elements (thin wires and half-pins) are
exercises is as tolerated, avoiding pain. Sometimes, exten- removed (Fig. 14.22).
Fig. 14.22 Use of the Ilizarov

a b
frame in the treatment of a
comminuted humeral fracture
caused by a gunshot. (a, b) X-ray
images obtained during the
period of external fixation show
significantly restricted elbow-
joint flexion. Intensive physio-
therapy was started during
fixation and continued after
removal of the Ilizarov frame,
(c, d) Six months after the
removal of the circular external
fixation frame the patient has
achieved full range of movement
of the elbow
d
c
wires and/or wires with stops, “half-pin pullers,” and “half-

14.5 Universal Reduction Units pins pushers” is a classic approach in external fixation and,
owing to its high efficacy, frequently employed for fracture
Bone fragment reduction based on the use of “basic” and repositioning.
“reductionally fixing” supports and transosseous elements The methods used to change the spatial orientation of bone
was discussed in previous chapters. Changes in the spatial fragments by moving the transosseous modules are described
location of the bone fragments in these settings are achieved in detail in Chaps. 2.2.1 and 16 (Figs. 2.4, 2.5, 2.6, 2.7, 2.8, and
by moving only the transosseous elements that fix the bone 2.9). An orthopedic surgeon should stably fix the proximal and
fragments; the external supports and the device modules distal bone fragments. The proximal and distal transosseous
remain immobile (Chaps. 1.5 and 2.2.2). The use of bent modules are then connected with the aid of a unified reduction
a b
Fig. 14.23 External fixation devices with universal reduction units. (a) The Oganesyan device and (b) the Matsukidis-Shevtsov device
unit appropriate for the elimination of a transverse translation, Ortho-SUV Frame (Chap. 17), solve this problem at a qualitative
angle translation, or torsion translation. Multi-component level. Figure 14.24 shows the use of the Ortho-SUV Frame in
displacement reduction units should be replaced. This the treatment of a patient with a complex atypical position of
method is difficult and demands an experienced specialist for the bone fragments.
its execution. For this reason we recommend that, at least
initially, fractures, including open fractures, should be treated Conclusion
with reduction and fixation “inside a frame” (Chap. 2.2.2). The severe general condition of the patient with a com-
However, the configuration of a reduction device based on plex high-energy injury often results in extensive tissue
mutual displacement of the modules (Chap. 2.2.1 and 2.8) is loss and thus a high rate of complications. In these
in most cases less bulky. Moreover, this approach to bone patients, an early multi-surgery approach cannot be rec-
fragment reduction is advantageous in acute shortening, onciled with the basic principles of damage control.
acute angulation, acute rotation, and the combination Instead, a staged treatment protocol based on minimally
thereof. invasive methods and performed according to damage
It is possible to solve this contradiction using external control principles will enable the preservation and func-
fixation devices based on universal reduction units, for tional restoration even of limbs at risk. The Ilizarov
example the Oganesjan and Shevtsov-Matsukidis devices method provides rapid and minimally invasive stabiliza-
[233] (Fig. 14.23). The disadvantages of these frames are tion regardless of the fracture configuration. Moreover,
their limitations in achieving osteosynthesis of the proximal unlike methods of internal fracture fixation, the Ilizarov
parts of the humerus and femur and the necessity of repeated device allows, if necessary, the gradual elimination of
radiological control at all stages of the reduction. bone fragment displacement, while stabilizing the fixation
External fixation devices controlled by computer naviga- and creating the conditions for the repair of extensive
tion, so-called hexapod devices (Fig. 1.2p–r), including the bone and soft-tissue defects.
Fig. 14.24 Use of the Ortho-SUV

a
Frame in the treatment of an open
fracture of the lower leg. (a, b)
Acute rotation + angulation +
translation provide optimal
conditions for soft-tissue healing
b
Fig. 14.24 (continued) (c, d)

c
All components of the purposely
created deformity are eliminated
using the “integrated” trajectory,
omitting the need for the
stage-by-stage replacement of
Ilizarov reduction units
d
Malunited Fractures
15
When bone fragments unite in the wrong position (Figs. 15.1, fragments) installation of the device supports promotes
15.2, 15.3 and 15.4), the advantages of external fixation with “automatic” improvement of the bone fragments’ arrange-
respect to both the possibility of gradual elimination of the ment. The use of reductionally fixing transosseous elements
soft-tissue retraction and the preservation of the interfrag- (Figs. 2.10, 2.11 and 2.12) or mutual displacement of the
mentary regenerate are clear. Depending on the degree of modules fixing the bone fragments (Figs. 2.4, 2.5, 2.6, 2.7,
maturity, the mechanical stability, and the type of fragment 2.8 and 2.9) will achieve final reduction of the bone
displacement, various frame configurations and rates of fragments.
repositioning are applied. If the fracture occurred 4–6 weeks previously (2–3 weeks
If no more than 2 or 3 weeks has passed from the time of for metaphyseal fractures), the bone fragments have usually
fracture (about 7–10 days for metaphyseal and metadiaphy- already united and the soft tissues have retracted. The tasks
seal fractures), and one-stage repositioning is complicated of external fixation in this case are: (a) repositioning of the
by muscle retraction, then accelerated repositioning using an bone fragments by transformation of the interfragmental
external fixation technique is indicated. The operation is con- regenerate by distraction and (b) the prevention of neu-
veniently carried out under conditions of skeletal traction on rotrophic impingement, which can occur during accelerated
an orthopedic table. The device configurations are similar to reduction.
those recommended for emergency fractures at the same Frame configurations are similar to those recommended
location. Reductionally fixing wires are fixed to the external for fractures in the emergency setting (Chaps. 10, 11, 12, and
support not with traction clips but with bolts. Half-pins can 13). However, during the first stage, as a rule, only basic tran-
be used to eliminate the residual displacement of bone frag- sosseous elements are inserted.
ments by pushing or pulling. In stable angular bone fragment deformity, the basic sup-
It must be kept in mind that one-stage forced traction can ports of the conventional Ilizarov assembly should not be
cause neurotrophic problems and the formation of contrac- placed perpendicular to the anatomic axis of the bone frag-
tures. Therefore, the distraction force is applied on the oper- ment, rather with 5–7° of hypercorrection. A basic wire sup-
ating table only within the limits of the moderate elastic port allows the connection of modules that fix both bone
tension of the soft tissues. Thus, the longitudinal displace- fragments using threaded rods, due to elastic deformation of
ment of fragments is usually eliminated by no more than the wires. It is necessary to consider that the use of pins in
10–15 mm in one stage, and angular deformity by no more the basic support allows the connection of transosseous mod-
than 25–35°. All other types of residual displacement should ules, fixing the proximal and distal bone fragments with the
be eliminated gradually. use of hinges (Chap. 16).
Distraction is started at 3–5 days to provide movement of Reduction by mutual movements of the intermediate
1.5–2 mm a day six to eight times. Indications to reduce the (reductionally fixing) support and the modules fixing each
amount of movement and increase the frequency are the bone fragment (Figs. 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9) can
occurrence of neurotrophic problems that result in pain syn- be used to eliminate any component of the deformity
dromes. Correct (perpendicular to the anatomic axis of the (Chap. 16). These procedures, as a rule, are complementary
to the basic approach, including the opportunities for reposi-
tioning with the help of reductionally fixing transosseous
elements (Figs. 2.10, 2.11, and 2.12).
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia In the first step, the longitudinal displacement is
e-mail: solomin.leonid@gmail.com eliminated. The rate of distraction should be, on average,
536 L.N. Solomin
b c
Fig. 15.1 (a–c) Fibular osteotomy is better performed in the distal instrument. Osteotomy is carried out with the soft tissue protected by
third because in this location it is technically simpler and less traumatic. the protector (a frame clamp) at a distance from the skin equal to the
A longitudinal anterolateral skin incision of 7–10 mm is made towards diameter of the fibula. Fibular osteotomy is achieved by two or three
the anterior surface of the fibula. A periosteal elevator is used to sepa- impacts of a hammer. This procedure avoids damage to interfragmen-
rate the soft tissue and periosteum and to introduce the osteotomy tary vessels
1.0–1.5 mm (0.25 mm four to six times a day). Usually, correction of the transverse and residual angular displace-
simultaneous with the elimination of shortening, angular ments of the fragments. Any rotational deformity is elimi-
deformity decreases as well. nated as a last step in deformity correction, after which the
Reductionally fixing transosseous elements should be diastasis between the bone fragments is eliminated.
inserted after the creation of a diastasis between the bone If more than 6–8 weeks has passed since the fracture then
fragments of up to 3–5 mm. These elements allow a gradual there is minimal mobility between the bone fragments (the
15 Malunited Fractures 537
a b c
1 2 3 4
(I,8-2)I,8-2; I,4-10 –– IV V –– (VIII,8-2)VIII,8-2; VIII,4-10 (a)
150 150 150 150
5 6
(I,8-2)I,8-2; I,4-10 –– IV,3-9 –– V,9-3 –– (VIII,8-2)VIII,8-2; VIII,4-10 (b)
150 150 150 150
7 8
II,1,120; IV,3-9 V,9-3; VII,12,70 (c)
1/2 150 1/2 150
Fig. 15.2 (a–c) External fixation devices for the fixation of malunited joints of the half-rings of the reductionally fixing supports are posi-
fractures of the tibia. Modular transformation of the device (c) is the tioned in the frontal plane
method of choice, bearing in mind that this technique requires that the
fragments have become united). In this case closed transfor- A detailed description of the use of Ilizarov hinges is pro-
mation of the regenerate requires a significant distractional vided in Chap. 16, in a discussion of the external fixation of
effort. Loosening of the callus by wire drilling or partial cor- deformities. New opportunities of deformity correction using
ticotomy can provide successful closed bone fragment reduc- computer navigation based on the Ortho-SUV Frame fixator
tion. The deformity should be corrected at a rate not exceeding are detailed in Chap. 17.
0.75 mm per day (0.25 mm three times per day). Large bone splinters are repositioned by means of wires
In these patients, a more common approach is gradual with a stop and/or bent wires. They can be inserted transcor-
repositioning of the bone fragment by mutual movement of tically or paracortically to a bone splinter. The method of can
the transosseous modules fixing each bone fragment (Figs. also be used (Fig. 2.16). When the splinter is located in an
2.4, 2.5, 2.6, 2.7, 2.8, and 2.9). For each stage of reposition- interbone space or near main vessels and nerves, a fork-
ing (elimination of longitudinal, angular, peripheral, and shaped half-pin is recommended for repositioning (Fig.
twisting displacement), a unified reductional node should be 2.17).
used. With increasing experience in the use of external After elimination of the bone fragment displacement, an
fixation, the surgeon can carry out some of the reposition- external fixation can be converted to an internal one (Sect.
ing simultaneously, using combined repositioning units. 26.3; Figs. 7.1 and 17.65).
538 L.N. Solomin
a b c
1 2
II,5-11 – IV VI – VIII,9-3 (a)
1/2150 140 140 3/4 140
1 3 4 2
II,5-11 – IV,8,90 – VI,8,90 – VIII,9-3 (b)
1/2 150 140 140 3/4 150
5 3 4 2
III,11,120; IV,8,90 VI,8,90 – VIII,9-3 (c)
140 140 3/4 140
Fig. 15.3 (a–c) Devices for the stepwise reduction of malunited humeral fractures. In patients with osteoporosis, the basic supports should have
two basic wires
15 Malunited Fractures 539
a b c
1 2 3 5 4
I,4-10; I,5,90(I,5,90); (II,9,90) – III V – (VII,10,120); (VIII,7-1) (a)
3/4 120 120 120 120
7 6
I,4-10; I,5,90(I,5,90); (II,9,90) – III V –– VII,8,120; (VII,10,120); VIII,6-12(VIII,6-12 (b)
3/4 120 120 120 120
8 9 10 11
I,4-10; I,5,90(I,5,90) – III,8,90; (IV,10,90) V,8,6,90; (V,11,90) –– VIII,6-12(VIII,6-12) (c)
3/4 120 120 120 120
Fig. 15.4 (a–c) In the treatment of malunited forearm bone fractures, shortening of the radius are shown. At each stage of reconstruction, the
restoration of the relationships of the radioulnar joint is especially method demands the insertion of additional transosseous elements and
important for the segment’s subsequent function. As an example, the the removal of wires and half-pins that have completed their task
stages of treatment of a malunited forearm bone fracture with primary
Basic Principles of External Fixation
in the Correction of Long-Bone 16
Deformities
Leonid Nikolaevich Solomin, Konstantin Igorevich Novikov,

Anna Majorovna Aranovich, Mark Eidelman,
This chapter presents the general theoretical principles images obtained during X-ray examination (Chap. 18.1) is
regarding the correction of long bone deformities and obligatory in planning the correction of long bone deformities.
describes the basis of its clinical realization for the upper and The anatomic axis of a long bone is the mid-diaphyseal
lower extremities. Information concerning basic training in line (Figs. 16.1, 16.28, and 16.74). The term “longitudinal
deformity correction is available at http://rniito.org/solomin, axis” (of a bone or bone fragment) is synonymous with the
http://www.rniito.org/download/ortho-suv-course-9-eng.pdf term “anatomic axis.”
and http://ortho-suv.org. It is necessary to take into account, that the term “axis” in
this case is conventional, as long bones are not rectilinear.
However, the physiological curvature of some of them, in a
16.1 Terminology and Classification clinical context, can be approximated to a straight line. For
other bones the anatomic axis is accepted as the curved line
Leonid Nikolaevich Solomin (Figs. 16.28, 16.74, 16.75, and 16.76). In the femur, for
example, the line is straight in the frontal plane and curved in
A deformity (in Latin “deformatio” means distortion) is a the sagittal plane (Fig. 16.28).
change in the relative positioning of the points of a solid body The mechanical axis of the bone is a straight line connect-
when as a result of external forces the distance between them ing the centers of the proximal and distal joints of the limb.
varies. Deformation is elastic if it disappears after the removal In the lower limb, the mechanical axis is a straight line con-
of these forces and plastic if it does not completely disappear. necting the centers of the hip and ankle joints (Fig. 16.1). In
This definition also applies to orthopedics. Indeed, it is easy the upper limb, it is a straight line connecting the centers of
to imagine that elastic deformation is common in fractures the humeral and ulnar heads (Fig. 16.74).
whereas plastic deformation describes non-union, malunion Joint orientation lines are drawn using special anatomic
(so-called traumatic deformities), and congenital curvatures. and radiological reference points (Figs. 16.1, 16.32, 16.33,
For each of the bones of the body, referent (basic) lines are 16.75, and 16.76). The intersection of an anatomic axis with
assigned. The angles at which these lines intersect indicate a joint orientation line yields anatomic (or “epidiaphyseal”)
whether or not a deformity is present. These standard referent angles: proximal and distal for each bone (Fig. 16.1b). The
lines are referred to as anatomic axes, mechanical axes, and intersection of a mechanical axis with a joint orientation line
joint orientation lines and all of them are drawn in the frontal forms the mechanical angle (Fig. 16.1c).
and in the sagittal planes. Therefore accurate analysis of the Note that the tops of the anatomic and mechanical angles
should be at a definite point of the joint orientation line.
L.N. Solomin, M.D., Ph.D. • P.N. Kulesh, M.D., Ph.D. These points along with the anatomic and mechanical angles
R.R. Vreden Russian Research Institute of Traumatology are specific for each bone.
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia Thus, the reference lines and angles (RLA) include: (a)
anatomic axes, (b) mechanical axes, (c) joint lines, (d) ana-
K.I. Novikov, M.D., Ph.D. • A.M. Aranovich , M.D., Ph.D. tomic angles, and (e) mechanical angles and each of these is
Department of Orthopedics, Russian Ilizarov Scientific Center
defined in the frontal and sagittal planes.
“Restorative Traumatology and Orthopedics”, M. Uljanova Str., 6,
Kurgan 640014, Russia The direction of displacement of one bone fragment relative
to another can be seen if both are viewed within a coordinate
M. Eidelman, M.D.
Technion Faculty of Medicine, Rambam Health Care Campus, system comprising three standard planes (Fig. 16.2). Therefore
Meyer’s Children Hospital, P.O.B. 9602, Haifa 31096, Israel deformities can be designated, as one-, two-, or three-plane.
Fig. 16.1 (a–c) Referent lines and angles. (a) Anatomic

axis, (b) mechanical axis, (c) proximal and distal anatomic
angles, (d) proximal and distal mechanical angles of the
femur and tibia
a b c d
Superior
Vertical
axis
e
lan
talp
git
Sa
Fro
n
pla tal
ne
Tra
n
pla svers
ne e Mediolateral
axis
Anteroposterior
axis
Pos
ter ior
t
p ec
as
al
Ant
erio ter
r La
Fig. 16.2 Standard planes
and axes Inferior
16 Basic Principles of External Fixation in the Correction of Long-Bone Deformities 543
Referent lines and angles are compared with the image of long bone deformities (Table 16.1). According to this
accepted as the standard, allow the deformity components to classification, a deformity can be one-, two-, or three-plane
be defined. Thus, the typical deformity components are: and one-, two-, three-, four-, five-, or six-component. In
1. Axial translation: limb length discrepancy (shortening or total, there are 33 types of deformities. These are divided
over-lengthening) (Fig. 16.3a) into:
2. Peripheral translation (Fig. 16.3b) Simple deformities (one plane-one component)
3. Angulation (Fig. 16.3c) Middle complex deformities (one plane-two component–
4. Rotation (torsion) (Fig. 16.3d) three plane-three component)
The standard deformity components can occur in isola- Complex deformities (two plane-four component–three
tion or be combined in standard planes in different vari- plane-six component)
ants. The standard planes and standard deformity The factors determining deformity complexity are pre-
components form the basis for the practical classification sented in Table 16.1. However, one should note that a bone
Fig. 16.3 (a–d) Deformity a b c d

components
Table 16.1 Practical classification of long bone deformities

One-plane Two-plane Three-plane
One-component Translation in one standard plane
Angulation in one standard plane
Axial translation Rotation
Two-component Axial translation + rotation Translation in two standard planes
Translation in one standard Angulation in two standard planes
plane + rotation
Angulation in one standard Translation in one standard
plane + rotation plane + angulation in one standard
plane
Angulation in one standard
plane + axial translation
Translation in one standard
plane + axial translation
(continued)

Three-component Translation in two standard Angulation in two standard planes + axial
planes + rotation translation
Angulation in two standard Translation in two standard planes + axial
planes + rotation translation
Translation in two standard Translation in one standard plane + angulation
planes + angulation in one in one standard + axial translation
standard plane
Angulation in two planes +
translation in one standard plane
Translation in one standard
plane + angulation in one standard
plane + rotation
Four-component Translation in two planes + Angulation in two standard planes + axial
angulation in one standard translation + rotation
plane + rotation
Translation in two planes + Translation in two planes + angulation in one
angulation in two planes standard plane + axial translation
Angulation in two planes + Translation in one standard plane + angulation
translation in one standard in one standard plane + axial translation + rotation
plane + rotation Angulation in two standard planes + translation
in one standard plane + axial translation
Angulation in two standard planes + axial
translation + rotation
Five-component Translation in two standard Translation in two standard planes + Angulation
planes + angulation in two in one standard plane + Axial translation + rotation
planes + rotation Translation in two standard planes + angulation
in two standard planes + axial translation
Translation in one standard plane + angulation
in one standard plane + axial translation + rotation
Six-component Translation in two standard planes + angulation
in two standard planes + axial translation + rotation
can have more than one deformity level and at each level the deformity is defined either clinically or on the basis of com-
deformity will have its own components. puter tomography images.
For angular and rotational deformities, a special term, As an example, a theoretical conventional limb (Fig. 16.4)
proposed by Dr. Nasuo Yasui (Osaka, Japan) is used: “center is used as follows: (1) The anatomic axis of each of bones coin-
of rotation of angulation” (CORA) [102]. For similar situa- cides with a mechanical one: the line drawn through the centers
tions, the Russian scientific literature uses the term “apex of of the proximal, middle, and distal joints corresponds to the
deformation.” The two terms are used synonymously in this mid-diaphyseal line of each of the bones. (2) Each epidiaphy-
book because there is no semantic difference between them seal angle (intersection of the proximal and distal joint lines
(Fig. 16.12). Thus, “apex of deformation” (CORA) is a point with an anatomic axis) is equal to 90°. Since, as noted above,
of intersection of the anatomic or mechanical axes of bone the anatomic and mechanical axes coincide, the proximal and
fragments. In the German literature, the term “Fulcrum” is distal mechanical angles of each bone also are equal to 90°.
sometimes used [234]. To determine whether a deformity is present, a line from
the center of the proximal joint up to the center of the distal
one is drawn. If this line passes through the center of the mid-
16.2 Planning the Correction of a Deformity dle (“intermediate”) joint it does not mean that a deformity is
absent. Joint lines are drawn. If the mechanical angles are
Leonid Nikolaevich Solomin normal, then angular and translation deformity components
are absent (Fig. 16.4). If any of the mechanical angles does
Note: Referent lines and angles define the presence and sizes not correspond to the expected size (Fig. 16.5), then a careful
of only two deformity components: angulation and transla- analysis of the potential deformity is warranted in order to
tion. Length discrepancy can be determined by comparative reveal its components and characteristics. In addition, at the
measurement with another limb. The torsion component of a same stage, middle joint dislocation should be determined.
Fig. 16.4 “Conventional” limb: the anatomic and Fig. 16.6 Defining the apex
mechanical axes coincide; the proximal and distal of deformation (CORA) at
epidiaphyseal and mechanical angles are equal to 90° the diaphysial part of the
bone. The anatomic angles
correspond to the normal
values
In those bones in which the anatomic and mechanical axes

do not coincide, theoretically, it does not matter which of
them is used to define the apex of deformation (CORA).
However, in some cases the proper identification of the
mechanical axis of a bone fragment is impossible; for exam-
ple, when on the X-ray image the joint part of a bone is not
seen or if there is a torsion component of the deformity
(Fig. 16.34). Therefore in the absence of sufficient experi-
ence in deformity correction, the CORA definition is preferred
based on the anatomic axis of each bone fragment. A mechan-
ical axis is used for purposes of confirmation, as a criterion of
the accuracy of deformity correction. The two methods of
deformity correction planning (using the anatomic or mechan-
ical axes) are not contradictory but supplement each other.
The stages of deformity correction planning are as
follows:
1. Drawing the anatomic axis (anatomic axes of each bone
fragment)
2. Drawing the proximal and distal joint lines
3. Comparing proximal and distal anatomic angles with the
normal values
4. Choosing an osteotomy level
5. Modeling of the deformity correction
6. Drawing the mechanical axis
7. Comparing the mechanical angles with the normal values
Similar stages are carried out for both the frontal and the
sagittal plane.
It is possible to determine whether the apex of deforma-
Fig. 16.5 The mechanical axis passes tion (CORA) involves the shaft part (diaphysis) of the
through the centers of the joints, but
bone already at stage 1 (anatomic axis drawing). Defining
the middle and distal mechanical angles
do not correspond to the accepted norm the diaphysial deformity is not usually problematic
of 90° (Fig. 16.6).
a b c d
Fig. 16.7 Defining a CORA located in close proximity to a joint. (a) located at the level of the bone metaphysis. (c) The apex of deformation
The point at which the anatomic axis and a joint line normally intersect. is at the level of the joint line. (d) CORA is located at a more proximal
Here, since the anatomic and mechanical axes coincide, this point will distance (i.e., higher) along the joint line
be located at the center of the joint line. (b) The apex of deformation is
a b c
Fig. 16.8 (a) The deformity level coincides with the joint line. If Displacement of the osteotomy to a more distal level provides sufficient
osteotomy is performed close to a joint, the external fixation module rigidity of bone fragment fixation (c)
will not provide sufficient rigidity of fixation for this bone fragment (b).
To define epiphysial, metaphysial and metadiaphysial place this level at the deformity apex (CORA). However, in
deformities, it is necessary to use the joint lines. First, a joint some cases it is irrational, e.g., when there is an osteomy-
line of the proximal joint is drawn, after which a point where elitic cavity or a foreign body, including a bone fixator or
the joint line should be crossed by the mid-diaphyseal line is endoprosthesis shaft, and in others it is impossible, e.g.,
identified (Fig. 16.7a). If the anatomic axis intersects a joint when the apex of deformation is located at an epiphysis level
line at this point at the proper angle, then there is no defor- or even at a joint line (Fig. 16.7c, d). In these cases, the length
mity at this level (Fig. 16.6). If the anatomic axis intersects a of a bone fragment between the joint line and osteotomy
joint line at a different point and (or) at the wrong angle, then level should be determined on the basis of the rules of frame
the following steps are taken: From the specified point of a assembly; that is, the number of transosseous elements and
joint line, a line at a right angle is drawn. This line will be the the distance between them should provide rigid fixation of
anatomic axis of the proximal bone fragment. The CORA the bone fragment (Fig. 16.8). If rigid bone fragment fixation
will be found at the intersection of the anatomic axis of both is not possible, for example, due to osteoporosis, the adjacent
bone fragments (Fig. 16.7b–d). joint should be fixed.
Similarly, one should determine whether there is a defor- One should note that, in angular deformities, the greater
mity involving the distal part of a bone. the distance between the CORA and osteotomy levels, the
The next stage in the planning of a deformity correction is greater the value of translation needed to restore the bone
the choice of osteotomy level. It is generally advisable to axis (Fig. 16.13).
At this point in deformity correction planning, the skia- The external fixation frame for lengthening must consist
gram (bone contour) is prepared and then used in the model- of two transosseous modules fixing each bone fragment and
ing of the deformity correction. The skiagram should be on a connected by threaded rods. Any type of devices (Table 1.1)
1:1 scale with the roentgenogram. can be used. However monolateral and sectorial devices pose
The final stage is drawing the mechanical axis and estimating a higher risk of secondary displacement of bone fragments
all mechanical angles. If they correspond to the expected values, and of deformation of the distraction regenerate than is the
preoperative planning has been done successfully. It should be case with circular and semicircular frames (Fig. 2.3a–d).
noted that if one of the deformity components is torsion, after its As a rule, corticotomy with osteoclasis (Chap. 1.11) for
correction, all stages of planning should be repeated. lengthening is carried out outside the zone of the former
Nowadays special software is available to virtually exe- fracture. However, one should bear in mind that the closer
cute all of the planning stages [16, 235]. The software for the the osteotomy is to the joint, the greater the danger of con-
Ortho-SUV Frame also allows virtual modeling of the defor- tracture development in that joint.
mity correction (Chap. 17). The extent of the immediate lengthening, with the intro-
duction into the gap of plastic materials (grafting), is limited
by the danger of inducing a neurotrophic disturbance and joint
16.3 The General Principles of Deformity stiffness. In the lengthening of the long bones of the upper
Correction limb, a gap of up to 2–3 cm can be made immediately. In the
lower limb, maximal immediate lengthening is 3–4 cm.
Leonid Nikolaevich Solomin Another approach to eliminating a limb length discrep-
ancy (LLD) is shortening of the intact extremity. The estab-
Elimination of the deformity should be preceded by treat- lishment prior to the operation of good function in the
ment aimed at the restoration (improvement) of the functions extremity shortened because of trauma guarantees that the
of the joints adjacent to the segment. This aspect is discussed approach to the muscle attachment points on the sound leg
in Chap. 22, on the treatment of contractures. will ensure good function in terms of support and movement
Deformities can be corrected either immediately or grad- after shortening.
ually over time. However, simultaneous correction of all the In limbs of equal length, immediate shortening can be
components of a deformity has several disadvantages and executed as a component of the operation, for example, in
restrictions, discussed later in this chapter. spastic contractures. We are unaware of any research indicat-
Generally the surgical procedure for deformity correction ing the magnitude of shortening that can result in growth
is as follows (Fig. 7.34): reduction.
1. Installation of the transosseous module on the proximal
bone fragment
2. Installation of the transosseous module on the distal bone 16.3.2 Peripheral Translation Correction
fragment
3. Connection of the modules using a reduction subsystem: The amount of mechanical axis deviation at translation does
either uniform (Figs. 2.3, 2.4, 2.5, 2.6, 2.7 and 2.8) or not depend on the level of the deformity.
universal (Fig. 1.2p–r, Chap. 17) The units used in the gradual correction of a translation
4. Temporary separation of the modules are shown in Figs. 2.4b, 2.5, and 2.6. If the condition of the
5. Osteotomy (corticotomy and osteoclasia) soft tissues allows, a peripheral translation correction can be
6. Connection of the transoseous modules done immediately (Fig. 2.4a).
In immediate deformity correction, the transosseous mod- There are practical situations in which it is impossible
ules are, as a rule, connected by straight threaded rods. to perform an osteotomy at “the level of the deformity
It important to note that elongation of the great vessels apex,” e.g., due to the presence of an osteomyelitic cavity
and nerves, which are in a state of retraction and/or surrounded or foreign body or because of pronounced scarring. In such
by scar tissue, by more than 8–10 mm in one step is danger- cases, the osteotomy can be performed in the intact zone,
ous as it carries the risk of neurotrophic disturbance. thereby restoring the mechanical axis of the extremity
The principles underlying the correction of each of the (Fig. 16.9).
deformity components are discussed below. As long as the translation can be seen in both the frontal
and sagittal planes, each of these deformity components can
be eliminated. The variant in which the reduction unit is
16.3.1 Correction of Axial Translation: installed in the true plane of the deformity is also possible.
Shortening or Lengthening Further details concerning the oblique plane of deformity
correction are provided in Sect. 16.3.3.
Two conditions are considered here: a shortened and an abnor- Practically, the combination of peripheral translation and
mally lengthened limb. The first variant is more frequent. shortening are more frequent. There are two independent
a b
b c
Fig. 16.10 (a–c) Consecutive correction of a two-component deformity
a b
Fig. 16.9 (a, b) Variant of the correction of a peripheral translation
deformity
variants to remove this kind of deformity. In the first, a seg-

ment is lengthened along the anatomic axis of the proximal
bone fragment, and then the peripheral translation is elimi-
nated (Fig. 16.10). In the second, the fragments are moved
along a trajectory allowing the correction of all deformity
components in one stage (Fig. 16.11). The first variant is car-
ried out using classical “Ilizarov hinges”, and the second
using computer-navigation-assisted devices (Chap. 17).
16.3.3 Correction of Angular Deformities
This is one of the most complicated types of deformity cor-

rection from the point of view of the specific features of the
external device assembly. Frequently, the angular deformity
component is combined with peripheral translation, i.e.,
shortening.
Figure 16.12 illustrates the principles underlying angular
deformity correction. The bisector, formed by the axes of the
proximal and distal bone fragments, is a basic element in
planning a deformity correction in which one of the compo-
nents is angulation.
The extent of the mechanical axis deviation in angular
deformities, unlike in peripheral translation displacement, Fig. 16.11 (a, b) “One-stage” correction of a two-component deformity
a b c
Fig. 16.12 The deformity apex (CORA) is located at the intersection of deformation will be at some distance from the contact zone of the
of the anatomic (or mechanical) axes of the proximal and distal frag- basic fragments. This is often the case when the bisector is formed by
ments (a). If, as well as angular displacement, the fragments have fused the axes of the fragments
in a position of translation (b) or translation and shortening (c), the apex
depends on the level. The higher (more proximal) the apex of 5-mm incision from the projecting side of the curvature using
deformation, the greater the deviation of the mechanical axis. a narrow corticotome. Each passage of the osteotome through
An angular deformity can be eliminated either immedi- the cortical plate is finished by “kneading” movements
ately or gradually over time. By convention, angle deformi- (upwards–downwards) of the osteotome. Then, using assem-
ties up to 30–35° can be considered for immediate axis bled external supports, flexion or rotational osteoclasis of the
restoration. To determine the maximum increase in length remaining cortical plate is performed. In the presence of
that can be achieved in one step after removal of the angu- osteosclerosis or deformities exceeding 15–20°, this method
lar deformity, the skiagram or a special type of calculation of osteotomy is not always appropriate; instead, removal of a
is used to prevent neurotrophic disturbance as a complica- wedge of bone is preferred (Fig. 16.12a). When there are
tion [102]. To correct larger deformities in one step, it is great vessels and nerves, or scars, which can change the
necessary to reposition the adjacent joints while decreasing topography of the soft tissues in the osteotomy level projec-
the tension on the great vessels and nerves. tion, this stage of the operation is performed under visual
The operation should be started by mounting the tran- control. After one-stage restoration of the bone axis, the
sosseous modules above and below the deformity apex. The modules of each bone fragment are connected by half-pins
modules are assembled using preoperative planning on the and a compressive force is applied.
basis of the principles of frame construction (Chap. 7). If, for some reason, osteotomy was executed not at the
Assemblies recommended for the external fixation of frac- apex of deformation, then in order to immediately restore the
tures can be used as the starting point. Variants of the frame anatomic and mechanical axes additional peripheral transla-
assemblies are presented elsewhere in this chapter (Chaps. tion of the fragment should be done (Fig. 16.13).
16.5 and 16.6). The external fixation device can include one In the immediate correction of an angular deformity,
or two external supports in each transosseous module. In instead of the removal of a wedge-shaped piece of bone
order to place external supports perpendicular to the longitu- (Fig. 16.14a) a hinge osteotomy (Fig. 16.14b, c) can be per-
dinal axis of the bone fragment, corresponding control radio- formed. Inappropriate approaches to the hinge osteotomy are
graphs with labels are obtained. shown in Fig. 16.15a–c.
In the immediate correction of an angular deformity, the If significant shortening of the segment remains after the
adjacent and lateral cortical plates are destroyed through a immediate removal of the angular deformity, distraction is
a b c d Within 5–7 days, gradual discrete distraction is started,

using the swivel hinge such that the distance between the
opening of the cortical plates on the concave side of the bone
is increased by 0.25 mm four times a day, on average. It is
important to ensure that the degree of separation of the corti-
cal plates does not correspond to the displacement of each
rod of the swivel hinge in the external supports (Fig. 16.18).
If after removal of the angular deformity shortening of the
segment remains, the hinges are replaced by connecting rods.
If there is excessive tension, the soft tissue around the exit sites
of the basic supports inserted in the immediate vicinity of the
osteotomy level is cut and the basic supports are removed.
Distraction is performed such that the length is increased at the
rate of 0.25 mm four times a day, on average, to eliminate the
inequality in the lengths of the extremities. Next, the reduc-
tionally fixing transosseous elements are placed again to cor-
rect the position and stabilize the bone fragments. This method
for the correction of complicated deformities (angular or
shortening) is the first step in the formation of a triangular
regenerate. With even distraction, this regenerate is eventually
transformed into one with a trapezoidal shape (Fig. 16.19).
The variant of simultaneous correction of an angular defor-
mity and shortening is shown in Fig. 16.20.
If osteotomy was not executed at the level of the defor-
mity apex (CORA), the main rule of axial hinge assembly
must be followed. The axial hinges are installed in any plane
Fig. 16.13 (a–c) Osteotomy at the level of the deformity apex (CORA) of the deformity bisector. The bone at a similar approach of
makes additional peripheral translation of the bone fragment redundant correction acquires a “crankshaft” form. The size of the bend
(b). To restore the axis when the osteotomy is performed outside the depends on the distance of the osteotomy level from the apex
apex of the angular deformity, additional peripheral translation is needed.
The greater the extent of the angular deformity and the further the osteot-
of deformation (Fig. 16.21).
omy is performed from its apex, the greater the magnitude of the periph- If the axis of rotation of the axial hinges is not aligned
eral translation required to restore the mechanical and anatomic axes (c, with the line bisecting the angle of the deformity, lateral dis-
d). Therefore, the use of this approach to reconstruction is limited by the placement of the bone fragments (translation) will result
extent of the correction required, which should not involve fragment dis-
placement by more than one-third to one-half of the bone diameter
(Fig. 16.22a, b). The more the hinge is displaced relative to
the bisector of the angle, the greater the peripheral displace-
ment of the fragments.
If the angular deformity is not confined to the frontal
started after 5–7 days, with a lengthening of 0.25 mm three or sagittal planes, i.e., it is visible both in A-P and lateral
or four times a day until the inequality in the length of the views, two variants of deformity correction are possible: (1)
extremities is eliminated. Consecutive two-stage elimination of each component of
In the gradual removal of an angular deformity by regen- the deformity, first in the frontal plane, and then in the sag-
erate formation, external fixation is also started with the ittal plane (or vice versa). In this case, hinges to eliminate
assembly of the transosseous modules above and below the a deformity in the frontal plane should be assembled first,
apex of the deformity. The two modules are then connected after which the hinges are reinstalled for deformity correc-
by a pair of axial hinges, located diametrically opposite and tion in the sagittal plane. (2) One-stage correction in which
positioned symmetrically relative to the bone (Figs. 16.16, the axial hinges should be located in the true plane of the
16.17, 16.18, 16.19, and 16.20). deformity. This plane is identified based on the trigonometric
Based on a control roentgenogram, the coaxiality of each and graphic variants.
mounted device module and the correct mounting of the Note: In the two-stage deformity correction, the apex of
hinges should be confirmed. If the osteotomy is performed deformation (CORA) is defined on standard roentgenograms.
with open access, the hinges are mounted under visual con- As a rule, in most situations the CORA level in the frontal
trol. During osteotomy, the hinges are temporally plane does not coincide with that in the sagittal plane. If the
disconnected. magnitudes of the angular deformity in the frontal and
b c
Fig. 16.14 Rational options for one-stage angular deformity correc- point of intersection of the anatomic axes of the proximal and distal
tion. In an immediate correction, instead of the removal of a wedge- bone fragments, and a circle is made whose diameter is equal to the
shaped piece of bone (a) a hinge osteotomy (b, c) can be performed. In bone diameter at this level. Hinge osteotomy can be performed either
this case, the skiagram is used to position the needle of the caliper at the on the distal (b) or the proximal (c) fragment
a b
Fig. 16.15 Inappropriate approaches to the immediate removal of an fragments (a, b). The further the osteotomy is from the apex of the injury,
angular deformity. If the hinge osteotomy is carried out based on a circle the less will be the area of contact of the fragments. A hinge osteotomy
with a diameter exceeding that of the bone, restoration of the anatomic performed through the point of intersection of the anatomic axes of the
axis will be accompanied by a decrease in the area of contact of the fragments will lead to lateral displacement of the fragments (c)
sagittal planes are equal, osteotomy is carried out in the mid- In the trigonometric approach, a special nomogram, for-
dle of the deformity levels. If the deformity magnitude in one mulas, or trigonometric tables are necessary [236–237]. In
of the planes prevails, for example, in the frontal plane, the Table 16.2 the angles of deformation measured on A-P X-ray
osteotomy level should be displaced to the corresponding projections are shown in the columns, and the angles obtained
side: in this case closer to the apex of deformation in the in lateral view in the rows. The intersection of a column with
frontal plane. To more accurately define the osteotomy level, a rows identifies the angle of deformity as well as its
skiagrams are obtained (Fig. 16.66). magnitude.
a b
Fig. 16.16 To form a wedge-shaped regenerate, the hinge arms must hinges are moved (b). This version is acceptable only in the removal of
coincide with the projection of the cortical plates on the convex side of a minor deformity at the level of the bone metaphysis or in the presence
the deformity (a). The line connecting the hinge units should bisect the of osteoporosis (the second axial hinge is “invisible” because it is
angle of the deformity. Placing the hinges on the concave side of the located parallel to that shown on the diagram)
deformity will result in kneading of the bone when the arms of the
a b
Fig. 16.17 The swivel hinge is generally mounted on the concave side hinge is set more laterally from the axial hinge, from the deformity’s
of a deformity, parallel to the axial hinge (a). In the removal of a varus convex side. In this case, each arm of the swivel hinge is connected to
deformity of the proximal third of the femur or humerus, the swivel an external support by connection plates (b)
a b
d
2α
AB = BC
AD DE A a A
in case BC = 1, D
DE = AD
AB
a = 2 d · ctgα
B
E
C A
Fig. 16.18 The greater the distance from the bone to the swivel hinge, the greater the magnitude of the required distraction, which is calculated
with the skiagram (a). The amount of lengthening of the segment after removal of an angular deformity is determined, as shown in (b)
a b c
Fig. 16.19 If the elimination of an angular

deformity (a) has not corrected the limb
length discrepancy (b), after replacement of
the hinges with threaded rods the
proper distraction should be carried out (c)
a b e
d
2µ c
a A
b
A
a = (d+c)ctgµ
b = c · ctgµ
a b
c d
c d
Fig. 16.20 Location of the axial hinges at some distance from the ate. The further the axial hinges are from the bone (a, c), the greater the
bone, but with the line connecting the hinge units still bisecting the segment lengthening obtained (b, d). (e) Calculation of segment length-
angle of the deformity, results in the formation of a trapezoidal regener- ening in the formation of a trapezoidal regenerate
Fig. 16.21 If osteotomy is

executed below or above the a b c
deformity apex (a), after
deformity correction the bone
will have a “crankshaft” shape
(b). The greater the distance
between the osteotomy level and
the CORA, the more changeable
the bone will be (c). However,
if axial hinges have been
established in the plane of the
deformity bisector, the anatomic
and mechanical axes of a bone
will be restored. This approach to
reconstruction is limited by the
extent of the correction required,
which should not involve
fragment displacement by more
than one-third to one-half of the
bone diameter
a b
Fig. 16.22 If the axis of rotation of the axial hinge is not aligned with hinge is located above the bisector, the distal fragment will be displaced
the line bisecting the angle of the deformity, lateral displacement of the relative to the proximal one in the direction of the hinge location (a).
bone fragments (peripheral translation) will result. The more the hinge When the hinge is located below the bisector, the distal fragment will be
is displaced relative to the bisector of the angle, the greater the periph- displaced in the opposite direction (b)
eral displacement of the fragments. When the axis of rotation of the
Table 16.2 Definition of the true angle and plane of deformation based on the use of standard roentgenograms [230]
Projection
angle (°) Angle of location of a plane of deformation True angle of deformation
A-P/L-V 5 10 15 20 25 30 35 40 45 50 55 5 10 15 20 25 30 35 40 45 50 55
5 45 26 18 13 11 9 7 6 5 4 3 7 11 16 20 25 30 35 40 45 50 55
10 64 45 33 26 21 17 14 12 10 8 7 11 14 17 22 26 31 36 41 45 50 55
15 72 57 45 36 30 25 21 18 15 13 11 16 17 21 24 28 33 37 41 46 51 55
20 64 54 45 38 32 27 23 20 17 14 20 20 22 24 27 31 34 38 42 47 51 56
25 79 69 60 52 45 39 34 29 26 21 18 35 26 28 31 33 37 40 44 48 52 56
30 81 73 65 38 51 45 39 35 30 26 22 30 31 32 34 37 39 42 46 49 53 57
35 83 76 69 63 56 51 45 40 35 30 26 35 36 37 38 40 42 45 48 51 54 58
40 84 78 72 67 61 55 50 45 40 35 30 40 41 41 42 44 46 48 50 53 56 59
45 85 80 75 70 65 60 55 50 45 40 35 45 45 46 47 48 49 51 53 55 57 60
50 86 82 77 73 69 64 60 55 50 45 40 50 50 51 51 52 53 54 56 57 59 62
55 87 83 79 76 72 68 64 60 55 50 45 55 55 55 56 56 57 58 59 60 62 64
In the graphic method, with the help of a full-scale ski- totally) projection of the true arrangement of the bone frag-
agram (or a selected scale) the magnitude of the deviation ments onto a two-plane system of coordinates. With this true
of the deformity apex from either a mechanical or ana- view of the configuration of the frame supports, the sites of
tomic axis is defined. This value is marked along the axial hinge placement can be determined (Fig. 16.23).
abscissa and ordinate; crossing it perpendicularly will Moreover, the method defines the true plane and the
demarcate a vector that lies in the true plane of the defor- magnitude of the deformity in a peripheral translation as
mity and specifies the direction of the deformity correc- well as in combinations of peripheral translation and angu-
tion [9] (Fig. 16.23). lar deformity components. An alternative to the “classical”
Paley [102] developed a graphic method, referred to as methods used in the correction of similarly complex
the oblique plane of deformity correction. The main point of multicomponent deformities is the method based on com-
improvement is the step-by-step (there are seven steps puter navigation (Chap. 17).
Fig. 16.23 The diagram shows the

definition of the true plane and the
magnitude of the angular deformity. P and
P1 are the magnitudes of the deviation of
the deformity apex from a mechanical axis;
AB is a vector lying in the true plane of the
deformity
P R
A P
P
R A P
16.3.4 Torsion Deformity Correction When the bone fragments are not located strictly at the
center of a support and (or) the support is not located strictly
Torsion deformity is corrected using one of the previously perpendicular to the anatomic axes of the bone fragments, at
described methods of external fixation (Chap. 2). When the torsion correction a secondary displacement of the frag-
distal fragment is rotated immediately after osteotomy, ments (peripheral translation) will occur (Fig. 16.24a–e).
threaded rods are mounted at an angle, connected to the sup- Variants of special units that avoid the secondary peripheral
ports. All other versions presented in the following figures translation of bone fragments are shown in Figs. 16.25 and
are suitable for the gradual correction of the deformity. 16.26.
a b c
d e
Fig. 16.24 Torsion deformity correction. Note that derotation will not the support, simultaneous with derotation lateral displacement of the
lead to lateral displacement of the fragments only when the longitudinal fragments will occur (c, d). This is eliminated through reciprocal dis-
(anatomic) bone axis does not coincide with the center of the supports placement in the plane of the deformity of the transosseous modules
(a, b). However, in practice, this orientation of the device supports is fixing the bone fragments (e)
rarely used. If the bone is located eccentrically relative to the center of
a b
Fig. 16.25 (a, b) Special methods are used to prevent the peripheral the osteotomy, an intermediate ring is placed such that the bone axis
displacement of fragments fixed eccentrically relative to the center of coincides with its center (see [236])
the support during their reciprocal rotation. For example, at the level of
a b
Fig. 16.26 In this version of rotational deformity correction, a large After osteotomy, the rotation deformity is corrected (b). In the final
support is fixed to the proximal and distal transosseous modules. These stage, the transosseous modules are connected to half-pins and the ring
supports are oriented such that the bone is in the center of each one. supports of larger diameter are removed (c)
Between them, a derotation unit is placed, e.g., sloping half-pins (a).
16.4 Order of Deformity Components mechanical) axes of the proximal and distal bone fragments.
Correction However, it can be difficult to follow this convention, espe-
cially in deformities that include a torsion component. After
Leonid Nikolaevich Solomin one deformity component has been eliminated it may well be
the case that, “unexpectedly,” one of modules (or both of
In the presence of all the basic deformity components (axial them) is not perpendicular to the axes of the bone fragment
translation, periphery translation, angulation, torsion), the (Fig. 16.27a). In such cases the orthopedic surgeon should
“classical” order in which they are eliminated is: (1) shorten- insert an additional intermediate support (Fig. 16.27b).
ing, (2) angulation, (3) torsion, (4) peripheral translation. The partial reassembly of the frame used to change the
When angular and torsion deformity components are reduction unit is a quite laborious manipulation. In our expe-
present in the frontal and sagittal planes, the first and fourth rience, in complex deformities it is necessary to change the
steps can be two-stage ones. The oblique plane of deformity reduction unit 3–5 times [238]. Each stage of correction
correction (Fig. 16.23) is an alternative method. Trapezoid demands radiological confirmation of its efficiency. Mistakes
regenerate formation (Fig. 16.20) permits the elimination of and the incorrect installation of a reduction unit are much
an angular component of a deformity in combination with more likely to occur in multi-stage corrections.
shortening. Thus, to eliminate each deformity component One approach to increase the efficiency of deformity
(shortening, angular deformity, peripheral translation, tor- correction is the use of computer technologies and the
sion), the orthopedic surgeon should use the unified unit, to installation of external fixation devices adapted using com-
be mounted at partial frame reassembly. puter programs. The Ortho-SUV Frame, Taylor Spatial
The general features of frame assembly for deformity cor- Frame, and Ilizarov hexapod system allow all components of
rection should be noted. By convention, the proximal and a deformity to be corrected in one step (Figs. 1.2–18 and
distal transosseous modules in the frontal and sagittal planes Chap. 17). However, these devices cannot be used in every
are established strictly perpendicular to the anatomic (or situation. When navigation has failed, a reduction (deformity
a b
Fig. 16.27 In assembling the reduction unit, if one of the modules is not perpendicular to the axes of a bone fragment (a), it will be necessary to
mount an additional support (b)
Table 16.3 Practical classification of long bone deformities a b c d

One-component 4 variantsa
Two-component 4 variantsb 5 variantsb
Three-component 5 variantsb 2 variantsb
Four-component 3 variantsc 5 variantsc
Five-component 1 variantc 3 variantsc
Six-component 1 variantc
a
Simple deformities (green): use of the Ilizarov frame is recommended
b
Deformities of intermediate complexity (yellow): choice between the
Ilizarov frame and hexapod
c
Complex deformities (red): hexapod use is expedient
correction) based on hexapods should be completed using

Ilizarov hinges. It is therefore essential that anyone who
installs a frame using computer navigation nonetheless has
full command of the Ilizarov method. In our opinion, in the
treatment of simple deformities the use of Ilizarov hinges is
expedient while in deformities of intermediate complexity
the choice of external fixation device (Ilizarov hinges or
hexapods) will depend on the surgeon’s experience and skills.
In the treatment of complex deformities the use of computer-
assisted devices is preferable. The recommendations guiding
the rational choice of the device for deformity correction
(“classical” or “computer”) are summarized in Table 16.3.
After all components of the deformity are eliminated,
union of the bone fragments will occur gradually. For bone
fragment stabilization, the same external fixation frame can
be used. The alternative is a transition to internal fixation
[102, 239, 240]. Lengthening of the segment “over” an
intramedullary nail (LON), with subsequent removal of the
external distraction device [102, 241–243] can also be con- Fig. 16.28 Mechanical (a, b) and anatomic (c, d) axes of the femur
sidered in this context. Detailed information on these meth- and tibia [102, 241]. The mechanical axis of the lower extremity is a
ods is provided in Chap. 26.3. straight line joining the centers of the femoral head, the knee, and the
ankle joint (a, b). In contrast to the mechanical axis, the anatomic axis
of each long bone is the mid-diaphyseal line (c, d). A synonym for
“anatomic axis” is the “longitudinal axis” (of a bone, fragment). In the
16.5 Basic Principles of Long-Bone Deformity sagittal plane, the anatomic axis of the femur is a curved line. In the
Correction in the Lower Limbs tibia, the mechanical and anatomic axes are parallel to each other. In the
frontal plane, the anatomic axis of the tibia (crossing a joint line in a
projection of the internal intercondylar eminence) is located somewhat
Leonid Nikolaevich Solomin inside the mechanical axis, and in the sagittal plane anterior to it
16.5.1 Referent Lines of the Lower Limbs

and Their Mutual Relations
The mechanical axis does not always pass through the
For many reasons, the accuracy of joint loading and gait center of the knee joint; rather, the mechanical axis deviation
mechanics depends on the equal lengths of the lower limbs (MAD) is between 1 and 15 mm [102]. It is conventionally
and the correct spatial orientation of the articular surfaces possible to set the MAD to 5 ± 4 mm (Fig. 16.29). When
relative to the mechanical (Fig. 16.28) and anatomic axes there is doubt, control roentgenograms of the contralateral
(Figs. 16.28, 16.29, 16.30, and 16.31). As shown below, the lower limb should be obtained.
two parameters are strongly interconnected. As noted in Sect. 16.1, in the planning of reconstructive
In the frontal plane, the anatomic axis of the tibia is operations, it is necessary to consider the orientation of the
located approximately 4 mm inside the mechanical axis. In relative joint lines of the femur and tibia with respect to the
the planning of a tibial deformity correction in the frontal anatomic (Fig. 16.30) and mechanical axes (Fig. 16.31). In
plane, the axes are considered to be conterminous. the frontal plane, the mechanical and anatomic axes of the
a b
130° 170°
(124–136°) (165–175°)
84°
(80–89°)
81° 83°
(79–83°) (79–87°)
87°
(85–90°) 81°
(77–84°)
MAD
4.1±4 mm
89° 80°
(86–92°) (78–82°)
Fig. 16.29 Mechanical axis deviation (MAD)

Fig. 16.30 Orientation of the joints relative to the anatomic axes in the
frontal (a) and sagittal (b) planes
a b c d
53°
90° (50–65°)
(85–95°)
78°
(73–84°)
88°
(85–90°)
87° 83°
(85–90°) (79–87°)
Fig. 16.31 (a, b) Orientation of
the joints relative to the
mechanical axes in the frontal
and sagittal planes. (c) The
correct mechanical axis shows
deviations in the diaphyseal parts
of the femoral and tibial bones.
Mechanical angles are normal. 82°
There are no indications for (78–85°)
correction. (d) The “ideal” 89°
mechanical axis does not exclude (86–92°)
the potential for deviations of the
femoral and tibial bones.
Correction is necessary
femur form an angle of 7° ± 2°. The angle between the hip In Fig. 16.33 the points needed to draw reference lines in
joint orientation line and a mechanical axis is 44° ± 2º. These the sagittal plane are shown. It must be emphasized that for
angles can be used for the construction of the mechanical correct preoperative planning radiological examination
and anatomic axes of the proximal and distal bone fragments should be executed according to the standards described in
(Fig. 16.32). Chap. 6.1 (Fig. 16.34).
Fig. 16.32 (a–n) Frontal plane reference points and lines. (a) Points bone fragment anatomic axis definition: (1) the axis of the femoral neck
for reference line identification: the midpoint (center) of the femoral is drawn; (2) an anatomic axis is drawn from the piriformis fossa at an
head, proximal tip of the greater trochanter, the center of the femoral angle of 130° to the hip neck orientation line. (h) Method of proximal
neck, and the piriformis fossa. (b) The centers of the knee joint relative bone fragment anatomic axis definition: (1) the proximal joint line is
to femur and tibia. Points for drawing joint lines. For the femur, these drawn; (2) an anatomic axis is drawn from the piriformis fossa at an
are the two most convex points on the femoral condyles. For the tibia, angle of 84° to the joint line. (i) The point opposite to the medial tibial
they are the two points on the concave aspect of the plateau of the sub- spine is the point of intersection of the femoral anatomic axis and the
chondral line. (c) The center of an ankle joint. The points for drawing joint line. Therefore, to determine the anatomic axis: (1) the distal knee-
the ankle joint line are placed on either end of the ankle plafond line. joint orientation line is drawn; (2) the point specified by the anatomic
(d) Average magnitude of the angles of the triangle formed by: a neck line at an angle of 81° to the joint line is formed. (j) Method of distal
shaft angle; an angle formed by the mechanical and anatomic axes of bone fragment mechanical axis identification: (1) the knee-joint orien-
the femur; an angle formed by the axis of the femoral neck and the tation line is drawn and divided in half; (2) the mechanical axis passes
femur’s mechanical axis. (e) Method of proximal bone fragment at an angle of 88° to this line. (k) Method of proximal tibial bone frag-
mechanical axis definition: (1) A line from a midpoint of the femoral ment mechanical and anatomic axes identification: (1) a line of the knee
head parallel to the femoral anatomic axis is drawn; (2) a line at an joint is drawn and divided in two; (2) from the middle of joint line
angle of 7° to the first line is drawn. The second line is the mechanical another line is drawn at an angle of 87° to the joint line. This is the
axis. (f) Method of proximal bone fragment mechanical axis mechanical axis. The anatomic axis is located 4 ± ±4 mm medial to the
identification: (1) the axis of the femoral neck is drawn; (2) the mechan- mechanical axis
ical axis passes at an angle of 44° to this line. (g) Method of proximal
a b c
d e f g
44°
7° 44°
130°
130°
7°
h i j k
87°
84°
81°
88°
l m n
890
30−350
20−250
Fig. 16.32 (continued) (l) Method of distal tibial bone fragment ral head and neck; the second line is parallel to a line drawn through the
mechanical and anatomic axis identification: (1) an ankle-joint line is points connecting the back edges of the femoral condyles. (n) External
drawn and divided in two; (2) from the middle of the joint line another torsion of the distal part of the tibia forms an angle of 30–35° (range:
line is drawn at an angle of 89° to the joint line. This is the mechanical 16–50°) [245–247]. One of the lines forming an angle is drawn parallel
axis. The anatomic axis is located 4 ± 4 mm medial to the mechanical to the back edge of the tibial condyles, while the second line is drawn
axis. (m) Anteversion of the proximal part of the femoral bone from the from the center of the pylon to the center of the distal tibiofibular
frontal plane forms an angle of 20–25° (range: 6–40°) [245–247]. One syndesmosis
of the lines forming the angle is drawn through the centers of the femo-
a b c d
10º
(5–15º)
16º
(12–25º)
7º
(4–13º)
e f g h i
83º
2/3 1/3 2/3 1/3
80º
4/5 1/5 4/5 1/5
81º
1/2 1/2 1/2

1/2
Fig. 16.33 (a–i) Sagittal plane reference points and lines. (a) In the lines. (f) Points for drawing a distal tibial joint line and the intersection
sagittal plane, the mid-diaphyseal lines of the proximal and middle of the joint line and mid-diaphyseal line. (g) Anatomic axis definition
thirds of the bone shaft intersect at an angle of 10º (5–15º) (Solomin LN in a distal bone fragment: (1) a knee-joint line is drawn and sequentially
and Skomoroshko PV, unpublished data). (b) In the middle third, the divided into three parts; (2) from the foremost third of the joint line
mid-diaphyseal lines intersect at an angle of 16º (range: 12–25º) another line is drawn at an angle of 83° to the joint line. (h) Anatomic
(Solomin LN and Skomoroshko PV, unpublished data). (c) In the sagit- axis definition in a proximal tibial bone fragment: (1) a knee-joint line
tal plane, the mid-diaphyseal lines of the middle and distal thirds of the is drawn and sequentially divided into five parts; (2) from the foremost
bone shaft intersect at an angle of 7º (range: 4–13º) (Solomin LN and fifth of the joint line another line is drawn at an angle of 81° to the joint
Skomoroshko PV, unpublished data). (d) Points for drawing a distal line. (i) Anatomic axis definition in a distal tibial bone fragment: (1) an
femoral joint line (at the closed and open growth plate) and a proximal ankle-joint line is drawn and divided in half; (2) from the middle of the
tibial joint line. (e) Intersections of the joint lines and mid-diaphyseal joint line another line is drawn at an angle of 80° to the joint line
Fig. 16.34 Finding the axes of the proximal fragment of the femur. (a) In the presence of torsion, correct identification of the mechanical axis is
impossible; (b) however, it is possible to find an anatomic axis at any degree of rotation
16.5.2 Length Discrepancies of the Lower Limbs restriction in the movement of the knee joint, the femoral
distraction regenerate should be formed over the length of
As discussed above, bone shortening is considered a type of the proximal/central two-thirds of the segment (from level II
deformity. However, a length discrepancy of the lower limb to level V). Lengthening the lower leg should be similarly
up to 1.5 cm is not an absolute indication for surgical correc- approached if there is contracture of the ankle joint, etc. An
tion because it can be adequately compensated by means of external fixation device assembly for the monolocal length-
orthopedic inserts in the footwear or by adding height to the ening of the femur is shown in Fig. 14.2.
heels. For lengthening the femur, tibia, and fibula at the level
The problem of lengthening the femur in accordance with of the proximal third of the segment using the Ilizarov
the anatomic or mechanical axis is solved individually apparatus, the orientation of the proximal basic support
(Fig. 16.35). In the lengthening of the lower leg, this is not a after placement of the wires deserves particular attention
consideration because the anatomic and mechanical axes of [26, 248]. The plane of the proximal basic support ring on
the bones of the lower leg are parallel. the femur should be at an angle of 100–110° to the femoral
Corticotomy with osteoclasis (Fig. 15.1) for femoral (or axis, open to the outside. This is necessary for the correc-
lower leg) lengthening is performed outside the zone of the tion of the varus deformity of the femur during distraction.
former fracture and, as a rule, involves a longer fragment. The proximal basic support ring on the lower leg is placed
However, one should bear in mind that the nearer to the joint so as to prevent recurvation valgus deformity, at an angle of
the lengthening is performed, the greater the danger that a 100–110° open to the inside and forward. Only then are the
contracture will develop in that joint. Therefore, if there is a wires mounted in the support. Then, exploiting the elastic
Fig. 16.35 Femoral lengthening along a

the anatomic and mechanical axes.
(a) Relationship between femoral
shortening and deviation of the extremity
from the mechanical axis. The greater the
shortening of the femur along the anatomic
axis (e.g., in the event of union of
fragments after a fracture, resulting in a
bone defect), the more significant the
deviation of the extremity from the
mechanical axis. Thus, in traumatic
shortenings, the bone is lengthened along
its anatomic axis. (b) In some inborn
pathologies that require aesthetic surgery to
increase the patient’s height, the
mechanical axis of the extremity is retained
(a). In these cases, femoral lengthening of
the femur along its anatomic axis will
result in a deviation of the lower leg from
the mechanical axis (b). The greater the
amount of lengthening, the more
pronounced this deviation will be.
Therefore, in such cases, the femur is
lengthened along its mechanical axis
(c). Accordingly, transosseous modules
that fix the proximal and distal bone
fragments after corticotomy are arranged
perpendicular to the mechanical axis of the
extremity
90°
90°
deformation properties of the wires, the proximal basic distraction is carried out at the rate of 0.25 mm two or three
support is oriented parallel to the transosseous module— times a day.
which will fix the distal fragment after corticotomy—and To define the rate of lengthening in patients with open
the two components are connected. Basic supports based growth zones, special formulas are used [102, 249].
on half-pins are placed perpendicular to the longitudinal Another approach to eliminating a length discrepancy
axis of the bone. is to shorten the intact extremity, as discussed above in
Lengthening the segment by more than 5 cm should be Sect. 16.3.1. In shortening of the femur, deviation of the
performed with the help of polyclonal distraction osteosyn- lower leg from the mechanical axis must be prevented
thesis (Figs. 16.36 and 16.37). by additional translation of the distal bone fragment
The rate of distraction lengthening at the level of the (Fig. 16.38b). In shortening the lower leg, it is not necessary,
proximal corticotomy should be, on average, 0.25 mm three since the tibia’s anatomic and mechanical axes are parallel.
or four times a day. At the distal level of lengthening, to pre- The device assemblies are similar to those recommended
vent the formation of a hypoplastic distraction regenerate, for the fixation of fractures and deformity correction.
Fig. 16.36 (a, b) Schemes for Ilizarov bilocal distraction a b

osteosynthesis (From [26])
1 2 3 4 8 9 5 6 7
I,6-12; I,11-5; II,11-5; II,6-12 IV,1-7; IV,6-12 VII,3-9; VIII,8-2; VIII,4-10 (a)
arc 210 arc 210 180
1 2 3 4 8 9
(I,8-2)I,8-2; I,4-10; I,9-3; II,3-9 (IV,8-2)IV,8-2; IV,4-10
150 150
7 5 6
VII,3-9; (VIII,8-2)VIII,8-2; VIII,4-10 (b)
150
a b
1 2 3 6 7 5 4
I,8,120; I,11,90; II,9,90 IV,10,120; V,8,90 VII,8,120; VIII,3-9 (a)
1/3 225 3/4 195 3/4 180
1 2 3 6 7 5 4
Fig. 16.37 (a, b) Schemes for bilocal distraction
(I,8-2)I,8-2; I,4-10; II,1,90 IV,12,120; V,3-9 VII,12,90; (VIII,8-2)VII,8-2 (b)
osteosynthesis with combined external fixation 3/4 150 150 150
Fig. 16.38 (a, b) Mechanical axis

restoration at femoral shortening.
Shortening the intact extremity (a) there is
an internal deviation of a mechanical axis at
femur shortening, (b) additional peripheral
translation of distal bone fragment restores
correct mechanical axis
a b
16.5.3 Peripheral Translation e.g., in patients at risk of necrosis, with scarred and bone-
connected soft tissues, the transosseous modules are dis-
Figure 16.39 shows the importance of correcting the periph- placed gradually in a reciprocal manner (Fig. 2.4).
eral displacement of fragments so that the mechanical axis of In practice, there are situations in which it is either impos-
the lower extremity can be restored. To eliminate this kind of sible to perform an osteotomy at the level of the deformity or
deformity, each bone fragment is fixed with a transosseous it is undesirable because of an osteomyelitic cavity, foreign
module, without connecting them. Osteotomy is carried out body, pronounced scarring, etc. In such cases, the osteotomy
and, if necessary, the fragments are openly adapted with sin- can be performed in the intact zone, with restoration of the
gle-stage restoration of the extremity’s axis. Then, the tran- mechanical axis of the extremity. Restoration of the mechan-
sosseous modules are connected in the new state. If ical axis by osteotomy below the deformity level is shown in
displacement of the fragments in one step is not possible, Fig. 16.40.
a b
a b
Fig. 16.40 (a, b) Restoration of the mechanical axis in peripheral

Fig. 16.39 (a, b) Relationship between peripheral translation and the translation. Note that if there is preoperative knee-joint stiffness, the
mechanical axis osteotomy should be performed above the level of the deformity
16.5.4 Angular Deformities External fixation in patients with traumatic angular defor-
mity of the femur with segment shortening, shown in
Figure 16.41 demonstrates that in the immediate correction of Figs. 16.43 and 16.44, serves as an example.
an angular deformity it is preferable to carry out the osteotomy When the fibular fragments have united at the angle, with
at its apex. In a long-term correction, the axial hinges should no visually apparent deformity (usually up to 30–35°),
be located on the bisector of the deformity angle (Fig. 16.42). osteotomy is performed in the lower third of the diaphysis,
An alternative to the identification of a distraction regen- because it is technically simpler and less traumatic. If pro-
erate of trapezoidal shape is the correction of the angular nounced curvature is present, the bone is cut at the level of
deformity and lengthening of the segment at different levels. the deformity apex.
Fig. 16.41 To restore the

mechanical axis of an extremity
when the osteotomy is outside
the apex of the angular
deformity, peripheral translation
of the distal fragment must be
additionally performed. The need
for this procedure does not
depend on whether the osteotomy
is carried out above (b) or
below(c) the apex of the
deformity. The greater the extent
of the angular deformity and the
further the osteotomy site from
its apex, the greater the
magnitude of the translation
needed to restore the mechanical
axis. Therefore, the use of this
approach is limited by the extent
of the correction required, which
should not involve fragment
displacement by more than a b c
one-third to one-half of the bone
diameter
Fig. 16.42 (a) Despite the level of the

osteotomy, the axial hinges should be a b c
located in the bisector of the deformity
angle (CORA). (b) Only in this case can
the mechanical axis be restored.
(c) Otherwise, the purpose of the
operation will not be achieved
Bisector
a b
Fig. 16.43 Bilocal compression-distraction in the

combined external fixation of a malunited fracture of the
trochanter. By means of corrective osteotomy in the
intertrochanteric region, the neck-shaft angle (a) is
restored in one stage. Limb length discrepancy is
removed through identification of the distraction 1 2 5 6 4 3
regenerate in the middle third of the segment. During the I,8,120; I,11,90 III,10,120; IV,8,90 ––VI VII,8,120; VIII,3-9 (a)
fixation period, after the femur has been lengthened to 1/3 225 3/4 195 180 3/4 180
the required size, the proximal support is dismantled and 7
the reductionally fixing transosseous element, e.g. I,8,120; III,10,120; IV,8,90 –– VI,9-3 –– VII,8,120; VIII,3-9 (b)
VI,9-3, is inserted (b) 3/4 195 180 3/4 180
Fig. 16.44 The closer the

distraction regenerate is to the a b
knee joint, the greater the danger
of knee-joint stiffness. Therefore,
when there is epicondyle angular
deformity of the femur combined
with segment shortening, bilocal
compression distraction external
fixation is also advisable (a). If
the distraction regenerate exceeds
5 cm, the time needed for its
conversion to bone exceeds the
period of fragment union in the
epicondylar region. In this case,
an additional half-pin VII,8,70 is
inserted and the distal support is
dismantled (b)
1 2 3 6 7 5 4
I,8,120; II,11,90; III,9,70 V,8,120; IV,3-9 VIII,8,120; VIII,3-9 (a)
1/3 225 180 3/4 180
8
I,8,120; II,11,90; III,9,70 –– V,8,120; IV,3-9; VII,8,70 (b)
1/3 225 180
16.5.5 Torsion Deformities the auxiliary support of the detorsion unit (the basic support
of the device is almost always assembled eccentrically) is
Taking into consideration the large range of normal values of difficult enough. Therefore, the orthopedic surgeon should
femoral and tibial bone torsion (Fig. 16.32i, j), this kind of be ready either to correct the secondary bone fragment dis-
deformity should be evaluated by comparison with the placement or to eliminate torsion with the aid of hexapods
contralateral side. A difference over 15° is defined as a tor- (Chap. 17).
sion deformity [247]. Elimination of a femoral bone torsion deformity along the
The unified units for the correction of a torsion deformity mechanical axis will lead to secondary displacement of the
are presented in Chap. 2. It should be emphasized that if peripheral fragments. Thus, the higher the osteotomy is per-
even one of the basic supports of the device is not positioned formed, the greater the amount of translation.
perpendicular to the axis of a fragment, torsion correction When choosing the osteotomy level in a patient with a
will lead to secondary angulation and translation. Also, congenital deformity, it is necessary to consider the fixation
achieving an exact arrangement of the bone in the center of points of the muscles, tendons, and ligaments [102].
16.5.6 Examples of Deformity Correction Examples of deformity correction planning in femoral

Planning in the Femur: The Basic Frames shaft deformities, along with the basic frame assemblies, are
Assemblies shown in Figs. 16.46, 16.47, 16.48, 16.49, 16.50, 16.51,
16.52, and 16.53.
Figure 16.45 provides an example of deformity apex Figures 16.54 and 16.55 provide examples of deformity apex
definition and approaches to the correction of a deformity in definition and approaches to the correction of a deformity in the
the proximal femur. External fixation in similar cases can be distal femur. External fixation in similar cases can be carried out
carried out using the devices shown in Figs. 12.6 and 12.7. using the devices shown in Figs. 16.53, 16.56, and 16.57.
Fig. 16.45 Planning the correction of a coxa vara deformity. The defor- deformity components. (d) Turning around a point crossing the bisector
mity components are located in the frontal plane: angulation, translation, of the deformity and external cortical plate leads to over-lengthening of
shortening. (a) Deformity skiagram: the femoral neck line, mid-diaphy- the femur. (e) Turning around a point located at the intersection of the
seal line, and mechanical axis are drawn. (b) The bisector of the defor- bisector and the internal cortical plate necessitates the removal of a bone
mity angle is shown; the osteotomy line is marked. (c) Turning around a wedge (osteotomy “−”). In this approach, shortening remains. The sec-
point located at the apex of the deformation leads to the correction of all ond osteotomy for lengthening should be executed
a b c
d e
Fig. 16.46 Planning the

correction of a deformity in the
proximal third of the femoral shaft.
The deformity components are
located in the frontal plane:
angulation, translation, shortening.
(a) Deformity skiagram; the
anatomic axes of the proximal and
distal bone fragments and the
mechanical axis are drawn. (b) The
bisector of the deformity is shown;
the osteotomy line is marked. (c)
Turning around the intersection of
the bisector of the deformity and
the internal cortical plate will allow
the removal of both the angular
deformity and peripheral
translation; shortening remains. It
is necessary to perform distraction
or to execute the second osteotomy
for lengthening. (d) Turning around
a point located on the deformity
bisector medially (inside) with
respect to the cortical plate will
allow the immediate correction of
all deformity components
a b c
d e
Fig. 16.47 Basic device assembly for the correction of deformities of the proximal third of the femoral shaft. (a) Before correction; (b) after
correction and the 1st stage of module transformation (MT)
Fig. 16.47 (continued) (c) 2d stage c

of MT
1 3 4 2 6 5 7 8
I,9,90; I,11,90; II,8,130; II,10,90 -o- IV,10,120; V,9,90; VI,8,70 – VII,8,70 (a)
arch 210 195 1/3 180
I,9,90; I,11,90; II,8,130; II,10,90 -- IV,10,120; V,9,90; VI,8,70 – VII,8,70 (b)

1/3 210 1/2 195 1/3 180
I,9,90; I,11,90; II,8,130; II,10,90 -- IV,10,120; V,9,90; VI,8,70 (c)

1/3 210 1/2 195
Fig. 16.48 Planning the a b c

correction of a deformity of
the middle third of the femoral
shaft. The deformity
components are located in
frontal plane: angulation,
peripheral translation,
shortening. (a) Deformity
skiagram; the anatomic axes
of the proximal and distal
bone fragments and the
mechanical axis are drawn.
(b) The bisector of the
deformity is shown; the
osteotomy line is marked. (c)
Turning around a point where
the bisector and the external
cortical plate intersect will
permit the removal of the
angular deformity; peripheral
translation and shortening
remain. (d) Distraction along
the anatomic axis eliminates
the last component of the
deformity. (e) Turning around
a point on the bisector of the
deformity, laterally from the
cortical plate, allows
immediate correction of all
components of the deformity
d e
a b c d
Fig. 16.49 Planning the correction of a deformity in the middle third f. (c) To find the mechanical axis of the distal bone fragment, draw a
of the femoral shaft using the mechanical axes of the proximal and line through the center of the knee joint at an angle of 88° to the distal
distal bone fragments. The deformity components are located in the joint orientation line. The point where the mechanical axes of the proxi-
frontal plane: angulation, peripheral translation, shortening (similar to mal and distal bone fragments intersect is the deformity apex (CORA).
Fig. 16.48). (a) Deformity skiagram; the mechanical axis of the lower Note that the level of the deformity apex identified with the help of the
limb is drawn. (b) A method to determine the mechanical axis of the mechanical axes does not coincide with that determined using the ana-
proximal fragment, drawing a line from the proximal tip of the greater tomic axes (Fig. 16.48b). (d) Turning around a point obtained at the
trochanter to the center of the femoral head. The mechanical axis passes bisector of the deformity allows the one-stage correction of all compo-
through the center of the femoral head perpendicular to the former line. nents of the deformity
Otherwise, the mechanical axis can be drawn as shown in Fig. 16.32e,
a b c d
Fig. 16.50 Planning the correction of a deformity in the middle third The bisector of the deformity is shown; the osteotomy line is marked.
of the femoral shaft. The deformity components are located in the sagit- (c) Turning around the intersection of the bisector of the deformity and
tal plane: angulation, translation, shortening. (a) Deformity skiagram; the anterior cortical plate will allow the removal of the angular defor-
the anatomic axes of the proximal and distal bone fragments and the mity and the peripheral translation; shortening remains. (d) Turning
mechanical axis are drawn. Taking into account physiological recurva- around a point found on the bisector in front of the anterior cortical
tion, the points used to define the anatomic axis should be placed as far plate allows the immediate correction of all components of the
from the joint ends of the fragments as possible (see Fig. 16.33a–c). (b) deformity
Fig. 16.51 Basic device assembly

for the correction of deformities of
a
the middle third of the femoral
shaft. (a) Before the correction.
(b) After the correction
b
Fig. 16.51 (continued) (c) Modular c

transformation of the frame
4 2 1 3 6 5 7
I,9,90 _ II,11,120; III,9,90; IV,8,70 -o- V,8,120; VI,9,90; VII,8,70 (a)
1/3 200 2/3 200 195
I,9,90 _ II,11,120; III,9,90; IV,8,70 -o- V,8,120; VI,9,90; VII,8,70 (b)

1/3 200 2/3 200 195
I,9,90; II,11,120; III,9,90; IV,8,70 -- V,8,120; VI,9,90; VII,8,70 (c)
1/3 200 1/3 200
a b c d
Fig. 16.52 Planning the correction of a deformity in the distal third of of the deformity is shown; the osteotomy line is marked. (c) Turning
the femoral shaft. The deformity components are located in the sagittal around the intersection of the bisector and the internal cortical plate will
plane: angulation, translation, shortening. (a) Deformity skiagram; the allow the removal of the angular deformity and peripheral translation;
anatomic axes of the proximal and distal bone fragments and the slight shortening remains. (d) With the aid of distraction, the last com-
mechanical axis are drawn. The method used to define the anatomic ponent of the deformity is eliminated
axis of the distal bone fragment is shown in Fig. 16.32. (b) The bisector
Fig. 16.53 Basic frame assembly

for the correction of deformities of a
the distal third of the femoral shaft.
(a) Before the correction, (b) after
the correction
b

(c) modular transformation of the
c
frame
2 1 3 6 5 4
III,10,120; IV,9,90; V,8,70 -o- VI,8,90; VII,3-9; VIII,4,90 (a)
195 195
III,10,120; IV,9,90; V,8,70 – VI,8,90; VII,3-9; VIII,4,90 (b)

195 195
III,10,120; IV,9,90; V,8,70 – VI,8,90; VII,3-9; VIII,4,90 (c)
1/2 195 2/3 195
a b c
Fig. 16.54 Planning the correction of a supracondylar deformity. The to the joint line (Fig. 16.32c). (b) The bisector of the deformity is
deformity components are located in the frontal plane: angulation, shown. Its level is close to the knee-joint line. The osteotomy line is
translation. (a) Deformity skiagram; the anatomic axes of the proximal marked. (c) Turning around a point located in the bisector allows the
and distal bone fragments and the mechanical axis are drawn. To define removal of all components of the deformity. Discrepancies between the
the anatomic axis of the distal bone fragment, a joint line for the distal bisector and osteotomy levels have caused the peripheral translation of
femur should be drawn. A point located opposite the medial tibial spine the compelled fragments
is marked on this line. From this point, a line is drawn at an angle of 81°
a b c
Fig. 16.55 Planning the correction of a supracondylar deformity. The deformity and the osteotomy line are shown. (c) Turning around a point
deformity components are located in the sagittal plane: angulation, located in the bisector allows the removal of all components of the
translation, shortening. Femoral deformity mimics a knee-joint flexion deformity. Discrepancies between the bisector and osteotomy levels
contracture. (a) Deformity skiagram; the anatomic axes of the proximal have led to the peripheral translation of the compelled fragments
and distal (Fig. 16.33c, g) bone fragments. (b) The bisector of the
Fig. 16.56 (a) Basic frame

assembly for the correction of a
deformities in the distal part of the
femur. (a) Before correction,
(b) after correction
b
Fig. 16.56 (continued) (c) First stage of module

transformation (MT) of the frame: partial removal c
of the distal support. (d) Second stage of MT:
wire VIII,3-9 has been removed; partial removal
of the proximal and distal basic supports
1 2 3 6 5 4
III,9,90 _ IV,10,120; VI,9,70 -o- VII,8,90; VIII,8,90; VIII,3-9 (a)
1/3 195 200 195
III,9,90 _ IV,10,120; VI,9,70 _ VII,8,90; VIII,8,90; VIII,3-9 (b)

1/3 195 200 195
III,9,90 _ IV,10,120; VI,9,70 _ VII,8,90; VIII,8,90; VIII,3-9 (c)

1/3 195 200 2/3 195
III,9,90 _ IV,10,120; VI,9,70 _ VII,8,90; VIII,8,90; VIII,3-9 (d)

1/3 195 1/3 200 1/3 195
a b c d
Fig. 16.57 Planning the correction of a two-level femoral deformity. deformity and the osteotomy lines are given. (c) Coxa vara correction.
The deformity components are located in the frontal plane. The first Discrepancies between the bisector and osteotomy levels have led to
level of the deformity is at the level of the proximal metaphysis, the the peripheral translation of the compelled fragments. (d) Turning
second at the distal third of the femoral shaft. (a) Deformity skiagram; around a point located in the bisector allows the removal of all compo-
the femoral neck line, anatomic axes of the proximal and distal bone nents of the deformity
fragments, and the mechanical axis are shown. (b) The bisectors of the
16.5.7 Examples of Deformity Correction tibial deformity. External fixation in similar cases can be car-
Planning for the Lower Legs: The Basic ried out using the devices shown in Figs. 13.4, 16.60, 16.61,
Frame Assemblies 16.62, 16.63, 16.64, 16.65, 16.66, 16.67, 16.68, 16.69, 16.70,
16.71, 16.72, and 16.73.
Figures 16.58 and 16.59 provide examples of deformity apex
definition and approaches to the correction of a proximal
a b c
Fig. 16.58 Planning the correction of a deformity in the proximal tibia bisector of the deformity is shown; the osteotomy line is marked. (c)
and fibula. The deformity components are located in the frontal plane: Turning around a point at the bisector allows the one-stage correction of
angulation, translation, shortening. (a) Deformity skiagram; the all components of the deformity
mechanical axes of the proximal and distal bone fragments. (b) The
a b c
Fig. 16.59 Planning the correction of a deformity in the proximal located at 1/5 of the joint line (Fig. 16.33b, e). The anatomic axis of the
tibia. The deformity components are located in sagittal plane: angula- distal bone fragment is the mid-diaphyseal line. (b) The bisector of the
tion, translation, shortening. The tibial deformity mimics a flexion con- deformity is shown; the osteotomy line is marked. (c) Turning around a
tracture of the knee joint. (a) Deformity skiagram; the anatomic axes of point on the bisector allows the immediate correction of all components
the proximal and distal bone fragments. The anatomic axis of the proxi- of the deformity
mal bone fragment is the line drawn at an angle of 81° from a point
Fig. 16.60 Basic device assembly for the

correction of a proximal tibial deformity. If a
there is indication case for fibula osteotomy,
addition VIII(8–2)8-2 should be mounted.
(a) Before correction. (b) After correction
b
Fig. 16.60 (continued) (c) Hinges are replaced with threaded c

rods. (d) Modular transformation of the device
1 2 3 5 4 6
I,3-9; I,2,90; I,10,90 -o- III,12,120; IV,10-4; V,2,70 (a)
150 150
I,3-9; I,2,90; I,10,90 -o- III,12,120; IV,10-4; V,2,70 (b)
150 150
I,3-9; I,2,90; I,10,90 _ III,12,120; IV,10-4; V,2,70 (c)

150 150
I,3-9; I,2,90; I,10,90 _ III,12,120; IV,10-4; V,2,70 (d)

2/3 150 1/2 150
a b c
Fig. 16.61 Planning the correction of a deformity in the proximal angle of 81° from a point located at 1/5 of the joint line (Fig. 16.33b).
third of the tibial shaft. The deformity components are located in the The anatomic axis of the distal bone fragment is the mid-diaphyseal
sagittal plane: angulation, translation, shortening. (a) Deformity skia- line. (b) The bisector of the deformity is shown; the osteotomy line is
gram; the anatomic axes of the proximal and distal bone fragments. The marked. (c) Turning around a point on the bisector allows immediate
anatomic axis of the proximal bone fragment is the line drawn at an correction of all components of the deformity
Fig. 16.62 Basic device assembly for

the correction of deformities of the a
proximal third of the tibial shaft.
(a) Before correction. (b) After
correction
b
Fig. 16.62 (continued) (c) Modular

transformation of the frame c
1 2 3 5 4 6 7
I,3-9; I,2,90; II,10,90 -o- IV,12,120; V,10-4; VI,2,70 – VIII(8-2)8-2 (a)
150 150 150
I,3-9; I,2,90; II,10,90 – IV,12,120; V,10-4; VI,2,70 – VIII(8-2)8-2 (b)

150 150 150
I,3-9; I,2,90; II,10,90 – IV,12,120; V,10-4; VI,2,70 (c)

2/3 150 1/2 150
a b c
Fig. 16.63 Planning the correction of a deformity in the middle third tions are close enough and that the basic bone fragments are parallel to
of the tibial shaft. The deformity components are located in the frontal one another, transversal osteotomy will restore the anatomic axis of the
plane: translation, shortening; the basic bone fragments are parallel. (a) tibia in one stage. This approach would be optimum if shortening were
Deformity skiagram; the anatomic axes of the proximal, intermediate, absent. (c) Distraction and translation allow the removal of all compo-
and distal bone fragments. (b) Assuming that the apexes of deforma- nents of the deformity
Fig. 16.64 Basic frame assembly for

the correction of a deformity of the
middle third of the tibial shaft. (a) a
Before correction. (b) After correction
b
Fig. 16.64 (continued) (c) Modular transformation

of the frame c
2 1 3 5 4 6
II,2,120; III,1,90; IV,12,70 -o- V,12,120; VI,10-4; VII,2,70 (a)
150 150
II,2,120; III,1,90; IV,12,70 – V,12,120; VI,10-4; VII,2,70 (b)

150 150
II,2,120; III,1,90; IV,12,70 – V,12,120; VI,10-4; VII,2,70 (c)

1/2 150 1/2 150
a b c
Fig. 16.65 Planning the correction of a tibial shaft deformity. There proximal, intermediate, and distal bone fragments. (b) The bisectors of
are two apexes of deformation. The deformity components are located the deformity are shown; the osteotomy lines are marked. (c) Deformity
in the frontal plane. (a) Deformity skiagram; the anatomic axes of the correction
a b c
d e
Fig. 16.66 Planning the correction of a tibial shaft deformity. There levels are the same, as in Fig. 16.65. (c) Deformity correction: since the
are two apexes of deformation. The deformity components are located osteotomy was performed beyond the levels of the deformity apexes,
in the sagittal plane. This example is based on the same patient described restoration of the anatomic axis of the segment requires an additional,
in Fig. 16.65. (a) Deformity skiagram; the anatomic axes of the proxi- significant peripheral translation. (d) For a smaller peripheral transla-
mal, intermediate, and distal bone fragments. (b) The bisectors of the tion, the osteotomy must be performed between the levels of the defor-
deformity are shown; the osteotomy lines are marked. The osteotomy mity apexes in the frontal and sagittal planes. (e) Correction results

correction of a deformity of the distal third of a
the tibial shaft. (a) Before the correction.
(b) After the correction
b

(c) Modular transformation of c
the frame
2 1 3 5 4 6
III,2,110; IV,12,90; V,3,70 -o- VII,10,100; VIII(8-2)8-2; VIII,1,90 (a)
140 140
III,2,110; IV,12,90; V,3,70 – VII,10,100; VIII(8-2)8-2; VIII,1,90 (b)
140 140
III,2,110; IV,12,90; V,3,70 – VII,10,100; VIII(8-2)8-2; VIII,1,90 (c)
1/2 140 1/2 140
a b c
Fig. 16.68 Planning the correction of a distal tibial deformity. The at 1/2 of the joint line (Fig. 16.33c). The proximal bone fragment axis
deformity components are located in the sagittal plane: angulation, is the mid-diaphyseal line. (b) The bisectors of the deformity are shown;
translation, shortening. (a) Deformity skiagram; the mechanical axes of the osteotomy line is marked. (c) Turning around a point found on the
the proximal and distal bone fragments. The anatomic axis of the distal bisector allows the immediate correction of all components of the
bone fragment is the line drawn at an angle of 80° from a point located deformity

correction of a distal tibial deformity. a
(a) Before correction. (b) After correction
b
Fig. 16.69 (continued) (c) Ilizarov hinges are replaced with

c
threaded rods. (d) Modular transformation of the frame
2 1 3 6 4 5
IV,2,120; V,9-3; IV,12,70 -o- VIII,1,90; VIII(8-2)8-2; VIII,4-10 (a)

150 150
IV,2,120; V,9-3; IV,12,70 -o- VIII,1,90; VIII(8-2)8-2; VIII,4-10 (b)

150 150
IV,2,120; V,9-3; IV,12,70 – VIII,1,90; VIII(8-2)8-2; VIII,4-10 (c)

150 150
IV,2,120; V,9-3; IV,12,70 – VIII,1,90; VIII(8-2)8-2; VIII,4-10 (d)
1/2 150 150
a b c
Fig. 16.70 Planning the correction of a deformity in the proximal and bone fragments. (b) The bisectors of the deformity are shown; the
distal parts of the tibia parts. The deformity components are located in osteotomy lines are marked. (c) Deformity correction. Since the osteot-
the sagittal plane: angulation, translation, shortening. (a) Deformity omies were performed beyond the levels of the deformity apexes, resto-
skiagram; the anatomic axes of the proximal, intermediate, and distal ration of the anatomic axis requires additional peripheral translation
a b c d
Fig. 16.71 Planning the correction of a deformity in the distal femur the osteotomy lines are marked. (d) Correction of the deformity. Since
and proximal and distal tibia. The deformity components are located in it was not possible to perform the osteotomies at the levels of the bisec-
the frontal plane. (a) There are three apexes of deformation but no devi- tors, restoration of the mechanical axis requires additional peripheral
ation in the mechanical axis. (b) The axes of the proximal and distal translation
bone fragments are drawn. (c) The bisectors of the deformity are shown;
a b c d
Fig. 16.72 Planning the correction of a two-level deformity of the axes will lead to unacceptable peripheral translation. (c) Intermediate
femur and lower leg. (a) The anatomic axes of the proximal and distal fragments are determined and their axes are drawn; the bisectors are
bone fragments of the femur and tibia are drawn. (b) After the osteoto- shown; the osteotomy levels are marked. (d) Correction of the
mies, executed on one level, restoration of the anatomic and mechanical deformity
a b c
Fig. 16.73 Planning an operation for a hip fused in the wrong posi- the former head of the femur) is the apex of deformation (CORA). Note
tion, here accompanied by femoral shortening and a valgus deformity that the mid-diaphyseal line crosses the knee-joint line at the wrong
of the distal femur. In this case, planning should be based on the use of point and the wrong angle, indicating the presence of the second level
the mechanical axes of the fragments. (a) The perpendicular drawn of the deformity. (b) Since the osteotomy was performed in the intertro-
from the bispinal line through the center of the former head of the femur chanteric area (at some distance from the apex of the deformation),
is the mechanical axis of the proximal bone fragment. To define the additional peripheral translation is necessary. The intersection of the
mechanical axis of the intermediate fragment, a line parallel to the mid- mid-diaphyseal line with the anatomic axis of the distal bone fragment
diaphyseal line should be drawn from the center of the former head of is in the supracondylar area. The osteotomy line is marked. (c) Final
the femur. Next, a line is drawn at an angle of 7° to a line parallel to the correction of the deformity; due to the hip-joint fusion, a 1.5 cm short-
mid-diaphyseal line. This line is the mechanical axis of the intermediate ening remains
fragment. The point of crossing of the mechanical axes (the center of
16.6 Technical Tips and Tricks for a deformity. The anatomic designations of the frontal and
the Correction of Deformities sagittal planes are kept without changes.
of the Humerus and Forearm The support function of the upper limb compared with
that of the lower limb is not significant. Therefore, strict con-
16.6.1 Referent Lines of the Upper Limbs formity of the referent angles and lines to the normal values,
and Their Mutual Relations as must be observed in the lower limb, is not required for the
upper limb. Furthermore, the referent lines and angles of the
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh upper limb have a wider range. Thus, in the planning of
an upper limb deformity correction the lines and angles of
Figure 16.74 shows the axes of the humerus and forearm the contralateral (“healthy”) limb should be obtained. In the
bones. As noted in Sect. 16.1, in the planning of reconstruc- event that functional and cosmetic damage does not
tive operations, the orientation of the relative joint lines of significantly inconvenience the patient (the compensatory
the femur and tibia with respect to the anatomic and mechan- possibilities of the upper limb are numerous), then in most
ical axes must be considered (Figs. 16.75 and 16.76). cases deformity correction is not absolutely necessary.
Note that in the schemes of the referent angles and lines However, it should be recognized that predicting the further
of the forearm (Fig. 16.76), the forearm bones are repre- influence of one or the other deformities on function and on
sented in a mid-position (between supination and pronation), the development of degenerate-dystrophic changes in the
which is how they are fixed in the frame in the correction of joints is not currently possible.
a b c d e f
Fig. 16.74 Mechanical (a, b) and anatomic (c–f) axes of the upper axes are the mid-diaphyseal lines of each bone. Therefore, the anatomic
limb. The mechanical axis passes through the center of the humeral axes of the bones of the elbow and the radius in the frontal and sagittal
head, the center of the capitate eminence of the humerus, the center of planes are the curved lines (e, f)
the head of the radius, and the center of the ulnar head. The anatomic
130−140° 130°
81°
9−10°
a b c d
150−155°
60−70°
84°
e f g 30° h
Fig. 16.75 (a–h) Finding the reference lines and angles of the through the center of the capitate eminence and the point of transition
humerus (a) Finding the proximal anatomic angle in the frontal plane. from the medial epicondyle to the block of the humeral bone is used
(1) A line connecting the extreme points of the anatomic neck is to draw the axis of rotation of the elbow joint. (2) From the half dis-
drawn (line 1). (2) In the middle of this line, a perpendicular is drawn. tance between these points, a line at an 84°angle to the first line is
This is the axis of the anatomic neck (line 2). The middle of the axis drawn. (f) Finding the proximal anatomic angle in the sagittal plane.
of the anatomic neck is the center of the humeral head. (3) The mid- (1) A line connecting the extreme points of the anatomic neck is
diaphyseal line is identified (line 3). (4) The angle between the axis of drawn (line 1). (2) In the middle of this line, a perpendicular is drawn.
the anatomic neck (line 1) and the mid-diaphyseal line (line 2) should This perpendicular is the axis of the anatomic neck (line 2). The mid-
be 130–140°. (b) Finding the anatomic axis of the proximal bone dle of the axis of the anatomic neck is the center of the humeral head.
fragment. (1) The axis of the anatomic neck is drawn (a perpendicular (3) The mid-diaphyseal line is drawn. (4) The angle between the axis
from the middle of the line connecting the extreme points of the ana- of the anatomic neck (line 1) and the mid-diaphyseal line (line 2)
tomic neck). (2) From a point where the axis of the anatomic neck should be 150–155°. (g) Finding the distal anatomic angle in the sag-
crosses the line limiting the anatomic neck, a line at 130° angle to the ittal plane. (1) The mid-diaphyseal line (line 1) is drawn. (2) A line is
axis of the anatomic neck is drawn. Alternative variant: From the drawn through the center of the radiological circle corresponding to
middle of the line connecting the extreme points of an anatomic neck, the internal edge of the block and the top part of the plate, separating
a second line at a 40° angle to the first is drawn. (c) The joint line is the olecranon fossa and the processus coronoideus fossa (line 2).
crossed by a line perpendicular to the mid-diaphyseal line (anatomic Lines 1 and 2 should intersect at an angle of 30° (20–45°). (h) Finding
axis) at an angle of 9–10°. The distal joint line passes through the a retroversion of the distal part of the humerus. (1) A line through the
most distal points of the capitate eminence and the block of the center of the humeral head and intertubercular sulcus (line 1) is drawn.
humeral bone. (d) Finding the anatomic axis of the distal bone frag- (2) A second line is drawn through the center of the humeral condyle
ment. (1) The distal joint line is drawn. (2) From the block of the in the frontal plane (line 2). The angle between lines 1 and 2 should,
humeral bone a line at an 81° angle to the joint line is drawn. (e) on the average, be 60–70° (40–80°) (From [247])
Variant of finding the anatomic axis of the distal fragment. (1) A line
16.6.2 Upper-Limb Length Discrepancies If the arm is lengthened at the level of the proximal third
of the segment, the orientation of the proximal basic support
The general principles for the correction of these types of of the Ilizarov apparatus after wire placement has its specific
deformities are presented in Sect. 16.5.2. If the bone frag- requirements. The plane of the proximal basic half-ring
ments have consolidated, with shortening of the segment and should be at an angle of 100–105° to the axis of the arm,
retention of its axis, functional limitation of the extremity or open to the outside. Only then are the wires attached to the
cosmetic considerations should be considered as indications support. Next, taking advantage of the elastic deformation of
for reparative surgery. To lengthen the humerus, corticotomy the wires, the proximal basic support is oriented perpendicu-
with osteoclasis is performed above or below the zone of the lar to the longitudinal axis of the bone and connected to the
united bone fragments. Assembly of the external fixation transosseous module, which will fix the distal fragment after
device is similar to that shown in Fig. 2.3. corticotomy. This is necessary to correct a varus deformity of
Fig. 16.76 (a–o) Referent lines and angles of the bones of the fore- angle of the ulna is 112º (99–120º). (d) In the sagittal plane, the ulna has
arm. (a) In the frontal plane, the axis of the olecranon is located at an three bends: at the level of the border of the metaphysis and diaphysis,
85º angle (78–88º) to the joint line. The proximal anatomic angle is 20º 2º (0–5º); at the border of the proximal and middle thirds of the ulnar
(10–28º). At the border of the metaphysis and diaphysis, the ulna has a shaft, 1º (0–4º); and at the border of the middle and distal thirds of the
14º (7–20º) bend. (b) In the frontal plane, the mid-diaphyseal line of the ulnar shaft, 2º (0–5º). (e) In the sagittal plane, the ulna has a 3º (0–6º)
ulna has two bends: 5º (2–7º) at the level of the proximal and distal bend at the level of the middle third. (f) In the frontal plane, the proxi-
thirds of the diaphysis and 3º (0–5º) at the level of the middle and distal mal anatomic angle is 87º (86–88º). The radial bone has a 13° (9–18°)
thirds of the diaphysis. (c) In the sagittal plane, the proximal anatomic bend at the level of the tuberculum
m n o
840
1 mm (0)
(–)
12 mm
2–3 mm
(+)
the arm during distraction. Basic supports based on half-pins The assembly of the device used in the reconstruction
are placed perpendicular to the anatomic axis of the bone. stages is as shown in Fig. 16.77.
At humeral bone lengthening, corticotomy with osteocla-
sia should be done in the middle of the deltoid tuberosity of
the humerus, through the attachment zone of the deltoid 16.6.4 Angular Deformities
muscle [250].
The configuration of the Ilizarov device for bifocal upper The general principles for the correction of these kind of defor-
arm lengthenings is described in Sect. 16.7. mities are presented in Sect. 16.5.4. This deformity component
If both forearm bones are shortened uniformly and rota- leads to the greatest damage of arm function, especially defor-
tional movements are permanently limited, with a significant mities involving rotational movements of the forearm.
decrease in the arm force due to the closeness of the muscle As discussed previously, translation is crucial for arm
attachment points, corrective surgery is indicated. If the patient function. Therefore, in the correction of an angular deformity,
considers the rotational function to be satisfactory, cortico- the, osteotomy should be done as close to the CORA level as
tomy with osteoclasis of the ulna, usually above the deformity, possible; particularly in the correction of a radial deformity.
is warranted; the equivalent operation on the radius is per-
formed below the union of the bone fragments.
If the forearm bones are shortened unequally, as is gener- 16.6.5 Torsion Deformities
ally the case, only the shorter bone should be lengthened, to
restore the relationships in the radioulnar joint. However, it is Taking into consideration (Fig. 16.75h) the great range of
not improbable that both the ulna and the radius need to be normal values of humeral torsion, a torsion deformity is best
lengthened, for example in young patients with an occupa- identified by comparison with the other upper arm. Humeral
tion that requires complete restoration of the anatomy and retroversion <40° should be considered as pathological [247]
function of the forearm. In this case, osteotomy in the area of and therefore corrected.
the fragment union is preferable. After the length of the Elimination of humeral and forearm bone torsion along
bones has been restored, if the ends of fragments are incon- the mechanical axis will lead to secondary width displace-
gruent, their open adaptation may be required. ment (translation). The higher the osteomy is done, the
To determine the amount of lengthening for a segment greater the displacement.
with open growth zones, special calculations are used [102], In choosing the osteotomy level in the treatment of a con-
as described in Sect. 16.8. genital deformity, it is necessary to consider the attachment
sites of the muscles, tendons, and ligaments, as in the correc-
tion of lower limb deformities [102].
16.6.3 Peripheral Translation
The general principles for the correction of these types of 16.6.6 Examples of Deformity Correction
deformities are presented in Sect. 16.5.3. It must be taken into Planning in the Humerus: The Basic
account that translation is more significant for the forearm Frames Assemblies
bones (especially the radius) since rotational movements in this
case are the most limited. Greater range-of-movement limita- Figure 16.78 provides an example of deformity apex (CORA)
tion results in the combination of translation and shortenings. definition and approaches to the correction of a deformity in the
Fig. 16.76 (continued) (g) In the frontal plane, the radius has a 13° (sagittal plane). (1) Draw the mid-diaphyseal line in the distal third of
(8–15°) bend in its middle third. (h) At the border of the proximal and the bone (line 1). (2) Draw the joint line (line 2). Lines 1 and 2 should
middle thirds, the radius in the frontal plane has a 5º (4–6º) bend. At the cross at an angle of 83° (77–90°). Note that mid-diaphyseal line does
border of the middle and distal thirds the bend is 8º (5–13º). (i) Finding not cross the joint line at its center. (n) Finding the joint location levels
the distal anatomic angle of the radius (frontal plane). (1) Draw the of the radius and elbow bones. (1) Draw a line through the top of the
mid-diaphyseal line in the third of the bone (line 1). (2) Draw a line radial styloid process, perpendicular to the mid-diaphyseal line of the
forming a tangent to the top of the styloid process of the radius and radius (line 1). (2) Draw a second line parallel to the first line at the edge
internal edge of the articulate surface of the radius (line 2). Lines 1 and of the articular surface of the elbow bone. The distance between the two
2 should intersect at angle of 62° (61–63º). Note that the mid-diaphyseal lines should be 11–12 mm. (o) Determination of the variants of the joint
line does not cross the joint line through its center. (j) In the sagittal location levels of the radius and elbow bones. Draw the joint line of the
plane, the proximal anatomic angle is 86°(85–87º). The radial bone has elbow bone. In the (0)-variant, the joint lines are at one level (74%). In
a 5° (3–10°) bend in its proximal third. (k) In the sagittal plane, the the (−)-variant, the head of the elbow bone is located more proximal to
radius has a 4° (1–5°) bend at the border of its proximal and middle the radial joint line (4.3%). In the (+)-variant, the head of the elbow
thirds. (l) In the sagittal planes, the radius has a bend of 4° (1–6°) in its bone is located more distal to the radial joint line (21.7%) (From
middle third. (m) Finding the distal anatomic angle of the radius Ashkenazi 1990)
a b c
1 2 3 5 4
I,4-10; I,5,90(I,5,90); (II,9,90) – III V – (VII,10,120); (VIII,7-1) (a)
3/4 120 120 120 120
7 6
I,4-10; I,5,90(I,5,90); (II,9,90) – III V – VII,8,120; (VII,10,120); VIII,6-12(VIII,6-12) (b)
3/4 120 120 120 120
8 9 10 11
I,4-10; I,5,90(I,5,90) – III,8,90; (IV,10,90) V,8,6,90; (V,11,90) – VIII,6-12(VIII,6-12) (c)
3/4 120 120 120 120
Fig. 16.77 Stages of external fixation in patients with traumatic of the distal radial and ulnar joints has been restored, the distal
deformities of both forearm bones. (a) Since the radial bone is shorter fragments of the elbow bones and the radius are fixed by common
than the elbow bone, transosseous elements are inserted only through wire VIII,6-12(VIII,6-12). (c) After deformity correction
the distal fragment of the radius. (b) After the correct mutual location
proximal humerus. External fixation in similar cases can be Figures 16.84 and 16.85 provide examples of the defor-
carried out using the devices shown in Figs. 10.5 and 16.79. mity apex location and approaches to the correction of a
Examples of deformity correction planning for humeral deformity of the distal humerus. External fixation in similar
shaft deformities and the basic frame assemblies are shown cases can be carried out using the devices shown in Figs.
in Figs. 16.80, 16.81, 16.82, and 16.83. 10.16 and 16.56.
a b c
Fig. 16.78 Planning the correction of a varus deformity in the proxi- of the joint line at an angle of 40° to the joint line (Fig. 16.75b). The
mal humerus. The deformity components are located in the frontal mid-diaphyseal line is drawn. (b) The bisector of CORA and the osteot-
plane: angulation, translation, shortening. (a) Bone contour of the omy line are shown. (c) Turning around a point located on the defor-
deformity. The axis of the proximal fragment is drawn from the center mity bisector will eliminate all components of the deformity

for the correction of deformities a
of the proximal part of the humerus.
(a) Before correction. (b) After
correction
b

(c) Modular transformation of the c
frame
1 2 3 4 5
I,8,120; I,10,120; I,11,120 -o- III,9,120; V,10,70 (a)
1/2 150 140
I,8,120; I,10,120; I,11,120 -- III,9,120; V,10,70 (b)

1/2 150 140
I,8,120; I,10,120; I,11,120 -- III,9,120; V,10,70 (c)

1/2 150 1/2 140
a b c
Fig. 16.80 Planning the correction of a deformity in the distal third of are drawn. (b) The deformity bisector is shown; the osteotomy line is
the humeral shaft. The deformity components are located in the frontal marked. (c) Turning around a point located on the bisector, from the
plane: angulation, peripheral translation, shortening. (a) Deformity medial to the internal cortex, will eliminate all components of the
skiagram; the anatomic axes of the proximal and distal bone fragments deformity
Fig. 16.81 Basic device

assembly for the correction of a a
deformity in the proximal third
of the humeral shaft. (a) Before
correction. (b) After correction
b

c
transformation of the frame
3 1 2 4 5
I,10,120; II,8,90; II,11,90 -o- IV,9,120; VI,8,70 (a)
1/2 150 140
I,10,120; II,8,90; II,11,90 -- IV,9,120; VI,8,70 (b)

1/2 150 140
I,10,120; II,8,90; II,11,90 -- IV,9,120; VI,8,70 (c)

1/2 150 1/2 140
Fig. 16.82 Basic device

assembly for the correction of a a
deformity in the middle third of
the humeral shaft. (a) Before
correction. (b) After correction
b

3 1 2 4 5
II,8,120; III,10,90; IV,11,90 -o- V,9,90; VII,7,70 (a)
1/2 150 140
II,8,120; III,10,90; IV,11,90 -- V,9,90; VII,7,70 (b)

1/2 150 140
II,8,120; III,10,90; IV,11,90 -- V,9,90; VII,7,70 (c)

1/2 150 1/2 140

for the correction of a deformity a
in the distal third of the humeral
shaft. (a) Before correction.
(b) After correction
b

1 2 3 4 5
III,9,120; V,10,70 -o- VII,9,90; VIII,4,120; VIII,8,120 (a)
140 2/3 140
III,9,120; V,10,70 -- VII,9,90; VIII,4,120; VIII,8,120 (b)

140 2/3 140
III,9,120; V,10,70 -- VII,9,90; VIII,4,120; VIII,8,120 (c)

1/2 140 2/3 140
Fig. 16.84 Planning the correction of a supracondylar deformity. The

deformity components are located in the frontal plane: angulation,
translation, shortening. (a) Deformity skiagram; the anatomic axes of
the proximal and distal bone fragments are drawn. The axis of the distal
bone fragment is found as described in Fig. 16.75f. (b) The bisector of
the deformity and the osteotomy line are shown. (c) Turning around a
point located on the bisector will remove all components of the defor-
mity. Discrepancies between the bisector and osteotomy levels have led c
to the peripheral translation of the compelled fragments
a b c
Fig. 16.85 Planning the correction of a supracondylar deformity. The (b) The bisector of the deformity and the osteotomy line are shown.
deformity components are located in the sagittal plane: angulation, (c) Turning around a point located in the bisector will remove all com-
translation, shortening. (a) Deformity skiagram; the anatomic axes of ponents of the deformity
the proximal and distal (Fig. 16.75g) bone fragments are drawn.
16.6.7 Examples of Deformity Correction deformities of the forearm. External fixation in similar
Planning in the Forearm Bones cases can be carried using the devices for fracture healing
(Chap. 11). The basic difference is that the necessary spatial
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh orientation of the fragments is obtained not in one stage, but
gradually. The principles of mutual displacement of tran-
Figures 16.86, 16.87, 16.88, 16.89, 16.90, 16.91, 16.92, sosseous modules (Figs. 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9) can
16.93, 16.94, 16.95, and 16.96 provide examples of the be applied as well.
deformity apex location and approaches to the correction of
a b c
Fig. 16.86 Planning the correction of a supracondylar deformity. The The bisector of the deformity and the osteotomy line are shown. (c)
deformity components are located in the sagittal plane: angulation, Turning around a point located in the bisector will remove all compo-
translation, shortening. (a) Deformity skiagram; the anatomic axes of nents of the deformity
the proximal and distal (Fig. 16.75g) bone fragments are drawn. (b)
a b
2 1 3 4
III,9,120; V,10,90 – VIII,3-9; VIII,8,120 (a)
140 3/4 140
III,9,120; V,10,90 – VIII,3-9; VIII,8,120 (b)

1/2 140 3/4 140
Fig. 16.87 (a) Basic frame assembly for the correction of a deformity in the distal part of the humerus. (b) Modular transformation of the frame
a b c d e f
1/2
900
1/2
1130
Fig. 16.88 Planning the correction of a deformity in the proximal osteotomy line, located at the same level, are shown. (d) Turning around
third of the elbow bone in the sagittal plane (with the forearm in mid- a point located at the intersection of the bisector and the posterior cor-
position between supination and the pronation). The deformity compo- tex will eliminate the angular deformity; insignificant shortening
nents are angulation, shortening. (a) Bone contour of the deformity; the remains; (e) With the aid of distraction, the last component of the
anatomic angle is 90º. (b) The anatomic axes of the proximal part of deformity (shortening) is eliminated. (f) The epidiaphysis angle is
the ulna and the diaphysis are drawn. (c) The deformity bisector and the normalized (113º)
a b c d e f
30
30 30
Fig. 16.89 Planning the correction of a deformity in the middle third line is marked (more distal than the CORA level due to the poor condi-
of the elbow bone in the sagittal plane (with the forearm in mid-position tion of the soft tissues). (d) The osteotomy is performed, shortening is
between supination and the pronation). The deformity components are eliminated by means of distraction. (e) Turning around a point located
angulation, translation, shortening. (a) Deformity skiagram; the ana- at the apex of the deformity level will eliminate the angular deformity
tomic axes of the proximal and distal halves of the diaphysis are drawn. and the peripheral displacement. (f) A superfluous periosteal callus on
(b) The arrow specifies the apex of the deformation. (c) The osteotomy a posterior surface of an elbow bone is removed
a b c d e
50 50 50 50 50
Fig. 16.90 Planning the correction of a deformity of the

middle third of the ulna in the frontal plane (with the
forearm in mid-position between supination and
pronation). The deformity components are angulation,
translation, shortening. (a) Deformity skiagram; the 30 30 30 30 30
anatomic axes of the proximal and distal thirds of the
ulnar shaft are shown. (b) From the side of the proximal
and distal fragments, the axes of the shaft’s middle third
are drawn. The apex of deformation (CORA) is at the
intersection of these lines (arrow). (c) The bisector of the
deformity is shown. (d) An osteotomy is performed at the
CORA level. Turning around a point located at the
intersection of the bisector and the external cortex will
eliminate the angular deformity and the translation;
insignificant shortening remains. (e) With the aid of
distraction, the last deformity component is eliminated
a b c d e
Fig. 16.91 Planning the correction of a deformity the middle third of specifies the apex of the deformation (CORA). (b) The bisector of the
the radial shaft in the frontal plane (with the forearm in mid-position deformity is shown. (c) A line indicates the assumed osteotomy level
between supination and pronation). The deformity components are (through the union zone of the bone fragments). (d) In the first stage,
angulation, translation, shortening. (a) Deformity skiagram; the axes of radial shortening is eliminated. (e) In the second stage, angulation and
the proximal and distal halves of the radial shaft are drawn; the arrow translation are eliminated by turning around the CORA point

(f, g) Turning around a point located f g h i
on the deformity bisector will
eliminate all the components of the
deformity. (h) Variant of osteotomy
at the level of the apex of deforma-
tion. Angulation and translation are
eliminated by turning around the
crossing point of the bisector and the
internal cortex. (i) By means of
distraction, shortening is eliminated
a b c d e
140 140 140
40 40
Fig. 16.92 Planning the correction of a deformity of the middle third the deformity is shown. (c) The osteotomy line (at the level of CORA)
of the radial shaft in the sagittal plane (with the forearm in the mid- is marked. (d) Turning around the intersection of the bisector and exter-
position between supination and pronation). The deformity components nal cortex will eliminate both the angular deformity and translation;
are angulation, translation, shortening. (a) Deformity skiagram; the insignificant shortening remains. (e) With the aid of distraction, the last
axes of the proximal and distal halves of radial shaft are drawn; the deformity component is eliminated
arrow indicates the apex of deformation (CORA). (b) The bisector of
Fig. 16.93 Planning the correction of a

deformity in the distal third of the radial a b c d
shaft in the sagittal plane (with the forearm
in mid-position between supination and
pronation). The deformity components are
angulation, shortening. (a) Deformity
skiagram; the axes of the proximal and
distal halves of the radial shaft are drawn;
the arrow indicates the apex of deformation
(CORA). (b) The deformity bisector is
shown and the osteotomy line (at the CORA
level) is marked. (c) In the first stage,
angulation is eliminated by turning around
the crossing point of the bisector and the
external cortex. (d) With the aid of
distraction, the last component of the
deformity is eliminated
40 40
40 40
a b c d
Fig. 16.94 Planning the correction of a

deformity of the radial distal metaphysis in the
frontal plane (with the forearm in mid-position
between supination and pronation). The
deformity components are angulation,
translation, shortening. (a) Deformity skiagram;
the axes of the proximal and distal bone
fragments are drawn; the apex of deformation is
shown. (b) The deformity bisector is drawn and
the point on the bisector for deformity correction
specified. (c) A line specifies the assumed
osteotomy level. (d) Turning around this point
eliminates all components of the deformity
Fig. 16.95 Planning the correction of a deformity a b c d

of the radial distal metaphysis in the sagittal plane
(with the forearm in mid-position between supination
and pronation). The deformity components are
angulation, translation, and shortening. (a) Deformity
skiagram; the axes of the proximal and distal bone
fragments are drawn; the apex of deformation is
shown. (b) The deformity bisector is shown, and the
point on the bisector for deformity correction
specified. (c) A line indicates the assumed osteotomy
level. (d) Turning around this point eliminates all
components of the deformity
a b c d
Fig. 16.96 Planning the correction of

a deformity of the ulna and radius
(with the forearm in mid-position
between supination and pronation).
The deformity components are
angulation, translation, shortening.
(a) Deformity skiagram; the axes of
the proximal and distal bones
fragments are drawn; the apexes of
deformations are shown. (b) Angular
deformity of the ulna is eliminated.
(c) Angular deformity of the radius is
eliminated; there is “over-
lengthening.” (d) The radial fragments
are compressed; the correct mutual
relationships between the distal
radial-ulnar joint are restored
16.7 Special Features of Deformity achondroplasia is identified as disproportional dwarfism

Correction in Achondroplasia accompanied by isodactylism and micromelia of the seg-
ments of both the upper and the lower extremities. Despite
Konstantin Igorevich Novikov the retardation in intrauterine limb growth, the height of the
and Anna Majorovna Aranovich newborn with this condition is approximately the same as
that of healthy infants. Due to skull-base malformation, the
face acquires a shape typical for the condition: protruded to
16.7.1 Introduction forward frontal bones, a saddle nose, and prognathism. The
calvarial bones and the facial bones arise from endesmal
Achondroplasia is a systemic skeletal disorder that has been ossification and develop normally [259].
studied thoroughly by clinicians, radiologists, and geneti- Throughout physical development, the predominant
cists. The disease is associated with disturbances in the lon- symptom of the disease is growth retardation, such that when
gitudinal growth and development of the tubular bones and is natural growth is completed patients with achondroplasia are
characterized by evident clinical symptoms. The condition typically 30–41 cm shorter than healthy individuals of com-
results from abnormal enchondral growth in the long and parable age. The average height of patients with achondro-
short tubular bones, in turn leading to short stature, microme- plasia, as measured in a standing position, is 130 cm for
lia, and a disproportionate relationship between the length of males and 122 cm for females.
the torso and that of the extremities [27, 251–255]. Short stature and the disproportionality between the
The first mention of this disease in the medical literature length of the trunk and limbs is not only a cosmetic defect
was by Glissan (1660). The term achondroplasia was intro- but also has psychological repercussions, as many of these
duced in 1876, by Parrot, who described the disease in detail. patients have an inferiority complex that is manifested in
Until the 1870 s, achondroplasia was considered to be due many aspects of their social environment. For example, they
to congenital syphilis or a manifestation of rickets. In 1900, have difficulties when using household devices or public
Marie specified this type of dysplasia, and the disease received transport, in buying clothes, and in everyday life. Moreover,
the name Parrot-Marie syndrome. In 1892, Kaufmann intro- when they become adults their job opportunities are extremely
duced the term chondrodystrophy, which more exactly limited. These problems as well as the desire for cosmetic
reflected the pathogenesis of the disease. He also proposed improvement are the reasons why many patients desire oper-
a classification that identified its three types: chondrodystro- ative treatment. Despite the marked clinical manifestations,
phy hyperplastica, hypoplastica, and malacica. According to patients with achondroplasia are physically strong and their
the classification of Volkov [256], achondroplasia refers to intelligence is normal [260].
physeal dysplasias. The international classification accepts Usually, an achondroplastic infant has a thoracolumbar
achondroplasia as the most rational term,, since the condi- hump at birth that gives way to a considerable lordosis when
tion is associated with an anomaly in the development of the the child starts walking. Lordosis occurs at the lumbar-sacral
fetal chondroblastic system, i.e., a congenital deficiency in junction and contributes to the significant loss in height
the zone of chondral proliferation. (Fig. 16.97).
Achondroplasia is inherited as an autosomal dominant In children and adolescents, there is commonly excessive
trait; however, most cases appear as spontaneous mutations extension in the majority of the joints. Overextension in the
(80% are sporadic and 20% are inherited from affected par- knee joint is accompanied by instability in practically all
ents). The incidence of the disease ranges from 1:40,000 to cases. As a rule, the extension in the elbow joint is limited. By
1:100,000 births. However, while achondroplasia is undoubt- the time of growth completion, persistent contractures develop
edly a genetic condition, the causes of the mutations remain in the hip and elbow joints that not only aggravate the appar-
unclear, such that active prevention of the disease is not, at ent cosmetic defect but also considerably affect locomotor
this point in time, possible and the only preventative mea- function. The elevated position of the fibular heads visually
sures are family planning. worsens the varus deformity in the lower limbs (Fig. 16.98).
A statistically significant rise in the frequency of sporadic Given the absence of etiological and pathogenetic
achondroplasia has been shown to increase with parental approaches to prevent achondroplasia, orthopedic surgeons
age, particularly that of the father (32.7 ± 0.02 years for the have examined operative methods of skeletal correction. The
father and 29.3 ± 0.02 years for the mother) [257]. Thompson complex approach to the operative lengthening of the upper
et al. established the tendency that advanced parental age and lower extremities, aimed at partial or complete elimina-
correlates with a increased severity of achondroplasia. Wilkin tion of the disproportion between the trunk and the limbs,
et al. [258] found that the incidence of sporadic mutations in has become possible only since the development of external
achondroplasia was about 97% and was directly associated fixators. Nevertheless, despite reliable external fixators and
with the age of the father. limb lengthening techniques, until the mid-1980s orthopedic
Achondroplasia is easily diagnosed based on its typical surgeons did not unanimously support this form of operative
physical features, evident immediately at birth. Clinically, treatment.
16.7.2 Special Features of Long Bone Formation reduced longitudinal bone measurements, thickened cortical
in the Lower Limb plates, and sharply widened metaphyses and apophyses.
By the age of 7–10 years, the length of the femur in these
The long bones of the lower limbs of patients with achondro- patients is only 19–21 cm. The greater trochanter is exces-
plasia have several peculiarities: increased transverse and sively marked and beak-shaped. When measured on radio-
graphs, the neck-to-shaft angle is 124° ± 4° (Fig. 16.99). The
a b height of the growth zone is uneven and multilayered in
structure. The epiphyses are deformed and the intercondylar
fossa has the shape of an irregular oval.
In patients 11–14 years of age, the length of the femur is
23–25 cm. The intertrochanteric area is widened; the greater
and lesser trochanters are excessively marked and deformed.
The cortical layer is unevenly thickened (Fig. 16.100).
In achondroplasia patients age 15–17 years, the length
of the femur is 26–29 cm. Femoral radiographic images
show maturity and the same features as those in the previ-
ously described age period. At the time of natural growth
completion, the average standing height is 132.3 ± 0.17 cm in
males and 125.9 ± 0.2 cm in females. Compared with healthy
individuals of the same age, this corresponds to an average
height difference of 21.3% in males and 23.6% in females
(Fig. 16.101).
In the sitting position, the height is 85 and 80.5 cm for
males and females, respectively (Fig. 16.102), and thus close
to the normal values for this age group. The small difference
Fig. 16.97 Lumbar lordosis in two patients with achondroplasia: of 5–7% is associated with the accompanying spinal defor-
(a) 6 years and (b) 14 years of age mities in patients with achondroplasia.
a b c
Fig. 16.98 Patients with

achondroplasia: (a) 6 years, (b)
14 years, and (c) 25 years of age
a b
Fig. 16.99 Radiographs of the femurs in two patients with achondroplasia: (a) 7 years and (b) 10 years of age
a b
Fig. 16.100 Radiographs of the femurs in two patients with achondroplasia: (a) 11 years and (b) 14 years of age
Fig. 16.101 Height dynamics in 180

patients with achondroplasia and 170
healthy individuals, based on height
measured in the standing position 160
150
140
130
120
cm
110
100
Female (healthy)
90
Female (achondroplasia)
80
Male (healthy)
70
Male (achonftoplasia)
60
50
8 9 10 11 12 13 14 15 17
Age
Fig. 16.102 Height dynamics in 100

patients with achondroplasia and
healthy individuals, based on 95
height measured in the sitting
position 90
85
80
cm
75
70
Female (healthy)
65
Female (achondroplasia)
60
Male (healthy)
55
Female (achondroplasis)
50
8 9 10 11 12 13 14 15 17
Age
The anatomic length of the femur in achondroplasia of 15. In males, it is 61.7 ± 0.5 cm, or 46.5% of body height
patients is 25.9 ± 0.6 cm in males and 25.1 ± 0.2 cm in females, (54.1% in healthy male subjects of the same age). In
which is 42% less than the corresponding values of healthy females, the length of the lower limb upon growth com-
subjects of the same age. According to the Filatov, who completion is 58.0 ± 0.7 cm, 46% of body height (53.9% in
pared the parameters of the adult body and lower limbs for healthy females). In all age groups, males and females
healthy individuals and those with achondrolasia, the ratio of with achondroplasia have a significant retardation in lower
femoral length to height in an upright standing position is limb growth, with the mean difference of 26.8 ± 1.4 cm or
24.2%. In achondroplasia, it is 19.8% (Table 16.4). 33.9% compared to measurements in healthy subjects.
Moreover, the length of the lower limbs in patients with The limitation of the joint motion is characterized by
achondroplasia remains practically constant until the age symmetry (Table 16.5).
The greater trochanter lies on the Rozer-Nelaton line; the The mean lower leg length is 21.6 ± 0.3 cm in males, and
Trendelenburg sign is absent. The range of motion in the 21.3 ± 0.4 cm in females. The difference from the normal
knee joints is not considerably affected. In children of young anthropometric sizes is 49.1%. The normal ratio of lower leg
age, overextension in the knee joints displaces the center of length to height in an upright standing position is 23.5%
gravity forward, thus increasing the lumbar lordosis. Specific while in achondroplasia it is only 16.5%. The relationship of
gender-related differences have not been noted. the lower leg to the entire lower extremity is 43.5% and
The patients’ joints have several distinct features, both 35.6%, respectively (Table 16.6).
in bone and ligament structure. In achondroplasia, the lat- An ultrasound study of the knee joint in achondroplastic
eral condyle of the femur is underdeveloped; there is a patients will reveal the laxity of the lateral ligaments and
compensatory varus deformity of the proximal tibial epi- thickening of the lateral and cruciate ligaments when com-
physis, narrowing of the knee-joint gap, and changes in the pared with healthy subjects of the same age.
elasticity of the musculoligamentous system (lateral insta- It is generally believed that, in achondroplasia, the bones
bility in 100% of children or adolescents, and 30% of of the proximal parts of the limbs (humerus and femur) have
adults; “anterior drawer” in 84% of children and adoles- a greater degree of growth lag. However, the large bulk of the
cents, and in 10% of adults). soft tissues, the short limb segments, and the absence of clear
Lateral instability in the knee joint is characterized by age anatomic borders impair accurate anthropometric measure-
dependence: in young children it is 100% but by age 15–18 ments. The femoral and tibial age-related parameters obtained
it decreases to 46.2% for valgus and 30.8% for varus from radiographic studies in achondroplasia point to a
deformities. decreasing tendency in the ratio of the tibial length to that of
the femur by the end of natural growth (Fig. 16.103).
Table 16.4 Lower limb segment-length dynamics with age in patients The length of the femur is less than that of the complex
with achondroplasia (anthropometric data)
formed by the tibia plus foot. The bones of the hind foot that
Age Femur length (cm) Lower limbs length (cm) are not of tubular structure develop practically normally,
(years) M F M F such that foot height is retained and adds to the length of the
6–8 19.4 ± 0.1 19.2 ± 0.1 45.6 ± 0.1 44.9 ± 0.4 distal limb part. In the normal tibia plus foot complex, the
9–11 21.1 ± 0.2 20.8 ± 0.1 51.3 ± 0.3 49.2 ± 0.2
length is approximately equal to the that of the femur. The
12–14 23.4 ± 0.4 23.0 ± 0.4 52.2 ± 1.5 53.4 ± 1.1
mean length of achondroplastic tibia plus foot complex is
15–17 25.5 ± 0.2 24.2 ± 0.4 58.9 ± 1.1 55.7 ± 0.9
111.2% that of the femoral length (Fig. 16.104).
18–20 25.4 ± 0.1 24.7 ± 0.06 61.7 ± 4.2 58.7 ± 4.8
The local bone age of the tibia in a 1-year old child with
>20 25.9 ± 0.6 25.1 ± 0.2 61.7 ± 0.5 58.0 ± 0.7
achondroplasia does not differ from that of the normal child
of the same age. Instead, the difference consists of radio-
Table 16.5 Range of motion (in degrees) in the lower limb joints of graphic peculiarities in the structure of the achondroplastic
patients with achondroplasia according to age group
lower leg bones. The metaphyses are plate-shaped and wid-
Motion range in age groups ened. The surface of the epiphyseal growth zone is uneven
Up to 7–10 11–14 15–18 and fringed. The fibula is of the same length as the tibia and
6 years years years years
Joint Motion type old old old old is frequently deformed in its middle third (Fig. 16.105).
Hip joint Abduction 135 140- 145 155 At the age of 2 years, the ossification points are not
Adduction 60 55 50 55 delayed in their development and correspond to those of
Flexion 40 40 40 30 healthy children. However, the distal tibial epiphyseal growth
Extension 150 155 160 170 zone is uneven, forming an arch with signs of varus or valgus
Internal rotation 55 40 50 40 deformities (Fig. 16.106).
External rotation 65 60 70 45 At the age of 3 years, the proximal epiphysis frequently
Knee joint Flexion 40 30 35 45 acquires a ball shape. Points of ossification are seen in the
Extension 180 + 5 180 180 180 distal tibial and fibular epiphyses. The distal tibial epiphysis,
Age Lower leg length (cm) Foot length (cm) Lower leg + foot (cm)
(years) M F M F M F
6–8 16.3 ± 0.4 15.7 ± 0.1 16.4 ± 0.0 15.8 ± 0.1 21.7 ± 0.1 21.1 ± 0.0
9–11 18.1 ± 0.1 17.2 ± 0.0 18.1 ± 0.1 17.1 ± 0.0 24.5 ± 0.2 22.9 ± 0.0
Table 16.6 Growth 12–14 19.3 ± 0.4 18.6 ± 0.2 18.7 ± 0.2 18.0 ± 0.0 26.8 ± 0.3 24.1 ± 1.6
dynamics of the lower limb 15–17 21.5 ± 0.2 19.7 ± 0.1 20.2 ± 0.0 19.0 ± 0.8 27.2 ± 1.1 24.4 ± 0.3
segments of achondroplasia
18–20 21.8 ± 0.1 21.5 ± 0.3 21.8 ± 0.1 20.0 ± 1.0 28.5 ± 0.4 25.5 ± 0.9
patients according to age
(anthropometric data) >20 21.6 ± 0.3 21.3 ± 0.4 21.3 ± 0.4 20.0 ± 0.1 27.2 ± 0.1 27.9 ± 0.2
Fig. 16.103 Relationship 82

between tibial and femoral
lengths in achondroplasia (based 81
on radiographic studies)
80
79
78
77
76
75
74
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age
Fig. 16.104 Relationship 114

between the tibia + foot complex
and femoral length in
achondroplasia 113
112
%
111
110
Female
Male
109
108
9-8 9-11 12-14 15-17 18-20 CT-20
Age
in the presence of a varus deformity, is more marked from of the tibia becomes uneven and fringed. There is a notable
the medial side. Valgus deformity quite often involves the lag in the height of the medial edge of the proximal epiphy-
middle third of the tibia. The fibula is straight, resembling a sis. The structure of the metaphyses is not uniform but is
“tensed bow string” relative to the deformed tibia. Its length porous, with areas of rarefaction that are limited by the zone
is equal to that of the tibia. of sclerosis and well-visualized in the central part. As a
By 4 years of age, the points of ossification in the tibia are rule, the fibula is 0.8–1.0 cm longer than the tibia
considerably smaller than normal. This is more evident dis- (Fig. 16.108).
tally (Fig. 16.107). By the age of 8 years, the proximal epiphysis is widened,
The fibula acquires a concave or convex arch. The length flattened, and has acquired a cuneiform shape. The tibia axis
of the bone is equal to or slightly exceeds that of the tibia. features a varus deformity of the diaphysis at the junction of
The transverse aspects of the lower leg bones tend to become the upper and middle thirds, in the majority of patients. The
wider than is normal. fibula is arched backwards and deformed; typically, it is 1.0–
Occasionally, in 6-year old patients, proximal ossification 1.5 cm longer than the tibia. There are ossification points in
points can be identified in the fibulas. The articular surface the calcaneal tuberosity of the foot (Fig. 16.109).
Fig. 16.107 X-ray image of the lower limbs of a 4-year-old patient

Fig. 16.105 X-ray image of the lower limbs in a 1-year-old child with with achondroplasia
achondroplasia
Fig. 16.106 X-ray image of the lower limbs in 2-year-old child with Fig. 16.108 X-ray image of the lower leg in a 6-year-old patient with
achondroplasia achondroplasia
Fig. 16.110 X-ray image of the lower leg of a 14-year-old female

patient with achondroplasia
Fig. 16.109 X-ray image of the lower leg in an 8-year-old patient with
achondroplasia
By age 14–15, the growth zones can no longer be visual-

ized (Fig. 16.110) and the region of the epiphyseal cartilage
is sharply narrowed.
Due to uneven growth, the fibula goes upwards, bows
arch-like and becomes located posteriorly in relation to the
tibia. In patients age 15 years and older, the radiographic pic-
ture of the lower leg bones and foot does not change
(Fig. 16.111).
16.7.3 Special Features of Humerus Formation
The peculiar radiographic features of the humerus in patients

with achondroplasia become apparent beginning in early
childhood. The normal humerus develops from a single pri-
mary point of ossification and has seven accessory points of
ossification, three in the upper end of the bone and four in the
distal part. Normally, each point appears at a definite age of Fig. 16.111 X-ray image of the lower leg of a 26-year-old female
the child’s development, but in achondroplasia at some patient with achondroplasia
growth stages the timing of ossification is abnormal. Thus,
the point of ossification in the achondroplastic humeral head By 6 years of age, the shape of the humerus in achondro-
appears between 14 and 18 months of age, and even later, plasia becomes more evident. The diaphyseal part acquires
which is a 6–12 month delay compared to normal growth. By its contours but the metaphyses are massive and deformed.
the age of 4 years, the humerus of a child with achondropla- The deltoid tuberosity is well expressed and the ossification
sia is a massive formation, with sharply widened and irregu- points in the greater tuberosity are seen. As development
larly shaped metaphyses. continues, all points of ossification merge to form a whole
bone mass, at which stage the humerus takes on its charac- Synostosis of the distal epiphysis with the metadiaphysis
teristic achondroplastic shape, i.e., the humeral head occurs in patients 14–15 years of age (Fig. 16.112). By the age
becomes a massive greater tuberosity that occupies almost of 17, the short size of the bone is obvious. It is massive, fre-
the entire bone diameter. The epiphyseal fissure is deformed quently bowed and the metaphyseal parts are considerably
and of unequal width, displaced outwards, while the base of thickened while the medial condyle protrudes beak-like. The
the triangle that represents the epiphyseal fissure, as seen on points of attachment (apophyses) of the most powerful muscles
the radiograph, is located at an angle to the longitudinal of the shoulder girdle (pectoralis major and deltoid muscles)
bone axis. are sharply expressed in some patients. The deltoid tuberosity
At 9 years of age, the humerus obtains its specific achon- maintains its rough fibrous structure but increases further in
droplastic shape and structure. It is S-like deformed, with size such that it rises over the diaphysis for 1.5–2 cm.
humeral varus frequently seen in the lower third of the bone. In patients with achondroplasia, longitudinal bone growth
The cortical plate is thickened and the diaphyseal part is disturbance is the main symptom, with a number of age-
dense, which produces an intensive shadow (unlike the epi- related features. In patients 1.5–2 years of age, the length of
physes) on X-ray. the humerus, as measured on radiographs, is 6–7 cm. From
The greater tuberosity and the deltoid tuberosity achieve the age of 2–10 years, it grows faster, adding 6–7 cm on aver-
considerable size and acquire a rough fibrous structure. age, i.e., its length practically doubles.
Fig. 16.112 (a, b) X-ray images

of the humerus in a 14-year-old
a
patient with achondroplasia
b
16.7.4 Special Features in the Formation

of the Forearm Bones
Unlike the humerus, the bones of the forearm in patients with

achondroplasia do not exhibit rough deformities in radio-
graphs obtained from children 1–2 years of age. Their thick-
ness and structure differ little from normal bones of the same
age. The radius seems distally displaced as a result of the late
appearance of the distal point of ulnar ossification and the
delayed growth of the ulna as a whole, including its proximal
part. By the age of 4 years, the first signs of the deformities
in both bones can be detected. At age 10–11 years, ulnar and
radial tuberosities become evident, and are clearly mani-
fested in patients 13–14 years of age. A Madelung’s or anti-
Madelung deformity is possible due to the unequal growth of
the forearm bones, as well as to the subluxation or disloca-
tion of the radius. The points of attachment of the most pow-
erful muscles to the forearm bones become sharply expressed
in most patients, and the olecranon (the site of the humeral
triceps muscle attachment), at least in our experience, causes
incomplete extension of the elbow joint. The ossification
point of the distal radial epiphysis appears by age 3 and not
earlier, with the bone achieving its full width in patients age
9–10 years (as in normal children); the epiphysis acquires a
triangular shape and is frequently shifted transversally, to the
medial side relative to the diaphysis. The proximal point of
Fig. 16.113 X-ray image of the forearm in a 17-year-old patient with
ossification is seen by the age of 7–8 years. achondroplasia
The accessory distal point of ulnar ossification develops
by the age of 8 years but in some patients as young as 6 years
old the ossification nucleus may be detected radiographi- length of the upper limb segments is 74% for the humerus
cally. The synostosis in the proximal epiphysis occurs at the and 75% for the forearm relative to the length of the seg-
age of 14–15 years, and in the distal epiphysis at the age of ments of normal children of the same age. By 17 years of
16–17 (Fig. 16.113). The length of the radius in most 2-year- age, these values are 70% and 69%, respectively, indicating
old patients measures 6–6.5 cm, and its length doubles only delays in segment growth with increasing age.
by the age of 13–14 years. By age 18, the radius is 13–15 cm In achondroplasia patients 2–18 years old, the basic abso-
long, such that the total increment is 7–9 cm or 120–130% lute increment is 150–170% for the humerus and 120–130%
from the bone’s length at 2 years of age. for the forearm.
The growth rate of the forearm is fast in young children,
although it is notably less than the growth rate of the humerus,
with significant alterations in the annual mean of 5.4%. By 16.7.5 General Principles of Operative
14–15 years, the forearm length has increased 2.3-fold, cor- Treatment
responding to a 130% increment.
Normal skeletal development is characterized by a faster In November 1983, at the Soviet-German orthopedic sympo-
growth rate in the proximal limb segments than in the distal sium organized by the Faculty of Medicine of Munich
ones. This tendency, according to our data, is also seen in the University and held in that city, G.A. Ilizarov delivered a report
course of growth of patients with achondroplasia. Thus, the on the operative treatment of patients with achondroplasia and
linear regression equation describing the age dynamics of for the first time presented the results of their medical rehabili-
upper limb segment length in achondroplasia patients tation. After the presentation, H. Wagner, chairman of the
between the ages of 2 and 7 (according to anthropometric symposium, stated that it was absolutely hopeless to increase
findings) is y = 0.7355x + 11.342 for the humerus and the stature of these patients. He concluded that their orthope-
y = 0.5017x + 10.41 for the forearm. The angle coefficients dic management should be limited to operative correction of
reveal that the growth rate is notably higher in the proximal the existing deformities and the prevention of others yet to
segments than in the distal ones. In boys 8 years of age, the appear. But a great number of specialists unanimously agreed
that limb lengthening in achondroplasia was not only a medi- Fig. 16.114 Patient K. A hump in the
cal but also a social obligation. thoracic spine is seen on this lateral view
In 1991, Caton [261] specified that distraction osteosyn-
thesis using external fixation devices—preferably the Ilizarov
apparatus—was the most promising method to achieve limb
lengthening aimed at stature increase in patients with achon-
droplasia. Operative lengthening in such cases is aimed not
only at solving the problem of short stature and restoring the
proportions between the segments of the upper and lower
limbs but also at improving the proportions between torso
length and the lengths of the extremities.
In patients with achondroplasia, the specific contraindica-
tions to operative lengthening of the limbs using the Ilizarov
method of transosseous osteosynthesis are severe accompa-
nying somatic diseases, psychological disorders and other
conditions indicating the patient’s inability to follow through
with treatment, chronic inflammation independent of its
location, anatomic disorders involving the spine, such as spi-
nal deformities or a hump (Figs. 16.114 and 16.115), and
neurologic disorders, either congenital or acquired. In addi-
tion, any trophic disorder in the distal parts of the limbs is an
absolute contraindication to a lengthening procedure in
achondroplasia. A contraindication to femoral lengthening
in such patients is femoral or tibial subluxation. Knee-joint
contracture with a range of motion <90° can be a temporary
contraindication to femoral lengthening.
a b
Fig. 16.115 X-ray images of

the spine with wedged vertebrae:
(a) AP view, (b) lateral view
Considering (or due to) the fact that extensive lengthening adult cases, when the patient does not plan to undergo length-
for each segment is planned from the very beginning in ening of the lower limbs or the operation is not possible, then
patients with achondroplasia, bifocal distraction osteosyn- he or she should be encouraged to nonetheless undergo
thesis is generally used, with the lengthening of two seg- lengthening of the upper limbs, as this is of great importance
ments in a single treatment stage. Lengthening of the lower for self-esteem reasons in addition to the fact that longer
limb segments (femurs and tibias) is performed to achieve arms allow greater self sufficiency.
height augmentation while lengthening of the humerus is
sufficient to restore the proportions between the lengths of 16.7.5.1 Clinical Case
the lower and upper limbs and for functional purposes. A 7-year old female patient was diagnosed with: achondro-
The preoperative planning for a patient to be operated on plasia, short stature, and a 170° varus deformity in the tibias.
for the first time should consider all stages of treatment from The objective findings at admission were: height in an upright
the very beginning. The RISC RTO algorithm, developed for standing position 97 cm and in a sitting position 66 cm. The
treating such patients, is based on their division into two age lower limb length measured 40 cm down to the medial mal-
groups: children 6–12 years of age, and adolescents and leolus and 46 cm to the heel. The anthropometric length of
adults. In the first group, the following stages of rehabilita- the lower limb segments was: femur, 19 cm; tibia, 15 cm;
tion are recommended: foot, 18 cm. Bifocal distraction osteosynthesis was per-
Stage I. Parallel lengthening of both tibias following pro- formed in the consecutive lengthening of the right tibia and
cedural variants such as simultaneous lengthening of both the contralateral femur. First, upon completion of the planned
tibias and consecutive lengthening of the tibias. examination, a double corticotomy was performed in the
Stages II and III. Crossed lengthening of the femur and patient’s right lower leg bones followed by osteosynthesis of
tibia following procedural variants such as simultaneous the tibia and foot using the Ilizarov fixator. On postoperative
lengthening of the contralateral femur and tibia and consecu- day 39, the intervention aimed at lengthening of the left
tive lengthening of the contralateral femur and tibia. femur was carried out.
In the case of primary lengthening of both tibias, young The duration of the distraction period at the first stage was
patients have the opportunity to catch up in height with chil- 89 days for the tibia and 71 days for the femur; the fixation
dren of the same age after a one-stage procedure, with a period lasted 67 and 54 days, respectively (Fig. 16.116). The
break in treatment of several years. objective findings at that stage were: height in standing posi-
In adolescents and adults who are considering operative tion 112 cm, and in the sitting position 69 cm.
treatment for the first time, two-stage lengthening of the lower One year later, at the second stage, consecutive lengthen-
limbs is recommended. Stages I and II include crossed length- ing of the right femur and left lower leg bones resulted in
ening of the femur and tibia in procedural variants of simulta- limb segments of equal length (Fig. 16.117). The distraction
neous lengthening of the contralateral femur and tibia, and period was 62 days for the femur and 76 for the tibia; fixation
consecutive lengthening of the contralateral femur and tibia. lasted for 48 and 63 days, respectively. The lower limb seg-
Lengthening of the humerus in both groups is performed, ments were equal in length. At discharge from the hospital,
as a rule, during the final treatment stage. The technique of the patient’s height was 124 cm (Fig. 16.118).
simultaneous segment lengthening is always used for single- At the age of 10 years, the same patient underwent a
stage lengthening of both humeri. 10-cm bifocal lengthening of both humeri. Objective findings
In addition, the orthopedic surgeon should consider social at the time of discharge from the hospital were: height in
and organizational factors, and, of course, the patients’ and standing position 132 cm and in the sitting position 74 cm.
his or her parents’ wishes. Thus, for a number of patients, The relative length of the lower limbs was 63 cm down to the
lengthening can be carried out according to an individual medial malleolus and 68 cm to the heel. The range of motion
treatment algorithm. For example, parents may prefer a two- in the joints of the lower limbs recovered completely
staged lengthening of the lower limbs for their child. In some (Fig. 16.119).
Fig. 16.116 X-ray images of a

7-year-old female patient during
a b
the course of lower leg
lengthening. (a) The lower leg
before treatment and (b) after
surgery, (c) The lower leg during
the fixation period and (d) after
fixator removal
c d
Fig. 16.117 X-ray images of

a b
the same 7-year old female
patient during the course of
femoral lengthening. (a) The
femur before treatment and
(b) after surgery. (c) The femur
during the fixation period and
(d) after fixator removal
c d
Fig. 16.118 The 7-year old female patient during the course of limb lengthening. (a) Before treatment; (b) after the first stage of treatment; (c)
with fixators at the second treatment stage (fixation); and (d) after fixator removal upon completion of the lengthening procedure
16.7.6 Special Features of Lengthening and

Deformity Correction of the Lower Limbs
Despite the symmetry of the shortened limb segments, knee-

joint deformities and weight-bearing on the right and left
lower limbs may differ. These factors should be considered
in choosing the osteosynthesis technique and in treatment
planning. Thus, tibial lengthening is initiated from the less
weight-bearing and more deformed limb.
One-stage crossed lengthening of the contralateral lower
limb segments, i.e., consequent lengthening of the femur and
contralateral tibia in one stage, allows the completion of
lower limb lengthening in two stages.
Following the main principle of the Ilizarov method of
gradual lengthening and deformity correction, procedures to
correct any initial accompanying deformities are not per-
formed acutely in the operating room. An independent defor-
mity correction without lengthening is not practiced since the
Fig. 16.119 The same patient at the age of 10, demonstrating function
primary goal of patients is height augmentation. Correction of
in the knee and ankle joints 1.5 years after the second stage of the lower
limb lengthening procedure the limb axis is done simultaneously alongside lengthening.
It should be noted that, although the goal is one-stage of contralateral segment lengthening (Fig. 16.120c) has
treatment, at least for now, lengthening of the contralateral become the method of choice (Fig. 16.120a, b). Additional
femur and tibia is performed sequentially as follows information on the Ilizarov apparatus assemblies for imple-
(Fig. 16.120). First, the tibia is lengthened; when the planned menting bifocal osteosynthesis is presented in Chap. 16.
length is achieved, then during its fixation surgery is In children and young adolescents, it is preferable to
performed for femoral lengthening, or in the opposite order lengthen both tibias (Fig. 16.121 and 16.122), as the two
depending on the initial deformities and the patient’s age. segments will be equal in length upon completion of the
This type of consecutive segment lengthening is more easily first stage, giving the family a pause in treatment for
endured by patients, who adapt faster to the lengthening pro- 3–4 years until the following stage, which consists of a
cedure and do not need to be constantly assisted, unlike in two-staged contralateral lengthening of the lower limb seg-
simultaneous lengthening in which frequent assistance is ments that includes a shorter (6–12 months) pause between
required. The following figures make clear why the variant the stages.
a b
I,6-12; I,11-5; II,11-5; II,6-12 IV,1-7; IV,6-12 VII,3-9; VIII,8-2; VIII,4-10 --o-- II,8-2; II,4-10
arc 180 arc 180 160 140
(I,8-2)I,8-2; I,4-10; I,9-3; II,3-9 (IV,8-2)IV,8-2; IV,4-10 VII,3-9; (VIII,8-2)VIII,8-2; VIII,4-10

140 140 140
Fig. 16.120 Osteosynthesis diagrams: (a) bilateral bifocal osteosynthesis in both femurs; (b) bifocal unilateral osteosynthesis in the femur and
tibia; (c) bifocal osteosynthesis in the femur and contralateral tibia
a b c
Fig. 16.121 This 6-year old female, had a height of 95 cm before treatment (a). During lengthening of both tibiae by 9 cm (b); 1 year after
apparatus removal (c)
a b
c d
Fig. 16.122 X-ray images of the same 6-year old female patient before treatment (a); during tibial lengthening (b); during the fixation period (c);
and 1 year after apparatus removal (d)
16.7.7 Lengthening and Correction of Upper cortical plate. However, it may be necessary to rotate the
Limb Deformities adjacent supports with dosed efforts in the opposite direc-
tions in order to achieve osteoclasia. The apparatus supports
The apparatus for lengthening of the humerus is assem- are then reconnected to the previous position of the rods, and
bled from three support components: two arches and a ring the wound is sutured.
(Fig. 16.123). Threaded rods, hinge units, and plates are An alternative variant of the apparatus construct for
used to connect the supports. The surgery can be condition- humeral lengthening is that in Fig. 16.124. It allows module
ally divided into two phases: phase one consists of place- transformation of the assembly and has the advantage that it
ment of the apparatus for osteosynthesis, and phase two, avoids the need to insert wires into antagonist muscles, thus
corticotomy. amplifying the potential range of motion in the joints. The
Three to four crossing wires are inserted in the upper third patient can wear his or her normal clothes and feels more
of the humerus in the anteroposterior direction: one with a comfortable in bed, as the device is less bulky.
stopper on the posterior bone surface and the other with an The conventional technique of humeral elongation at two
anterior surface stopper. The support at this level is posi- levels specifies that humeral osteotomy is carried out more
tioned such that the angle between the longitudinal bone axis proximal to the deltoid muscle attachment site, with subse-
and the support plane opens outwards to 110–115° and for- quent gradual transport of the fragments by the required
wards to 100°. Depending on the anatomic and topographic distance using the compression-distraction device. However,
features of the humerus, all wires at this level are oriented in in this case, during elongation of the bone segment, the
the anteroposterior direction, with the maximal angle of wire length of the muscle will remain as before and therefore
crossing in the transverse plane being 50–60°. will not correspond to the new biomechanical
In the middle third of the humerus, two wires should pass relationships.
in a strictly transverse plane in the anteroposterior direction. In monofocal osteosynthesis, humeral osteotomy is per-
The support component at this level is fixed in the plane performed more distally to the site of deltoid muscle attach-
pendicular to the humeral axis. The maximum angle of wire ment. In this case, during the course of subsequent
crossing here is 70–80°, and all wires are inserted in the lengthening, the muscle stretches to meet the produced
anteroposterior direction. The wires are tensioned in the amount of lengthening. Patients with achondroplasia are at
direction opposite the neurovascular bundle. considerable risk of developing dystrophic changes in the
In the lower third of the humerus, three to four wires are deltoid muscle once lengthening has reached 50% of the ini-
also inserted in the plane perpendicular to the limb axis; one tial length of the humerus, which will ultimately limit move-
of these should have a stopper on the lateral bone surface and ments in the shoulder joint and impair the function of the
another a stopper on the medial bone surface. The maximal lengthened limb.
crossing angle at this level is 45–50°. More detailed informa- To avoid these complications, in such patients we perform
tion on the possible variants of transosseous element inser- the osteotomy through the region of the deltoid muscle
tion through the humerus is presented in Chap. 5. attachment (Fig. 16.125) [262]. Due to the division of the
After the frame has been mounted, a partial corticotomy attachment area into proximal and distal portions, it under-
of the humerus is performed, preceded by disconnecting the goes correspondingly “portioned” lengthening in the course
hinge junction of the supports at the corticotomy level. The of gradual distraction, in which only one part of the muscle
lateral, posterior, and, partially, the medial cortical plates are shifts distally. This results in a reduction of the natural retrac-
cut with a straight osteotome in the transverse and oblique tion of the muscle, thus enabling an increase in its functional
transverse planes. abilities, the prevention of contracture development, and the
Normally, the wedging rotation of the osteotome around avoidance of additional physiotherapy in addition to shorten-
its axis will complete the fracture of the medial portion of the ing the general rehabilitation period.
Fig. 16.123 The classical bifocal

osteosynthesis variant for humeral a b
lengthening: (a) AP view, (b) lateral
view
I,7-1; I,11-5; II,6-12 ↔ V,7-11; V,11-5 ↔ VII,3-9; VIII,9-3; VIII,4-10

1/2 150 130 2/3 130
a b
I,7-1; I,11-5; II,6-12; I,10,90; I,8,90; II,9,90 ↔ V,7-11; V,11-5 ↔

1/2 150 130
Fig. 16.124 Variant of the apparatus VII,3-9; VIII,9-3; VIII,4-10 (a)
assembly for humeral bone fixation: (a) 2/3 130
prior to and (b) following module I,10,90; I,8,90; II,9,90 – – VII,3-9; VIII,9-3; VIII,4-10 (b)
transformation 1/4 150 1/4 (130) 2/3 130
The distraction rate is 0.5–1.0 mm/day at each corticotomy

level. On distraction day 35 ± 8, when femoral distraction has
reached a total of 6.0–8.0 cm, the common signs of soft-tissue
overstretching in the lengthened limb will appear. These are
usually expressed as limitations in the motion of the knee joint
and enhanced muscle tone. Such patients are administered
baclofen 5 mg three times a day initially, increasing the dose by
5 mg every third day until it reaches 35–45 mg. To avoid the
“withdrawal” syndrome, myorelaxation drugs are administered
during the entire period of distraction, which in turn depends
on the amount of lengthening, and the dosage is then reduced
gradually in the reverse order during the fixation period.
In patients administered these myorelaxants, distraction is
continued in the regular mode. Once the required amount of
lengthening is achieved, the apparatus is converted into the
stable fixation mode, at which time the dosage of the drug is
reduced gradually.
Following this protocol, the group of patients who received
baclofen had a 15–20% reduction in the elasticity index during
the entire distraction period compared to the control group
(Fig. 16.126). The process of distraction was continued at the
usual rate without any interruption. Upon distraction comple-
tion, the apparatus was converted into the stable fixation mode.
Thus, pharmacological correction of the protective mus-
Fig. 16.125 Optimal levels for osteotomy during bifocal lengthening
of the humerus cle tension enables control of both the increase in muscle
elasticity and the pain threshold, which makes it easier for
patients to endure distraction.
16.7.8 Postoperative Care Dosed longitudinal distraction of bone fragments begins
around postoperative day 4 or 5, until the required amount of
The inevitable development of muscle stiffness due to exten- lengthening is reached. The distraction rate is 0.5–1.0 mm/
sive segment lengthening is, as a rule, accompanied by sec- day. In bifocal osteosynthesis, this rate is maintained at each
ondary contractures. To prevent this complication, muscle corticotomy level. Stable fixation with the frame on should
relaxants can be prescribed to the patients during the distrac- be continued until there has been complete reorganization of
tion period, e.g., baclofen and mydocalm. the regenerated bone into mature bone tissue.
250
200
150
Baclofen
100
50
0
Fig. 16.126 Elasticity dynamics 0 20 40 60 80 100 120 140 160 180
in the anterior group of femoral
muscles during distraction and
fixation
16.7.8.1 Clinical Case the operated limb. Fifteen months later, she had full range
A 13-year-old female patient, B., with achondroplasia and of motion in the knee. The same technique was used for her
short stature, underwent bifocal osteosynthesis with the left femur as her tibiae had been simultaneously lengthened
Ilizarov apparatus to achieve a height increase. Dosed dis- during the first stage. Her treatment resulted in a 35-cm
traction beginning on day 5 was produced at the rate of gain in stature, with no limits in the motion of her joints
1 mm/day at each level. On day 35, when the femur had been (Fig. 16.127).
lengthened by 7.0 cm, signs of soft-tissue overstretching Two and a half years after the device’s removal, B. could
were noted on the lengthened limb that resulted in motion walk without the use of additional support, wore regular
limitation in the knee joint and increased muscle tone. shoes, and did not limp. The relative and absolute lengths of
The patient was prescribed a course of baclofen that began the lower limbs were equal, the range of motion in the hip
with the administration of 5 mg three times a day, followed joints was improved, lumbar lordosis decreased, and knee
by an additional 5 mg every third day until the daily dose was movements were in the full range (Fig. 16.127). She prac-
35–45 mg. The drug was administered according to the pre- tices swimming and attributes her improved quality of life to
scribed plan during the entire lengthening period. Restoration her taller stature.
of motion freedom was noted alongside absent muscle tonus.
The total amount of lengthening was 10 cm. Upon transition
to the fixation period, for 87 days, the relaxant dose was 16.7.9 Complications
gradually reduced in the reverse sequence.
After the apparatus was dismounted, the patient under- The complications do not differ from those associated with
went a 3-week course of exercise therapy. At discharge general orthopedics and may be related to the bone or the
from the hospital, she could walk, bearing full weight on joint, infection, or neurovascular problems [168].
a b c
Fig. 16.127 (a–e) Patient B’s photos before treatment, at different treatment stages and upon its completion
d e
For preventing equinus of the foot during tibial lengthen- rotational subluxation of the tibia medially is seen in 3.85%
ing and to protect the ankle joint, the transosseous module on of patients due to the weakness of the knee ligaments. Such
the foot is mounted with a wire that fixes the foot in the nor- problems require additional operative correction. In order to
mal position during the entire period of distraction. avoid them and thus the need for additional intervention dur-
A temporary limitation of the range of joint motion in the ing lengthening, osteosynthesis with a supplementary tran-
hip, knee, and ankle during the period of distraction should sosseous module on the tibia is used to protect the knee
be considered as an inevitable event due to the large amount joint.
of lengthening. A decreased range of motion in the joint A rare complication (1.54%) involves subluxation of the
adjacent to the lengthened segment can be recovered during femoral head and is the result of the high level of the proxi-
the fixation period by appropriate exercise therapy in combi- mal corticotomy in the intertrochanteric area and the lower-
nation with physiotherapy, electrostimulation, and muscle ing of the lesser trochanter, which serves as an attachment
massage of the operated limb. site for the ileopsoas muscle, during distraction (Fig. 16.128).
An analysis of the results of femoral lengthening shows In all the treated cases, subluxation was reduced by traction,
that if the femur is lengthened by between 10 and more than with the weight through the distal ring, without the need for
12 cm, the knee develops a valgus deformity. In addition, surgery.
a b
Fig. 16.128 X-ray images of a male patient: (a) subluxation of the femoral heads; (b) reduction of the subluxation by applying weight; (c)
8 months after apparatus removal
16.8 Principles of Limb Lengthening sis can be injured by trauma, infection, metabolic disease, or
and Deformity Correction in Children the direct penetration of a tumor. These conditions often
and Adolescents result in growth arrest and subsequent deformity (Fig. 16.29,
16.30, and 16.31).
Mark Eidelman As a result of an injury, the growth plate might be com-
pletely closed (complete growth arrest), which results in
The main difference between adults and children, which limb shortening and leg length discrepancy. Another possi-
directly influences the strategy used in deformity correction, ble complication is damage to part of the physis, which
is the presence of open physes in children. While open causes a partial growth arrest. This common complication
growth plates may cause more complications, in some cases will lead to both shortening and angular deformity
the presence of an open physis facilitates treatment. The phy- (Fig 16.132).
a b
Fig. 16.131 Valgus deformity of the distal ankle due to partial growth
arrest in a 12-year-old boy with multiple osteochondromatosis
Fig. 16.129 (a, b) A 16-year-old boy with severe post-traumatic genu

varum secondary to growth arrest
Fig. 16.130 A 7-year-old girl

with a 7-cm leg length
discrepancy secondary to
sepsis and subsequent growth
arrest of the left distal femur at Fig. 16.132 Partial growth arrest of the left distal femoral epiphysis in
the age of 6 months a 10-year-old girl. Note the severe valgus and shortening of the femur
16.8.1 Prediction of Leg Length Discrepancy The growth-remaining method is also based on the data-
base of Green and Anderson [264]. Using these databases
The physis of the femoral head grows by about 4 mm/year, (different for girls and boys of the same age), one can calcu-
and the distal physis of the femur by about 10 mm/year. late LLD at skeletal maturity, and most importantly the opti-
Accordingly, growth of the proximal tibial physis is 6 mm/ mal age for epiphysiodesis [264].
year and that of the distal tibia 5 mm/year [263]. These data The straight-line method was developed by Mosley [267] in
allow a rough estimation of the leg length discrepancy (LLD) order to accurately time an epiphysiodesis. This graphic method
at skeletal maturity (Fig. 16.133). requires several X-ray-image-derived measurements of limb
There are four basic methods of predicting LLD and the length, which are then plotted on a graph. Although very accu-
timing of epiphysiodesis: (a) arithmetic method, (b) the rate, the method’s complexity is such that most pediatric ortho-
growth-remaining method, (c) the straight-line method, and pedic surgeons prefer the simpler, but no less accurate multiplier
(d) the multiplier method. method developed by Paley and coauthors [268].
The arithmetic method is based on the database of Green Like most of the existing methods, the multiplier method is
and Anderson [264]. Girls cease growing around the age of based on the database of Green and Anderson [264], which com-
14 years, and boys around the age of 16 years. Since growth prises measurements of the femurs and tibias of girls and boys
of the distal femoral epiphysis is approximately 10 mm/year from 0 to 18 years of age. The multiplier is a number, specific
and that of the proximal tibia 6 mm/year, the average addi- for each age and distinguishing between males and females,
tional LLD of the limb is 3 mm/year [265, 266]. This method that is calculated from limb measurements and specifically
is fairly accurate, but not in young children. Another reported for each age and gender [102] (Table 16.7).
significant disadvantage is that it is based on chronological Using the multiplier method, one can predict the LLD at
and not on skeletal age. skeletal maturity in children with congenital and acquired
deformities and the optimal timing of epiphysiodesis. The
formulae for congenital deformities is:
Dm = D ´ M
where Δm is the discrepancy at maturity, Δ is the age-
specific discrepancy, and M the age-specific multiplier. The
L/ mm/r
congenital formula is useful in the prediction of LLD in
patients with congenital shortness of the femur, tibial and
fibular hemimelia, hemihypertrophy, and other congenital
conditions. For example, in a boy with a congenitally short
femur, age 2.3 years and LLD of 32 mm, the multiplier is
2.480. Therefore, the predicted LLD at skeletal maturity is ~
79:Δm = 32 mm × 480 = 79.36 mm.
In congenital cases, the multiplier can be used to determine
the predicted LLD and thus to explain to the parents the strategy
of treatment until maturity. Let us take our example of an 80-mm
10 mm LLD in a boy with a short femur. The logical and easier approach
is to lengthen the femur by 40–50 mm and the epiphysiodesis of
6 mm the long limb by another 30–40 mm at appropriate age (which
also can be determined by the multiplier method).
A more difficult task is predicting LLD in acquired (devel-
opmental) deformities, such as in traumatic growth arrest,
infection, tumors, Ollier’s disease, polio, and after limb-
lengthening conditions. The developmental LLD formula is
different from the congenital formula:
Dm = D + I ´ G
5 mm
where Δ is the age-specific discrepancy, G = L(M − 1),
i.e., the amount of growth remaining, I = 1 (S − S¢)/(L − L¢),
i.e., growth inhibition as explained below, L the age-specific
Fig. 16.133 Growth of the proximal femoral physis is 4 mm/year, that
of the distal femur 10 mm/year, the proximal tibia 6 mm/year, the distal length, and M the age-specific multiplier. Therefore, for
tibia 5 mm/year determination of LLD in developmental conditions I (growth
Table 16.7 Multiplier values

Lower limb multiplier for boys Lower limb multiplier for girls
Age (years + months) M Age (years + months) M Age (years + months) M Age (years + months) M
Birth 5.080 7+6 1.520 Birth 4.630 6+0 1.510
0+3 4.550 8+0 1.470 0+3 4.155 6+6 1.460
0+6 4.050 8+6 1.420 0+6 3.725 7+0 1.430
0+9 3.600 9+0 1.380 0+9 3.300 7+6 1.370
1+0 3.240 9+6 1.340 1+0 2.970 8+0 1.330
1+3 2.975 10 + 0 1.310 1+3 2.750 8+6 1.290
1+6 1625 10 + 6 1.280 1+6 2.600 9+0 1.260
1+9 2.700 11 + 0 1.240 1+9 2.490 9+6 1.220
2+0 2.590 11 + 6 1.220 2+0 2.390 10 + 0 1.190
2+3 2.480 12 + 0 1.180 2+3 2.295 10 + 6 1.160
2+6 2.358 12 + 6 1.160 2+6 2.200 11 + 0 1.130
2+9 2.300 13 + 0 1.130 2+9 2.125 11 + 6 1.100
3+0 2.230 13 + 6 1.100 3+0 2.050 12 + 0 1.070
3+6 2.110 14 + 0 1.080 3+6 1.925 12 + 6 1.050
4+0 2.000 14 + 6 1.060 4+0 1.830 13 + 0 1.030
4+6 1.890 15 + 0 1.040 4+6 1.740 13 + 6 1.010
5+0 1.820 15 + 6 1.020 5+0 1.660 14 + 0 1.000
5+6 1.740 16 + 0 1.010 5+6 1.580
6+0 1.670 16 + 6 1.010
6+6 1.620 17 + 0 1.000
7+0 1.570 Mature length = L + M
Limb length discrepancy prediction formulae: Timing of epiphysiodesis
Congenital limb length discrepancy formula: Δm = Δ × M Me = LM/(LM − e/K)
(Use for congenitally short femur, fibular hemimelia, hemihypertro- Me = Multiplier at age of epiphysiodesis
phy, hemiatrophy, posteromedial bowing of the tibia)
Developmental limb length discrepancy formula: e = Desired correction by epiphysiodesis
Δm = Δ + I × G Use current L and M
Growth remaining = G = L (M − 1) Choose k =
Growth inhibition = I = 1 − (S − S¢)/(L − L¢) 0.71 for the distal femur
(Use for Ollier’s disease, polio, growth arrest; also applicable to 0.57 for the proximal tibia
congenital discrepancies after lengthening)
Length at skeletal maturity: 0.67 for the femur and tibia together
Lm = L × M Determine
(Use for femur, tibia, femur plus tibia, or lower limb length, Ae = Age at epiphysiodesis that corresponds to Me from the
including foot height; applies equally to short and long limbs) multiplier table
L = Age-specific length
M = Age-specific multiplier
Δ = Age-specific discrepancy
Δm = Discrepancy at maturity
inhibition), G (amount of growth remaining), and Δ (current normal femur 1 year ago (L) was 26 cm. The current length
LLD) must be known. of the short femur (S) is 25.3 cm, and 1 year ago (S) it was
Growth inhibition is calculated from the ratio of growth in 24.4 cm. The multiplier at age 8 years for girls is 1,33. Thus,
the short leg to growth in the long leg during the same time growth remaining for the normal femur is:
interval. Two measurements, separated by an interval of
G = L (M - 1) = 28 (1.33 - 1) = 28 ´ 0.33 = 9.2 cm
6–12 months, of the “short” (S − S¢) and “long” (L − L¢) legs
should be performed. The amount of growth of the normal femur during the pre-
The following example uses the developmental formulae vious year (L − L) = 28 − 26 = 2 cm. During the same period
in “Principles of Deformity Correction” [102]. An 8-year- of time, growth of the short femur (S − S) was 25.3 −
old girl, after post-traumatic growth arrest 3 years previously, 24.4 = 0.9 cm. Therefore growth inhibition I =1−(S − S¢)/
has an LLD of 2.7 cm in the affected limb while the current (L − L¢) = 1 − 0.9/2 = 1 − 0.45 = 0.55. Finally, the total predicted
length of the normal femur (L) is 28 cm. The length of the LLD is Δ m = Δ + I × G = 2.7 + 0.55 × 9.2 = 2.7 × 5.06 = 7.76 cm.
16.8.2 Basic Principles of Treatment of Leg should explain that the goal is not only lengthening of the limb
Length Discrepancy but lengthening without neurological damage, preserving the
normal range of motion of stable joints. A functional short
The correct term describing an inequality of the limbs is the limb is better than an atrophic “equal” stiff limb. Thus, length-
LLD. In most patients, discrepancies of up to 2 cm do not ening should be done without functional sacrifice.
require special treatment. Mild limb discrepancy is very In many patients lengthening is combined with deformity
common. Indeed, differences of 5–15 mm have been found correction. In the case of partial growth arrest with shorten-
in 32% of volunteers; in 4% of normal individuals the dis- ing and angulation, the first step should be to complete the
crepancy is >15 mm [263]. closure of the growth plate. This will prevent the recurrence
In children with open physes, a LLD between 2 and 6 cm of the deformity after lengthening.
can be equalized using epiphysiodesis. Of course, a 13-year- How many centimeters should the lengthening be? There
old boy with a projected height of 160 cm and projected LLD is no universal answer: every patient is different. For a child
of 50 mm is a better candidate for lengthening than for epi- 4 years old with an LLD of 15 cm the lengthening strategy
physiodesis. On the other hand, epiphysiodesis is a simple will be different than the one used in a 13-year-old teenager
operation that can easily equalize LLDs up to 50–60 mm. with a 5-cm LLD. However, it is better to perform a rela-
This operation should be performed at the proper age, taking tively “short” lengthening of 4 cm than a “heroic” lengthen-
into consideration the chronological and skeletal age of the ing of 10 cm in which range of motion is disturbed and there
child. Chronological age is the actual age of the child is subluxation of the knee and hip joints (Fig. 16.135).
expressed in years and months, while skeletal age is Joint stability should be evaluated before lengthening. In
determined according to a special skeletal age atlas. children with a congenitally short femur, knee and hip insta-
As discussed above, there are several methods to deter- bility are common. Therefore, in many cases pelvic osteot-
mine the timing of epiphysidesis, but the multiplier method omy should be done before lengthening to correct an
is currently the most popular. In the majority of children, acetabular dysplasia. Knee subluxation during femoral
bone age matches chronological age. Therefore, taking into lengthening is prevented by extending the external fixator to
consideration that girls grow until age 14 years and boys the tibia with hinges, in order to obtain knee motions
until 16–18 years, an LLD of 50 mm can be corrected through (Fig. 16.136). Further information is available in Chap. 23.5.
an epiphysiodesis of the distal femur and proximal tibia in External fixation can be performed using monolateral,
girls 11 years of age and in boys 13 years of age. circular, or hybrid external fixation devices. A classical
In this operation, the incisions are made from the medial example of a monolateral external fixator is the Orthofix
and lateral sides of the physis, or percutaneously through monorail (Fig. 16.137). The advantages of monolateral
minimal incisions (usually only the lateral side of the physis is fixation are its relative simplicity and, most importantly,
approached) (Fig. 16.134). Correct epiphysiodesis of the prox- patient comfort. Its disadvantages are less stability (com-
imal tibia requires closure of the proximal epiphysis of the pared to a circular fixator) and difficulties in the correction of
fibula to prevent future overgrowth of the bone. The proximity an angular deformity. Nonetheless, in a case of straightfor-
of the peroneal nerve must be kept in mind, to prevent nerve ward femoral lengthening in children with open physes, we
damage through exposure or during drilling of the physis. prefer a monolateral external fixator.
Circular external fixators are bulkier and less comfortable
for the patient but they provide a more stable fixation, are
16.8.3 Limb Lengthening more versatile, and allow easier correction of deformities.
Thus, in all patients with combined shortening and deformity
Lengthening of a lower limb is indicated in patients with LLDs we prefer circular fixation using either the Ilizarov frame, the
>20 mm and when an epiphysiodesis cannot be performed. It Taylor Spatial Frame (Fig. 16.138), or the Ortho-SUV Frame
is crucially important that before the operation both the patient (Chap. 17). The Ilizarov apparatus is a classic example of a
and his or her family are adequately informed about all possi- circular frame. All hexapods allow correction of any defor-
ble complications during and after the procedure. The surgeon mity using six struts and a virtual hinge.
a b
c d
Fig. 16.134 Epiphysiodesis of the proximal tibia. (a) Insertion of the canullated reamer over the K-wire; (d) percutaneous epiphysiodesis of
K-wire into the physis of the proximal tibia under fluoroscopy guid- the proximal tibia and proximal fibula
ance; (b, c) completion of the percutaneous epiphysiodesis using a
a b
Fig. 16.135 (a) Hip subluxation after a 6-cm femoral lengthening; (b) knee subluxation after a 5-cm femoral lengthening
a b c
Fig. 16.136 (a–c) Typical hinge placement to prevent knee subluxation during lengthening
Fig. 16.137 Monolateral

external fixator (Orthofix).
Note knee flexion after 5 cm
of femoral lengthening
osteotomies is also described in Paley’s book “Principles of

Deformity Corrections” [102]. In this chapter we briefly dis-
cuss the important nuances in osteotomy technique. In most
cases, the osteotomy can be performed using a drill and an
osteotome. Skin incision should be minimal, limited to
accommodating the length of the osteotome. Careful handling
of the soft tissue is very important. The periosteum should be
minimally violated, with only a small window created using
a pediatric periosteal elevator. The bone should be drilled in
three different directions and only then should the osteotome
be inserted to complete the osteotomy. We recommend
fluoroscopic control to prevent driving the osteotome in the
wrong direction, but probably most important is the “feel-
ing” of osteotome resistance in the bone. The osteotomy
should be completed by turning the osteotome using an
Ilizarov wrench.
Fig. 16.138 Taylor Spatial Frame in the correction of bilateral femoral Osteotomy of the proximal tibia and in the supramalleolar
valgus region can be performed using a Gigli saw. This osteotomy is
especially practical in the correction of rotational
deformities.
16.8.3.1 Osteotomy First, we describe the technique used to apply an Orthofix
It is obvious that the osteotomy in children should be per- monorail. This is probably the simplest construction, and we
formed above the growth plate. The site of the osteotomy is use it in all femoral lengthenings performed in children with-
dictated by several factors: (1) in most cases metaphyseal out deformities. Despite the apparent simplicity of the con-
osteotomy will lead to the best regenerate quality; (2) during struction and its application, errors in the technique can be
femoral lengthening, diaphyseal osteotomy may be preferred unforgiving and lead to the failure of the procedure.
(Fig. 13), because it is distant from the hip and knee joints, In the case of a normal mechanical axis, half-pins should
thereby decreasing the risk of hip and knee subluxations; (3) be inserted perpendicular to the mechanical axis of the bone.
in a combined deformity and shortening, the CORA is often The mechanical axis on the skin is marked using fluoroscopy
the best site for the osteotomy. and a diathermy cord, which should be applied from the
Again, the level of osteotomy should be chosen based on center of the femoral head to the center of the knee
many factors, as was discussed previously in this chapter (Fig. 16.140).
(Fig. 16.139). The first half-pin is inserted in the proximal femur, per-
The osteotomy technique according to the Ilizarov method pendicular to its mechanical axis. This half-pin will serve as
is described in Chap. 7.8. A detailed explanation of various a guide to all other half-pins (Fig. 16.141).
Fig. 16.139 (a, b) Completion

a b
of a percutaneous osteotomy
a b
Fig. 16.140 (a, b) The surgeon uses a diathermy cord to mark the mechanical axis of the limb. Note perpendicular insertion of the K-wire for
further insertion of the first half-pin
a b
Fig. 16.141 (a, b) Insertion of a half-pin perpendicular to the mechanical axis of the femur
The next step is insertion of the distal half-pin parallel to

the proximal one. All others pins are inserted parallel to each
other and perpendicular to the mechanical axis of the femur.
The diameter, geometry, and quality of the half-pins are cru-
cially important. In small children, the diameter of the femur,
especially its proximal part, does not allow the insertion of
6-mm pins; instead, pins of smaller size (4.5 or 5 mm) should
be inserted (Fig. 16.142).
After the insertion of all half-pins, the monorail should be
removed and an osteotomy performed. The monorail is then
reapplied and tightened.
In the majority of femoral lengthening cases, we release
the tensor fascia lata to prevent postoperative stiffness. This
can be done through the same incision made for the osteot-
omy, or through a separate small incision.
16.8.4 Osteosynthesis by Circular External

Fixation
In most cases, fixation of the distal femur can be performed

using one Ilizarov wire and 2–3 half-pins, inserted above the
growth plate (Fig. 16.143).
Proximal fixation is simpler and relatively easy to per-
form, with the insertion of 3–4 pins usually sufficient to
obtain stability. The stability of the construction can be Fig. 16.142 An 11-year-old girl undergoing a 40-mm femoral length-
increased by widely separating the pins and inserting them at ening. Note the combination of 6-mm and 4.5-mm half-pins
different angles. Additional information on the frames used
in the correction of femoral deformities was previously pro-
vided in this chapter (Fig. 16.144).
a b
VI,8,90; VII,4,90; VIII,3-9; VIII,8,90
Fig. 16.143 (a, b) Typical fixation of the distal femur using three 6-mm half-pins and a 1.8-mm K-wire
Fig. 16.144 (a, b) Proximal

fixation of the femur using 4 a b
half-pins. Note the insertion
of all pins at different angles
II,9,90; III,10,90 – IV,9,90; V,8,90 – TSF – VII,9,90; VII,2-8; VII,4-10; VIII,8,90; VIII,3-9; VIII,4-10
Generally, we prefer fixation of the tibia using a circular mal ring is attached to this wire. The next step is insertion of
frame. Proximal tibial osteotomy is usually performed at the two half-pins I,3-9; I,10,90; II,2,90. Additional insertion of
level of the metaphysis, just below the tibial tubercle. an Ilizarov wire or another half-pin is indicated when the
Fixation of the proximal tibia above the osteotomy can be surgeon feels that the fixation is not stable enough. The distal
challenging because of the limited space available for the fragment should be fixed using 4 half-pins or one wire and
fixation. We start the operation by marking the level of the 2–3 half-pins (Fig. 16.145).
knee joint and growth plates by fluoroscopy. A 1.8-mm Additional descriptions of the correction of leg deformi-
Ilizarov K-wire is inserted parallel to the knee joint. A proxi- ties was provided earlier in this chapter.
a b
I,3-9; I,10,90; II,2,90 ⎯TSF⎯ V,12,90; VI,2,90; VII,2,90
Fig. 16.145 (a–d) Post-traumatic deformity of the proximal tibia with valgus and procurvatum secondary to growth arrest. Typical fixation of the
tibia
16.8.5 Supramalleolar Osteotomy rior to the tibialis anterior tendon. This tendon passes over
the posterior slope of the distal tibia. To find the correct
Supramalleolar osteotomy should be performed about point of the incision, we probe this slope using a K-wire.
20–25 mm above the level of the ankle joint. This is one of A transverse anteromedial incision is made just anterior to
the most common operations for deformity correction at the this wire (Fig. 16.146d). The suture and the Gigli saw are
distal tibia. In children, it is commonly used in the correction passed all the way to the anteromedial incision. Before per-
of rotational deformities. The osteotomy can be carried out forming the osteotomy, the surgeon should check the lat-
through two incisions, one at the distal tibia and the other eral incision to make sure that the peroneal tendons are not
through the distal fibula. Another option is to perform the entrapped within the saw. At this level, the tendons lie very
osteotomy using a Gigli saw (Fig. 16.146). superficially and can be easily identified. Applying tension
In any case, this osteotomy should be carried out com- to the saw tends to cause it to migrate proximally. This can
pletely subperiostally. The periosteum should be elevated be prevented by inserting a K-wire into the distal fibula,
360º around the osteotomy level. At the level of the supra- just above the Gigli saw (Fig. 16.146e). At this point, the
malleolar osteotomy, there is no space between the fibula Gigli saw can be activated, while two periosteal elevators
and the tibia. Therefore, the two bones should be osteoto- protect the soft-tissue structures. If an external fixator is
mized together (according to D. Paley [102]). The operation applied to correct the deformity, it is much more convenient
begins by drawing two lines: one at the level of the ankle to complete the osteotomy subsequent to the application of
joint and the other along the route of the tibialis anterior the fixator. This is why we prefer to perform an incomplete
tendon (Fig. 16.146a). A small anterolateral transverse inci- osteotomy first (Fig. 16.146f, g), completing the tibial cut
sion is made first, just medial to the tibialis anterior tendon. following the application of the external fixation device.
A pediatric periosteal elevator is then used to elevate the Our preferred external fixation device is the Taylor Spatial
periosteum all the way to the fibula along the lateral aspect Frame. Only two anterior struts should be removed in order
of the ankle (Fig. 16.146b). The fibular (lateral) skin inci- to complete the osteotomy. The final few millimeters of the
sion is made over the tip of the periosteal elevator, which is tibial cortex should be cut with the saw held in the sur-
passed all the way subperiostally from medial to lateral and geon’s fingers (Fig. 16.146h) and not by the saw’s handles.
can be palpated laterally. The longitudinal incision is about This confers greater “sensitivity,” thereby preventing an
10 mm long. A hemostat is then used to pass a strong suture inadvertent cut of the skin and periosteum. Two crossed
from the lateral incision, for later passage of the Gigli saw 1.8-mm Ilizarov wires are inserted into the tibia below the
(Fig. 16.146c). Then the periosteum is elevated circum- osteotomy level, with additional fixation through the calca-
ferentially from the lateral, posterior, and anteromedial neus, talus, and metatarsals. Fixation above the osteotomy
aspects of the tibia. An anteromedial incision is made ante- usually consists of at least four 6-mm half-pins.
a b
c d
e f
Fig. 16.146 Supramalleolar osteotomy in a 13-year-old girl. (a) The passed from the lateral to the anterolateral aspects of the incision for
ankle joint, the level of the supramalleilar osteotomy, and that of the later passage of the Gigli saw. (d) An anteromedial incision should be
tibialis anterior tendon are marked. An anterolateral incision should be made just lateral to the tibialis posterior tendon. (e) Insertion of a
made just medial to the tendon. (b) A pediatric periosteal elevator is K-wire into the fibula prevents the proximal migration of the Gigli saw.
used to elevate the periosteum all the way to the fibula. (c) A suture is (f) Incomplete osteotomy
g h
Fig. 16.146 (continued) (g) Incomplete osteotomy. (h) Completion the supramalleolar osteotomy after the correction of a post-traumatic
of the osteotomy after application of external fixation. (i, j) Healing of varus of the distal tibia and a 25-mm lengthening
16.8.6 Correction of Deformities in Children prefer to carry out a partial permanent closure of the epiphy-
by Partial Epiphysiodesis sis, a modification of the classic Phemister technique [269].
(Hemiepiphysiodesis) Since closure of the growth plate will cause significant short-
ening of the limb, this technique is useful only in children
The physis does not always interfere with surgery, as in seri- close to maturity. However, the optimal timing for this oper-
ous deformities an open physis allows manipulation and cor- ation cannot always be accurately determined and the draw-
rection without the need for osteotomy. Some surgeons backs of an untimely permanent epiphysiodesis, in the form
of undercorrection or overcorrection, are quite evident.
Blount and Clarke [270] described partial epiphysiodesis
a
(hemiepiphysiodesis) using epiphyseal stapling. Partial epi-
physiodesis (hemiepiphysiodesis) is a simple and minimally
invasive procedure compared to osteotomy. When done by sta-
pling, most complications are the result of flawed technique.
Eidelman and D’Agostino [271] described a technique
using a grooved staple inserted percutaneously (Fig. 16.147).
Despite the wide use of staple hemiepiphysiodesis, this
technique has several disadvantages, the most serious being
staple extrusion, especially in young children.
Another method of correction was introduced by
Metaizeau and coworkers, who used a transphyseal screw
[272]. The disadvantage of this technique is the risk of per-
manent closure of the epiphysis.
Stevens and coworkers introduced a method of hemiepi-
physiodesis involving guided growth using a plate construc-
b tion that resembles the number 8 [273], such that the
technique is commonly referred to as “eight plating”
(Figs.16.148 and 16.149).
Fig. 16.147 (a–c) Insertion of a grooved staple for application in Fig. 16.148 Eight (8) plating of a hemiepiphysiodesis of the proximal
hemiepiphysiodesis tibia
a b
Fig. 16.149 (a–d) Operative insertion of an 8 plate

The operation is performed with the patient under general incorrectly the procedure can lead to growth arrest. However,
anesthesia and includes the use of a tourniquet. The growth in syndromic disorders in which there is a “sick physis,” even
plate is marked under fluoroscopy in the coronal and sagittal a perfect technique cannot guarantee a successful correction.
planes. For precise skin incision, we mark the skin before It should be carefully noted that this type of correction can be
applying the plate. A needle is inserted through a small cen- done only in children with an open physis, otherwise failure
tral hole in the plate, into the growth plate. Usually, the skin of the procedure is predictable (Fig. 16.151).
incision is no more than 25 mm. Dissection should be done Occasionally, in children with syndromic disorders, the
until the periosteum, which should not be disturbed. One of contralateral limb alignment that was perfectly normal before
the rules for dissection is that all that should be elevated by the procedure regresses and becomes deformed
“pick ups” (tweezers) is that which can be released. The (Fig. 16.152).
periosteum is tightly attached to the bone and cannot be ele- In the case of partial growth arrest, we recommend that
vated by pick ups. After completion of the exposure, two treatment of the growth arrest be carried out first, followed
K-wires are inserted through the holes in the 8 plate, and a later by the correction of the deformity (Fig. 16.153).
3.2 cannulated drill is inserted over the wires to a depth of
about 5 mm. The final step of this procedure is the insertion
of cannulated screws, either in 24 or 32 mm lengths, and 16.8.7 Principles of Deformity Correction
verification of the screws and the plate position under of the Upper Extremities
fluoroscopy in both planes (Fig. 16.149).
This operation can be performed as an out-patient proce- The common indications for operative treatment are congen-
dure, with the patient discharged the same day. Full weight- ital and acquired deformities of the upper limbs, non-union
bearing is possible the day after surgery. Radiological and malunion after fractures, shortening, and contractures.
monitoring of correction is imperative and should be carried Correction may be acute or gradual, using external fixation.
out every 4–6 months. In young children, in order to prevent a This section discusses the basic principles underlying the
“rebound effect,” we prefer to achieve a slight overcorrection correction of most of the common upper extremity deformi-
of the deformity (Fig. 16.150). ties in children. These deformities include radial and ulnar
A hemiepiphysiodesis is not always successful; for club hand, humeral shortening, and contractures and defor-
example, sometimes the staples or screws break. When used mities of the elbow.
a b
c d
Fig. 16.150 Use of the 8-shaped plate. (a, b) An 8-year-old boy with Fanconi syndrome and bilateral genu valgum. (c) Overcorrection of the left
limb to slight varus. (d) Slight overcorrection of the right limb to prevent deformity recurrence
e abnormalities). About one-third of these patients do not

survive, with mortality due to the complications of these
disorders [274].
Children with a normal contralateral hand have nearly
normal function whereas bilateral involvement can result in
severe functional limitation. Bora [275] noted that patients
who did not undergo surgical treatment had more limitations
than surgically treated patients.
Treatment of radial club hand should be carried out only
by surgeons experienced in dealing with this complex pathol-
ogy. The following problems must be addressed: unstable
wrist, digital weakness secondary to the radially deviated
wrist, thumb hypoplasia or aplasia, and a shortened and
deformed ulna.
The goal of treating radial club hand is to create a hand
that is as functional as possible. When the thumb is absent,
pollicization is often preferred, before lengthening and cor-
rection of the ulnar deformity. Centralization of the carpus
over the third metacarpal has been a standard procedure for
many years. Wrist fusion is contraindicated in young chil-
dren because of the risk of growth arrest of the epiphysis of
the distal ulna. However, wrist fusion with lengthening in
adolescents and young adults with recurrent deformities has
been reported [276].
During lengthening, the surgeon should prevent con-
tractures of the fingers, which is best achieved by the inser-
tion of wires through the metacarpals. Additional fixation
consists of the insertion of two 4.5-mm half-pins in the
Fig. 16.150 (continued) (e) Clinical appearance after plate removal distal and proximal parts of the ulna (Fig. 16.154). The
correction velocity should be slower than in the lengthen-
ing of other long bones: we prefer 0.5–0.75 mm/day instead
16.8.7.1 Radial Club Hand of the standard 1 mm/day. This rate of correction causes
In this syndrome, the radius is absent, the forearm is short, less pain and decreases the risk of neurovascular
and the hand is radially deviated, accounting for the name complications.
“radial club hand.” In 50–62% of the affected children,
this congenital pathology is unilateral. The thumb is often 16.8.7.2 Ulnar Club Hand
absent and many of these children have cardiac problems This condition occurs less frequently than radial club hand
(Holt-Oram syndrome), genetic defects of the bone marrow and it is mostly seen in boys, with only 25% of the cases con-
(Fanconi syndrome), or VATER syndrome (vertebral anom- sisting of a bilateral deformity [277]. Bayne [278] classified
alies, anal atresia, tracheo-esophageal fistula, and renal ulnar club hand into four groups based on abnormalities of
a b c
d e f
Fig. 16.151 Treatment of a patient in whom stapling failed. (a, b) A 14-year-old with severe genu valgum and failure of stapling. (c, d) Correction
of the deformities using a Taylor Spatial Frame. (e, f) Clinical appearance during and after correction of the deformities
Fig. 16.152 (a) A 12-year-old with

a b
chronic renal failure (renal rickets). On
the right there is a genu valgum whereas
in the left knee the mechanical axis is
normal. (b) Correction of the right limb
but deterioration to genu valgum of the
left limb. (c, d) Correction of the
deformities on both sides
d c
Fig. 16.153 (a) An 11-year-old girl

a b
with partial growth arrest and a 7-cm
shortening of the left femur.
(b) Completion of growth arrest of the
distal femur to prevent further
deformation. (c, d) Deformity correction
and lengthening of the left femur
accompanied by an epiphysiodesis of
the right distal femur
c d
a b
Fig. 16.154 (a–g) Severe radial club hand, status post-pollicization (Images courtesy of D. Paley). (h) Alternative placement of the wires and pins
in a younger patient (Image courtesy of J. Herzenberg)
e f
the elbow and forearm. Type I is a deficiency of both the Treatment of ulnar club hand with resection of the ulnar
proximal and distal ulnar physes, with foreshortening of the anlage is indicated when ulnar deviation is >30º in types 2
ulna and mild bowing of the radius. In type II, the most com- and 4. Resection of the anlage is performed until a neutral
mon type, there is partial absence of the radius. Type III is position of the wrist is achieved intraoperatively. In type 2,
complete absence of the radius with an unstable elbow joint with dislocation of the radial head, resectioning of the head
(Fig 16.155). Type IV is complete absence of the radius and and radial anlage with the creation of a single bone is
synostosis of the distal humerus to the proximal ulna. mandated.
c d
Fig. 16.155 (a–e) Clinical and radiological images of a patient with type 3 ulnar club hand
Fig. 16.156 Humeral

lengthening. (a) Left humeral
a
shortening due to damage of the
proximal humeral epiphysis by
osteomyelitis. (b, c) AP and
lateral X-ray images
demonstrating humeral
lengthening using the
monolateral Orthofix monorail
b c
16.8.7.3 Humeral Lengthening Patients with untreated lateral condyle non-union present
There are several indications for humeral lengthening: post- with cubitus valgus and late ulnar nerve palsy. The principles
traumatic growth arrest of a humeral epiphysis, growth arrest of treatment are : (1) open reduction and anatomic fixation in
due to infection, and in patients with a short humerus, with children for fractures occurring <12 months previously; (2)
the classic example being patients with achondroplasia. In in children presenting with non-union more than a year after
our opinion, the simplest and easiest strategy for both sur- the fracture, the goal is not anatomic reduction but the estab-
geon and patient is lengthening using a monolateral frame, lishment of union [279]. Usually, bone graft interposition
such as an Orthofix monorail, with four half-pins. In the dis- with non-anatomic fixation with screws will suffice to create
tal fragment, because of the proximity of the radial nerve, a solid union (Fig. 16.157).
two half-pins should be inserted at level VII, with a distance
of 2 cm between them (Fig. 16.156). 16.8.7.5 Cubitus Varus
This is a common complication of supracondylar fracture of
16.8.7.4 Lateral Condyle Non-union the distal humerus, a typical elbow fracture in children.
and Cubitus Valgus Usually, cubitus varus is a three-dimensional deformity that
Lateral condyle fractures are relatively common in children include varus, medial rotation, and extension. The standard
but they are probably the only pediatric fracture involving treatment is lateral exposure, osteotomy, and pinning, with
the elbow region in which there is a real risk of non-union. 6 weeks of cast fixation (Fig. 16.158). Complications reported
a b
c d
Fig. 16.157 Cubitus valgus. Radiographic and clinical appearance of a lateral condyle non-union (a, b) 3 years after the fracture and (c, d) after
correction using bone grafting and internal fixation
a b
c d
Fig. 16.158 (a) Clinical appearance of right cubitus varus in a 7-year-old girl. (b) X-ray image and (c, d) clinical appearance after correction
in the literature are delayed union, loss of correction, elbow gradually using external fixation. In patients presenting less
stiffness, lateral prominence, neurovascular damage, and than 12 months after the dislocation, our preferred technique
under-correction. is acute correction using ulnar osteotomy and bone grafting
Correction of cubitus varus by external fixation is less (Fig. 16.161). More than a year after radial head dislocation,
common but the advantages are tolerance, accuracy, gradual gradual reduction using external fixation is probably a more
correction, and percutaneous osteotomy. Herzenberg devel- reliable method of correction (Fig. 16.162).
oped a method of correction of cubitus varus using the Taylor
Spatial Frame (Chap. 17). He also developed a new technique 16.8.7.7 Correction of Forearm Deformities
for use in children, i.e., extra-articular half-pin insertion, and Forearm Shortening
which avoids damage to the growing physis (Fig. 16.159). Use Forearm deformity is common after damage of the epiphysis
of the Taylor Spatial Frame in cubitus varus enables the pre- due to infection, trauma, or tumor. Physis involvement results
cise correction of this complex 3D deformity (Fig. 16.160), in shortening of the forearm, deformity, and loss of rotation.
while all other methods of correction are effective only in a In younger children, epiphysiodesis of the normal epiphysis
one-plane deformity. The prerequisite for this method of cor- should be performed prior to correction and lengthening
rection is familiarity with this particular external fixator and (Fig. 16.163). Regarding the amount of shortening, external
its software. fixation can be used to either shorten a normal bone or
lengthen a short bone (Fig. 16.164).
16.8.7.6 Post-traumatic Dislocation of the Radial The amount of lengthening in the upper extremities
head (Chronic Monteggia Fracture depends on the amount of shortening of the humerus or fore-
Dislocation) arm bones. In the humerus, this depends on the regenerate
Failing to recognize a subtle radial head dislocation can lead bone quality and patient tolerance of the lengthening pro-
to catastrophe, with loss of forearm rotation ability. Radial cess. For the bones of the forearm, the guidelines are clear:
head reduction can be performed acutely using ulnar osteot- restoration with respect to the distal radioulnar joint
omy with or without annular ligament reconstruction, or (Fig. 16.164d).
Fig. 16.159 Cubitus varus. (a–c)

Various methods of pin insertion in Non-ossified bone a
children and adults. Note the Thin bone
Herzenberg method of pin insertion, (Olecranon fossa)
aimed at preventing epiphyseal
damage. (d) Relation of the osteotomy
to the pins before correction of the
cubitus varus (Courtesy of J.
Herzenberg)
Osteotomy
Osteotomy Osteotomy Osteotomy
Typical Yasui Herzenberg Herzenberg

(Lengthening) Technique: Adult Technique: Adult Technique: Child
(Varus deformity (Varus deformity (Varus deformity
and lengthening) ± lengthening) ± lengthening)
© 2009 Sinai Hospital of Baltimore
b c
15°
Herzenberg Technique
(Varus deformity
± lengthening)
© 2009 Sinai Hospital of Baltimore
d
Osteotomy
b c
Fig. 16.160 Cubitus varus. (a) Before correction. (b, c) Insertion of the pins according to the Herzenberg technique and osteotomy at the
CORA
e f g
Fig. 16.160 (continued) (d) Clinical appearance during correction. (e, f) AP and lateral X-ray images taken after the completion of correction.
(g) AP X-ray images after removal of the Taylor Spatial Frame (Courtesy of J. Herzenberg)
a b
Fig. 16.161 Post-traumatic radial head dislocation. (a) The patient grafting of the ulnar osteotomy site and angulated plate fixation. Note
presented <6 months after injury. (b) Osteotomy and provisional inser- the radial head reduction
tion of two screws. (c, d) AP and lateral X-ray images after iliac cortical
a b
Fig. 16.162 Neglected radial head dislocation after a Monteggia fracture. (a) Before treatment. (b, c) Clinical appearance after osteotomy and
correction using the Ilizarov fixator. (d) Lateral X-ray images after removal of the fixator (Courtesy of N. Bor)
Fig. 16.163 (a) Growth arrest a b

of the distal radius epiphysis in
an 11-year-old girl who
presented 6 years after the
occurrence of osteomyelitis.
(b) Distal ulnar epiphysiodesis
carried out to prevent further
discrepancy
Fig. 16.164 Growth arrest after damage to the distal

a b
radial epiphysis due to infection. (a) Before treatment. (b,
c) Clinical and radiographical images during radial
lengthening using the Taylor Spatial Frame. (d) X-ray
images after removal of the fixator. Note the equal lengths
of the radius and ulna after lengthening (Courtesy of J.E.
Herzenberg)
c d
Deformity Correction and Fracture
Treatment Using the Software-Based 17
Ortho-SUV Frame
Leonid Nikolaevich Solomin,

Alexander Igorevich Utekhin,
17.1 Introduction when five struts are used, the system loses its stability, while
seven struts cause overstraining.
In the correction of complex multi-component and multi- The first hexapod was proposed by Gough in 1947 [281]
planar deformities (Tables 16.1 and 16.3) using the Ilizarov for testing wheels exposed to combined forces (Fig. 17.2a).
frame, unified reduction nodes have to be replaced three to Ceppel, in 1962, unaware of Gough’s invention, created a
five times (Fig. 17.1) [280]. Every frame re-assembly involves similar mechanism while developing a vibration device
a change in the reductional units and is a highly laborious (Fig. 17.2b). Stewart, in 1965 [281], proposed a platform on
process in which there is additional patient exposure to radia- the basis of the original hexapod (Fig. 17.2c).
tion. Sometimes, due to the peculiarities of frame assembly Lengthening or shortening of even one strut causes one
(external supports are not oriented at a right angle to the axes platform to move relative to another in three planes.
of the bone fragments, a bone is not at the center of a support, Integration and control of these complicated movements
the support for some reason is not closed, etc.), correction accordingly requires computer navigation.
of one component can lead to the secondary translation of In robotics, there are active and passive types of navigation.
other(s). These secondary translations will, in turn, require Regarding the mechanisms discussed above, active navigation
correction and therefore additional frame re-assembly. implies that the computer, programmed with the coordinates
While it is not just in orthopedics that the issue of control- of the required position of the object (a mobile platform in this
ling an object’s position in three-dimensional space is of case), uses its sensors to automatically obtain all the parame-
interest, it is our focus in this chapter. Specifically, we ters necessary to achieve the result. When this response is
describe the use of hexapods, which have shown great prom- confirmed by the operator, the computer manipulates the
ise for orthopedic applications. Hexapods structurally con- machinery needed to implement a controlled movement. In
sist of two platforms, one static (basic) and the other mobile. passive navigation, the operator provides not only the coordi-
A system of six telescopic rods (struts) serves to connect nates to be achieved by the mobile platform but also the
these platforms. The ways in which the telescopic rods con- parameters defining its original position, including those
nect to each other and to the platforms differ and depend ensured by the initial strut lengths. The computer program
upon the author’s approach (Fig. 17.2). The number of struts then calculates the necessary length change for all the struts.
does not rely upon the number of planes and the degrees of Only after this stage can the operator, fine-tuning these lengths,
freedom that the platforms must have relative to each other: bring the mobile platform into its proper position.
In orthopedics, the hexapod may be viewed as universal
reduction unit, a mechanism that allows the movement of one
L.N. Solomin, M.D., Ph.D. (*)
R.R. Vreden Russian Research Institute of Traumatology platform (one basic support, with the bone fragment fixed
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia inside) relative to another by the shortest “integral” trajectory.
e-mail: solomin.leonid@gmail.com The first “orthopaedic hexapod” was patented in 1985 in
A.I. Utekhin France by Philippe Moniot [713]. In the early 1990s at the
Department of Innovation and Development, “Ortho-SUV” Ltd., Ilizarov Russian Research Center the device presented in
Uchitelskaja Str., 23 A, St. Petersburg
Figure 17.3a was developed (Shevtsov et al. 2008, unpub-
195269, Russia
lished data). As far as we know, these devices were not used
V.A. Vilensky, M.D., Ph.D.
in the clinic, in part due to the lack of software.
Department of Orthopedics, R.R. Vreden Russian Research Institute
of Traumatology and Orthopedics, 8 Baykova Str., The first orthopedic hexapods to be operated based on com-
St. Petersburg 195427, Russia puter navigation principles appeared in the USA and Germany:
a b
c d
Fig. 17.1 To correct a multi-component deformity, the Ilizarov frame correction of an angular deformity and translation in the sagittal plane;
has to be reassembled three to five times: (a) lengthening; (b) correc- (d) correction of a rotation
tion of an angular deformity and translation in the frontal plane; (c)
respectively, the Taylor Spatial Frame (TSF; Fig. 17.3b), begin- Sometimes it is mistakenly noted in the literature that
ning in 1994, and the Ilizarov hexapod system (IHS; Fig. 17.3c), all orthopedic hexapods function according to the Stewart
in 1999 [282]. In offering the possibility of deformity correction platform [282, 283, 285]. Actually, however, the IHS and
with mathematical precision, without the need to for repeated TSF devices are closer in structure to Gough’s and
changes of the unified reduction nodes, these devices were Ceppel’s platforms (Fig. 17.2a,b). The Ortho-SUV device
quickly accepted for fracture treatment, in particular fractures of only superficially resembles the Stewart platform, as it
the long bones [280, 283, 284]. In 2006, in Russia, an original operates on the basis of the unique Solomin-Utehin-
transosseous hexapod was created, the Ortho-SUV Frame. Vilenskij (SUV) system, such that its kinematics are quite
17 Deformity Correction and Fracture Treatment Using the Software-Based Ortho-SUV Frame 707
different from those of all known hexapods. Due to potential, and the rigidity of the achieved osteosynthesis.
improvements, the Ortho-SUV has succeeded over its Additionally, the Ortho-SUV Frame is equipped with
analogs through a number of design features, its reductive sophisticated software [280, 286].
a b
Fig. 17.2 Hexapods. (a) Gough’s system; (b) Ceppel’s system; (c) Stewart’s platform (Bonev 2003)
b c
Fig. 17.3 Orthopedic hexapods. (a) The device created at the Ilizarov Russian Research Center; (b) the Taylor Spatial Frame; (c) the Ilizarov
hexapod system
17.2 Design of the Ortho-SUV Frame rod, which is fixed to the joint using a small lock nut and a
blocking washer.
Two external supports comprise the Ortho-SUV Frame The strut length changing unit (Fig. 17.8) consists of a
(Fig. 17.4), one basic and the other mobile. These are united by fracture reduction unit and a deformity correction unit.
six struts connected in series. Together, these parts constitute the The fracture reduction unit is made up of a threaded bush,
“universal reduction node” mentioned above. The basic sup- the body, fixing screw #1, and a lock nut. With the fixing
port, with the aid of the transosseous elements, fixes the main screw loosened, the connecting threaded bush can be moved
bony fragment, while the mobile support holds the bony frag- along the threaded rod (Fig. 17.9). This design enables oper-
ment to be transported. If necessary, the rigidity of the osteosyn- ation of the frame in “fast struts” mode, used for manual
thesis can be increased by using additional stabilizing supports. fracture reduction (see Sect. 17.4.1).
The Ortho-SUV Frame’s set (Fig. 17.5a) comprises six The deformity correction unit (Fig. 17.8) consists of: the
uniquely designed telescopic rods, or struts (Fig. 17.5b), six body (equipped with a hexahedron for the M12 wrench),
simple plates (Fig. 17.5c), six Z-shaped plates (Fig. 17.5c), six fixing screw #2, a threaded bush, the axle for connection
strut labels (Fig. 17.5d), six strut number markers (Fig. 17.5d), with an adjacent strut’s joint, and lock nut M12. Note that the
spanner wrenches and a screwdriver (Fig. 17.5e), and a device threaded rod and threaded bush must have different thread
for changing the strut lengths and triangle legs (Fig. 17.5f). hands. The bush of the deformity correction unit has a scale
with 1-mm divisions. There is also an indicator of the strut
length change.
17.2.1 Strut Design of an Ortho-SUV Frame
A strut consists of three main elements: a joint, a threaded 17.2.2 External Supports
rod M6, and a strut length changing unit (Fig. 17.6).
The joint (Fig. 17.7), in turn, consists of a bolt that fixes Supports from any circular external fixation device may be
the joint to the plate and a hole to connect it with the adjacent used to assemble an Ortho-SUV Frame (Fig. 17.10a,d,g).
strut. To fasten the strut to the joint of the adjacent strut, the Additionally, the use of supports comprising 1/2, 2/3, and
axle is connected to a red butterfly screw. There is an M6 5/8 of a ring (Fig. 17.10b, e, h) is possible, as are supports of
hole at the joint’s butt-end that connects with the threaded any shape: triangular, oval, or rectangular (Fig. 17.10c,f,i).
a b
1
Fig. 17.4 Ortho-SUV Frame design. (a) Basic set; (b) set completed with stabilizing supports. 1 Basic support, 2 mobile support, 3 struts,
4 stabilizing supports
Fig. 17.5 (a–f) A standard Ortho-SUV Frame’s set. (a) The full set; (b) struts;
c d
Fig. 17.5 (continued) (c) plates (simple and Z-shaped); (d) X-ray-positive strut labels and strut number markers; (e) wrenches and a
screwdriver;

(f) a device for changing the strut f
lengths and triangle legs (addi-
tional tool)
Fig. 17.6 Struts of an Ortho-

SUV Frame
Plate
Joint
Bush with scale

Deformity correction block
Fracture reduction block
Strut length changing block
Threaded rod
a 1 b c
6 8
Fig. 17.7 Design of a joint of the Ortho-SUV Frame’s strut. (a) Joint simple plate, 3 threaded rod, 4 blocking washer (“footstep” type), 5
in conjunction with the adjacent strut; (b) joint linked to the adjacent small lock nut, 6 hole for connection with an adjacent strut, 7 axle for
strut by the red butterfly screw; (c) adjacent strut disengaged. 1 Bolt, 2 connection with an adjacent strut; 8 butterfly screw (red)
1 2
2.8
2.1
1.4 1.1 1.2 2.2 2.4
2.3
1.3 2.6 2.7

2.5
Fig. 17.8 Design of the strut length changing unit. 1 Fracture reduc- 2.4 threaded bush, 2.5 scale with 1-mm division, 2.6 indicator showing
tion unit, consisting of: 1.1 connecting threaded bush, 1.2 fixing screw the strut length change, 2.7 axle to connect the joint of an adjacent strut,
#1; 1.3 body, and 1.4 lock nut; 2 deformity correction unit, consisting 2.8 lock nut M12
of: 2.1 body, 2.2 hexahedron for the M12 wrench, 2.3 fixing screw #2,
1.1
Fig. 17.9 Design of the fracture

reduction unit: 1.1 connecting
threaded bush
Fig. 17.10 In the assembly of

an Ortho-SUV Frame, supports a
of various shapes and types can
be used: (a, d, g) supports from a
range of circular external fixation
devices; (b, e, h) 1/2, 2/3, 5/8
rings; (c, f, i) oval, triangular,
and polygonal shaped supports
b
d e

f g
h i

17.3 Ortho-SUV Frame Assembly strut #1, situated at any point of the front half-round of the
basic ring. Two rules must be observed:
The number of supports in the frame’s modules and the 1. The red screws rule: In the process of connecting the
quantity and type of transosseous elements to be inserted in struts to each other and fastening them to the supports, the
a particular case are chosen based on the principles laid out red screws should always be positioned along the inner
in Chaps. 2 and 7. A precondition is that the degree of fixation side of the struts (Fig. 17.13a).
rigidity for any given bone fragment has to be sufficient to 2. The watch rule: The #1 strut is always, no matter what
exclude any correction errors in the process of moving one segment it is linked with, positioned on the left and it con-
module relative to another. nects to the joint fixed to the basic support (Fig. 17.13b).
This strut is symbolized by a left arm wearing a watch.
The #2 strut is adjusted to the joint of strut #1 and then
17.3.1 Assembling the Universal Reduction Unit heading away from it to the right and down. This strut is
symbolized by a right hand pointing to the watch. The
The universal reduction unit of the Ortho-SUV Frame positions of struts #1 and #2 should always comply with
consists of six struts connected in a certain order (Fig. 17.11a, this rule regardless of whether the frame is applied to the
b). Special removable clips are used to mark their numbers left or to the right limb (Fig. 17.13c). Further numbering
(Fig. 17.11a). is implemented counter-clockwise (Fig. 17.14).
The struts are fastened (Fig. 17.12) to the supports using Every joint is numbered in accordance with the strut that
simple or Z-shaped plates. it receives (Fig. 17.15). Thus, joints #1, #3, and #5 are fas-
Struts are fastened to basic and mobile supports at three tened to the basic (proximal) support, and joints # 2, #4, and
points. The starting point of a frame assembly is the joint of #6 to the mobile (distal) support.
Fig. 17.11 Set of struts for an Ortho-SUV Frame. (a) Full set, with arrows pointing to the clips indicating the strut numbers;
Fig. 17.11 (continued) (b) the

interconnected struts
b
2
a c
Fig. 17.12 Frame struts are fastened to supports using a simple plate (a) or the Z-shaped plate (b). (c) The single plate (1) and the Z-shaped plate
(2) are applied. Note: Struts can be fixed not only to basic but also to stabilizing supports
2
1
Fig. 17.13 The connected struts. (a) The arrows point to the red normally wears a watch; 2 strut #2 corresponds to the right hand, point-
screws, which are positioned “inside” of the frame. (b) The mnemonic ing to the watch.
“watch rule:” 1 Strut #1 corresponds to the left arm, i.e., the arm that
Fig. 17.13 (continued) (c) No matter which anatomic side is involved,

the positioning of struts #1 and #2 must comply with the “watch rule”
a b
5
6
4
2
1
2 4
3
6
5 3
Fig. 17.14 Struts are placed counter-clockwise, proceeding from the first one. (a) Scheme; (b) model
Fig. 17.15 Joint numeration. Joints #1, #3, and #5 correspond to struts
#1, #3, and #5 and are fixed to the proximal (basic) support. Joints #2,
#4, and #6 correspond to struts #2, #4, and #6 and are fixed to the distal
(mobile) support
17.4 Modes of Ortho-SUV Frame Operation lengthened or shortened. The strut length changing unit is
equipped with a scale. For a strut to be lengthened, the strut
For practical reasons, the distal (mobile) support is moved length indicator is set in its extreme “−” (minus) position; for
relative to the proximal (static, basic) support. A length a strut intended for shortening, the indicator is set in its
change of even one of the struts will cause the mobile sup- extreme “ + ” (plus) position. The position of the indicator is
port to dislocate in three planes. By changing the lengths of changed as follows:
every strut, displacement of the mobile support over the 1. Loosen the lock nuts.
required direction and distance is achieved. The amount of 2. Using the screwdriver, loosen fixing screw #2 of the
length change for every strut is calculated by a computer pro- deformity correction unit (Fig. 17.17a).
gram. There are two modes of operation for an Ortho-SUV 3. By opposing hand motions, rotate the deformity correc-
Frame: the “Fast struts” mode and the chronic “Deformity tion unit and fracture reduction unit in opposite directions
correction” mode. (Fig. 17.17b). If the strut’s length was minimal, the defor-
mity correction unit is rotated clockwise; if it was maxi-
mal, rotation is counter-clockwise. While counter-rotating
17.4.1 Fast Struts Mode the deformity correction and fracture reduction units, the
strut length does not change and the bone fragments are
This mode is used for acute fracture reduction or when defor- not displaced.
mity correction is implemented under visual control or 4. Tighten fixing screw #2 and the lock nuts.
fluoroscopy. The procedure starts with the loosening of the Sometimes the scale length does not suffice for a fragment
large lock nuts, moving them, by their rotation, away from the displacement to be corrected completely; in such cases, the
strut length changing unit. Fixing screws #1 are loosened using entire procedure has to be repeated.
the hexahedral screwdriver (Fig. 17.16a). The connecting To change a strut’s length, the lock nuts must be loosened
threaded bushes are moved behind the lock nuts (Fig. 17.16b). and the body of the deformity correction unit rotated
The next step is a reduction, implemented by manually mov- (Fig. 17.18). Clockwise rotation of the body causes an
ing the supports relative to one another (Fig. 17.16c). The con- increase in the strut length while counter-clockwise rotation
necting threaded bushes are then moved along the threaded shortens the strut. The body of the deformity correction unit
rods until each one locks with its respective strut length chang- is marked respectively: “ + ” and “−”. The amount of change
ing unit. Fixing screws #1 are fixed (Fig. 17.16d). in the strut length is estimated by the position of the indicator
on the scale relative to its initial position. When the neces-
sary length is achieved, the lock nut is moved back along the
17.4.2 Deformity Correction Mode strut, thus fixing its length. This procedure is repeated for all
struts with a change in length.
This mode is applicable when deformity correction, or The precisely controlled relocation of bone fragments
fracture reduction, takes place over an extended time period. requires that the amount of length change be calculated for
The computer program calculates which struts are to be every strut. This is done using specialized software.
a b
c d
Fig. 17.16 Fracture reduction in fast struts mode. (a) Fixing screws #1 reduction. (d) The connecting threaded bushes are moved along the
of all the struts are loosened. (b) The connecting threaded bushes are threaded rods until each one locks with its own strut length changing
moved along the threaded rods; reduction is implemented. (c) Acute unit; the fixing screws are tightened
Fig. 17.17 (a–c) Equipping a

a
strut. (a) Scale before the
procedure: the indicator is set in
its extreme “+” position. (b)
Loosening fixing screw #2; the
deformity correction unit and
fracture reduction unit are
counter-rotated.
Loose

c
(c) Counterrotation of the
fracture reduction unit and
deformity correction unit.
Fig. 17.17 (continued) (d)

Fixing screw #2 is tightened. (e, d
f) The scale after the procedure:
the indicator is in its extreme “−”
position; the strut length has not
been changed!
e

f
Fix
a
b
Fig. 17.18 (a–d) Deformity correction mode

17.5 Software for the Ortho-SUV Frame Note: When a radio-opaque ruler is used (for scaling;
Step 4 in the program), the focal distance is measured
The software included with the Ortho-SUV Frame calculates between the anode and the ruler. Therefore, if the ruler is
the amount of change in the strut length necessary for defor- placed directly on top of the plate-holder, the general
mity correction or fracture reduction. In either case, it rule works. However, if the plate-holder is placed inside
requires the input of two sets of parameters: of its bin while the ruler is positioned on the top of the
1. Those measured on the frame (12 parameters) and during X-ray table, the focal distance is defined as the distance
X-ray imaging (2 parameters) from the anode to the ruler.
2. Those measured on the X-ray films (14 parameters) 3. The X-ray beam center has to be indicated on the image.
Type one parameters are obtained using measurements This is done by placing a small, (about of the size of a cent
made by the operator, as described below, while for type two coin), usually cross-shaped marker on the plate-holder at a
parameters those of the program’s are used. point where the center of the X-ray tube will project
(Fig. 17.21b, c). During imaging, make sure that this beam-
center marker does not overlap with any radio-opaque
17.5.1 Parameters Measured on the Frame parts of the frame, such as the struts or the supports.
4. To facilitate strut identification on a roentgenogram, spe-
The 12 parameters measured on the frame are strut length (6 cial clips, i.e., the radio-opaque markers of the strut num-
parameters) and the side lengths (6 parameters) of the trian- bers, are fixed to the struts (Fig. 17.23a–i).
gles whose apexes are the centers of the bolts fixing the strut 5. In cases in which AP and lateral views cannot be obtained
joints to the support. tangentially (that is, at right angles to one another), they
The strut length is the distance between the strut joint and can instead be obtained at an angle not less than 45º.
the end of the strut length changing unit (Fig. 17.19). Views that are <45º to one another make it impossible for
The sides of the triangles are measured between the cen- the computer program to perform the calculations.
ters of bolts that fix the joints to the plates (Fig. 17.20a, b). 6. If a radiograph is first made in analog mode, it has to be
Note: It is erroneous to measure the distances between the converted into digital form, for instance, by photograph-
centers of the bolts that fix the plates to the supports! ing it. In the process, the camera lens has to be parallel to
For the basic support, the sides of the triangle are indi- the viewing surface of the negatoscope, and the X-ray
cated as A1 (Base), B1 (Base), C1 (Base). Thus, A1 (Base) film must completely fit within the size of the photograph
is the distance between joints #1 and #5; B1, (Base) between (Fig. 17.24).
joints #5 and #3; and C1 (Base), between joints #3 and #1.
For the mobile support, the sides of the triangle are indi-
cated as A2 (Mobile), B2 (Mobile), C2 (Mobile). Thus, A2 17.5.3 Working with the Program
(Mobile) is the distance between joints #6 and #4; B2
(Mobile), between joints #4 and #2; and C2 (Mobile), The program for working with the Ortho-SUV Frame was writ-
between joints #2 and #6. All measurements are made using ten using the language “C++ Builder.” Its volume is about
the special measuring tool (Fig. 17.20b). 1,400 kb. To install the program, copy the executable file onto a
hard disc. The minimal requirements are: IBM PC-compatibility,
operating system Windows 2000, XP or Vista, processor with a
17.5.2 Parameters Measured on X-Ray minimal quality of the DX486 and a minimum frequency of
1.5 GHz, and a memory of 256 Mb RAM. Installation requires
When roentgenograms are intended for the determination of at least 10 Mb of disk space. Color display with a minimal reso-
the above-noted parameters, not only the standard rules lution of 800 × 600 pixels is necessary.
(Chap. 6.1) but also the following must be observed: Working with the program involves advancing through its
1. The image field has to cover as many joints and struts as sequence of 12 steps. At every step, if necessary, the operator
possible. Therefore plate-holders <30 cm in width are can return to the previous one. If the obligatory actions
inappropriate (Fig. 17.21). required at every given step are not performed, continuation
2. The focal distance, defined as the distance between the to the next step is prevented.
X-ray tube anode and the film cassette, has to be mea- The program works with digital roentgenograms saved in
sured. X-ray units are often equipped with focal distance a variety of formats: bmp, tif, jpg, etc.
sensors or their own fixed measuring-tapes (Fig. 17.22). If To start working, double-click on the “SUV.exe” file. The
a measuring device has not been provided with the X-ray program window appears. Click on the “New document”
unit, the focal distance is measured, using a standard mea- button. A new document will be created with its first page
suring tape, in millimeters. entitled “Step 1” (Fig. 17.25).
a b
Fig. 17.19 Length measurements: (a) Strut length L is measured between the strut joint and the end point of the strut length changing unit, using
a special tool (b), a ruler or measuring tape (c), or a laser range-finder (d)
The following tools are available in the new document “Save” in the “File” menu) with the name of the file corre-
window (Fig. 17.26): (a) Zoom in/out button; (b) Move frag- sponding to the patient’s surname. Saving the file after every
ment markers button; (c) Move roentgenogram images; (d) step is strongly recommended.
fields displaying the angles between the axes of the bone Note: If for some reason difficulties have occurred
fragment markers. These tools are described further in the (usually associated with incorrect usage), quit the pro-
step-by-step manual for the Ortho-SUV program. gram, save the file, and send it to the following email
Note: Immediately after the new document (that is, the address: orthosuv@gmail.com. In the accompanying mes-
“clinical case”) has been created, it must be saved (command sage, explain in detail the problem that has been encoun-
a B1(base)
A1(base)
J5
C1(base)
J1 J3
J4
J6 A2(mobile)
B2(mobile) J2
C2(mobile)
Fig. 17.20 Measuring the sides

of the triangles whose apexes are
the centers of the joint’s bolts.
(a) Schemes; (b) measurement
using the special tool;
c d
Fig. 17.20 (continued) (c) measurement using a device assembled from parts of the Ilizarov’s frame; (d) the same, using a laser range-finder
tered. To resume working, it is usually enough to re-start function, choose the previously prepared AP roentgenogram,
the program and, obviously, avoid one’s previous mistakes. which may be located in any folder on the local hard drive or
Step 1: Input of Strut Lengths and Those of the Sides stored on the Internet. Click on the button “Open.” At this
of the Triangles point, the operator is returned to Step 2. Note that the AP
Fill in the window “Patient data” (Fig. 17.27, 1) by typing view itself does not appear. Click on the “Forward” button
in the patient’s surname, name, age, and diagnosis as well as and continue to the next step.
the modeling date. Step 3: Uploading the Lateral (Profile) Roentgenogram
Fill in the fields “Strut 1–Strut 6” (Fig. 17.27, 2) by insert- To upload the lateral digital roentgenogram, click on the
ing the lengths of the corresponding struts, as measured button “Lateral” (Fig. 17.29). A drop-down menu appears.
according to the rules described in Sect. 17.5.1 (Fig. 17.19). The previously prepared lateral roentgenogram is located by
Fill in the fields “Triangles A1 (Base), B1 (Base), C1 browsing through local files or through those stored on the
(Base), A2 (Mobile), B2 (Mobile), C2 (Mobile)” (Fig. 17.27. Internet. Click on the “Open” button. Two radiographic
3) by typing in the respective sizes of the sides of the trian- images will appear in the document window: the AP view to
gles whose apexes are the centers of the bolts fixing the strut the left and the lateral view to the right (Fig. 17.30). After
joints to supports. The rules for measuring the sides of the these two views appear, click on the “Forward” button and
triangles are provided in Sect. 17.5.1 (Fig. 17.20). continue to the next step.
After completion of these fields, click on the “Forward” Step 4: Scaling of the AP View
button and continue to the next step. A special tool is available in the program, referred to as
Step 2: Uploading the AP Roentgenogram a “ruler” (Figs. 17.31 and 17.32). In order to scale an AP
A movable panel appears with a button to load the AP view, use this ruler to measure a “known interval” on the
roentgenogram: “AP view” (Fig. 17.28). image; that is, a segment or interval whose length is known
To upload the AP roentgenogram, click on the button to the operator. This “interval of known length” may sim-
“AP view.” A drop-down menu appears. Using the “browse” ply be any section on the image of the operator’s choice.
a b
c d
Fig. 17.21 Image field, beam center. (a) When a narrow film is used, strut numbers are visible. The arrow points to the beam center.
the number of struts and joints visualized will be insufficient to allow (c) Self-adhesive X-ray-positive mark for visualizing the beam center.
measurement of the necessary parameters. (b) Image field encompass- (d) The mark fixed on the film cassette
ing most of the struts and joints. On the struts, bar-codes indicating the
The outermost points of the “ruler” are set at the outermost of the X-ray table, before the roentgenogram is taken. This
points of this interval, thus allowing its length to be mea- “measured interval” serves as the segment of known length
sured. With analog images as the original source, an option (Fig. 17.32).
for this interval might be the length or width of the roentgen- Note: Scaling will be more precise if the interval of known
ogram itself (Fig. 17.31). When digital images are intended length is not less than 80 mm.
for scaling, an object of known length (e.g., a radio-opaque To move the ruler, place the cursor directly on its center
ruler) might be placed within the image field, e.g., at the top (visible as a small circle) and, while left-clicking the mouse,
Note: The strut and joint numbers indicated in the pro-

gram must be the same as the strut and joint numbers used in
the external fixation device calculations. Arbitrary designa-
tion of the numbers is not allowed.
The simplest way to identify strut numbers on the roent-
genograms is to use the X-ray-positive markers of the strut
numbers (Sect. 17.5.2, Fig. 17.23).
In order to mark a strut, click on the field of the strut.
Then, while left-clicking the mouse, drag the line along the
projection of this strut onto the X-ray image (Fig. 17.36a).
A joint marker consists of a line ending with a point and a
circle with a point inside. The joint number is always the
same as the number of the strut that it receives (Fig. 17.37).
To mark a joint, click on the field of the joint. Then place the
cursor over the projection of this joint on the X-ray image
and left-mouse click. The joint marker will be displayed
(Fig. 17.36b). For accuracy, the side (line) in this type of
marker is aligned with both the strut received by the joint and
the bolt that fixes the joint (Fig. 17.36c). To do this, place the
cursor over the end of the joint marker (visible as a red dot).
While left-clicking the mouse, drag a line along the axis of
the bolt that fastens the joint. Then place the cursor over
another red dot located inside the marker circle. Again, while
left-clicking the mouse, drag a line along the axis of strut
received by the joint. It does not matter which marker line
corresponds to the strut and which marks the bolt. The strut
marker and its respective joint marker have the same color.
Fig. 17.22 Measuring the focal distance (two parameters: AP and lat-
eral views)
Strut and joint markers of different numbers are colored
differently.
If the joint field is checked after its respective strut field
move the ruler around the display. To shorten or lengthen the has already been checked, the strut marker is completed with
ruler, place the cursor directly on one of its outermost points a line and a circle and becomes the marker of both the strut
and drag it while left-clicking the mouse. After the length and the joint. The reverse is true as well: when a strut field is
and position of the ruler have been set, fill in the field “Interval checked when the respective joint field has already been
between” (AP view) by typing in the length of the known checked, the joint marker is completed with a line and again
interval in mm (Fig. 17.31); then click on the “Forward” but- becomes the marker of both the strut and the joint. For exam-
ton to continue to the next step. ple: joint #6 was already marked on the AP view. If the field
Step 5: Scaling of the Lateral View of strut #6 is checked, the marker becomes both a strut and a
Lateral view scaling is implemented in the same way as joint marker and the line dragged along the strut axis becomes
described for the AP view (Figs. 17.33 and 17.34). Click on thicker (Fig. 17.36d).
the “Forward” button to continue to the next step. Note: For the program to function, it usually suffices to
Step 6: Entering the Focal Distance and Beam Center; indicate three struts and one joint, with the joint number dif-
Indicating Strut and Joint Projections on the AP View fering from the numbers of struts that have been marked
Type in the value of the focal distance for the AP view, (Fig. 17.37). If the views are not orthogonal, that is, at a 90°
i.e., the distance between the anode of the X-ray tube and the angle to one another, all visible struts and joints must be
plate-holder, in the field “Focal distance (AP view).” indicated.
Additionally, indicate the X-ray beam center, using a marker As soon as the program has enough information to con-
in the form of a blue cross with a red center, on the AP view tinue, the “Forward” sign turns green, at which point con-
image (Fig. 17.35). The focal distance and the location of the tinuation to the next step is possible.
beam center are defined during the X-ray examination. Step 7: Indicating the Focal Distance and Beam Center,
Detailed explanations can be found in Sect. 17.5.2 and the Strut and Joint Projections on the Lateral View
(Fig. 17.22). Step 7 (Figs. 17.38, 17.39, and 17.40) is carried out
The next stage involves marking the strut and joint projec- essentially as described for Step 6. Here, it must again be
tions on the AP view (Figs. 17.36 and 17.37). emphasized that the numbers assigned to the strut and the
joints in the program must correspond to those used in the As soon as the program has enough information to con-
corresponding frame calculations. The arbitrary designation tinue, the “Forward” button turns green and continuation to
of numbers is not allowed. the following step is possible.
As a rule, for the program to work successfully, it suffices After the “Forward” button has been clicked on, the pro-
to indicate three struts and one joint, with the joint num- gram processes all the data fed into it and produces a digital
bered differently from the indicated struts. The struts and frame model in which the lengths and positions of the strut
joints indicated on AP and lateral roentgenograms might projections have been calculated for both AP and lateral
not coincide. In other words, the AP view might feature one views. This takes, depending on the speed of the computer,
set of indicated joints and struts, and the lateral view between 10 s and 2 min.
another. When the calculation has been completed, red lines will
Note: If the AP and lateral views are not orthogonal, that appear on both images: six on the AP view and six on the
is, are at 90° to one another, then all visible struts and joints lateral view. These lines have to exactly match the projections
should be indicated. of all strut axes. Permissible deviation is limited by a strut
Fig. 17.23 Strut markers.

(a) Appearance;
(b–g) correspondence between
the bar codes and strut numbers;
(h) strut markers fixed to the
struts; (i) the strut markers on the
X-ray (indicated by arrows)
g
h i
width as it appears on the image. The congruency between The axis line (Fig. 17.42, 1) always divides the centering
red lines and struts serves as a criterion of correct data input line (Fig. 17.42, 2) and the line of the angle marker (Fig. 17.42,
(Fig. 17.41). If this congruency is present for all the struts, 4) into two equal parts. The angle marker (Fig. 17.42, 3) con-
click “Yes” and continue to the next step. sists of two short blue lines emerging from the intersection of
Caution: If even a single red line does not match a strut the axis line and the angle marker line. The first, short line
as the latter appears on the computer screen, click “No” to travels along the axis line, and the second along the angle
return to Step 7. It is then necessary to return to the previous marker line. The line of the superposition pointer (Fig. 17.42,
steps and consistently check the data input. Only when con- 6) connects the superposition pointer (Fig. 17.42, 5) with the
gruency between all red lines and all strut projections is axis line.
achieved may one continue to the next step! The axis lines of the fragment markers must be set to
Step 8: Marking the Bone Fragment Axes match the anatomic axes (middle-diaphyseal lines of the bone
Special tools are used to mark the axes of both the base fragments). An algorithm to accomplish this is as follows:
and the mobile bone fragments, the bone fragment markers 1. The field “Base fragment marker (AP view)” is checked.
(“trees”). The base fragment marker is colored green, and the The cursor is then brought to the distal portion of the base
mobile fragment marker violet, thus corresponding to a green fragment, over its middle part. While left-clicking the
tree and a violet tree. mouse, drag the axis line of the base fragment on the AP
The fragment markers (Fig. 17.42) consist of the axis line, view from bottom to top. When the line is completed, it
centering line, angle marker, line of the angle marker, super- will be replaced by the green base fragment marker
position pointer, and line of the superposition pointer. (Fig. 17.43). If the position of the base fragment marker is
a b
Fig. 17.24 Converting an analog roentgenogram into digital format. (a) Technique to obtain the photographs; (b) resulting image
Fig. 17.25 Program window

after the new document has been
created in Step 1
Fig. 17.26 Program window at

Step 1. 1 Zoom in/out button,
2 Move fragment markers button,
3 Move roentgenogram images
button, 4 fields displaying the
angles between the axes of the
bone fragment markers
Fig. 17.27 Data input during

Step 1. 1 Patient data, 2 strut
lengths, 3 triangle side lengths
Fig. 17.28 Ortho-SUV program

window in Step 2: Uploading the
AP view
Fig. 17.29 Ortho-SUV software

window in Step 3: Uploading the
lateral view

window after Step 3, in which
the AP and lateral views appear

window during Step 4: Scaling of
the AP view. An analog
roentgenogram was the initial
source. (a) Prior to and (b) after
scaling. An arrow points to the
scaling ruler. As the interval with
known length, the width of the a
analog roentgenogram was used
0,0 0,0

the AP view. A digital
scaling rulers. As an interval of
known length, a radio-opaque a
ruler was used

window during Step 5: Scaling of the
lateral view. An analog roentgenogram
was the initial source. (a) Prior to and
(b) after scaling. An arrow points to
the scaling ruler. As an interval of
known length, the width of the analog
a
roentgenogram was used

lateral view. A digital
scaling ruler. As an interval of
known length, the segment
between the extreme points of a a
radio-opaque ruler was used
correct, the line of the superposition pointer will be its 2. The field “Mobile fragment marker (AP view)” is
lowest part. If the operator has mistakenly dragged the checked. The cursor is then brought to the proximal por-
line not from bottom to top but from top to bottom, the tion of the mobile fragment, over its middle part. While
line of the superposition pointer will assume the wrong left-clicking the mouse , drag the axis line of the distal
location; that is, at the very top of the fragment marker. To fragment on the AP view from top to bottom. When the
correct this mistake, deselect the field “Base fragment line is completed, it will be replaced by the violet mobile
marker (AP view),” place the cursor over the image of the fragment marker. If the position of the mobile fragment
AP view, and left-click the mouse once. Then, go through marker is correct, the line of the superposition pointer
the algorithm again, this time dragging the line in the will be located at its highest point. If the operator has
proper direction. mistakenly dragged the line not from top to bottom but
To strictly align the axis line of the fragment marker from bottom to top, the line of the superposition pointer
with the anatomic axis of the base bone fragment, place will assume the wrong location, that is, at the very bot-
the cursor over the end of the centering line of the angle tom of the fragment marker. To correct this mistake,
marker and, while left-clicking the mouse, place this point deselect the field “Base fragment marker (AP view),”
on the cortical layer positioned to the left. Similarly, place place the cursor over the image of the AP view and left-
the second outermost point of the centering line of the click the mouse once. Then go through the algorithm
base bone fragment marker on the cortical layer posi- again, this time dragging the line in the proper direction.
tioned to the right. With the same technique, set the outer- To strictly align the axis of the fragment marker with the
most points of the centering line of the angle marker on anatomic axis of the mobile bone fragment, place the cur-
another level of the bone. As a result, the anatomic axis of sor over the end of the centering line of the angle marker.
the proximal bone fragment will be constructed on AP While left-clicking the mouse, set this point on the cortical
view (Fig. 17.44). layer positioned to the left. Similarly, place the second

window during Step 6. The focal
distance has been entered and the
X-ray beam center marked. An
arrow points to the marker of the
beam center
outermost point of the centering line of the base bone frag- comminuted fractures, when it is relatively easy to define
ment marker on the cortical layer positioned to the right. the points for superposition. To do this, the superposition
Using the same technique, set the outermost points of the pointer corresponding to the base bone fragment marker
centering line of the angle marker on another level of the is placed on a (user-defined) point on the base bone frag-
bone. As a result, the anatomic axis of the distal bone fragment. Set the cursor over the pointer and while left-click-
ment will be constructed on the AP view (Fig. 17.45). ing the mouse bring the pointer to the required point; then
3. Select the field “Base fragment marker (lateral view).” let release the left mouse button. Similarly, place the
The axis line of the base bone fragment on the lateral view superposition pointer that is part of the mobile fragment
is defined as described for the AP view. The line is dragged marker on the point of the mobile fragment intended for
from bottom to top (Fig. 17.46). superposition (Fig. 17.48).
4. Select the field “Mobile fragment marker (lateral view)”. (b)Another application of the superposition pointers
The axis line of the mobile bone fragment on lateral view involves those situations in which axial displacement of
is defined as described for the AP view. The line is dragged the mobile fragment is required, i.e., compression or dis-
from top to bottom. traction. When the superposition pointer corresponding
After the completion of these steps, the anatomic axes to the base fragment marker is set below the end of the
of both the proximal and the distal bone fragments are base fragment, and (or) another pointer corresponding to
defined on AP and lateral views (Fig. 17.47). If the bone the mobile fragment marker is set above the end of the
fragment markers are not set, no further work with the mobile fragment, the program calculates the distraction
program is possible. (Fig. 17.49).
5. Set the superposition pointers (Fig. 17.42, 5). These have In order to achieve compression (approximation of the
several different applications depending upon the required bone fragments), the pointer of the base fragment marker is
effect: placed proximal to the level of the base fragment end, and
(a) To indicate the points on the proximal and distal frag- the pointer of the mobile fragment marker distal to the end of
ments to be superposed, as is often the case for non- the mobile bone fragment (Fig. 17.50).
Fig. 17.36 Ortho-SUV software window

during Step 6: Indicating the strut and
joint projections. (a) Marker of strut #1; a
(b) marker of joint #6 after its first
appearance on the computer screen;
b
Fig. 17.36 (continued) (c) marker of

joint #6 after its alignment with the bolt
and the strut; (d) appearance of a strut c
marker in the presence of a previously
marked joint with the same number. An
arrow points to the marker of joint #5
d

during Step 6, after the projections of struts
#2, #3, and #4 and joint #6 are indicated on
the AP view

during Step 6, after the focal distance has
been entered and the beam center indicated
on the AP view. An arrow points to the
marker of the beam center

during Step 7: Indicating the Strut and Joint
Projections. (a) Marker of strut #1; (b)
marker of joint #2 upon its first display on
the computer screen;
Fig. 17.39 (continued) (c)

marker of joint #2 after its
alignment with the bolt and the
strut; (d) appearance of a strut
marker in the presence of a
previously marked joint with the
same number. Arrows point to
the marker of joint #2

window during Step 7, after the
projections of struts #4, #5, and
#6, and of joint #2 have been
indicated on the AP view
Fig. 17.41 Ortho-SUV software window after Step 7. The red lines must match the strut projections
2 measuring and assigning the necessary compression or dis-

traction values is explained in Step 11.
Note: For Step 8, the obligatory part is setting the bone
fragment markers. The rest of the manipulations (setting the
markers in alignment with the bone fragments, assigning the
axial displacement of the bone fragments, marking the super-
1
position points) may be carried out or fine-tuned in Step 11.
The program also possesses the capability to position the
4 axis lines such that they correspond with the positioning of
the mechanical axes of the bone fragments. This enables
deformity correction and fracture reduction using the
mechanical axes in the planning stage. A detailed explana-
tion is provided in Step 11.
After the fragment markers have been set, click on the
“Forward” button.
3 Step 9: Drawing the Bone Contours
The contour of the mobile bone fragment is outlined with
6
a yellow solid or dashed line on the AP and lateral views
5
(Fig. 17.51). To do this, the cursor is placed over the surface
of the cortical layer of the mobile bone fragment. While left-
clicking the mouse, draw a line. Similarly, draw the neces-
sary series of lines until the bone fragment is outlined. If the
last fragment of the line is drawn incorrectly, use the button
“Erase the last line.”
Fig. 17.42 Fragment marker in the Ortho-SUV software (“tree”).
1 Axis line, 2 centering line, 3 angle marker, 4 line of the angle marker, Once the bone contours have been drawn on the AP and
5 superposition pointer, 6 line of the superposition pointer lateral views, click the “Forward” button.
Note: The lengths of the bone contours on the AP and
lateral views must be equal. Dots or lines drawn accidentally
To move the superposition pointer, place the cursor over it with the yellow marker may end up beyond the bone con-
and while left-clicking the mouse move the pointer along the tours, e.g., while trying to move the bone contours in the
axis line for the required distance. The technique for window, and the “Erase” button special program option is
Fig. 17.43 Ortho-SUV software window at Step 8, after the proximal bone fragment has been marked on the AP view
Fig. 17.44 Ortho-SUV software window during Step 8, after the axis of the proximal bone fragment has been constructed on AP view
not used. However, the program interprets both these dots In this step, the settings of the bone fragment markers can
and lines and the outlined contour of the distal fragment as a be corrected for the following cases:
single picture. Consequently, the next step will be impossible 1. If this step shows that the markers set on Step 8 are not
to perform because the program will not consider the bone accurate enough.
contours’ medial line to be correct. Thus, all accidental dots 2. If the length of one of the bone fragments is small and, in
and lines must be promptly erased. order to draw the fragment’s anatomic axis, an epidiaphy-
Step 10: Marking the Anatomic Axes of the Mobile seal (anatomic) angle must be constructed.
Fragment on the AP and Lateral Views 3. If there is a planned correction of the bone fragment’s
To mark the anatomic axis, the cursor is placed in the cen- position using the mechanical axes.
ter of the bone contours of the mobile bone fragment, several 4. When correction does not imply alignment of the axes of the
centimeters above its proximal end. While left clicking the basic and mobile bone fragments; for instance, in reconstruc-
mouse, draw a solid line along the center of the bone contour tion surgeries such as Ilizarov reconstruction of the proximal
of the mobile bone fragment (the line can consist of several part of the femur (pelvic support osteotomy), and when
segments but without any intervals between them; it can be a hypercorrection of the bone fragments’ position is necessary.
single straight, curved, or zigzag line). If the bone has several To correct the bone fragment markers, the operator should
curvatures, the line must outline all of them. The medial lines deal with the full range of manipulations possible with them.
on the bone contours are marked on the AP and lateral views Moving the Bone Fragment Markers
(Fig. 17.52). To move a bone fragment marker, click the “Move object”
Note: The anatomic axes of the mobile fragment must button. While placing the cursor on any of the dots on the
exceed the proximal and distal ends of the bone contour of the bone fragment, left-click the mouse and, holding it, move the
fragment by several centimeters. If the X-ray image is short marker across the window.
and it is impossible to draw the medial line above the distal The angular position of the bone fragment marker (mostly
end of the bone contour, the operator must return to Step 9, required in reconstruction surgeries) is changed in one of the
remove the bone contour, and draw a new, shorter one. following ways:
Step 11: Choosing the Mode of Bone Fragment 1. The cursor is placed on the point where the axial line and
Reduction the centering line intersect. While left-clicking the mouse,
Once Stage 10 has been completed and the “Forward” change the position of this point of intersection. At the
button clicked, roentgenograms with the bone fragment same time, the fragment marker will begin to rotate around
markers in the positions set in Step 8 will be visible in the the point where the axial line and the line of the angle
field of the program window (Fig. 17.53). marker intersect.
Fig. 17.45 (a, b) Ortho-SUV software window during Step 8, after the axes of both the proximal and the distal bone fragments have been con-
structed on the AP view. The identification of the anatomic axis of a fragment with the help of a “tree” is shown in (b)
2. The cursor is located on the point where the axial line and elements of the fragment marker rotate around the
the line of the angle marker intersect. While left-clicking point where the axial line and the angle marker line
the mouse, change the position of the intersection point. intersect.
At the same time, the fragment marker will begin to rotate 4. The cursor is placed on the end point of the angle marker
around the point where the axial line and the centering line opposite to the angle marker. While left-clicking the
line intersect. mouse, change the position of the point. At the same time,
3. The cursor is placed over one of the end points of the the second end point of the angle marker line remains
centering line. While left-clicking the mouse, change fixed as the other elements of the fragment marker rotate
the position of the point. At the same time the second around the point where the axial line and the centering
end point of the centering line remains fixed as the other line intersect.
Fig. 17.46 Document window of the Ortho-SUV program during Step 8, after the axis of the proximal bone fragment has been defined on the
lateral view
Fig. 17.47 Ortho-SUV software window during Step 8, after the axes of the proximal and distal fragments have been defined on AP and lateral views
AP view Lat. view
Fig. 17.48 Superposition pointers are placed on the projection of the points on the proximal and distal fragments that will be superposed in frac-
ture reduction. (a) Ortho-SUV software window; (b) scheme, with the arrow indicating the superposition points
Angle Marker bone fragment marker and the location of the angle marker
Angle markers are present on each marker of the bone frag- line related to the axial line are changed in two ways:
ments (“tree” signs) (Fig. 17.42). They are indicated in blue 1. Place the cursor over one of the ends of the angle marker
and show the angle between the axial line and the angle marker line. While left-clicking the mouse, change the angle
line. On the detached panel in Step 11, there are fields (absent position of the marker line related to the axial line.
in Step 8) that automatically show the values of the marker Changes in the angle value are monitored simultaneously
angles of the basic and mobile bone fragments, for both the with the manipulation, since the current values are shown
AP and the lateral view (Fig. 17.54b, arrow). The angle of the in the field of the marker being changed.
AP view Lat. view
Fig. 17.49 Ortho-SUV software window: setting the lines of the superposition pointers to separate the bone fragments (distraction), (a) Document
window; (b) scheme, with the arrows indicating the lines of the superposition pointers
AP view Lat. view
Fig. 17.50 Ortho-SUV software window: setting the lines of the superposition pointers to approximate the bone fragments (compression). (a)
Program window; (b) scheme, with the arrows indicating the pointer lines
Fig. 17.51 Ortho-SUV software window after the completion of Step 9. (a) The line is drawn on the AP view; (b) the mobile fragment on the AP
and lateral views is outlined with a yellow line
b c
Fig. 17.52 Ortho-SUV program window after completion of Step 10. On the AP and lateral views, the anatomic axes of the mobile fragment are
marked with blue lines (a) and explanatory schemes (b, c)
Fig. 17.53 Ortho-SUV program window for Step 11: roentgenograms and the axes of the proximal and distal fragments
2. In the window of the fragment angle marker that is angle marker line at the point where the anatomic axis and
being corrected, change the current value to the required knee joint line normally intersect (Fig. 17.54b,c).
one. To do so, place the cursor on the field showing the 2. Angle markers are used when the deformity correction is
value of the angle marker (for example, the marker planned based on the mechanical axes of the bone fragments.
angle of the basic bone fragment on the AP view). Left- After Step 8, the bone fragment markers are placed
click and set the text cursor in the field. Using the Delete opposite to the bone fragments (Fig. 17.55a); this position
and Backspace keys on the keyboard, erase the current is also kept after Step 10. The normal mechanical axis of
value, replacing it with the new value. While left-click- the lower extremity intersects with the line connecting the
ing the blue field located to the left of the value field, center of the femoral head with the apex of the greater
confirm the new value of the angle. After these manipu- trochanter at an angle of 90º (85–95º), at a point located in
lations, the position of the marker line of the bone frag- the center of the former. The mechanical axis also inter-
ment will change automatically with respect to the axial sects with the middle part of the knee joint in its center at
line. an angle of 88º (85–90º).
Using the angle markers is necessary in two cases: To set the bone fragment markers (“tree” signs) a number of
1. When the fracture or the deformity angle is located close manipulations are required. Using one of the above-mentioned
to the joint, which prevents construction of the axis for methods, enter 90º for the marker angle of the basic bone frag-
this short bone fragment. For example, Fig. 17.54 shows ment on the AP view. Move the basic bone fragment marker so
a deformity of the distal metaphysis of the femur. After that the line of the angle marker: (a) is in the projection of the
Step 8, the bone fragment markers are placed in their pro- line connecting the center of the femoral head with the apex of
jections (Fig. 17.54a), maintaining this position after Step the greater trochanter and (b) intersects with the axial line in
10. The known point and angle of the normal intersection the center of the femoral head. Using one of the above-men-
of the anatomic axis and knee joint line for the AP view is tioned methods, enter 88º as the value of the marker angle of
81º (79–83º) and for the lateral view 83° (79–87º). Using the mobile bone fragment on the AP view (Fig. 17.55b,c).
one of the above-mentioned methods to construct the ana- Relocate the mobile bone fragment marker so that the line of
tomic axis of the short distal fragment, set the marker the angle marker is in the projection of the knee joint line while
angle of the mobile bone fragment to 81º for the AP view the axial line intersects with it in the joint’s center.
and 83º for the lateral view. Pop-up Menu Options
To set the “tree” marker of the bone fragment, the In Step 11, the options of the pop-up menu are actively
angle marker line must be located on the projection of the used. To see this menu, right-click the mouse in the program
knee joint line, while the axial line must intersect with the window (Fig. 17.56).
The pop-up menu offers the following options: 3. “Visibility of bone fragment contours.” Left-clicking on
1. “Visibility of the panel.” Left-clicking this option will this option will cause the appearance or disappearance of
cause the panel to appear or disappear. Only the roentgeno- the bone contours.
grams and tool bar remain visible in the program window. 4. “Visibility of the rulers.” Left-clicking on this option will
2. “Visibility of bone fragment markers.” Left-clicking on cause the appearance or disappearance of the rulers.
this option will cause the appearance or disappearance of 5. “Visibility of the vertical and horizontal lines.”
the bone fragment markers. Left-clicking on this option will cause the appearance or
Fig. 17.54 Ortho-SUV software: setting the angle marker lines for a (arrows point to the fields showing the values of the marker angles of the
pathology of the distal meta-epiphysis of the femur. (a) Setting the bone basic and mobile bone fragments for AP and lateral views);
fragment markers after Step 8; (b) placing the markers after Step 11
c hexapod model constructed in Step 7 (red lines and strut

projections).
This pop-up menu can also be used before Step 11,
although it becomes relevant only at Step 11.
Bone Contours
To switch on the “Bone contours” function in Step 11,
choose the proper option from the drop-down menu. In the field
of the roentgenogram, both the initial (yellow) and the final
(red) bone contours appear (Fig. 17.57). The latter will show the
position of the bone fragments after fracture reduction or defor-
83° mity correction. The correct position of the final bone contours
81° (79−87°)
(79−83°) requires that the rules for the placement of the bone fragment
markers have been observed. When the position of the markers
is changed, the position of the final bone contours also changes.
Bone contours should be used in all cases of deformity correc-
tion and fragment reduction since they allow visual assessment
of the planned final position of the bone fragments.
The “Bone contours” function is most beneficial in cases
in which the bone fragments are to be positioned such that
they do not correspond with the alignment of the anatomic
Fig. 17.54 (continued) (c) scheme (or mechanical) axes of the bone fragments. This may occur
in an aesthetic reconstruction (Chap. 18), specifically, an
disappearance of the vertical and horizontal lines that Ilizarov reconstruction of the proximal femur (Chap. 23.4).
mark the points needed to calculate the time required for Having set the markers of the bone fragments and/or after
the deformity correction. the final bone contour has assumed the correct position, choose
6. “Visibility of the frame.” Left-clicking on this option either the “Fracture reduction” or “Deformity correction”
will cause the appearance or disappearance of the option by checking the appropriate box (Fig. 17.57).
Fig. 17.55 Ortho-SUV software: setting the lines of the angle markers in a correction of a femoral deformity according to the mechanical axes.
(a) Setting the values of the bone fragments after Step 8;
Fig. 17.55 (continued) (b) placing the bone fragment markers after Step 11; (c) scheme
Fig. 17.56 Ortho-SUV program window at Step 11, Right-clicking has opened the pop-up menu (arrow)
Fig. 17.57 Ortho-SUV program window in Step 11. The “Deformity position of the mobile bone fragment; the red bone contour its position
correction” option is chosen; the value and direction of the mobile bone as a result of the correction
fragment rotation are set. The yellow bone contour shows the initial
The “Fracture reduction” option has a number of special so, on the roentgenograms two points are marked, those of
features, in that while the program calculates the alignment the “structures at risk.”
of the bone fragments axes it fits the connection points previ- In the pop-up menu (obtained by right-clicking the mouse
ously marked on each bone fragment. This feature is most button on the roentgenogram field), choose the “Visibility of
important in the anatomic reduction of an oblique spiral frac- the vertical and horizontal lines” option. After the cursor has
ture. In such cases, rotational displacement of the bone frag- been placed on this option and with a left-click of the mouse,
ments relative to each other is almost impossible to measure green vertical and horizontal lines intersecting at a right
clinically and on the roentgenogram. Consequently, the result angle to each other will appear at opposite ends of each
will be an inaccurate anatomic reduction with remaining image (one intersection at opposing ends of each view). The
rotational movement and a partial diastasis between the frag- intersection can be moved across the window in the image
ments. By contrast, the “Fracture reduction” option, due to field. To do so, the cursor is placed over the intersection or
the program’s ability to accurately match the connection over one of the lines involved in it. While left-clicking the
points, enables an anatomic reduction without these mouse, move the intersection across the image field and
inaccuracies. place it at the required point.
The “Deformity correction” option can be used, obvi- The first point is set on the line of the osteotomy (fracture)
ously, in deformity correction but also in fracture reduction. at the spot from which this point will be moved over the lon-
When this option is chosen, the program ignores the connec- gest distance during reduction of the mobile bone fragment.
tion points. The levels of the marker points indicate only the In an angular deformity, this point is located on the concave
necessity of compression and distraction. surface (Figs. 17.58 and 17.59a). Having set the first point at
In addition, the “Deformity correction” option enables the chosen spots on the AP and lateral views, click on “Input
input of the value of the necessary rotational movement of the first point” (Fig. 17.59a).
the mobile bone fragment. The appropriate box is checked The second point, set during the deformity correction, is
(internal or external rotation) and the rotational value, in located in the projection of the main vessels and nerves where
degrees, is entered (Fig. 17.57). they will be maximally stretched (Figs. 17.58 and 17.59).
In Step 11, additional values are entered to calculate the Having set this point on the chosen sites of the AP and lateral
time of the deformity correction (fracture reduction). To do views, click on “Input the second point” (Fig. 17.59b).
2
1
0
0
1
2
2
0’
1’
2’
Fig. 17.58 Point 1 in case of the deformity correction must pass the distance (1–1¢), which is longer than that of point 0 (0–0¢), but shorter than
that of point 2 (2–2¢), located in the projection of the fibular nerve
Fig. 17.59 The Ortho-SUV program window in Step 11, showing the points that during the deformity correction will pass the longest distance.
(a) Point 1 passes the longest distance during reduction. (b) Point 2 shows the projection of the main vessels and nerves
In addition to entering the structures at risk, the operator Note: Axial translation (compression or distraction) will
can use the intersections of the vertical and horizontal lines occur along the axial lines of the basic bone fragment markers.
for different measurements on the roentgenograms, e.g., to In Step 11, note that the tool bar fields “Angle 1” and
measure the maximal distance that the bone will pass during “Angle 2” show the angles between the axial lines of the
the deformity correction period. To do this, locate an inter- markers of the basic and mobile bone fragments: “Angle 1”
section opposite one of the points on the initial bone contours for the AP view and “Angle 2” for the lateral view. This
on the AP and lateral views and click on the “Input the first option is especially useful in reconstruction surgeries in
point” button. The intersection of the lines will be located in which the aim is not to align the axes of the bone fragments
the appropriate point on the final bone contour on both views; but to create a definite angle between them, such as in Ilizarov
that is, where the first point will be after the deformity cor- femoral reconstruction, or to create special positions of the
rection. Click on the “Input the second point” button. In the bone fragments in esthetic surgery.
field of the program bar, the distance between the points will Having identified the structures at risk, click on the
be indicated. “Forward” button to continue.
Also, at Step 11 there is a program option allowing input Note: Before continuing on to Step 12, use maximal
of the value of the distraction or compression between the magnification to check the position of the red bone contour
bone fragments. To do this, the lines of the connection points relating to the basic fragment; otherwise, you may fail to
of the proximal and distal bone fragment markers are set at notice a slight residual displacement.
one level (Fig. 17.60a). In the tool bar field “Axial transla- Step 12: Strut Length Change
tion,” check the box indicating the appropriate option: “to To define the rate of deformity correction (fracture reduc-
lengthen” or “to shorten.” Enter the value of the required tion) a value (in mm/day) is entered in the “Rate of correction”
compression or distraction in mm in the appropriate field. field (Fig. 17.61). The default value is 1 mm/day but the user
Then click on the “Move” button. The lines of the bone frag- can enter any other value; the minimal value is 0.1 mm/day.
ment markers and bone contours will move lengthwise rela- Next, click the “Calculate” button; the program will cal-
tive to each other over the input distance (Fig. 17.60b). culate the number of days required for the deformity
Fig. 17.60 Ortho-SUV program window in Step 11: distraction. (a) Line markers of the connection points’ markers are located on the same
level;
Fig. 17.60 (continued) (b) after lengthening input by 20 mm
Fig. 17.61 Ortho-SUV program window in Step 12. The deformity correction rate has been entered
Fig. 17.62 Ortho-SUV program window in Step 12. The program has calculated the number of days recommended for the deformity correction
based on a rate of 1 mm/day, which is 26 days
Fig. 17.63 Ortho-SUV program window in Step 12. The program has calculated the daily changes in each strut length to achieve the required
deformity correction
correction at the given rate. The results appear in the I,9 - 3; II,9 - 3 IV,3 - 9
“Recommended number of days” field (Fig. 17.62) and they - - Ortho - SUV
2/3140 140
represent the situation in which neither of the structures at
risk can be moved faster than the chosen rate, for example, IV,3 - 9 IX (8 - 2)IX,8 - 2; IX,4 - 10
- -
1 mm a day. Once again, however, the user can enter the 140 140
required number of days for the deformity correction in the
appropriate field. An attempt at closed reduction in fast struts mode only
Having defined the number of days required for the defor- partially succeeded in improving the positions of the bone
mity correction (reduction of the fracture), click on the fragments, and their displacement remained (Fig. 17.64c).
“Show” button. The program will then show a table, in the Calculations were made using the Ortho-SUV software.
right lower field of the window, containing the values of the Fracture reduction mode was used, indicating the super-
daily changes of each strut length (Fig. 17.63). position points of the proximal and distal fragments
The first column of the table shows the starting day of the (Fig. 17.64d,e). Proceeding from these calculations
correction. The following six columns show the length of (Fig. 17.64f), fracture reduction was carried out (Fig. 17.64g).
each strut. The rows show the appropriate integer values, in The second stage involved intramedullary osteosynthesis
mm, of the strut length for each day. Between the rows, a with a locking nail (Fig. 17.64h, i).
delta 0.25 parameter is shown for each strut, indicating how
many times and in what direction the strut length has to be
changed by 0.25 mm in order to achieve the daily norm. 17.6.2 Diaphyseal Deformities
If there is no need for further adjustment of the deformity
correction rate and time (or fracture reduction), click on the Patient E. (Fig. 17.65a) was hospitalized with a diagnosis of
“Print” button to obtain a paper copy of the recommenda- non-unions of the distal thirds of both tibias; specifically,
tions for the daily length change of each strut. Using the complex six-component, three-planar deformity of the right
“Clean” button, one can clear the fields of the strut lengths. lower leg, and complex five-component, two-planar defor-
This function is needed in case recalculation is required. mity of the left lower leg. In the first stage, combined exter-
The file can be saved on any electronic medium. To do nal fixation of the bones in both lower legs was performed
this, click on the “Save” button located in the tool bar. using the Ortho-SUV device (Fig. 17.65b).
The program requires the following time for the comple- For the right leg:
tion of the 12 steps (after training and including 10–12
III,12,100; IV,10 - 4; V,2,80
calculations): 8–12 min in case of fractures and diaphyseal - Ortho - SUV
deformities, and 12–15 min in case of epimetaphyseal defor- 150
mities and reconstruction surgeries. VI,12,90; VII (8 - 2)8 - 2; VIII,1,90
-
150
17.6 Application of the Ortho-SUV Frame: For the left leg:

Clinical Cases
IV,12,100; V,10 - 4; VI,2,80
17.6.1 Fracture Treatment - Ortho - SUV
150
VII,12,90; VIII (8 - 2)8 - 2; VIII,4 - 10
Patient B., 22 years old, was hospitalized following a diag- -
nosis of old (dated 3 months back) midshaft fracture of the 150
left tibia with shortening, translation, and angulation of the
bony fragments (Fig. 17.64a). For both legs, Step 11 consisted of deformity
correction mode. Fragment markers were set over the
I,9 - 3; II,9 - 3 IV,3 - 9 projections of the anatomic axes of the bone fragments
- - Ortho - SUV
2/3140 140 (Fig. 17.65c,d).
IV,3 - 9 IX (8 - 2 )IX,8 - 2; IX,4 - 10 To determine the rate and the period of distraction, two
- - points were used: those of the structures at risk. Thus, in the
140 140
drop-down menu (which appears after right-clicking the
External fixation of the left tibia using an Ortho-SUV mouse) “Vertical and horizontal lines visibility switch in/
Frame was performed. Transosseous elements (wires) were out” was selected. The left mouse button was used to
inserted so as not to interfere with consequent nailing manipulate the green intersecting (90°) vertical and horizon-
(Fig. 17.64b): tal lines, which appeared next to both roentgenograms
a b
Fig. 17.64 (a–i) Patient B: photographs and roentgenograms

AP view Lat. view


h i
(one intersection per image). With the left mouse button held 17.6.2.1 Example of Diaphyseal Deformity
down, each intersection was moved into its respective image Correction in the Femur Using
area and placed at the required point. the Mechanical Axes
On the AP and lateral roentgenograms, the first point Patient E. was hospitalized with a diagnosis of post-traumatic
was set along the non-union line, exactly where the mobile complex five-component biplanar deformity of the left femo-
fragment in the process of its transport would eventually ral bone. To correct the deformity, an Ortho-SUV Frame was
cover the longest distance (Fig. 17.65e). The “Input the first used (Fig. 17.66a,b). Fragment markers were placed over the
point” button was clicked on. The second point was set in mechanical axes of the bone fragments using the following
the area where the main vessels and nerves were projected, algorithm:
where they will undergo maximum stretching during the The locations of the points of intersection of the mechani-
deformity correction process (Fig. 17.65f). After the sec- cal axis and the femoral head and between the mechanical
ond point was set on its selected locations on the AP and axis and the knee joint line on the AP view were previously
lateral roentgenograms, the button “Input the second point” established (Chap. 16). In Step 11, the angle of the base frag-
was clicked on. ment marker was set on the AP image at 90º using the
In Step 12, 1 mm/day was set as the rate of the deformity left-mouse function, placing the cursor over the point of
correction. The “Calculate” button was clicked on and the pro- intersection of the axis line and the line of the angle marker
gram calculated the recommended number of days required of the base fragment. The left mouse was also used to exactly
for the deformity correction. Clicking on “Show” resulted in place this intersection over the center of the femoral head,
the appearance of a table in the lower right field of the display, and then to set the cursor over the end of the line of the angle
with the values of the daily length change for each strut marker of the base fragment. Again with the left mouse, the
(Fig. 17.65g). This table was printed out and given to the angle between the line of the angle marker and the axis line
patient. The same procedure was done for the right lower leg. was altered such that this line connected the center of the
Deformity correction was performed according to these femoral head with the apex of the greater trochanter.
calculations (Fig. 17.65h). The second stage involved In the dialog box shown in Fig. 17.66c, d, in the field dis-
intramedullary osteosynthesis with locking nails for both playing the value of the angle marker for the base fragment,
lower legs (Fig. 17.65i). the required value of 90° replaced the previous one, thus
automatically changing the position of the line of the angle the ends of the line of the angle marker of the mobile frag-
marker of the mobile fragment. Moving the centering line ment. With the left mouse held down, the position of the line
manipulated the line of the angle marker, positioning it over was manipulated to change the angle between the line of the
a line connecting the center of the femoral head with the angle marker and the axis line. In the dialog box, in the field
apex of the trochanter (Fig. 17.66c,d). The angle of the mobile displaying the value of the angle marker for the mobile frag-
fragment marker was set to 88º by strictly placing the axis ment, the required value of 88º replaced the previous one,
line of the mobile fragment marker in the middle of the knee thus automatically changing the position of the line of the
joint. With the left mouse, the cursor was placed over one of angle marker of the mobile fragment with respect to the axis
Fig. 17.65 (a–i) Photographs and roentgenograms of patient E. before and during treatment




a b
Fig. 17.66 (a–g) Patient E: photographs and roentgenograms


line. The line of the angle marker, with the centering line (Fig. 17.67a) and a fracture of the left femur fracture, treated
serving as a guide, was then set on the distal joint line of the with an external fixation device.
femoral bone (Fig. 17.66c, d). As a first stage, combined external fixation of the right tibia
The rate and period of distraction were determined using was performed using the Ortho-SUV Frame (Fig. 17.67b, c):
two points, those of the structures at risk. For this purpose, in
the drop-down menu (which appears by a right-mouse click I,9 - 3; I,4 - 10; II,1,90 IV,10 - 4; V,2,90
-
within a roentgenogram field) “Vertical and horizontal lines 150 150
visibility switch in/out” was chosen. Holding down the left VII (8 - 2)8 - 2; VIII,4 - 10
-Ortho - SUV -
mouse button resulted in the display, next to the roentgeno- 150
grams, of the intersecting (90°) green vertical and horizontal calc., 8 - 2; calc., 4 - 10; m/tars., V - m/tars.,I
=
lines (one intersection per image). With the left mouse, the horseshoe -shaped support
intersection was moved into the image area and onto the
required point. In the computer program, “Deformity correction” was
The first point was set on the osteotomy line of both the AP selected at Step 11 (Fig. 17.67d). The base fragment markers
and the lateral images, exactly where the mobile fragment would were used to indicate the anatomic axes of the proximal frag-
be transported over the longest distance (Fig. 17.66e). The option ment on AP and lateral views. Due to the length of the proxi-
“Input the first point” was then clicked on. The second point was mal fragment, no difficulties were encountered.
set, on both roentgoenograms, in the projection area of the main However, due to the shortness (35 mm) of the distal frag-
vessels and nerves where they would undergo maximum stretch- ment, it was not possible to establish its anatomic axis line.
ing during the deformity correction process (Fig. 17.66f). The Instead, for the AP and lateral views, the program’s capabil-
“Input the second point” was then clicked on. ity to set the fragment markers in accordance with the epidi-
In accordance with the software calculations, deformity aphyseal (anatomical) angle was exploited. The locations of
correction was performed and the correct position of the the points of intersection between the ankle joint lines and
mechanical axis of the femur restored (Fig. 17.66g). the lines of the anatomic axes for the AP and lateral views
were known (Chap. 16). Thus, at Step 11 the angle of the
mobile fragment marker was set (Fig. 17.67d,e), placing the
17.6.3 Metaphyseal Deformities axis line of the mobile fragment marker exactly over the cen-
ter of the ankle joint. The left mouse was then used to move
Patient К. was hospitalized with a diagnosis of non-union of the cursor over an end of the line of the angle marker belong-
the right tibial distal meta-epiphysis; specifically, a four- ing to the mobile fragment. With left mouse held down, the
component, three-planar deformity of the right lower leg line of the angle marker was manipulated so as to change the
Fig. 17.67 (a–k) Patient K: photographs and roentgenograms prior to, tibial joint surface. (f) pointing “structure at risk #1”, (g) pointing
during, and after treatment. The arrows in (d) indicate the dialog boxes “structure at risk #2”, (h) software calculated days needed for defor-
where the values of the epimetaphyseal angles are entered, and those in mity correction at rate 1mm/day, (i) during deformity correction, (j),
(e) the lines of the angle markers of the mobile fragments set on the (k) after deformity correction and device module transformation

c
d


i j

angle between the line of the angle marker and the axis line. of the bones of the right foot using two Ortho-SUV Frames
In the dialog box, in the field displaying the value of the (Fig. 17.68b):
angle marker for the mobile fragment, the required values of
VII 11,110;VIII, 4 -10;VIII, 8 -2 (8- 2 )
89º for the AP view and 80º for the lateral one replaced the -0 = - Ortho - SUV
respective previous values (Fig. 17.67d), thus automatically 120
changing the positioning of the line of the angle marker of calc.4 -10; calc.8 -2 – tars.4 - 10; tars.8 - 2
- - 0- -
the mobile fragment relative to the axis line. The center line 2/ 3110 120
was then used as a guide to set the line of the angle marker m/tars.I - m/tars.II; m/tars. V- m / tars.III
Ortho - SUV - -120
on the joint surface of the tibia (Fig. 17.67e). 120
To determine the rate and the period of distraction, the
two points of the structures at risk were used. Accordingly, in To facilitate strut fixation, proximal and distal supports
the drop-down menu (which appears with a right-mouse (without transosseous elements) were used in the assembly
click within a roentgenogram field) the item “Vertical and process.
horizontal lines visibility switch in/out” was selected. With a Program calculations were performed separately for each
left-mouse click, the green intersecting (90°) vertical and frame (that is, for each osteotomy level). One document was
horizontal lines appeared next to the roentgenograms (one created corresponding to the calculations for deformity cor-
intersection per image). The left mouse was then used to rection of the hindfoot relative to the lower leg (Fig. 17.68c),
move each intersection to its respective image area and onto and another for that of the midfoot relative to the hindfoot
the required point. (Fig. 17.68d). The reference lines discussed in Chap. 22 were
The first point was set along the osteotomy line, exactly used. Based on these calculations, deformity correction was
where the mobile fragment would eventually be transported carried out (Fig. 17.68e), followed by module transformation
over the longest distance (Fig. 17.67f). After the first point using an external fixation device, with the struts of the Ortho-
was placed in the chosen location on the AP and lateral SUV Frame replaced by the hinges of an Ilizarov frame
roentgenograms, “Input the first point” was selected. (Fig. 17.68f). Final frame assembly was:
Similarly, on both images, the second point was set in the
projection area of the great vessels and nerves, where they VII 11,110; VIII,4 - 10; VIII,8 - 2 (8 - 2)
would undergo maximum stretching during the deformity 120
correction process (Fig. 17.67g). “Input the second point” calc.4 - 10; calc.8 - 2 tars.4 - 10; tars.8 - 2
-0 - -0-
was then selected. 2/3110 120
In Step 12, the rate of the deformity correction (1 mm/ m/tars.I - m/tars.II; m/tars.V - m/tars.III
day) was set and the recommended quantity of days required -0 -
120
for correction of the deformity calculated by selecting
“Calculate.” The selection of “Show” brought up a table, in
the lower right field of the display, containing the values of 17.6.5 Knee Joint Stiffness
the daily length change for every strut (Fig. 17.67h). This
Patient P. was hospitalized with a diagnosis of consolidated
table was printed out and given to the patient. Deformity
fracture of the left femur and severe extension stiffness of the
correction was performed in accordance with the pro-
left knee joint. Upon admission, motion range in the left knee
gram’s calculations (Fig. 17.67i). Struts of the Ortho-SUV
joint amounted to 15/0/0 (Fig. 17.69a). Arthrolysis, tenoly-
device were replaced by the hinges of an Ilizarov’s frame
sis, and myolysis of the joint were performed followed by
(Fig. 17.67j). The next stage consisted of bone transfer at
Ortho-SUV Frame application (Fig. 17.69b):
the non-union site, using an autogenous bone graft taken
from the iliac crest, followed by corticotomy and osteo-
III,10,90; IV,8,90 VII, 3 - 9; VII,8,90
clasy at level II to correct the limb length discrepancy - - Ortho - SUV
¼ 200 180
(Fig. 17.67k).
III, 4 - 10; IV,1,80 VIII (8 - 2)8 - 2; VIII, 4 - 10
- -
150 150
17.6.4 Deformity Correction of the Foot
For the program calculations, the motion arc of the tibial
Patient Z. (Fig. 17.68a) was hospitalized following a diagno- joint end relative to the femur was identified using scheme
sis of complex deformity of the right foot, with 5 cm shorten- 53 of Chap. 23. Based on these calculations, knee joint
ing. In the first stage of treatment, a V-shaped osteotomy of flexion up to 90° was completed (Fig. 17.69c,d) in 12 days.
the foot (calcaneum osteotomy and osteotomy at the level The Ortho-SUV Frame was then used to perform a course of
of tarsus bone) was followed by combined external fixation 90° flexion, 0° extension ten times over the course of the
following 5 days. The struts of the Ortho-SUV device were As the table makes clear, almost all possible complica-
subsequently removed and the patient performed regular tions are the result of incorrect use of the hardware and (or)
active motions involving the knee joint (Fig. 17.69e). This software. However, if despite consultation of the table the
was followed by the removal of the external fixation device. cause cannot be determined and difficulties in working
During the follow-up period, the range of motion in the knee with the program are experienced, the operator is advised
joint remained 90/0/0 (Fig. 17.69f). to save the program file and e-mail it together with
the patient’s roentgenograms to orthosuv@gmail.com. The
cover letter should include a detailed explanation of the
17.7 Tips and Tricks for Using nature of the problem encountered. This is one reason why
the Ortho-SUV Frame it is essential to save the file after each step of the program.
Complete information concerning training courses for the
The mistakes and complications typical for external fixation Ortho-SUV Frame can be found at http://ortho-suv.org,
are covered in Chap. 33. Table 17.1 lists the possible specific http://rniito.org/solomin, http://www.rniito.org/download/
difficulties that can occur while working with the Ortho-SUV ortho-suv-Iliz-course-9-engl.pdf and http://www.rniito.
Frame, as well as tips for their avoidance and elimination. org/download/ortho-suv-course-4-eng.pdf.
Fig. 17.68 (a–f) Patient Z: photographs and roentgenograms before and during treatment

b


Fig. 17.69 (a–f) Patient P: photographs and roentgenograms before, during, and after treatment. Note the correct interrelationships in the knee
joint during treatment
c d

f
17
Table 17.1 Complications occurring with the use of the Ortho-SUV Frame
Complications Main causes Precaution Elimination
During assembly of the external fixation The initial arrangement of the struts differs from that Arrange the struts as shown in Fig. 17.5b. Prior to the assembly of the external
frame, it is difficult to connect the struts shown in Fig. 17.5b. fixation frame, arrange the struts as
with each other. shown in Fig. 17.5b.
Due to the short distance between the basic The distance between the supports is <120–150 mm. 1. The distance between the supports, if possible, 1. Partial reassembly of the external
supports, it is difficult or impossible to must not be <150 mm. fixation frame.
arrange the struts. 2. Use Z-shaped plates to fix the struts 2. Strut fixation using Z-shaped plates
(Fig. 17.12b). (Fig. 17.12b).
3. Use stabilizing supports to fix the struts 3. Fixation of some of the struts to the
(Fig. 17.12c). stabilizing supports (Fig. 17.12c).
In advancing to Step 2, a dialog box 1. The values of the strut lengths or of the sides of the 1. Enter the correct values of the strut lengths and 1. Entry of the correct data in the
appears, either “The angle between the triangles have been incorrectly entered: wrong sides of the triangles in mm. program.
strut and the support is less than the valid length or the use of cm rather than mm. Potential
norm of 20°” or “Data error.” confusion of the strut numbers and (or) the sides of
the triangles.
2. The struts are located at an angle of 20° to the 2. The struts must be located at an angle >20° to 2. Partial reassembly of the external
support, i.e., close to the horizontal plane or there is the support. fixation frame, which requires an
even a negative angle in the assembly of the struts. additional X-ray image.
Loading the AP image (Step 2) does not A feature of the program is that both roentgenograms – –
result in its appearance in the program appear only after the second, lateral one has been
window. loaded.
During reloading of the file (with all steps This is a feature of the program: you will be able to – –
of the program previously completed), at work with the images on all of the following steps.
Step 3, the previously loaded roentgeno-
grams are not visible.
It is not possible to define the number of 1. The roentgenograms are made on narrow film and 1. The X-ray field must include all struts and The roentgenograms must be retaken.
struts and joints necessary and thus to do not include all struts and joints. joints.
proceed to the next step on the X-ray 2. The images were obtained without the use of strut 2. Strut markers must be placed on the struts prior
image(Steps 6 and 7); it is difficult to markers (Fig. 17.5d). to X-ray imaging (Fig. 17.5d).
define the numbers of struts and joints.
Deformity Correction and Fracture Treatment Using the Software-Based Ortho-SUV Frame
In spite of all struts and joints having been The focal distance and (or) the center of the beam Enter all the data required in this window. Enter the focal distance and the beam
marked in Step 6 or 7, the program does value was not entered. center.
not allow continuation to the next step.
(continued)
801
802
Complications Main causes Precaution Elimination

After Step 7 has been completed, the 1. Incorrect assembly of the external fixation frame: 1. Correct assembly of the external fixation frame. 1. Partial re-assembly of the external
program shows red lines that do not first of all, lack of adherence to the “red screws fixation frame, which requires an
coincide with the strut projections s, rule” and the “watch rule” (Sect. 17.3.1). additional X-ray image.
ranging from the non-coincidence of one 2. Incorrectly entered lengths of the struts and sides of 2. Exactly entered values of the lengths of the 2. Exact lengths of the struts and sides
of the lines to the total displacement of all the triangles or entry of the values in cm (Step 1). struts and sides of the triangles in mm. of the triangles are entered in mm.
lines relating to the external fixation frame. 3. Incorrect scaling (Steps 4, 5): the length of the 3. Exact value of the known section length 3. Exact length of the known section
In the extreme case, the red lines are known section is <80 mm and (or) the length of the entered in mm. is entered in mm.
beyond the visible field. known section was entered in cm.
4. Incorrectly entered focal distance (Steps 6, 7) or the 4. Exact value of the focal distance entered in 4. Exact focal distance is entered in
focal distance was entered in cm. mm. mm.
5. Incorrectly marked numbers of the struts and (or) 5. Marking the numbers of the struts numbers and 5. Entering the numbers of the struts
joints, i.e., lack of correspondence to the assembly (or) joints according to the assembly of the and joints according to the
of the external fixation frame (Steps 6, 7). external fixation frame by using the strut markers assembly of the external fixation
when obtaining an X-ray image (Fig. 17.5d). frame.
6. Coincidence of the red lines with the projections of 6. Control of whether the values have been 6. Thorough control of the data
the struts depends on the exact and correct entered correctly in the completion of Steps entered in Steps 1–7. Return to
completion of Steps 1–7. 1–7. If the AP and lateral roentgenograms were Steps 6 and 7 and mark the
not taken in orthogonal projections, then on maximally possible number of
Steps 6 and 7 the maximal possible number of struts and joints.
struts and joints must be marked.
In advancing to Step 11, the program 1. Different lengths of the bone contours (Step 9) of the 1. The lengths of the bone contours on the AP and 1. Erase the bone contours and draw
shows a dialog window “Specify the mobile bone fragment on the AP and lateral views. lateral views must be equal. them again, this time of equal length.
values of the mid-diaphyseal lines.” 2. The anatomic axes (Step 10) of the mobile bone 2. The anatomic axes must exceed the margins of 2. If it is impossible to draw the
fragment on the AP and (or) lateral views do not the bone contours by 20–30 mm. anatomic axis above the distal end
sufficiently exceed the upper or lower margins of of the bone contour (short X-ray
the bone contour. image). return to Step 9, erase the
bone contour, and draw a new one,
which must be shorter than the
initial bone contour.
3. In drawing the bone contours or constructing the 3. Before the roentgenograms are moved, 3. Erase accidental signs from the
anatomic axes, accidental marks (points, lines) were minimized, or magnified, click the “Move X-ray image fields.
drawn beyond the bone contour or anatomic axis. X-ray images” button (Fig. 17.26).
Attempts to change the position of the red The program is in “Fracture reduction” mode. Before moving the bone contour, confirm which Check the “Deformity correction”
bone contour by moving the distal program mode has been chosen: “Fracture box. If it is already checked, check the
fragment marker (Step 11) causes the form reduction” or “Deformity correction.” “Fracture reduction” box and then
of the bone contour to change, i.e., it return to the “Deformity correction”
begins to rotate. mode.
After the “Calculate” button has been In the program options, “Move of the bone markers” Before proceeding to Step 12, the “Move the bone Switch off the “Move the bone
clicked on to calculate the number of days and (or) “Move X-ray images” are switched in fragment markers” and “Move the X-ray images” fragment markers” and “Move X-ray
for the deformity correction or fracture (Fig. 17.26). Also, to make the program “understand” options must be unchecked (Fig. 17.26). Also, be images” options (Fig. 17.26). Click on
reduction (Step 12), the program shows the that the fragment will be moved in 3D views, before sure to click on the superposition points the superposition points (Fig. 17.42,
dialog window “Switch off the move proceeding to Step 12 click on the superposition (Fig. 17.42, 5) on the proximal and distal bone 5) on the proximal and distal bone
fragment markers button mode and click points (Fig. 17.42, 5) on the proximal and distal bone fragments on the lateral view. fragments on the lateral view.
on the superposition pointer.” fragments on the lateral view.
L.N. Solomin et al.
17
After the “Calculate” button has been To calculate the number of days required for the Do not forget to exactly locate both structures at Return to Step 11 and exactly set the
clicked on to calculate the number of days deformity correction or fracture reduction, the risk points (Figs. 17.58 and 17.59). structures at risk points (Figs. 17.58
required for the deformity correction or program always uses the structures at risk points and 17.59).
fracture reduction (Step 12), the program (Figs. 17.58 and 17.59). If these have not been set, the
gives an obviously incorrect result: for program considers the default settings for these
example, 17 days for a 5-mm distraction. structures, which cannot be applicable to the target
case.
During deformity correction, the struts Incorrect initial assembly of the external fixation During surgery planning, it is essential to consider Partial re-assembly of the external
begin to press on the soft tissues or on the frame. the direction in which the distal main support and fixation frame.
outstanding ends of the half-pins. struts will be moved.
In a maximal distraction in the “Deformity There is no thread on one of the ends of the threaded 1. Use only the threaded rods packed in the Partial re-assembly of the external
correction” mode, the threaded rod rods packed in the Ortho-SUV Frame set, which Ortho-SUV set. fixation frame, replacing the threaded
(Fig. 17.6) has completely dislocated itself precludes disconnection of the strut length changing 2. The threaded bush of the strut length changing rod by a longer one.
from the strut length changing unit unit and the threaded rod. If this complication has unit (Fig. 17.8) has a slot. It can be used to
(Fig. 17.8); disconnection of the unit and occurred, the rods being used in the external fixation control the position of the peripheral end of the
the threaded rod has occurred, thus frame assembly do not belong to the Ortho-SUV set. threaded rod.
destabilizing the external fixation frame.
On the control X-ray image, an exact 1. The location of the distal fragment was set by the 1. The yellow bone contour (Step 9) must exactly 1. Additional program calculation and
anatomic axis is not shown (deformity user in Step 11: therefore, at maximal coincide with the contours of the mobile bone elimination of the residual
correction); the location of the distal magnification, examine the location of the red bone fragment. In completing deformity correction displacement.
fragment does not fully correlate with that contour relative to the main (proximal) fragment. or fracture reduction planning (Step 11), the
of the red bone contour (Step 11). location of the red bone contour of the proximal
fragment must be visually controlled using
maximal magnification.
2. Unstable fixation of the bone fragments by the 2. Fixation of the proximal and distal bone Re-assembly of the external fixation
proximal and (or) distal external fixation unit. As a fragments must be stable and exclude the frame (stabilizing the supports),
rule, the bone fragment relating to the support possibility of fragment displacement relative to repeated calculation in the program,
becomes displaced due to the deformity of the the appropriate supports. and elimination of the residual
transosseous elements. displacement.
3. X-ray projections taken before and after the 3. Take roentgenograms in the same views. 3. Control X-ray images are obtained
deformity correction do not coincide. in views different from those that
enabled the detection of the
Deformity Correction and Fracture Treatment Using the Software-Based Ortho-SUV Frame
additional displacement of the

fragments. Perform an additional
calculation in the program and
eliminate the residual displacement.
The control X-ray image shows that the Note that the program calculates the integral trajectory If the proximal end of the distal fragment is higher
fragments have interconnected, which for the bone fragment reduction, i.e., according to the than the distal end of the proximal fragment,
prevents reduction or deformity correction. shortest distance. Thus, if there is axial displacement deformity correction (fracture reduction) must be
Thus, further changes in strut length will of the bone fragments (the proximal end of the distal performed in two stages: (1) distraction to provide
result in the deformation of not only the fragment is higher than the distal end of the proximal a 3–4 mm diastasis between the bone fragments
bone fragments but of the whole external fragment) and attempts are made to eliminate the (program calculation planned for distraction); (2)
fixation frame as well. translation, the fragments will become inevitably residual displacement is eliminated (the second
interconnected. calculation in the program).
After the work is complete, the program The hasp-key was removed before the program was First shut down the program and only then Insert the hasp-key into the USB-port
does not shut down. shut down. remove the hasp-key. and then shut down the program.
803
Basics of Aesthetic Correction
of the Lower Extremities 18
Leonid Nikolaevich Solomin, Oleg Anatoljevich
Kaplunov, Pavel Nikolaevich Kulesh,
and Alexander Aleksandrovich Artemev
18.1 Introduction with the norm measurements of the distal anatomic (epidia-
physeal) angle of the femur and proximal anatomic angle of
Leonid Nikolaevich Solomin, Oleg Anatoljevich Kaplunov, the tibia. Since in aesthetic correction of the lower extremities
and Pavel Nikolaevich Kulesh the contour is almost always seen in the frontal plane, the
schemes show these angles in the frontal plane only. The bor-
Aesthetic surgery is an aggregate of medical specialties united derline valgus conditions (according to D. Paley, unpublished
by the purpose of implementing the ideas of a healthy person findings) requiring orthopedic corrections in the presence of
about physical perfection by means of operative intervention clinical symptoms are those shown in Fig. 18.1f, g.
[287] Aesthetic surgery of the lower extremities can be con- Thus, in a patient desiring aesthetic correction, it must first
sidered as an integral part of orthopedics and plastic surgery. be determined whether he or she has an orthopedic deformity.
Medical indications for deformities corrections were cov- The presence of a torsion component involving the thigh, shin,
ered in the previous chapter. Here it should be noted that the or both segments even though the epidiaphyseal angles and
presence or absence of a deformity cannot be judged simply mechanical axis are within the norm results in an affirmative
according to the mechanical axis of the lower extremities: answer. A patient’s complaint is judged to be an aesthetic (cos-
when the mechanical axis is perfect the epidiaphyseal angles metic) defect, cosmetic deficiency, or aesthetic deformity when:
can have obvious abnormalities. Therefore, all reference lines (a) all reference lines intersect at the proper point and at the
must be taken into consideration, i.e., the anatomic and proper angle (normal RLA); (b) there is no torsion component
mechanical axes of the femur and tibia, the joint lines of the of the deformity; (c) the lower extremities are of equal length;
coxofemoral, knee, and ankle joints, and the mechanical axis and (d) correct proportions of the body lengths are maintained.
in two planes. Only when all reference lines indeed intersect The established diagnosis defines not only the tactics of the
at the proper point and at the proper angle (so called reference surgical treatment but also socioeconomic aspects: orthopedic
lines and angles, RLA; see Chap. 16) can one consider an procedures will usually be covered by the patient’s insurance
orthopedic deformity as absent. Figure 18.1 shows the schemes while cosmetic procedures are typically paid for privately.
of possible combinations of average and extreme compared However, it may be the case that a patient seeks medical
advice for aesthetic problems but, during the course of the
examination, components that define an orthopedic deformity
L.N. Solomin, M.D., Ph.D. are determined that contribute to the patient’s complaints con-
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia
cerning the shape of his or her legs. If pre-operational plan-
e-mail: solomin.leonid@gmail.com ning, discussed with the patient, indicates that when the
O.A. Kaplunov, M.D., Ph.D.
correct interrelations between the reference lines are achieved
Department of Orthopedics, the complaints will disappear, then a standard orthopedic cor-
The Orthopedic Center of City Clinical Hospital No. 3, rection will also address the patient’s aesthetic requirements.
45 Sovietskaja Str., Volgograd 400005, Russia Conversely, it may well be that altering the shape of the
P.N. Kulesh, M.D., Ph.D. lower extremities for aesthetic indications will result in an
R.R. Vreden Russian Research Institute of Traumatology and improved mechanical axis of the extremity or, at least, that it
Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia
will not be aggravated by the procedure. For example, the
A.A. Artemev, M.D., Ph.D. surgical procedure may be considered as the prevention of
Department of Traumatology and Orthopedics,
Mitischi City Clinical Hospital,
degenerative dystrophic diseases in the coxofemoral and
Kominterna Str., 24, Mitischi, Moscow 141009, Russia knee joints [288, 291]. Nonetheless, this is not universally
Fig. 18.1 (a–i) Variations from the

a b c d
accepted norm of combined values of
the distal anatomic (epidiaphyseal)
angle of the femur and proximal
anatomic angle of the tibia
79° 83°
81° 81°
87° 87° 87° 90°
e f g h i
83° 83°
79° 79°
81°
90°
85° 90° 85° 85°
18 Basics of Aesthetic Correction of the Lower Extremities 807
Table 18.1 Corrections and reconstructions

Orthopedic Aesthetic
a
Corrections Reconstructions Corrections Reconstructions
Initial RLA, torsion Beyond the norm Beyond (most often) or within the Within the norm Within or beyond (most often)
norm the norm
RLA after surgery, torsion Within the norm Beyond or within the norm Within the norm Beyond the normb
a
Examples of orthopedic reconstructions can be pelvic support osteotomy (Chap. 23.4.1), tibiofibular synostosis, radioulnar synostosis (Chaps.
19 and 24, Fig. 23.18)
b
The torsion component can be within the norm
true: hyper-valgization or medialization of the distal fragment Table 18.2 Types of surgeries to change the low extremities form
can disturb the correct interrelations of the reference lines in Before surgery After surgery
Procedure type
a preoperatively orthopedically healthy subject. Accordingly, Normal RLA Normal RLA Aesthetic correction
an “aesthetic correction” should be distinguished from an Abnormal RLA Normal RLA Orthopedic correction (resolving
“aesthetic reconstruction” when the shape of the lower the aesthetic problems as well)
extremities is altered. The former term should be used when Normal RLA Abnormal RLA Aesthetic reconstruction
the surgery results in the normal intersection of all reference Abnormal RLA Abnormal RLA Aesthetic reconstruction
lines and angles (RLA), including the mechanical axis. For
example, in a patient in whom the proximal mechanical
angles of each tibia is 85°, which is the varus extreme value, advised to undergo contour plastic surgery with membrane
there are no indications for orthopedic correction because an implants [288, 292].
“orthopedic deformity” is absent. However, if planning The “orthopedic” contraindications to aesthetic correc-
shows that a change in the angles up to 90° (the extreme tion surgery are identical to those discussed for external
valgus value norm) will improve the aesthetic complaints of fixation (Chap. 3). Decision-making concerning surgery in
the patient, the surgery is referred to as an aesthetic correc- physically healthy people implies both a high level of
tion. By contrast, if in order to address the patient’s com- responsibility for the physician and a fully informed patient.
plaint at least one of the accepted normal RLA values will be In the process of skeletal formation, the shape and length of
violated then the procedure is referred to as an “aesthetic the legs change, with development completed by
reconstruction.” For example, if a patient is not satisfied with 16–17 years. Therefore, surgeries for aesthetic indications
the shape of his or her lower extremities, despite a correct should not be performed in younger patients. Finally, there
interrelation of the bones and joints, and insists on surgery, is no doubt that aesthetic surgery requires a highly skilled
which would worsen the orthopedic situation, then the pro- surgeon.
cedure is considered to be an aesthetic reconstruction. The One of the major aspects of a purely aesthetic correction
term also applies to cases in which correction of the existing is that it is performed in response to the wishes and at the
orthopedic deformity (orthopedic correction) will not result insistence of the patient. According to the domestic and for-
in elimination of the cosmetic defect and an intentional eign literature, individuals likely to undergo surgical correc-
aggravation of the orthopedic status is required. A commonly tion of the anthropometric defects are typically young adults,
encountered situation is a patient who strongly refuses cor- 15–45 but most often 20–35 years of age [293, 294]. The
rection of a rather marked deformity, for instance, one involv- prevailing majority are females with “defects” of the lower
ing torsion, and insists on achieving the chosen shape of the extremities whereas males are usually looking to increase
legs. Such cases are likewise referred to as aesthetic recon- their height [26]. Thus, the psychological portrait of an aes-
structions. Regardless of the details of the case, patients thetic surgery candidate, especially in terms of self-appraisal,
undergoing aesthetic reconstruction must be warned about is of particular significance [295]. Belousov [296] distin-
the possible consequences, especially pain syndrome, insta- guishes the following main types of reaction to negative self-
bility and faulty positioning of the joints, the development of esteem:
degenerative dystrophic changes in the large joints, and other 1. Positive-passive: The person is pleased with his/her
as yet unrecognized problems since the long-term results of appearance but does nothing to preserve it.
such reconstructions have not yet been fully studied. 2. Positive-active: The person fervently takes care of his/her
The criteria for orthopedic corrections and reconstruc- appearance and is inclined to resort to surgery for any
tions and aesthetic corrections and reconstructions are listed reason.
in Tables 18.1 and 18.2. 3. Negative-conciliatory: The person is not pleased with his/
In case of a false aesthetic defect, when it is impossible to her appearance but does nothing.
compensate the so-called soft-tissue defect by conservative 4. Negative-resolute: The person does not strive to surgi-
activities (fitness exercises, body-building), the patient is cally improve his/her appearance but is willing to do so in
response to circumstantial pressure (family relations, pro- legs, will solve personal problems that the patient can hardly
fessional standards). formulate. Although modern psychology considers such
5. Unreasonably critical: Minimum deviations from stan- motivations to be a constructive means of psychological self-
dards of beauty are dramatized. The person is only assertion [297], the failure of surgery to solve these “prob-
satisfied with perfection and will consider the results of lems” can negatively affect the appraisal of the objectively
any operation unsatisfactory. excellent result of the aesthetic correction performed. A good
Based on these reactions, indications for aesthetic correc- psychotherapeutic effect can be achieved by providing the
tion can be established only for people belonging to the sec- surgical candidate with an opportunity to communicate with
ond and fourth groups. Those in the fifth group obviously other patients, either those undergoing the same treatment or
have steep demands that cannot be satisfied, e.g., an increase those who have already completed it.
in height by a value exceeding the possibilities of distraction A candidate for surgery must receive exhaustive infor-
osteogenesis, or if the procedure results in a disproportional mation about the outlook, severity, and duration of the
body build, then the patient demands a reduction in the nec- operation, and the entire pre- and post-treatment details.
essary period of treatment and rehabilitation. However, the Special attention should be paid to the probability of vari-
psychological characteristics of a patient cannot be known ous complications and to the consequences of the opera-
simply by sending him or her to a psychiatrist or to somehow tion, anesthesia, etc. Both the physician and the patient
obtain a certificate analogous to getting a driver’s license or should be well aware of their legal rights and liabilities.
a gun permit; rather, in case of doubt, team work involving Nonetheless, adequate and objective information provided
an orthopedist and a psychologist who together evaluate the by the physician to the patient prior to the operation sets the
cosmetic surgery candidate appears to be a reasonable basis for a mutual understanding throughout the long period
strategy. of treatment and avoids potential communication difficulties
Prolonged contact with the patient is an element of the at any stage of treatment. No matter in which form the rela-
pre-operative preparation. Long, sometimes hours-long tionship between the patient and medical institution are
communication allows thorough discussion of all the details legally secured (informed consent, agreement, application
of the treatment and makes it possible to establish a per- etc.), the final statement on the patient’s side must be words
sonal relationship that will be maintained for several months. to the effect of “… I have been warned about the possible
In this period, the patient may experience a moral break- complications and I insist on the surgical correction of the
down, change his or her view on the prospect and success of shape (length) of my legs. I will not engage in any claims
the enterprise, accuse the physician of nonobjective elucida- against the medical institution (surgeon) in case of compli-
tion of the negative aspects of the treatment (painfulness, cations that occur in the absence of negligent actions by the
duration, bulkiness of the device, related restrictions, etc.). medical personnel.” If an aesthetic reconstruction, as
If during the pre-operative communication the patient defined above, is planned, the patient should be adequately
reveals a hot temper, irritability, weak will, or any other warned about the possible consequences of intentionally
characteristic that will hinder treatment and personal con- aggravating an orthopedic condition. Furthermore, the
tact, the physician should refuse to perform the correction. patient should be warned that any waiver or addition to the
Identification of such patients and refusal to operate are approved treatment plan at a stage later than the planned
absolutely essential responsibilities of the physician and correction (reconstruction) or shortly thereafter is consid-
will avoid many problems. The participation of a trained ered to invalidate the contract (informed consent, agree-
psychotherapist certainly appears to be beneficial in such ment). In such cases a new contract must be negotiated.
cases. Otherwise, within the frame of the existing contract, the
One of the important questions that must be clarified prior surgeon will not be allowed to add or remove valgization,
to the operation is why the person is determined to take such first increase and then decrease the interspace between the
a step. Our experience shows that the most favorable option shins, reset the amount of torsion, etc.
is when correction is meant to meet certain professional Aesthetic correction of the shape and length of the legs in
demands, such as those of the entertainment, service, and which the osteotomy is performed only on the shin bones is
law-enforcement fields, which set special requirements done in one stage and on both legs at once. Consecutive sur-
regarding the height and shape of the legs, among others. In geries on the shins have been shown to be inefficient.
these cases, the treatment objective is confined to the solu- Moreover, our practice has shown that such surgical tactics,
tion of a particular technical problem—correction of the cur- besides the one and a half fold increase in the treatment
vature of the lower extremities or their lengthening by a period, is vulnerable to various challenges that can prevent-
definite number of centimeters—and moral issues and ing symmetrical lengthening of the second extremity. These
abstract objectives are set aside. The most ambiguous situa- challenges primarily consist of neurological disorders of the
tion for the surgeon is when the patient expects that changing second lengthening segment as well as a persistent
his or her appearance, including the shape or length of the inflammatory process in the soft tissues around the wires.
18.2 Correction of the Shape of the Legs examination table, with the feet parallel to each other. At the
same time, it is advisable to distract the patient so that the
Leonid Nikolaevich Solomin, legs are then relaxed. Afterwards, the patient should be inter-
Oleg Anatoljevich Kaplunov, viewed regarding the desired result of the correction.
and Pavel Nikolaevich Kulesh “Approximation of the knees” can be used, even in case of a
marked curvature, to show the patient the predicted result. In
The major shapes of the lower extremities are shown in this method, the patient is asked to slightly flex the knees
Fig. 18.2. However, the presented schemes are not universal. while closing them.
For example, some patients will insist on the absence of the Sometimes patients insist that the desired leg shape has a
second interspace under the knee joint (Fig. 18.3a). Others definite position: with outward, neutral, or inward rotation of
will express dislike for the outer contour of the middle third the feet, legs tightly forced together, or set slightly apart.
of the shins, others the contouring of the fibular heads, etc. These positions (standing position of the desired result) must
O-shaped (bow) legs (Fig. 18.2b) can be due to the shape of be photographed and considered during surgical planning. In
the femurs, shin bones, or both with or without orthopedic addition, the surgeon and the patient should take into account
deformities. The same can be said concerning X-shaped legs that a 3–4 cm heel will visually alter the shape of the legs. If
(Fig. 18.2c). The shin form shown in Fig. 18.2d, and the leg shape is essential to the patient, it should be documented
specific soft-tissue distribution (Fig. 18.3b), can be attrib- by taking a picture of her standing in high-heeled shoes.
uted to a true orthopedic deformity of the tibia (Fig. 18.3c).
Nevertheless, the suggested classification, with the inclu-
sion of the above-mentioned variations, is nowadays used in 18.2.2 X-Ray Examination Features
clinical practice.
Initial X-ray examination of the patient’s condition should be
carried out exactly as described for patients with deformities
18.2.1 Special Features of the Examination of the long bones of the lower extremities (Chap. 6.1). It is
not acceptable to make a conclusion based only on the shin
Some patients hide the shape of their legs from examination X-rays, “even” those including the adjacent joints. As men-
for years, involuntary rotating their legs outwards and clos- tioned in the Introduction of this chapter, at this stage of the
ing the knees, which can affect the evaluation. An objective evaluation the presence of an orthopedic deformity vs. an
assessment therefore requires that the patient fully relaxes aesthetic defect should be determined.
the muscles of the thighs and shins. The patient is positioned If the desired leg shape is to be achieved in the rotation
with his or her toes in and heels extended for 1–2 cm over the position then an additional teleroentgenogram should be
a b c d
Fig. 18.2 The shape of the

lower extremities is determined
in a neutral stance without
tension. (a) In the “ideally”
shaped legs there are three
fusiform gaps along the internal
contour limited by the perineum,
the touching knees, the
soft-tissue mass of the upper
third of the lower legs, and the
touching ankles. (b) True bow
legs are manifested as a defect in
the internal contour extending
from the perineum to the
touching ankles. (c) In a true
X-shaped curvature there is an
inability to close the ankles. (d)
A false curvature is associated
with an aesthetically unfavorable
distribution of the soft tissue of
the lower leg (Modified from
[288, 294])
Fig. 18.3 Variations in leg shapes. (a) The ideal shape

a b c
of the legs is often defined as no gap under the knee joints.
O-shaped shins can be attributed to a redistribution of the
soft tissues (b) and to shin-bone deformities (c). Or to both
made accordingly. The same can be said when the clinical reconstruction is performed using two techniques, either
view and standard long X-ray image show a torsion compo- separately or combined: (1) excessive valgization of the tibia
nent but the patient insists on its maintenance (preservation). bone and (2) medialization of the distal fragment.
In addition, the choice of the osteotomy level is a
significant factor affecting surgical outcome. As a rule,
18.2.3 Preoperative Planning varying the combinations of hypervalgization, medializa-
tion and osteotomy level enables achievement of the result
Preoperative planning for patients with a deformity of expected during surgery planning (Fig. 18.4). Figure 18.5
the femur and tibia is presented in Chap. 16. For patients shows how the elements of the aesthetic reconstruction
undergoing an aesthetic procedure, the expected results of change the interrelations of the reference lines. It can be
the surgery should be maximally visualized. In this case the seen that in most cases aesthetic reconstruction is per-
patient should be shown not the appearance of the bone alter- formed at the expense of the orthopedic valgus deformity
ations on X-ray (skiagram) but the changed appearance of of the tibia, valgus positioning of the knee joint, valgus
the soft-tissue contour. Accordingly, the use of orthopedic positioning of the ankle joint, medial shift of the distal tibia
graphic software is advisable, with the planned relocation bone fragment axis relating to the joint line of the knee,
demonstrated not only on images of the bones but also on lateral deviation of the mechanical axis, and combinations
those of the soft tissues. To assess the potential outcome of thereof.
the surgery, special software has been developed. This sub- It should be considered that during an orthopedic correc-
ject is covered in the following section. tion the aesthetic reconstruction of an O-shaped shin defor-
If an orthopedic deformity is present, the level of the mity may also be indicated. This is true in the presence of a
correction osteotomy (osteotomies) and the extent of the deformity of the tibia, the apex of which lies at the border of
correction are defined based on the principles discussed in the middle and distal thirds of the segment (Fig. 18.13).
Chap. 16. What is peculiar about this situation is that due to In the correction of an X-shaped legs, the difference is
the wishes of the patient a hypercorrection is made from the that an angular shift is made in the direction opposite to that
average to the extreme normal values with respect to the used in the correction of O-shaped legs.
intersection of the reference lines, the schemes of which are All mutual anatomic reductions of bone fragments that
shown in Fig 18.1. If it becomes evident that the results of become necessary during the correction can be done in a sin-
the aesthetic correction do not allow achievement of the leg gle-stage (on the operating table) or gradually. The first option
shape requested by the patient, aesthetic reconstruction is is preferable but has its limitations, as discussed in Chap. 16.
an option. The outer contour of the shin can be altered by lowering
In the majority of cases, patients seek medical advice for the fibular head (Fig. 18.21) or by fibular reconstruction
correction of O-shaped legs (shins). In this case, aesthetic (Fig. 18.16).
a b
Fig. 18.4 Possible variants of the shin shape, obtained following dif- medially deviated, the deformity height in each tibia is at the level of
ferent types of valgization, medialization, and osteotomy level changes. the proximal meta-epiphysis. (c) Model of the legs’ shape obtained
(a) The patient’s legs in the position showing the desired shape. (b) after the deformity correction using the high osteotomy approach: the
Teleroentgenogram of the lower extremities: the mechanical axes are inner contour defect from the perineum to the ankles remains
d e
Fig. 18.4 (continued) (d) Model of the legs’ shape obtained as a result axis is correct, and there is valgus deformity of both tibia. (e) Model of
of excessive valgization and medialization of the distal fragment of the the legs’ shape obtained with excessive valgization using a low osteotomy
tibia using the high osteotomy approach. At the same time, closure can be approach; there is closure at the level of the knee joints, approximation of
achieved at the level of the knee joints and at the level of the middle third the shins at the level of the middle third, the second gap remains, the
of the shins; the second gap is considerably narrowed, the mechanical mechanical axis is correct, and there is valgus deformity of both tibia
a b c d e
90°
(85-95°)
88°
(85-90°)
87° 91°
91° 92° 91°
(85-90°)
89°
(86-92°) 85° 83° 84° 83°
Fig. 18.5 Alteration of the interrelations among the reference lines in valgization by 5° and 5 mm medialization at the level of a high proximal
hypervalgization and medialization of the distal fragment. (a) Normal osteotomy; (d) interrelations of the reference lines with hypervalgiza-
interrelation of the mechanical axis and joint lines; (b) interrelations of tion by 5° at the level of a low proximal osteotomy; (e) interrelations of
the reference lines with hypervalgization by 5° at the level of a high the reference lines with hypervalgization by 5° and 5 mm medialization
proximal osteotomy; (c) interrelations of the reference lines with hyper- at the level of a low proximal osteotomy
18.2.4 Preoperative Planning Software: PC-compatibility for the operating systems Windows 2000, XP
“Leg Shape Correction” and Vista, with at least a DX486 processor not lower than
1.5 GHz, at least 256 MB of RAM, and an 800 × 600 color dis-
Oleg Anatoljevich Kaplunov play. Available hard-disk space necessary to install the software
is 10 MB. The peripheral equipment needed is a laser or ink-jet
Based on a large number of surgically treated patients and printer to print the patient’s chart and a scanner or digital camera
analyses of the correlation between their initial appearance to upload the patient’s photos.
and the result obtained, several comparisons and analogues The use of this software is shown below, with the main
have been made in order to better predict the results of sur- window demonstrating the user interface provided with a
gery. Clearly, the use of informative software to individually number of tabs (Fig. 18.6).
solve many of the problems discussed in this chapter is an Each tab is a section that enables the evaluation of dif-
obvious aid for the surgeon. At the same time, the ability to ferent anthropometric defects and/or the corresponding
virtually model the result allows patients to realistically surgical modeling technique. In Fig. 18.6, the first tab
imagine the outcome, thus psychologically preparing them shown at the start of the program is the correction of an
for the expected outcome and minimizing the emotional O-shaped cosmetic deformity of type I according to our
reaction to the resulting correction. classification [10].
One of the computer programs able to solve most of the As in all tabs, this window has two template fields: the left
lower-extremity problems discussed in this chapter, at least in one is used to copy and digitally analyze the patient’s appear-
terms of a preliminary evaluation of the correction result, is the ance (or a fragment of his/her appearance) before the inter-
“Leg Shape Correction” software. This software is written in vention, and the right one to show the programmed virtual
Delphi7 and is about 700 Kb. The system requirements are IBM model of the patient’s appearance following the performed
Fig. 18.6 Interface of the “Leg Shape Correction” software with the initial picture of the partial appearance of the patient in the left template
window of the first tab
Fig. 18.7 The program interface after setting the control points and processing the initial image, showing the virtual correction result in the right
template window
correction. The initial picture of the patient’s total or partial cursor, which converts to an arrow shape beyond the tem-
appearance (e.g., pelvis and lower extremities), which is not plate window, and then click the button “Choose a photo”
important for program functioning, can be uploaded from above the left template window. A Windows explorer dialog
any digital data carrier, including a built-in memory card or box will open and the photo can be chosen from the appro-
flash card of the camera. In each tab window in the right priate folder or data carrier. It is also possible to type the
upper corner there are control points that are to be checked in address of the photo into the command bar, located to the left
the given order on the initial picture of the patient in the left of the “Choose a photo” button.
template window. In the lower right corner, the needed con- After the initial picture of the patient’s appearance is
trol points can be correctly positioned on the patient’s pic- transferred from the proper folder into the left template, the
ture. Between these information sectors there are three control points are marked by the cursor in the strictly defined
control buttons: “Process”, “Clear,” and “Save”. The cap- sections of the body contour, as shown in the right template
tions on the buttons define the image-processing tasks attrib- window. When all control points have been marked in the bar
uted to each of the commands mentioned on these buttons. above the picture an appropriate message appears, which is
The program also includes dynamic elements, such as the the signal to initiate the “Process” command. After the result-
cursor used to mark the control points on the patient’s body ing picture appears in the right template window (Fig. 18.7),
contours. The cursor is moved by the mouse and has a cross- the program allows the virtual picture of the patient’s appear-
like coordinate sight design. A control point is marked by the ance to be saved on any digital data carrier (hard disk, mem-
left-click of the mouse while the cross-like sight cursor is ory cards, etc.) or to be e-mailed or shared in real-time, e.g.,
pointed at the appropriate site of the contour on the photo. while communicating with the patient on-line. In case of an
The working algorithm with each tab is easy and almost error in replication of the initial image of the patient made in
uniform. To upload the initial picture of the patient, use the the left template window or in case of an erroneous setting of
a b c d
Fig. 18.8 (a–d) Defining the termination of the intermediate correction outcome in an axial deformity of the lower limbs (see text for details)
the control points, it is possible to cancel these commands by of the axial deformity correction, i.e. evaluation of the
clicking the “Clear” button. Also, it is possible to continue intermediate outcome. Its working algorithm slightly dif-
working in the tab without deleting the processed image fers from that of the other tabs. A new technical option is
from the right template window. To continue working, just that the user is able to delete the image of the Ilizarov
click the “Choose a picture” button again or type the image external fixators even after obtaining the modeling result,
path in the address bar. by unchecking the “Switch on” field in the lower section
To work with other tabs that provide the expected result called “Erase Fixators” and setting the size of the eraser
for a candidate with an axial valgus deformity correction or a element. The informative value of this tab in defining ter-
desired increase of height or to estimate whether the correc- mination of the intermediate stage of correction is shown
tion is enough it is necessary to set the control points very in Fig. 18.8.
carefully, according to the present templates. In the tab Figure 18.8a shows the achieved correction of the axial
labeled “Height increase” there is additional information deformity in patient R., who was operated on for a type I aes-
concerning height increase planning, which is marked in the thetic varus deformity (the image of the patient was obtained
proper subsection of “Control points.” These settings are nec- at the correction termination stage). As shown in the program’s
essary for the scale calculation of the expected appearance processed image (virtual intermediate result; Fig. 18.8b) the
transformation. Some minor variations, easily understood performed correction is insufficient, as there is overlapping of
while working with the program, are present in each tab. the feet when the knee contours are closed (indicated by the
The program option set in the “External Fixators Check” arrow). Next, the effects of additional valgization of the tibia-
tab allows for decision-making concerning the termination femoral angle on both extremities by 2°, the obtained result
Fig. 18.9 Appearance of patient

V: (a) initial image on admission;
(b) virtual result suggested by the
software; (c) the real outcome
obtained by correction of the
type I varus axial deformity
(Fig. 18.8c) are examined by transforming the photo using the the only effective approach nor does it show the definitive
virtual software image (Fig. 18.8d), which demonstrates a final outcome. There are certain objective and subjective
sufficient and complete correction. Thus, the procedure can be conditions that can change the initially planned technique,
concluded having achieved the simultaneous contours pro- resulting in one or another inconsistencies between the real
duced by contact of both the knee and ankle joints (arrow in and virtual appearance. A surgeon should therefore pre-
Fig. 18.8d). This example shows that, by using the described liminarily warn the patient of the potential discrepancy,
options provided by the software, surgeons have an additional clearly explaining the relative probability that the desired
tool, along with X-ray examination, to assess the intermediate correction outcome will coincide with the actual result.
outcome of modeling the shape of the legs.
Our experience of working with “Leg Shape Correction”
software has confirmed the high accuracy of its results relat- 18.2.5 Correction of Leg Shape Using
ing to the actual outcome of the performed correction. An Circular Fixators
example is shown on Fig. 18.9. The patient’s appearance vir-
tually calculated by the software algorithm (Fig. 18.9b) closely Leonid Nikolaevich Solomin, Oleg Anatoljevich Kaplunov,
coincides with the obtained outcome (Fig. 18.9c). Insignificant and Pavel Nikolaevich Kulesh
differences between the virtual and real outcome are not criti-
cal and are mainly related to the moderate hypotrophy of the To change the shape of the legs, a variety of fixators can be
soft tissues due to during short-term rehabilitation. used: circular, semicircular, arch, monolateral, and hybrid
Despite the rather high prognostic capacities of the (Fig. 18.10). If a correction is intended to be a single-stage
software, it should be noted that the input of calculation one, carried out on the operating table, it is advisable to use
information is finite such that the software does not suggest monolateral or arch fixators to fix the bone fragments in
a b c
d e
Fig. 18.10 (a–f) Various types of external fixators used to change the shape of the legs

f
the newly achieved position. Gradual correction is best f, 18.11, and 18.12 show the use of circular fixators to change
achieved with semicircular, circular, and hybrid fixator the shape of the legs. Furthermore, it is possible to reduce the
constructions. bulkiness of the constructions by a module transformation
The surgery algorithm is generally standard: fixator approach (Figs. 18.13 and 18.15).
assembly, corticotomy with osteoclasia of the tibial bone,
correction of the bone fragments’ position (single-stage or
gradually), and stabilization of the external fixator. As a rule, 18.2.6 Correction of Leg Shape Using
an osteotomy of the fibula is not necessary. It should be con- Semicircular Fixators
sidered that in valgization there is a relative lengthening of
the fibula such that the fibular head can be more markedly Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh
contoured. If this is not desirable, an oblique osteotomy is
made on the fibula at the level of its middle third or on the We consider the ability to fully place the legs together already
border of its middle and lower segments. An osteotomy in at the beginning of the postoperative period to be the manda-
the lower segment is not advisable since duplication of the tory condition in the treatment of aesthetic patients. Only in
fibula can result in contouring under the skin. this case can the silhouette (contour) of the lower extremities
However, during the postoperative period a patient may be reliably evaluated by the patient and, if necessary, cor-
request additional correction, nor can pre-operative planning rected by the surgeon. At the same time, the fixator capacity
errors be excluded. Moreover, if surgery is performed simul- for anatomic reduction and fixation must not be inferior to
taneously on both legs the stabilizing fixators have to meet that of the original assembly of the Ilizarov external fixator.
special requirements. That is why we prefer circular, semicir- These requirements are fully met by the fixator assembly
cular, and hybrid fixators since they have the best capacities shown in Fig. 18.14 (approved patent application no.
in terms of anatomic reduction and fixation. Figures 18.10e, 2008153062).
Fig. 18.11 (a, b) Standard a b

assembly of the Ilizarov external
fixator to lengthen and alter the
shape of the legs
If the capacities of the semicircular assembly do not pro- anatomic reduction of the bone fragments, pain thresh-
mote the necessary anatomic reduction of the bone fragments old of the patient, change in the patient’s requirements,
(rotational is most common), then the initial assembly of etc.) the time needed for the correction can increase up to
choice is the circular one. Furthermore, module transforma- 3–4 weeks. The patient should be warned that the change
tion will minimize the fixator (Figs. 18.15 and 18.16). in the legs’ shape cannot be evaluated until the postopera-
tive swelling subsides.
The important prerequisite for a transition to the fixation
18.2.7 Postoperative Period period is the conviction of both the surgeon and the patient
that the legs are in the desired shape (Sect. 18.2.1). According
Leonid Nikolaevich Solomin, Oleg Anatoljevich Kaplunov, to the patient’s goals and additional changes in the informed
and Pavel Nikolaevich Kulesh consent have been made, further correction can be performed.
Here we would like to again emphasize that the patient must
The dosed correction begins on day 5–6 days at a rate be warned about the possible consequences associated with
of 1–2 mm/day (0.25 mm 4–6 times) and continues for possible deviation from the reference lines and angles con-
7–12 days. However, for various reasons (grade of the sidered to be normal.
a b
c
d e f
1 2 3 6 4 5
I,8-2; I,4-10; II,9-3 −о−VII,3-9; (VII,8-2)VII,8-2; VIII,4-10
150 150
Fig. 18.12 (a–f) In this variant of correction of a type I deformity the are more medial on the internal semicircle of the ring support. It is
fixator assembly includes two ring supports based on six 2-mm wires, important to ensure the exact alignment of the half-pins between them-
three wires with stops in each support. The supports are connected by selves and the lower leg axis and an equal distance between the medial
four telescopic rods with plane hinges at the level of the osteotomy. The pair of rods and the lateral rods. Otherwise, rotationally angular dis-
hinges are installed so that the external ones coincide with the external placement of the fragments is possible during the process of correction
contour of the tibia at the level of the osteotomy while the internal ones (From 10])
a b
1 2 5 6 3 4
I,8-2;I,4-10 –– V,9-3 –o– VII,9-3; (VIII,8-2)VIII,8-2; VIII,4-10
3/4 150 150 150
c d e
1 3 2 5 6 4
II,3-9 –– IV,12,120; V,9-3 –o– VII,9-3; VII,1,120; (VIII,8-2)VIII,8-2 (1)
3/4150 150 150
IV,12,120; V,9-3 →← VII,9-3; VII,1,120; (VIII,8-2)VIII,8-2 (2)

150 150
IV,12,120; V,9-3→← VII,9-3; VII,1,120; (VIII,8-2)VIII,8-2 (3)

1/2150 1/2150
Fig. 18.13 (a–f) In this kind of varus deformity, two proximal sup- wires and half-pins (f). When combined external fixation is used (f, 1)
ports are placed perpendicular to the mechanical axis of the segment. during modular transformation, first the proximal basic support is
The distal support is placed at an angle equal to the angle of correction. removed (f, 2) followed by the posterior half-rings of the remaining
The Ilizarov fixator is assembled using wires (a) or combination of supports (f, 3)
a 11 12 1 1 12 11 b
10 10
2
3 9
9
4
8 8
5
7 6 6 7
c d e
Fig. 18.14 Use of the Solomin-Kulesh external fixation approach in between the intersecting half-pins. (c) The patient’s legs before surgery;
the correction of the shape of the legs. (a, b) The use of bowed half-pins (d) pre-operative X-ray; (e) after the correction: the legs are placed
allows the support size to be minimized without decreasing the angle together with fixators assembled
Fig. 18.14 (continued) (f) X-ray

after the correction; (g) after f g h
disassembling the fixators;
(h) X-ray after disassembling
the fixators
a b
Fig. 18.15 Use of the

Ortho-SUV Frame for repeated
reconstructive surgery. (a, b)
The patient’s legs before
surgery
Fig. 18.15 (continued) c d

(c) pre-operative X-ray;
(d) during correction

(e, f) photo and X-ray after the
e
correction
f
h i j
Fig. 18.15 (continued) (g) module transformation of the fixators allows the legs to be placed together; (h) X-ray after module transformation;
(i) photo and (j) X-ray of the patient’s legs after disassembling the external fixators
gradually increase the load on the extremities to achieve full

loading within 3–4 weeks.
In a shin form correction, a transition from an external to an
internal fixator is possible. This approach has both advantages
and disadvantages, which are covered in detail in Chap. 26.
18.2.8 Volume and Contour of the Lower Legs
Leonid Nikolaevich Solomin and Oleg Anatoljevich

Kaplunov
The most appropriate method for plastic recontouring (e.g.,

remodeling using a sliver of the tibia, reconstruction of the
fibula, or soft implant) is chosen individually. The criteria
involved in the decision include both the objective data (degree
and symmetry of hypotrophy, character of the soft-tissue mass
of the lower legs, specific features of the segment contours)
and the opinion of the patient, who has been informed of the
advantages and disadvantages of each approach.
It should be considered that in the last 10–15 years the
differences in the techniques used in alteration of the shin
form have become less consequential, due to reductions in
neuroinfections following the exclusive or complementary
use of implants.
If atrophy of the soft tissue is present, mostly involving the
external semicircle of the lower leg, the extremity is remod-
eled by means of fibular reconstruction. The method used to
a b remodel the shape of the lower leg was developed based on the
experiments on lower leg thickening carried out by the staff of
Fig. 18.16 (a, b) Remodeling of the lower leg shape to correct a the Russian Ilizarov Research Center in 1970. The successful
hypotrophy of the external group of lower leg muscles. For gradual dis- development of the basic shin remodeling methods followed
placement of the intermediate fragments of the fibula, wires with stops from the research of Ilizarov et al. [298, 299] and Barabash
are inserted close to their ends. The ends of the wires exiting on the
postero-external surface of the shin are fixed by distraction rods to the
et al. [300]. Remodeling is performed by means of a fixator
support bar, while the opposite ends are cut off and left under the skin. assembled on two basic ring supports installed at the level of
The splinters of the fibula are moved by tightening the nuts of the dis- the proximal and distal metaphysis of the tibia and fibula. The
traction rods outwards and backwards. If double osteotomy is per- supports along the anterior and external surface are connected
formed, the middle fragment is abducted taking into account the
difference in the thickness of the proximal and distal parts of the lower
by rods. From the posterior external surface, the supports are
leg, i.e., the upper end is abducted more than the lower. The average rate connected by means of a support bar. Osteotomy of the fibula
of displacement is 0.5–0.75 mm/day is performed via small incisions, with an oscillating saw
preferably used to cut the bone. If atrophy of the external
semicircle is seen mostly in the upper half of the lower leg,
Mobilization starts the day after the operation so that by osteotomy of the fibula is performed on the border of the upper
the end of the first week the patient can move freely within and middle thirds. In case of more extensive atrophy, double
the room using crutches and within 3–4 weeks can start using osteotomy of the fibula is performed in the upper third and at
a cane. If the surgical trauma is minimal and the fixation is the border of the middle and lower thirds of the segment
sufficiently rigid, some patients are able to start working or (Fig. 18.16). In severe cases, the external contours can be fol-
studying as early as at the end of the first month. The fixation lowed more exactly by osteotomy of the fibula at three levels.
period is usually 50–65 days. The decision to remove the In abduction of the fragments, the posterior external con-
external fixator is made based on the control X-ray and a tour of the shin is expanded. To determine when remodeling
clinical trial of the union, as described in detail in Chap. 32. is complete, the surgeon should consider that the volume
After the fixator is removed, the patient must be advised to increase of the lower leg achieved intraoperatively will be
partially lost 10–14 days later, when the swelling subsides. postero-internal border of the tibia. Three transverse chan-
Therefore, if there is a sufficient initial stock of soft tissue, nels with the thickness of the cortical layer are made in the
hypercorrection by 1.5–2 cm of the circumference is advis- bone. Their level is chosen depending on the type and exten-
able. If there is soft-tissue atrophy combined with shortening sion of the hypotrophy. The chisel is then turned along the
of the lower leg, then functional and cosmetic effects are anatomic axis of the bone and a longitudinal osteotomy is
achieved by equalizing the segment length and simultaneous performed from the beginning of the upper transverse inci-
modeling of the shape of the lower leg. sion to the middle one and then to the lower one, thus achiev-
If there is a difference in the volumes of the extremities ing the detachment of the two slivers. During this operation,
due to atrophy of the soft tissues of the internal and external there is a risk that the tibia will be fractured; therefore, the
semicircles, additional remodeling of the internal contour is osteotomy must be performed by a surgeon with experience
recommended at the expense of slivers of the tibia. in working with bone tissue. Wires with stops are inserted
In first stage, a fixator comprising two rings is installed on through the slivers from the internal surface outwards and
the lower leg. Two slivers with the thickness depth of the backwards, near the ends of the distal fragment and at the
cortical layer are formed via three small longitudinal inci- proximal end of the distal fragment (Fig. 18.17).
sions, 1.5–2 cm long, made on the antero-internal aspect of Additional information concerning this technique is cov-
the lower leg (under the tuberosity of the tibia, at the middle ered in Chap. 31.
of the middle third, and at the border of the middle and distal Alteration of the external contour of the lower leg by
thirds of the tibia) using a narrow chisel and beginning at the descending the head of the fibula is covered in Sect. 18.3.
c d
83.735
Fig. 18.17 (a–d) Scheme for remodeling the internal and external narily made in the antero-external cortical plate. (b, d) The ends of the
contours of the lower leg. When a wire with a stop is inserted from the wires have been fixed by traction clips to the support bar installed along
side of the bone wound (b) it is not always possible to later remove the the postero-internal surface of the lower leg. (c) The support bar has
stop. An alternative method for transposition of the fragment is to use a been installed along the antero-external surface of the lower leg.
console “pushing” wire (c) or the usual wire with a stop (d). (c, d) A Traction starts on the fifth or sixth day at a rate of 0.75 mm/day
channel somewhat larger than the diameter of the stop has been prelimi- (0.25 mm three times a day)
18.3 Growth and Length of the Lower • Femur length 48% and lower leg length 43% of the total
Extremities Under Aesthetic Indications length of the extremity, with the ratio between them being
1:0.91 [301]
Alexander Aleksandrovich Artemjev, • Femur length 32–34% and lower leg length 21–23% of height
Oleg Anatoljevich Kaplunov, A more detailed and accessible model (with the ability to
and Leonid Nikolaevich Solomin clinically identify anatomic reference points) is provided by
the diagram of Karuzin (cited in Pavlov et al. [303]), shown
Formally, the correction of growth in individuals with a in Fig. 18.18. The diagram is intended for use in the
“low” subjective appraisal category should be distinguished identification of the proportions of the body and of the seg-
from the correction of the length of the lower extremities. ments of the lower extremities. The advantages of the dia-
However, as both types of corrections are based on segment gram are its simplicity and the possibility to clinically
elongation using the Ilizarov method, we consider them identify the primary clinical reference points without the
together. The specific features of external fixation in segment need for additional instrumental and invasive methods, such
removal from an extremity are considered in Sect. 18.2.8. As that the patient can carry out a self-assessment without the
there is seldom a need for leg shortening for aesthetic rea- help of a physician.
sons, in the following discussion primary attention is paid to However, independent of whether the scheme is applied to
issues of elongation. identify the ideal proportions, variability in the length of an
Candidates for surgery can be conventionally divided into individual segment of the extremities may often lead to the
two main groups [287]: situation in which correction of one segment (the lower leg,
1. Those wishing to increase their height: for example) restores the “ideal” ratio with the femur length
(a) By a definite amount to satisfy a professional but results in a disproportion between the total length of the
requirement lower extremity and body height. Moreover, these standards
(b) To overcome various psychological complexes are relative and vary depending on body build. Excessive
2. Those wishing to achieve certain body proportions changes in these parameters by more than 12–15% negatively
However, to meet these needs and thus satisfy the affect the overall aesthetic appearance; for example, an exces-
patient’s wishes it is often necessary to resolve completely sive elongation of the lower legs make the person look like a
different problems. For example, the maximum possible heron, an excessive increase in the length of the lower extrem-
elongation of the legs may be disproportionate to the rest of ities, even though the segments are in proportion, results in a
the body, while elongation by a small amount to achieve short-armed appearance. Disregard of these considerations
certain interrelationships (some of which are clear only to inevitably leads to unsatisfactory results. Therefore, common
the patient) may be difficult for the treating physician to sense and the limited technical possibilities of the Ilizarov
comprehend. Therefore, successfully addressing the prob- methods should be applied to properly identify the indica-
lem of aesthetic correction of the length of the lower extrem- tions (and contraindications) for elongation of the lower legs
ities requires: in order to increase the height of a healthy individual.
1. An understanding of the primary notions of the norm held The most rational approach is to use the Ilizarov method
not only by the physician but also by the patient. in the simultaneous elongation of both lower legs, as this
2. Correct implementation of the technical (sometimes quite ensures a symmetrical result and allows situations to be
limited) aspects of elongation of the lower extremities. avoided in which, after the elongation of one extremity by
The objective factors influencing the correlation among a known amount, a similar correction to the contralateral
the individual parts of the body are sex and age. Sexual dif- extremity becomes impossible due to the emergence of
ferences influence the shape and volume of the extremities complications (most often neurological) during the second
rather than their proportions. Therefore, in most cases it is stage of the procedure [154]. Femoral elongation is techni-
possible to disregard gender-specific features as applied to cally more complicated and requires a longer hospital stay
the problem of leg elongation. As aesthetic operations on for the patient. Moreover, irregular scars are formed in the
children are an exception, age-related anthropometric fea- soft-tissue mass of the upper leg. There is also a higher fre-
tures are rarely relevant. quency of specific complications in the form of stiffness
There are several standards to determine a rational height and soft-tissue inflammation at the exits of the transosseous
increase: elements.
• Manouvrier index: difference (in millimeters) in height Another important factor is the amount of elongation and
between standing and sitting according to the height meter thus the distraction rate. Their effects on the postoperative
(normal range 760–920 mm) course and on the formation of bone regenerates during elon-
• Lower extremity length from 40% [301] to 47% (quoted gation of the extremities under experimental and clinical
in [301] of height) conditions have been the subject of a large number of papers
Fig. 18.18 Proportions of 1

the body of an “average 2
person” according to N Location Relative distance
3
Karuzin (cited in Pavlov from
et al. [303]) and a table 4
5 the sole of the foot
designed on the basis of
6 1 Crown of the head 1.0
the scheme 7
9 8 11 Centre of the heads of the
10 11 0.8
humerus
11
14 Navel 0.61
15 Upper anterior iliac bone 0.57
16 Pubis 0.51
12 13
17 Centre of the figure 0.5
18 21 Tip of the middle finger 0.37
14 22 Knee 0.27
15 23 Medial malleolus 0
26
19
20 16
17
21
22
23
24 25
by researchers at the Kurgan Scientific Centre [27, 304, 305]. The above-mentioned studies deal with the elongation of
Those studies involved the use of radioisotopic, densitomet- one extremity in patients with lower extremities of differ-
ric, myographic, and biomechanical/biochemical methods to ent lengths. Simultaneous elongation of two segments results
establish the optimal distraction rate (1–2 mm/day) and in a much larger injury load. Clinical experience has shown
amount of elongation of the extremities. The optimal elonga- that the upper limit for the formation of full-value distrac-
tion rate is 18–20% of the initial segment length over one tion regenerates is 6–7 cm. While elongation can be greater,
stage, which corresponds to 6–7 cm for the lower leg in an the decision regarding by how much must be solved indi-
individual with a height of 175 cm. vidually, taking into account the aesthetic consequences of
Similar findings were also obtained by other authors. excessive elongation discussed above. Prior to the operation,
Vedensky [306] defined functionally permissible elonga- it is impossible to guarantee the patient a large amount of
tion as the maximum increment in length still allowing a elongation. Furthermore, there are as yet no objective clini-
recovery of function in the distal joint. This value is deter- cal, laboratory, or instrumental studies allowing the maxi-
mined by the response of the neuromuscular apparatus to mum possible value of elongation to be forecast for every
distraction and by the reparative and functionally restor- individual patient.
ative possibilities. A functionally permissible single-stage It must be emphasized that an operation to increase the
elongation is 20–30% of the initial segment length. The growth of an orthopedically healthy person is not considered
paradox is that greater elongation is possible in taller peo- as an aesthetic correction but as an aesthetic reconstruc-
ple (with a longer lower leg, accordingly) than in shorter tion procedure (Sect. 18.1). The long-term consequences of
people. similar interventions are still not unequivocally understood.
Therefore patients should be officially warned of the risk of elongation at two levels (Chap. 19). Bilocal lengthening is
further secondary deformations, joint stiffness, and painful recommended to achieve growth increases of more than
syndrome [250] as well as the potential for degeneration 5–6 cm.
of the articular cartilage owing to the increased load [307]. During lengthening of the lower legs, there is also a change
Methods of elongation of the extremities have been in their form: they become visually more harmonious (thin-
described in the literature, with the most detailed descrip- ner) due to a reduction in their “diameter” following distrac-
tions provided by researchers of the Russian Ilizarov tion. In addition to increase of growth, the approach is the
Research Center [27, 250, 308, 309]. The fundamentals of same as that used in the correction of leg shape without
the application of external fixation for elongation of the lengthening, such that the aesthetic reconstruction techniques
femur and lower leg are discussed in Chapters. 14, 16 and can be applied, i.e. valgization and medialization of the distal
19. Here, it suffices to note that elongation of a segment bone fragment (Figs. 18.19 and 18.20). In Fig. 18.21, the
shortened by trauma and elongation of a “healthy” extremity variant of lengthening of the lower legs by lowering the fibular
are different issues. head (to change the external contour of the shin) is shown.
The standard rate of elongation (1 mm/day in four stages) If requested by the patient, after elongation of the lower
must be constantly updated in accordance with: (a) the leg it is also possible to elongate the femurs; however, a num-
specific features associated with the formation of the distrac- ber of factors restrict the use of this method to increase height.
tion regenerate, (b) the pain experienced by the patient, and From an aesthetic point of view, as noted above, elongation of
(c) the condition of the peripheral parts of the extremity. A the lower extremities by >12% will create the visual effect of
radiographic examination is performed on the 10th day of a short-armed appearance. Our many years of experience of
distraction, then every 3–4 weeks. If the radiographs obtained height correction have shown that after elongation of the shins
on day 10 show a solid regenerate with the possibility of by the desired amount during the first stage, the patient is for
early consolidation of the fragments, the distraction rate is the most part freed of the earlier psycho-emotional conflicts:
increased to 1.5–2 mm/day with further regulation according his or her inferiority complex is largely resolved, accompa-
to the radiographic findings. nied by a considerable boost to the ego. In a considerable
The overall treatment period in the elongation of an majority of cases, these changes are the reason why the patient
extremity proceeds in several stages: refuses further elongation on positive grounds.
1. From the moment of the operation to the beginning of Only if the patient is extremely short (150–155 cm) should
distraction: Typically, this period lasts 5–7 days. the stages and sequence of segment elongations be planned
2. The distraction period: This depends on the amount of in advance. The most rational approach involves crossed
elongation but in general the duration of this period in mono- and bilocal elongation of the contralateral femur and
days is usually equal to the amount of elongation in lower leg, i.e., the right femur and left lower leg during the
millimeters. first stage and the left femur and right lower leg during
3. The distraction regenerate remodeling period. This is the second stage (Chaps. 16 and 19).This method enables the
highly patient-specific and depends on the amount of patient to avoid the inconveniences related to wearing large
elongation. heels and reduces the period of the height increase.
With elongations up to 5 cm, the treatment period in In conclusion, an increase in growth in a select group
months conventionally and approximately is equal to the of patients can be achieved by the lengthening over nail
amount of elongation in centimeters. With greater amounts and transition to internal fixation methods, after reaching the
of elongation (6–7 cm), the treatment period increases con- necessary length. Details about these methods are provided
siderably and in some cases is as long as 10–12 months. in Chaps. 26 . However, internal lengthening may yield even
One way to reduce the treatment period is to use auto- better results since it does not require external fixation
matic highly divided distractors [24, 310] which allow tibial (Albizzia, Bliskunov, Fitbone, ISKD nails) [173, 311–313].
a b
Fig. 18.19 (a–g) Aesthetic reconstruction of the lower legs: lengthening by 5 cm, with valgization and medialization of the distal bone
fragment
e f


a b c
d e
Fig. 18.20 (a–f) Aesthetic reconstruction of the lower legs: lengthening by 4 cm and valgization

f
Fig. 18.21 Change in the a

external contour of the lower legs
after lowering the head of the
fibula. (a) Functional diagram of
the procedure; (b, c) before
reconstruction;
b c d
f g
Fig. 18.21 (continued) (d–f) during correction; (g) the result

18.4 Complications control to maintain dorsal flexion accompanied by active

exercise therapy and round-the-clock use of foot support will
Leonid Nikolaevich Solomin avoid the need to assemble an additional hinge module on
the foot (Chap. 23.6).
Complications in external fixation are covered in detail in An objective analysis of the complications in aesthetic sur-
Chap. 33. In aesthetic correction of the shape and length of gery is extremely important. A complication rate beyond a cer-
the legs, the most significant is inflammation of the soft tain critical level, insurmountable difficulties, or unrecoverable
tissues at the exit site of the external fixator element (6.9%), errors in attempts to improve the quality of life of a healthy
in addition to wire osteomyelitis (1.96%), involvement of the person must lead to careful consideration, and even rejection, of
fibular nerve branches (2.94%), fracture (1.96%) and defor- such methods of treatment. Only the surgeon’s high degree of
mity (3.6%) of the regenerate, neurovascular complications professionalism and considerable experience in reconstructive
(4.7%), contractures (13.5%), and secondary deformities of operations, combined with the patient’s insistent desire for a
the feet (5.9%) [250, 314]. positive outcome, will ensure a successful aesthetic procedure.
Pin-tract infection generally responds to conservative
management. Fractures and deformities of the regenerate are
the consequences of inadequate postoperative management. Note After the title of this chapter, all Authors, who have contributed
Following lengthening of the lower legs, flexion contractures to the chapter, are listed. The specific authorship of the individual para-
of the ankle joints (pes equinus) are most common. Daily graphs is given after each section title.
Non-unions, Pseudoarthroses,
and Long-Bone Defects 19
Leonid Nikolaevich Solomin, Dmitry Jur’evich Borzunov,
Redento Mora, Vladimir Ivanovich Shevtsov,
and Luisella Pedrotti
19.1 Introduction the extent of probable additional loss of bone tissue

subsequent to the surgery should be considered, including
Leonid Nikolaevich Solomin, Dmitry Jur’evich Borzunov, adaptation resection of bone fragments, removal of devital-
and Redento Mora ized grafts, the required duplication of the fragments at the
junction, etc. Thus, in patients in whom the results of preop-
With rare exceptions, pseudoarthroses are accompanied by erative diagnostics and planning suggest that open or closed
the loss of bone tissue, i.e., by an anatomic defect. However, adaptation of the fragments and recovery of the limb axis
from a practical point of view, a clear definition of both will result in more significant shortening of the segment than
“pseudoarthrosis” and “defect” is of fundamental importance is characteristic of pseudoarthroses, then a defect-pseudoar-
in the correct selection of the extent and tactics of both treat- throsis or defect-diastasis is diagnosed. These nosological
ment and rehabilitation measures. A pseudoarthrosis refers units are divided into five groups that guide decision-making
to the condition in which it is anticipated that despite medi- in external fixation [315]:
cal interventions the achieved degree of union of the bone 1. Defect-pseudoarthrosis: a slit-like interfragmentary dia-
fragments will not lead to humeral shortening by >8–10 mm, stasis and anatomic shortening of the bone
or shortening of one of the forearm bones by >5 mm, or of 2. Defect-diastasis: an interfragmentary diastasis >10 mm
the femur and leg bones by >10–15 mm. but without anatomic shortening of the bone
In treatment planning, the bone defect is defined based on 3. Defect-diastasis: an interfragmentary diastasis >10 mm
the total width of the interfragmental diastasis and the amount and anatomic shortening of the bone
of anatomic shortening of the affected segment. In addition, 4. Defect-diastasis of the epiphysis without anatomic
shortening of the segment
5. Defect-diastasis of the epiphysis with anatomic shorten-
L.N. Solomin, M.D., Ph.D. (*) ing of the segment
Pseudoarthrosis, defect-pseudoarthrosis with segment short-
e-mail: solomin.leonid@gmail.com ening, and variants of defect-diastases are shown in Fig. 19.1.
In patients with defects and pseudoarthroses of the long
D.J. Borzunov, M.D., Ph.D.
Department of Orthopedics, Russian Ilizarov Scientific Center bones, reconstructive and restorative treatment using the
“Restorative Traumatology and Orthopedics”, M.Uljanova Str., Ilizarov system is based on the following main approaches to
Kurgan 6640014, Russia rehabilitation: lengthening of the fragments, their union at
R. Mora, M.D. the junction, tibiofibular synostosis, and closed graduated
Department of Orthopedics, University of Pavia, Polo Universitario distraction of the interfragmental tissues in conjunction with
“Citta di Pavia”, Via Parco Vecchio, 27, Pavia 27100, Italy
bone regeneration. Each of the steps requires separate meth-
V.I. Shevtsov, M.D., Ph.D. ods and potentially their modification, depending on the
Department of Orthopedics, The Russian Academy of
pathology’s components and the aim of treatment and reha-
Medical Sciences, Soljanka Str., 14, Moscow 109240, Russia
bilitation. An important component of any case is the com-
L. Pedrotti, M.D.
bined or sequential action of pressure stress (compression)
Department of Orthopedics,
University of Pavia, Polo Universitario “Citta di Pavia”, and tension stress (distraction), used on the basis of non-free
Via Parco Vecchio, 27, Pavia 27100, Italy osteoplasty according to G.A. Ilizarov.
a b The graduated distraction and compression of interfrag-

mental tissues using monolocal compression-distraction
osteosynthesis is shown in Fig. 19.2.
In the presence of pathologic mobility in a patient under-
going closed transosseous osteosynthesis, the surgery can be
performed under conditions of skeletal traction and on the
orthopedic table. In the presence of a marked “loose” mobil-
ity of the fragments, then, as a rule, preference should be
given to open variants of fragmental end adaptation. Closed
variants of union achievement are generally inconsistent and
plagued by the necessity for a protracted fixation of the frag-
ments using transosseous devices.
In the closed transosseous osteosynthesis of pseudoar-
throses, the configurations of the transosseous devices are
analogous to those recommended for the osteosynthesis of
fresh fractures (Chaps. 11, 12, 13, and 14) as well as to those
proposed for deformity correction (Chap. 8). In this chapter,
the configurations developed at the RISC RTO are demon-
Fig. 19.1 (a) Pseudoarthrosis or defect-pseudoarthrosis with and with-
strated in clinical cases.
out anatomic shortening of the bone. (b) Defect-diastases with and The rigidity of the osteosynthesis required for a reliable
without anatomic shortening chronic fixation of the bone fragments is achieved by the use
of additional stabilizing half-pins and wires with (olive or
19.2 Non-unions curved) stoppers. This is related to the duration of the trau-
ma’s consequences and thus to the decreased reparative
The external fixation methods listed in Table 19.1 are rec- potential of the tissues involved.
ommended for the treatment of pseudoarthroses of the long Postoperatively, longitudinal (axial) compression is per-
bones when, it must be emphasized, elimination of the formed for the transverse direction of the pseudoarthrosis.
interfragmentary space does not result in shortening of the Wires with stoppers are inserted close to the level of the
humerus by >8–10 mm, one of the forearm bones by >5 mm, pseudoarthrosis and fixed using traction clamps in the oblique
and the femur and bones of the lower leg by >10–15 mm. direction of the bone wound in order to generate supporting
Table 19.1 Methods of external fixation for non-unions and pseudoarthroses of the long bones
Method of external fixation Indications
Fragment displacement Bone non-union line Degree of pathological Type of osteogenesis
mobility
Closed monolocal Proper axis of the segment Oblique, transverse, ends Possibility of single-step Hyperplastic
compression or insignificant angular of the fragments congruent recovery of the segment
deformity that can be axis
eliminated in a single step
Closed monolocal Angular displacement of Oblique, transverse, ends Impossibility of single-step Hyperplastic
distraction the fragments of the fragments are recovery of the segment
congruent axis
Closed monolocal Angular displacement of Oblique, transverse, ends Impossibility of single-step Hyperplastic
synchronous distraction- fragments of the fragments are recovery of the segment
compression congruent axis
Closed monolocal Longitudinal displacement Oblique, transverse, ends Impossibility of single-step Hyperplastic
consecutive distraction- of the fragments (and at an of the fragments are recovery of the segment
compression angle) congruent axis
Open monolocal Any kind of displacement Ends of the fragments are Possibility of single-step Hypoplastic; necessity to
compression non-congruent recovery of the segment remove the ends of the
axis fragments (osteomyelitis,
broken implants)
Parafocal osteotomy Proper axis or angle Oblique, transverse, ends Possibility of single-step Hyperplastic
deformity of the fragments are recovery of the segment
congruent axis
19 Non-unions, Pseudoarthroses, and Long-Bone Defects 843
a b
c d
Fig. 19.2 (a–f) Diagram and clinical examples of monolocal osteosynthesis. Compression along the segment axis was maintained at 0.75–1.0 mm
once for 10–14 days. Humeral integrity was recovered 82 days after osteosynthesis
e f
side-to-side compression [316], which is provided by mutual compression and others for distraction (Fig. 1.6); thus, they
transposition of the fixator’s supports, most reliably by using are distinct from axial and swivel hinges (Fig. 1.5). Their use
external plates (Fig. 2.6, Fig. 19.3). was discussed in Chap. 16.
The marked effect of the tension stress factor on the acti- Methods of closed monolocal consecutive distraction-
vation of reparative osteogenesis is clearly observed in compression external fixation of non-unions and false joints
patients treated with closed graduated distraction of the are applied in cases of longitudinally displaced fragments. The
interfragmental tissue. At the same time, the expedience of specific features of the transosseous external fixation devices
using transosseous osteosynthesis techniques should be are generally analogous to those given in the sections devoted
emphasized, most of all in the hyperplastic type of callus to external fixation of fractures with incorrectly positioned
formation. The closed graduated distraction of atrophic and bone fragments (Figs. 15.2, 15.3, and 15.4). When longitudinal
avascular pseudoarthroses is unjustified. The most marked repositioning of the fragments exceeds 35–40 mm, the device
restorative reaction of the tissues has been demonstrated to is mounted only on the basis of basic transosseous elements.
occur in cancellous bone, and to a lesser extent in compact Distraction by 0.25 mm three or four times a day starts on post-
bone. Figure 19.4 provides an example of the effective use of operative days 3–5. If the process becomes painful or if a neu-
closed monolocal distraction osteosynthesis. rotrophic disorder arises, the distraction rate must be decreased.
Figures 19.5 and 19.6 show variants of closed monolocal After elimination of the longitudinal displacement of the frag-
distraction-compression external fixation. The basic sup- ments, reducing transosseous elements are inserted to achieve
ports must be installed perpendicular to the axis of the their gradual coaptation (0.25 mm 3–4 times a day) with subse-
respective bone fragment. When wire-based devices are used quent supporting compression of 1 mm every 7–10 days.
in fixed deformities, the modules fixing each bone fragment In case of narrow dimensions and a small size of one of
should be positioned in hypercorrection by 5°. Afterwards, the fragments, which in these cases are typically osteoporo-
the transosseous modules are connected by hinges located on tic, the additional fixation of an adjacent segment should be
the convex and concave surfaces. Some of the hinges are for performed to provide rigidity. The supports are connected
Fig. 19.3 (a–e) Monolocal a b

compression osteosynthesis in the
treatment of a tibial pseudoarthrosis.
Side-to-side compression was achieved
through transposition by the fixator’s
intermediate ring supports at a rate of
0.75–1.0 mm once for 7–10 days. Tibial
integrity was recovered by day 87 after
osteosynthesis
d e

with each other by hinge units to allow adjacent joint move- the bone tissue associated with the fragments, that is, eburna-
ments. Fixation of an adjacent segment should be continued tion of their ends. A saving resection of the ends will produce
until the established signs of osteogenesis appear in the zone sufficient contact of the bone wound surfaces and opening of
of pseudoarthrosis (Fig. 19.7). the medullary canals while sparing damage to the soft tissues
Malunited fractures, false joints, and hypotrophic distrac- surrounding the respective descending ends of the fragments.
tion regenerates also are treated using a method based on the It should be performed for surgical adaptation of fragmental
alternating application of microcompression and microdis- ends to avoid further aggravation of a purulent infection. In
traction. Golyakhovsky and Frenkel [317] referred to this as such cases, the foreign bodies in the interfragmental diastasis
“the accordion method.” It is implemented within 10–15 days (metal constructions, grafts) that prevent adequate contact of
postoperatively at a distraction rate of 0.25 mm twice a day. the fragment ends must be removed. As a rule, reorganization
After 3–5 days of stabilization, the fragments are brought of the bone tissues of the replants is unlikely; instead they
together in the same mode. The cycle of compression and will tend to undergo autolysis in response to the production
distraction must be repeated at least twice. and maintenance of compression at the junction of the frag-
Open surgical adaptation of the fragment ends is indicated ments. The ends of the fragments should be processed in a
for those with an incongruent shape, when it is not possible to single plane, thus enabling their maximal contact. Longitudinal
establish their sufficient and adequate contact for complete or side-to-side compression should be applied postopera-
healing. Open adaptation is also used for marked atrophy of tively depending on the plane of the bone wound’s location.
a b c
Fig. 19.4 (a–f) Monolocal distraction osteosynthesis for the treatment surfaces of the leg. Tibial integrity was recovered 63 days after
of tibial pseudoarthrosis. Distraction was performed at rate of 0.75– deformity correction
1.0 mm per day using traction units set along the posterior and-interior
d e

Fig. 19.5 (a, b) Combined external fixation for

humeral non-union. During gradual elimination of
a b
the angular deformity (at an average rate of
0.25 mm four times a day) forces are created in
the device in different directions: distraction on
the concave side of the bone and compression on
the convex side. At the same time, an additional
compression force is applied at the junction of the
fragments using reductionally fixing transosseous
elements
1 3 4 2
II,5-11 – IV,9,90 ↔o↔ VI,8,90 – VIII,3-9 (a)
½ 150 140 140 3/4 140
5
III,11,120; IV,9,90 →← VI,8,90 – VIII,3-9 (b)
140 140 3/4 140
a b c
1 2 3 5 6 4
I,8,90; II,11,90 –– IV,10,90 ↔o↔ VI,9,90; VII,8,70 –– VIII,3-9 (a)
1/3 225 3/4 195 180 3/4 180
I,8,90; II,11,90 –– IV,10,90 →← VI,9,90; VII,8,70 –– VIII,3-9 (b)

1/3 225 3/4 195 180 3/4 180
I,8,90; II,11,90 –– IV,10,90 →← VI,9,90; VII,8,70 (c)

1/3 225 1/3 195 1/3 180
Fig. 19.6 Osteosynthesis of a femoral pseudoarthrosis with a hybrid hybrid fixator can be converted into a sector (arch) fixator (c) if the
fixator (a). After elimination of the deformity, the hinges should be positive dynamics of bone wound healing and limb function recovery
exchanged for connection rods (b). After 1–1.5 months, the initial are evident
a b
c d
Fig. 19.7 (a–h) Compression-distraction osteosynthesis for the treat- axial compression were maintained at the junction of the fragments
ment of a humeral pseudoarthrosis. Given the small size of the distal throughout the period of transosseous osteosynthesis. Anatomic integ-
humeral fragment, a hinge module was applied to the forearm, which rity was achieved by 96 days
allowed continued elbow movement training. Both side-to-side and
g h

19.3 Parafocal Osteotomy of the non-union. It also takes advantage of the effect of peri-
focal improvements in the blood supply after osteotomy. The
Luisella Pedrotti required immobilization was initially achieved with a cast,
until Umiarov [320] proposed combining parafocal osteot-
Osteotomies performed for the management of non-unions omy (or, more exactly, parafocal corticotomy) and immobi-
of the long bones can be divided into three types [318]: (1) lization by means of a compression-distraction device.
intrafocal osteotomy (resection of the non-union area), (2) The surgical technique is simple: the non-union site is not
transfocal osteotomy (reshaping of the bone ends), and (3) addressed, and the exact corticotomy level is either proximal
parafocal osteotomy (osteotomy performed away from the or distal to the non-union site, avoiding dystrophic skin and
non-union level). Of these, we will more closely examine soft tissue areas as well as osteoporotic or sclerotic bone
parafocal osteotomy. In this method, which includes closed areas [321]. In the presence of a complex deformity, a perifo-
monolocal compression and closed monolocal synchronous cal osteotomy should be done at the CORA level. The devel-
distraction–compression external fixation, a single or double opers of the method recommend elastic fixation over a high
osteotomy is performed 3–6 cm away from the non-union degree of rigidity for the osteosynthesis.
site (which is not directly addressed) (Figs. 19.8, 19.9, and It should be noted that the potential of external fixation to
19.10). It is indicated in cases of hypertrophic non-unions, treat all types of false joints goes beyond the listed methods;
non-unions with simple or complex deformities, and non- rather, this approach can sometimes be used in combination
unions with skin lesions at the affected site, and contraindi- with others. For example, one option is the closed elimina-
cated in cases of defect non-unions or infected non-unions. tion of longitudinally displaced fragments followed by their
The limitation of this method is related to the possibilities of open adaptation with subsequent compression osteosynthe-
deformity correction when the osteotomy is carried out not at sis to treat incongruous fragment ends. In addition, the frag-
the CORA level (Chap. 16). In some cases a double cortico- ment ends can be supplemented (replaced) by bone graft.
tomy (proximal and distal to the lesion) is indicated to obtain Before concluding this section we should mention that the
a perfect anatomic axis of the bone segment. sequential techniques of osteosynthesis, both the tran-
Parafocal osteotomy was developed by the Italian ortho- sosseous and the internal types, are of particular interest in
pedic surgeon Paltrinieri [319], with the aim of transferring the treatment of pseudoarthroses. A key aspect is that all the
every mechanical stimulus from the non-union to the osteot- deformity components involved in the accompanying
omy level and simultaneously correcting the deformities, pseudoarthrosis should be eliminated at the first stage using
thus stimulating the bone’s regenerative potential at the level transosseous osteosynthesis. Then, in the second stage,
a b c
Fig. 19.8 Treatment stages for a

proximal tibial non-union. (a)
Hyperplastic tibial non-union at
the proximal metaphyseal level
with angular (varus) and
translational deformity. (b)
Parafocal osteotomy 6 cm distal
to the non-union level, with
correction of the varus and
translation deformity, together
with osteosynthesis. (c) Healing
of the non-union and osteotomy
at the end of treatment
Fig. 19.9 Treatment stages for a

distal femoral non-union. (a) a b c
Hyperplastic femoral non-union at
the distal metaphyseal level with
an angular (varus) deformity. (b)
Parafocal osteotomy is performed
5 cm distal to the non-union, with
correction of the varus deformity
and then osteosynthesis using a
circular device. (c) The circular
device can be removed after
healing of the non-union and
osteotomy
locked intramedullary or internal osteosynthesis is performed tively, of the contralateral segment length. This technique is
and the fixator is removed. This approach not only decreases preferable for defects of a traumatic genesis, and less effec-
the amount of labor for the surgeon postoperatively but also tive for those of congenital etiology because of frequent
improves patient comfort while reducing the risk of infec- recurrences and fractures of the distraction-regenerated
tious complications and transfixation contractures. More bones, which undergo lengthy organotypic reorganization.
detailed information about the conversion from external to In the oblique line type of defect-pseudoarthroses, the
internal fixation is given in Chap. 26. monolocal distraction variant of osteosynthesis can be
applied (Fig. 19.13).
In some cases of a defect-diastasis, simultaneous approxi-
19.4 Long-Bone Defects mation of the main bone fragments is not possible. The most
frequent cause of this is evident crimping of the soft tissues,
Leonid Nikolaevich Solomin, Dmitry Jur’evich Borzunov, resulting in trophic disorders and hindering wound suturing,
and Redento Mora e.g., in compound fractures. Such patients can be treated
with monolocal successive compression-distraction osteo-
In defect-pseudoarthroses the first stage of treatment involves synthesis. Accordingly, the bone fragments are gradually
recovery of the bone axis by means of external fixation, elim- approximated after the skin wound has healed. The rate of
ination of the longitudinal and lateral displacement of the approximation is limited by the presence of a neurotrophic
fragments, and correction of the torsion (Chap. 16). Further disorder and usually does not exceed 3–5 mm per day in four
action depends on the character of the osteogenesis in the to six sessions. The approximated bone fragments are then
zone of the false joint. A hyperplastic osteogenesis (stiff false compressed axially or laterally, depending on the plane of
joints) allows the use of monolocal distraction osteosynthesis the bone wound. In 14–18 days, the bone fragments are grad-
(Figs. 19.11b, c and 19.12b, c). Distraction is started on post- ually separated at a mean rate 0.25 mm two or three times a
operative day 5–7 at a rate of 0.25 mm 1–3 times a day day until the segment length is restored (Figs. 19.11 and
depending on the results of the biochemical tests [322]. 19.12). A mandatory condition is an adequate blood supply
According to the data of Makushin [323] and Shevtsov to the ends of the fragments. This type of osteosynthesis is
et al. [324], the use of tension stress on reparative osteogen- recommended, for example, when both bones of the forearm
esis activation is effective for a defect not exceeding 4 cm in show an equal degree of diastasis.
size, with complete 100%-filling of a tibial defect achieved If acute adaptation of the main bone fragments is impos-
in all cases involving an initial defect below 10% of the con- sible then bilocal distraction-compression osteosynthesis
tralateral segment length, and in 40% and 25% of the cases should be used (Fig. 19.14). The longer bone fragment is
when the initial defect was 11–20% and 21–30%, respec- lengthened according to the Ilizarov method [169]. After
b c
Fig. 19.10 (a–c) Patient with a tibial non-union at two levels that was treated with a double parafocal osteotomy according to the method of
Paltrinieri (see text)
adaptation of the intermediate fragment to the one being Single-stage osteosynthesis is considered the most ratio-
joined, supporting compression is applied between them, nal and effective strategy to lengthen a bone fragment, by no
either axially or side-to-side. more than 5–8 cm. According to Makushin [323] and to
a b c
1 2 3 6 5 4
I,8,90; II,11,90; II,9,90 →← V,8,90 –– VII,8,120; VIII,3-9 (a)
1/3 210 195 ¾ 180
I,8,90; II,11,90; II,9,90 ←→ V,8,90 –– VII,8,120; VIII,3-9 (b)

1/3 210 195 ¾ 180
I,8,90; II,11,90; II,9,90 –– VI,9-3 –– VII,8,120; VIII,3-9 (c)

1/3 210 195 ¾ 180
Fig. 19.11 Examples of open monolocal distraction (b®c) and alternating compression-distraction (a®b®c) in the external fixation of segmental
defects of the femur
a b c
1 2 4 3
I,11,90; II,8,90 →← V – VII,8,120; VIII,3-9 (a)
1/2 160 140 3/4 140
1 2 4 3
I,11,90; II,8,90 ←→ V – VII,8,120; VIII,3-9 (b)
1/2 160 140 3/4 140
1 2 5 4 3
I,11,90; II,8,90 – V,4-10 – VII,8,120; VIII,3-9 (c)
1/2 160 140 3/4 140
Fig. 19.12 Examples of open monolocal-distraction (b®c) and alternating compression-distraction (a®b®c) for external fixation of segmented
defects of the humerus
a b c
1 2 3 5 4
I,8,120; II,11,90; III,9,90 ←→ VII,8,70 –– VIII,3-9 (a)
1/3 225 180 3/4 180
7 7 6
I,8,120; II,11,90; III,9,90 ←→ V,9,120; VI,9-3; VII,8,70 (b)
1/3 225 180
I,8,120; II,11,90; III,9,90 –– V,9,120; VII,8,70 (c)

1/3 225 1/2 180
Fig. 19.13 Variant of external fixation for the correction of a hyper- the distal fragment (at the same time, half-pin VII,8,70 must be discon-
plastic non-union accompanied by shortening of the extremity (defect- nected from the support!). (c) During the fixation period, 3–5 weeks
pseudoarthrosis). (a) Osteotomy is performed perpendicular to the before the planned removal of the device, wire VI,9-3 is removed and
plane of the false joint. (b) After a distraction regenerate of the neces- the internal half-ring is removed from the distal support
sary length has formed, wire VI,9-3 is inserted to correct the position of
Fig. 19.14 Bilocal transosseous

osteosynthesis: (a) bilocal a b
simultaneous compression-
distraction osteosynthesis with
fragment lengthening; (b) bilocal
sequential compression-
distraction osteosynthesis with
fragment lengthening
Shevtsov et al. [324], single-stage filling of a leg bone defect axially or side-to-side (Fig. 19.17). The proper relationships
<40% of the segment length is highly effective. among the radioulnar articulations should be recovered with-
In hypotrophic defect-pseudoarthroses, open adaptation out distraction interruption, if required (Fig. 19.18).
of the bone fragments is generally performed: either in one- To reduce a chronic dislocation of the head of the radius,
stage or after gradual juxtaposition of the bone fragments. a reduction-fixation wire is used: (I,11-5)I,11-5 or (I,3-9) or
Bone autografting is applied if necessary. Simultaneous cor- (I,9-3). Open reduction of the radial head is applied as appro-
ticotomy with osteoclasia of the longer fragment is an option. priate. In chronic dislocations of the head of the radius and
The same method must be used when there are signs of marked degenerative dystrophic changes in the proximal
decreasing revascularization of the main fragment ends, e.g., radioulnar joint, removal of the radial head may be required
in the presence of free autografts (bone fragments with blood instead of open reduction. Wire VIII,6-12(VIII,6-12) is
circulation failure) and the monolocal distraction method is inserted for the fixation of the distal radioulnar joint.
ruled out. Elongation can involve only one of the bone fragments
Thus, there are two main variants of intermediate frag- when there is a thin “icicle-shaped” form at one end
ment transportation: rigid and elastic. Transosseous elements (Fig.19.19). It can be inserted into the bone marrow canal of
attached to the support are used for the “rigid” variant the opposite fragment, with the shortening compensated by
(“cross-wire technique”), and various flexible pulls for the the formation of a distraction regenerate at another level.
“elastic” variant (“oblique-wire technique”). Distraction is started at an average rate of 0.25 mm three
Among the variants shown in Fig. 19.15, fixation of the or four times a day on postoperative day 5–7. During forma-
intermediate (movable) fragment with transosseous elements tion of the distraction regenerate, fixation with compression
in the external support is the most rigid one. This arrange- at the level of the false joint is performed. If by the end of the
ment has a positive effect on the formation of the distraction- distraction period, signs of soft-tissue tension appear related
regenerated bone. It can be used to transport fragments over to the transosseous elements fixed in the reductionally fixing
a distance of 30–60 mm on average, depending on the seg- supports, they should be replaced. For example, in Fig. 19.11,
ment and the soft-tissue condition. In the next step, the soft half-pin V,8,90 is replaced with wire VI,9-3.
tissues will be penetrated by wires and half-pins, resulting in In Fig. 19.20, one of the variants of replacing a triangular
their inflammation. This can be avoided by first shifting aside long bone defect by means of a dosed rotation and lowering
the soft tissues, with a finger or a fine hook, to the site where of the intermediate fragment is shown. A variant of filling a
the distraction-regenerated bone will later be formed. marginal tibial defect involving >50% of the diameter by bone
If greater transposition of the fragment is planned, an splint (sliver?) transportation is illustrated in Fig. 19.21.
axial wire (Fig. 19.15d) or flexible pulls (Fig. 19.15e, f) In bilocal distraction-compression transosseous osteosyn-
should be inserted immediately during surgery. After the thesis, transport of the intermediate bone fragment is started
transporting support “has reached its limit,” the transosseous on day 5–7 postoperatively. The average rate of movement is
elements attached to it should be removed. The fragment is 0.25 mm four times a day. The goal should be to join the
further transported with the wire (flexible pulls). Distraction- fragments as soon as possible and to provide the conditions
guiding wires (“leading wires,” Fig. 19.15c) are inserted that promote their joining. Therefore, simultaneously with
directly before removal of the intermediate support’s tran- the distraction (for regenerate formation), the opposite bone
sosseous elements. The bone tissue of fragments that under- fragment should be approximated to the relocated fragment.
went chronic defect filling are typically osteoporotic and The approximation rates are limited by crimping of the soft
eburnated, with thinned cortical plates; thus, it is preferable tissues and the appearance of subsequent neurotrophic disor-
to use wires with stoppers such as curled wires, to transport ders. In osteosynthesis involving the lower leg, approxima-
the newly formed fragments. As a rule, wires with olives will tion of the fragments can be hindered by the fibula, perhaps
be prematurely expelled from the fragments. Special calcula- necessitating osteotomy or removal.
tions based on the skiagram are necessary to determine the Once fragment contact is achieved, the fixator should be
amount of traction by distraction-guiding wires that is needed partially remounted. The transosseous elements, attached to
to provide 1 mm of linear transport of the intermediate frag- the intermediate external support, are inserted again through
ment [9, 315, 324]. the transported fragment, and the distraction-guiding wires
The technique of bilocal sequential distraction-compres- (an axial wire, wire-pulls) should be removed. Opposing
sion osteosynthesis is also used for hypotrophic defect- compression is produced at the junction of the fragments. If
pseudoarthroses of one of the forearm bones and the second fragment adaptation was improper or if there are signs of
intact bone (Fig. 19.16). The longer bone fragment is avascularity at their ends, then their open juxtaposition is
lengthened according to the Ilizarov method. After adaptation indicated, as well as bone grafting. In this case, formation of
of the intermediate fragment to the fragment being joined, the distraction-regenerated bone is not stopped until the limb
supporting compression is applied between them, either length inequality has been corrected.
a b
c d e f
Fig. 19.15 Main variants for the relocation of intermediate fragments the sector with the half-pins is an independent module that is installed
in an external fixation device (“bone transport”). With the aid of: tran- in the preliminarily assembled device. In Weber’s technique (f), con-
sosseous elements fixed to the external support (a, b); traction guiding trary to the pulled wire (e), thin flexible stranded cables are used
wires (c); an axial wire (d); a pulled wire (e) are inserted. The technique together with roller units in the traction device. Thus, (a, b) are rigid
of M. Weber (f). Variant (b) differs in principle from variant (a) in that variants of bone transport, and (c–f) elastic ones
Please note that the duration of fixation for bone defect 19.4.1 Polylocal Osteosynthesis
filling is not the same as in the usual procedure of long bone
lengthening. Defect filling, as a rule, is required under condi- Large defects of the femur and tibia are replaced by the elon-
tions of impaired trophism and vascularization of the segment, gation of both bone fragments, i.e., polylocal compression-
scarring, and pathological changes in the bone tissue of the distraction osteosynthesis (Figs. 19.22, 19.23, 19.24, 19.25,
fragments (atrophy, sclerosis, osteoporosis, eburnation, etc.). and 19.26).
a b c
1 2 3 6 7 4 5
I,8,120; II,11,90;II,9,90 ←→ III,10,120; IV,8,90→← VII,8,120; VIII,3-9 (a)
1/3 225 3/4 195 3/4 180
8 9
I,8,120; II,11,90; II,9,90 ←→ V,3,130; V,9,130 →← VII,8,120; VIII,3-9 (b)
1/3 225 195 3/4 180
11 10
I,8,120; II,11,90; II,9,90 ←→ V,8,120; VI, 9-3 →← VII,8,120; VIII, 3-9;VIII,4,90 (c)
1/3 225 195 3/4 180
Fig. 19.16 (a–c) Bilocal distraction-compression osteosynthesis of the femur

Fig. 19.17 (a–c) Devices for the replacement

of defects of radial segments by elongation of
a b c
the proximal fragment
1 2 3 6 7
I,4-10; I,5,90(I,5,90); (II,9,90) ←→ (III,9,90); (IV,12,70) →←
3/4 120 120
5 4
→← (VII,10,120); VIII,6-12(VIII,6-12) (a)
120
I,4-10; I,5,90(I,5,90); (II,9,90) –V– (VII,10,120); VIII,6-12(VIII,6-12) (b)

3/4 120 120
I,4-10; I,5,90(I,5,90); (II,9,90) ←→ (V,2-8); (VI,11,70) →←

3/4 120 120
→← (VII,10,120); VIII,6-12(VIII,6-12) (c)
120
The filling of an extensive long bone defect by an 8–10 cm osteosynthesis compared with the traditional procedures of
lengthening of the fragment results in the retardation of bone defect filling by fragment lengthening according to
osteogenesis and the formation of hypoplastic (“ischemic”) Ilizarov.
distraction-regenerated bone in 1.6–13.8% of the cases. The average distraction rate for elongation of the proxi-
Based on experimental and clinical studies [325] the process mal fragment is 0.25 mm 3–4 times a day. The formation of
of multilevel lengthening of the proximal tibial fragment a hypoplastic distraction regenerate is avoided by elongating
was shown to be characterized not by the inhibition of endo- the distal fragment by 0.25 mm 2–3 times a day. Therefore,
and periosteal osteogenesis but by its high activity. Stress the defect is replaced mostly as a result of the elongation
induced by the osteogenesis processes and the formation of of the proximal fragment. The bone defect can also be
hypoplastic distraction-regenerated bones have been replaced using polylocal elongation of the fragment.
observed in the multilevel lengthening of a bone fragment. Figure 19.10 shows, as an example, the sequence of osteo-
By contrast, favorable conditions for the anatomic and func- synthesis in segmental defects of the femur.
tional recovery of the intraosseous arterial vascular network During the replacement of all segmental defects of the
of the involved tibia can be achieved within the optimal peri- long bones, after approximation of the displaced fragment to
ods for the filling of a defect in a leg bone by multilevel the primary position it is necessary to determine whether
lengthening of the proximal fragment. The effectiveness of open reduction is appropriate. Removal of the closing plates
exploiting the polylocal formation of distraction-regenerated and anatomic alignment of the ends of the fragments opti-
bones was confirmed by the possibility of a consistent 1.5- mize the conditions for successful healing of the bone wound.
fold reduction in the duration of treatment and transosseous If the ends of the fragments are hypotrophic or hypovascular,
Fig. 19.18 External fixation for the correction of an a b

ulnar defect-diastasis. Transosseous element VI,7,90 is a
4-mm half-pin. Console wire V,5,90 (a) is additionally
inserted for rotational stability of the intermediate
fragment. After the intermediate fragment is joined to
the distal one, the transosseous elements of the
intermediate support are replaced because they cut into
the soft tissues (b). Replacement of wire VIII,6-
12(VIII,6-12) with half-pin VIII,6,120 allows correction
of the rotational movements
1 2 3 6 7 5 4
I,4-10; I,5,90(I,5,90); II,6,90 ↔ V,5,90; VI,7,90 →← VII,7,110; VIII,4-10 (1)
3/4 130 130 130
8 9
I,4-10; I,5,90(I,5,90); II,6,90 ↔ V,8,120; VI,4-10 →←
3/4 130 130
10
→← VII,7,110;VIII,6-12(VIII,6-12) (2)
130
plasty can be performed according to the method of Albi- a wire (or wires) with a stop, inserted in the ring. Thus
Khakhutov or a spongy autograft can be placed in the groove the displaced fragment is moved towards the distal island
between the fragments. Open reduction of the fragments is fragment, thereby forcing the scars inwards and forwards
done in a single stage, with partial remounting of the device; (Fig. 19.27b).
this involves relocation of the external supports and the inser- If it is not possible to completely prevent soft-tissue
tion of transosseous elements. If the blood supply to the ends retraction between the fragments, the following approach
of the fragments is adequate, the diameters of the fragments should be adopted. The displaced fragment and primary
are identical, and an anatomically closed alignment is pos- fragment are approximated as far as possible, followed by
sible, then an open intervention may not be necessary. their open reduction. The defect arising as a result of the
One of the difficulties in relocating a fragment during soft-tissue excision is covered with locally mobilized skin or
bilocal osteosynthesis is retraction of the soft tissue in the by a free skin graft. While compression of the soft tissue
area of the defect. To prevent perforation and necrosis of between the fragments is acceptable, it carries the risk of
an indrawn scar, the direction of bone fragment movement infectious complications.
must be temporarily changed towards the uninjured soft Large soft-tissue defects must recover before the bone
tissue (Fig. 19.27). On the lower leg, it is generally neces- defect can be replaced. The best results are achieved using
sary to change the intermediate fragment’s vertical direc- vascularized full-thickness autotransplants.
tion of movement (coaxially to the primary fragments) In some cases bone and soft-tissue defects can be
in order to achieve outward and backward relocation treated in a single step by microsurgery. The optimal
(Fig. 19.27a). After the repositioned fragment has passed approach is to treat the segmental defects of the humerus
the scar zone, the distraction-guiding wires are replaced by and forearm bones using autotransplants from the fibula,
a b
c d
Fig. 19.19 (a–d) An example of bilocal sequential compression-dis- beginning on postoperative day 6 at a rate of 0.25 mm 2–3 times/day for
traction osteosynthesis in a patient with a post-traumatic 6-cm defect- 79 days. The fragmental ends were adapted to achieve union. Segmental
diastasis of the left ulna. Graduated transport of the formed fragment fixation with the Ilizarov device was carried out for 70 days
until contact with the end of the opposite fragment was performed
Fig. 19.20 Replacement of a

tibial defect according to the
method of A.P. Barabash
a b
Fig. 19.21 Filling an extensive marginal tibial defect. (a) Before sur- tissue cutting and inflammation. Thus, distraction-guiding wires were
gery. (b, c) A tibial split is created. Its transportation with half-pins inserted during surgery as well
provides substantial fragment stability but there is a high risk of soft-
c d
e f
Fig. 19.21 (continued) (d) Distraction was completed using only the distraction-guiding wires. (e) After open adaptation of the bone fragment
transported to the main one. (f) Treatment result
a b
c
d
Fig. 19.22 Types of polylocal osteosynthesis. (a) Multilevel lengthening of a fragment; (b) lengthening of both bone fragments; (c) lengthening
of a bone fragment and the adjacent segment; (d) combination of the techniques
a b c
1 2 3 5 8 9 10
(I,8-2)I,8-2; I,4-10; II,1,90 ←→III,3-9; III,4-10 →← VI,2-8; VI,4-10 ←→
¾ 150 150 150
6 4 5
←→ VII,1,90; (VIII,8-2)VIII,8-2; VIII,4-10 (a)
150
(I,8-2)I,8-2; I,4-10; II,1,90 –– IV –– VI ––

¾ 150 150 150
–– VII,1,90; (VIII,8-2)VIII,8-2; VIII,4-10 (b)

150
(I,8-2)I,8-2; I,4-10; II,1,90 ←→ IV,3-9; V,12,90 →← V,3-9; V,12,90 ←→

¾ 150 150 150
←→ VII,1,90; (VIII,8-2)VIII,8-2; VIII,4-10 (c)

150
Fig. 19.23 (a) Polylocal osteosynthesis for the replacement of a seg- elements (c). In the last stage, the intermediate rings are re-set at the
mental defect of the tibia. Note the necessity for stepwise replacement level of the transosseous elements insertion. This aspect is expanded on
of the transosseous elements, transferring the fragments towards one in the section devoted to the external fixation of open fractures
another using distraction-guiding wires (b) and then transosseous
a b c
1 2 3 7 8
I,8,90; II,9,90; II,11,90 ←→ III,9,90 ←→VI,9,90 →←
1/3 225 3/4 195 195
6 4 5
→← VII,8,120; VIII,3-9; VIII,4,90 (a)
3/4 180
I,8,90; II,9,90; II,11,90 ←→ IV ←→VI→←VII,8,120; VIII,3-9; VIII,4,90 (b)

1/3 225 3/4 195 195 3/4 180
9 10 12 11
I,8,90; II9,90; II,11,90 ←→IV,8,90; IV,20,90 ←→VI,9,90; VI,9-3 →← (c)
1/3 225 3/4 195 195
→← VII,8,120; VIII,3-9; VIII,4,90

3/4 180
Fig. 19.24 Bilocal elongation of the proximal fragment of the femur. result in inflammation, they are removed, with further movement of the
The supports of the device are mounted. Half-pins are inserted into the fragments achieved by distraction-guiding wires. Approximation of the
fragments to be transposed is necessary for the corticotomy and to opti- distal fragment is continued such that contact with the transposed frag-
mize the conditions during the early stage of distraction regenerate for- ment is made as early as possible (b). After the transposed distal frag-
mation. The distraction-guiding wires can be inserted immediately ment establishes contact with the primary fragment, distraction is
during the first stage of the operation. After the device has been continued until the planned amount of segment elongation is reached.
mounted, corticotomy with osteoclasia is performed first at the distal The device is then partly remounted: the distraction-guiding wires are
and then at the proximal level (a). The rate of movement of the distal removed, supports are placed at the level of the transported fragments
fragment must be greater than that of the proximal fragment. If there and the latter are stabilized by transosseous elements (c)
are signs that the half-pins are cutting into the soft tissue, which will
a b
c d
Fig. 19.25 (a–d) Ulnar head subluxation: bilocal lengthening of the open manner with longitudinal compression produced and maintained
proximal ulnar bone fragment in an 11-cm defect-diastasis. The dura- throughout osteosynthesis. The duration of segment fixation with the
tion of distraction was 38 and 104 days, respectively. After graduated fixator was 148 days
elimination of the subluxation, the fragment ends were adapted in an
wing of the ilium, or a rib. The transplant is fixed either by 19.4.2 Tibiofibular Synostosis
an external fixation device or by combined strained fixation
(Chap. 20). The lack of external supports, connection rods, Tibial defect filling using a thickened fibula and its tibializa-
and transosseous elements in the area of the graft facili- tion form the basis of the techniques of interosseous synosto-
tates the microsurgical stage of the operation as well as sis under the conditions of transosseous osteosynthesis.
postoperative monitoring of the neurovascular status of Tibiofibular synostosis is recommended for extensive
the flap. total tibial defects. According to RISC RTO data, fibular
a c d
Fig. 19.26 (a–e) Lengthening of both bone fragments (double bone cotomy after the proximal distraction-regenerated bone had reached
transport) for a 19-cm defect-diastasis of the tibia. The fragments was 5.0 cm. The fragment formed was transported 0.5–0.75 mm per day
transported by pulling the distraction-guiding wires 0.25 mm 3–4 times/ until it joined with the end of the distal fragment, a process requiring
day for 68 days (the proximal distraction regenerated bone) and 90 days 67 days. Open adaptation of the fragments was performed at their junc-
(the proximal distraction regenerated bone). At osteosynthesis; the tion. The duration of segment fixation with the frame was 165 days
proximal fragment being lengthened was subjected to additional corti-

e f
a b
Fig. 19.27 Transposition of an intermediate fragment to correct a soft- posed fragment has passed the scar zone, the traction-guiding wires are
tissue defect. In the lower leg, the vertical (coaxial to the primary frag- replaced by a wire (or wires) with a stop inserted in the plane of the
ments) direction of transposition of the intermediate fragment must be ring, so as to enable this fragment to move towards the distal island
changed to an outward and backward transposition (a). After the trans- fragment, thus forcing the scars inwards and forwards (b)
Fig. 19.27 (continued) Clinical example (c, d)

tibialization is maximally effective in the treatment of young a b

patients with defects of congenital etiology.
Tibiofibular synostosis comprises monolocal or polylocal
bypass synostosis, fibular tibialization as split-fragments or
synostosis variants with the proximal end of the fibula, and
polyfragmental simultaneous or sequential leg bone synosto-
sis (Figs. 19.28, 19.29, 19.30, 19.31, and 19.32). The gradu-
ated transport of the fibular fragment into the area of the tibial
defect is one of the many common variants (Fig. 19.29).
Use of the fibula in tibial reconstruction determines the
necessity for prolonged limb fixation after osteosynthesis by
means of additional immobilization (plaster cast, splint,
orthesis) until hypertrophy of the substituted bone is achieved.
Also, in some cases it is considered as limb preparation for
rational prosthetics.
It should be noted that operations in which the fibula
forms a synostosis with the tibial fragments outside the
defect, or those in which synostosis formation is combined
with the elongation of a fibular fragment, can be categorized
as complicated reconstructive-recovery interventions. They
should be performed only by a specialist experienced in the
use of external fixation [180].
Further information on the use of transosseous osteosyn-
thesis for the treatment of long bone pseudoarthroses and Fig. 19.28 Tibiofibular synostosis (a) using a split-fragment and (b)
defects is provided in Chaps. 16 and 24. using a cylindrical fragment
Quite frequently in clinical practice, a patient presents
with a false joint or a defect or shortening of the femur or
tibia together with stiffness of the joints. Recommendations
for the treatment of this group of patients are given in the eliminated at the first stage by transosseous osteosynthesis
sections devoted to external fixation in cases of large-joint procedures. Then, in the second stage, locked intramedullary
pathologies. Here we conclude by commenting on the com- osteosynthesis or internal osteosynthesis is performed, and
bined and sequential use of external and internal fixation in the fixator is removed. In the English medical literature this
the treatment of patients with long bone defects. Lengthening is called lengthening and then nailing (LATN) and lengthen-
or filling of a bone defect should be performed “over a nail” ing and then plating (LATP).
for combined techniques. In a second stage, the nail is By reducing the amount of time required for external con-
locked and the fixator removed. These techniques are structions, the postoperative demands on the surgeon become
referred to in the relevant English literature as lengthening fewer. Moreover, patient comfort is improved and the risk of
over a nail (LON) and bone transport over a nail (BTON). infection complications and transfixation contractures is
As for the sequential use of external and internal fixation, much lower. More detailed information about this technique
all the existing components of deformity shortening are is given in Chap. 26.
Fig. 19.29 Replacement of a tibial defect with a fibular a b

fragment (fibula transport). In the transposition of the
fibula, wires of 1.5 mm diameter are used. To avoid
damage to the blood vessels and nerves, the transposition
rate should not exceed 0.25 mm 4–8 times a day (a). After
the fragment of the fibula has reached the necessary
position, open adaptation of its ends with the ends of the
tibia is performed and additional stabilizing wires are
inserted: wires (III,3-9) and (VI,3-9), as shown in (b). If
there are signs of inflammation around the wires used for
fragment transposition and/or pain is caused by the wires
cutting into a large amount of soft tissue, thus causing
movement restriction, these wires are replaced by wires
(III,4-10) and (VI,4-10) or half-pins (IV,1,70) and
(V,1,120)
1 2 3 7 8
(I,8-2)I,8-2; I,4-10; II,1,70 ←→ (III,7-1) –– (VI,7-1) ←→
¾ 150 150 150 (a)
6 4 5
←→ VII,1,120; (VIII,8-2)VIII,8-2; VIII,4-10
150
9 10
(I,8-2)I,8-2; I,4-10; II,1,70 →← (III,7-1); (III,3-9) –– (VI,7-1); (VI,3-9) →←
¾ 150 150 150
→← VII,1,120; (VIII,8-2)VIII,8-2; VIII,4-10 (b)

150
a b
c d
Fig. 19.30 (a–f) Filling of a 10-cm tibial defect by polylocal lengthen- Distraction was carried out for 121 days. Anatomic integrity of the leg
ing of the fragments towards each other using the fibula. Fibular tibial- bones with tibiofibular synostosis formation was restored by day 382 of
ization was performed by graduated traction using wires with curved fixation. Complete weight-bearing of the operated limb became possi-
stoppers. The zone of the tibial fragment junction was descended into ble 2 months after fixator removal
the fibular wedge-shaped distraction-regenerated bone being formed.

e f
Fig. 19.31 Reconstructive tibialization of the fibula (From [205])

a b c
d e f
Fig. 19.32 (a–f) Filling of a tibial defect by combining tibiofibular was achieved 2 years after removal of the fixator. The patient did not
synostosis with the formation of fibular split and cylindrical fragments. use additional means of support and immobilization during the long-
The duration of osteosynthesis was 314 days. Complete restoration of term observation period
lower limb weight-bearing with hypertrophy of the transposed fibula
19.5 Treatment of Congenital Tibial solved since congenital pseudoarthrosis refers to a severe,
Pseudoarthrosis Using the Ilizarov comparatively rare, pathology of the locomotor apparatus.
Method of Transosseous Osteosynthesis Congenital pseudoarthrosis accounts for between 0.37–
0.46% [327] and 0.5–1% [328] of all orthopedic diseases, with
Vladimir Ivanovich Shevtsov two-thirds of the cases occurring in boys and one-third in girls.
According to Andersen [329], the incidence of congenital
19.5.1 Introduction pseudoarthrosis is 1 in 140,000 newborns, making it 100 times
rarer than congenital dislocation of the femur.
Well over more than 100 years have passed since Peget The lower third of the tibia is involved in two-thirds of the
described a congenital tibial pseudoarthrosis, in 1891 [326]. cases. According to literature data, the bones of the left tibia
Nonetheless, the problem of its management is far from are affected in 95% of the cases. whereas in our patients the
right (72 patients) and left (65 patients) tibial bones are osteogenesis and bone growth reflect cellular deficiencies,
involved almost evenly. impaired structural and functional properties of the intercel-
In congenital pseudoarthrosis, conservative treatment lular matrix and fibrous structures, disorders in the matura-
fails completely and surgery is ineffective in 20–50% of the tion of collagenous fibrils and their mineralization, and the
cases. Consequently, many surgeons, after repeated opera- appearance of atypical fibrous shapes.
tive invasions in these patients, recommend tibial amputation Advocates of a virus-based pathogenesis of congenital
with follow-up treatment and therapy to cope with the subse- pseudoarthroses cite the vascular or inflammatory manifesta-
quent difficulties. The frequent negative results explains why tions during pregnancy as well as the toxic effect of
congenital pseudoarthrosis is referred to as “malignant non- medications.
union” and as a “rare disease of unknown etiology and vari-
able history.” However, relapse, while a well-recognized
phenomenon, diminishes with time and is rarely observed 19.5.3 Signs and Symptoms of Tibial
after puberty. According to Gracheva [330], of the 511 Congenital Pseudoarthroses
patients with congenital pseudoarthrosis who were treated
worldwide before 1972 there were 171 (33.4%) cases in Latent and acquired types of congenital pseudoarthroses can
which treatment was not successful. Blanth and Falliner col- be clinically defined. In the latent type, parents report symp-
lected data on 835 patients; the outcome was negative in 150 toms indicative of varus or tibial antecurvation within the
(18%) of them. first few days of their infant’s life. An arch-shaped deformity
in the lower tibia and a narrowed or obliterated canal are
observed radiologically. Often, bone cysts (cystic type) are
19.5.2 Etiology of Congenital Pseudoarthrosis found in the deformity area. The fracture can take place after
minimal trauma and very often without it. According to
The rarity of congenital pseudoarthrosis accounts for the fact international data, the fractures develop in 50% of these
that little is known about it, but also that few physicians have infants during their first year of life, in 25% during the sec-
sufficient experience to attempt an explanation at its etiology. ond year, and in the remainder within 8 years.
Still, several theories have been postulated. In this regard, the The clinical manifestations typical for congenital pseudoar-
most obvious fact, and one of the few that is unanimously throses are: pain, abnormal functional and dynamical limb load-
accepted, is the congenital nature of the disease. ing, pathological mobility between 5° and 40° at the
Many authors have linked the pathological fracture of the pseudoarthrosis site, deformity of 5–90° of the longitudinal axis
lower third and the nominal tendency to regeneration at the of the tibia, and lower leg shortening of 2–16 cm. In all such
fracture site with a congenital local imperfect osteogenesis. cases additional means of fixation and support will be required.
Support for this scenario comes from the experience that Symptoms are also seen in the joints, soft tissues, and
supramalleolar osteotomy of the tibia for foot valgus correc- skin. In the knee they include lateral flailing. anterior or pos-
tion results in union within the normal timeframe. terior “drawer,” and overextension (50% of the cases) while
A related theory invokes an intense biological periosteal in the ankle there is limitation of plantar flexion or ankylosis.
deficiency, resulting in a very poor potential for bone tissue In the foot there is typically a 2–6 cm shortening and a calca-
repair at the pseudoarthrosis site. Supporters of a traumatic neal deformity. Atrophy of the soft tissues by 3–8 cm in the
origin of congenital pseudoarthroses explain its development femur and 5–14 cm in the lower leg are present as well.
by the impact of an endogenous or exogenous trauma or the Interestingly, there are pigment spots of light brown or cream
constant traction of an amnion fused to the tibia. color (café au lait) on the skin (Fig. 19.33).
Some authors consider fibrous dysplasia—foci of which Radiological signs are as follows: deformity of the longi-
are observed in morphological studies of bones removed tudinal axis of the tibia, thin ends of the bone, with a conical
during surgery on patients with congenital pseudoarthrosis— or icicle shape, sclerosis of the fragment ends, and a vertical
to be the prime cause of the disease. According to estimates, position of the heel.
neurofibromatosis occurs in 1:3,000 infants with congenital Skin thermometry registers a decrease in temperature
pseudoarthrosis and bone injury in 50%, suggesting a rela- along the tibia and foot but an increase of 2–3° at the pseudo-
tionship between Recklinghausen’s neurofibromatosis and arthrosis level. Blood circulation is correspondingly affected,
congenital pseudoarthroses. The observed development of with an increase or decrease of the blood supply in the entire
local osteolysis, osteoporosis, and bone thinning in associa- segment, hypervascularity at the pseudoarthrosis site, lim-
tion with that of neurofibromatosis tissue in the walls of ited thrombosis in the anterior tibia, and arteriovenous
small arteries favors this theory. anastomoses.
Angiography studies have detected arteriovenous anasto- Electrophysiological studies have measured abnormalities
moses as evidence of vascular dysplasia, leading to chronic in the muscles, including a reduction of bioelectrical activity
hypoxia, abnormal acid-restorative processes. Pathological and electrical potential, disordered reciprocal relations of the
Fig. 19.33 Pigment (café au

lait) spots on the body of a
patient with congenital
pseudoarthrosis
antagonistic muscles, a decreased irritability of spinal cord in turn the need for an exact approach in selecting the most
motor neurons, and a disturbed inhibitory process that defines appropriate form of treatment.
the severity and likelihood of the pseudoarthrosis relapse.
19.5.5 Treatment of Congenital Pseudoarthrosis

19.5.4 Morphology and Biochemistry
A study of the literature on the treatment of congenital
Morphological studies have defined different degrees of bone pseudoarthrosis leaves one with an appreciation of the
tissue formation, including osteoclastic resorption, the for- enormous efforts of the surgeons and especially the toler-
mation of randomly located bone trabeculae, and fibrous ance but also the frustration of their patients and their fam-
changes in the medulla. In addition, there is dense fibrous ilies. When a patient with congenital pseudoarthrosis
connective tissue and foci of the fibrous cartilage are observed presents for the first time, the surgeon must crucially
in the inter-fragmental gap. Necrotic foci are seen as well. answer the question, “At what age should treatment
Also at the inter-fragmental gap, bundles of small arteries start?”
and veins with thickened muscular walls occur at the Early treatment, i.e., already on the maternity ward or
periphery. soon after the child starts walking, is advocated by some. For
With the aid of ultra-microscopy studies, thin cytoplasmic instance, Guilliminet [331] recommended that treatment
processes and rare organelles have been identified in fibroblasts. begin at the stage of early congenital curvatures, but to avoid
The cells’ biosynthetic apparatus, namely, the granular endo- osteoclasia or osteotomy. Henderson, already in 1928 [332],
plasmic reticulum, is poorly developed or is not defined. There felt that the younger the patient the worse the chances for
is poor secretory activity by chondrocytes, with atypical nuclei, treatment success. He advised against operating on children
but also functionally active chondrocytes. Among collagenous under the age of 6 years and preferred to do so after they
structures, thin or atypical fibrils are seen. reached puberty.
The above-described changes are further supported by In a comparative analysis of treatment results in tibial
biochemical data, including a low calcium and phosphorus pseudoarthrosis, Joseph et al. [quote (cite) 333] examined two
content and abnormally high non-organic phosphate levels, groups of children, age until 3 years and between the ages of
thus preventing calcification of the organic matrix since col- 3 and 12 years. In the first group, consolidation was achieved
lagen is not a catalytic agent for mineralization. in 12 of the 13 children, in the second group in 5 of 7.
Taken together, the clinical, radiological, and laboratory The failures of these earlier conservative and operative
data reflect the profound changes in all areas of the body and treatments of congenital pseudoarthrosis emphasized the
bone deficiency in this pathology and the necessity of a new In attempts to overcome the obstacles hindering fragment
form of bone plastics. In response, auto-bone was one of the consolidation and preventing their assuming the proper posi-
newly developed construction materials and together with tion, together with the impossibility to achieve the necessary
allo-bone was referred to as a fragments fixator. fixation, surgeons attempted to use osteosynthesis with
Supporters of the early treatment of latent type disease metal. Indeed, many authors recommend trans-articular oste-
developed techniques of operative interventions aimed at osynthesis for very short and osteoporotic distal fragments.
achieving bone shaft thickening from the concave side, cor- An analysis of the results of the different techniques
rection of the curvature, and the prevention of pathological makes clear that they are associated with a significant num-
fracture. The technique described by Andrianov and Pozdeev ber of complications. Andersen [337] evaluated the manage-
[429] is an example. In this case, the periosteum is exfoliated ment of 36 patients, including 34 operated on from one to
along the entire tibia from two incisions using a special ten times. Multi-factorial analysis by the author showed that
grooved raspatory. Then demineralized allografts with no one operation among the 45 carried out in children age
lengths equal to that of the pathologically changed bone and 36–40 months led to consolidation of the pseudoarthrosis.
a volume fulfilling the needs for bone thickening are inserted In patients who were operated on from one to three times,
into the sub-periosteum canal from the lower incision. union was achieved in three pseudoarthroses but there were
Fixation with a plaster cast is carried out for 1 month. Six eight amputations. In patients operated on from four to six
months later, thickening of the bone, widening of the medul- times, there were eight unions and three amputations, while
lary canal, and correction of the longitudinal axis of tibia are in the group of patients operated on from seven to nine
observed. times there were five consolidated pseudoarthroses and two
In Wilson’s technique fibular transport was carried out in amputations.
a split stage-by-stage approach. Union of the proximal fibular These regrettable statistics are cautionary in two ways: (1)
fragment was followed by that of the distal one. In the sec- amputation may in many patients be premature since con-
ond stage of treatment of pseudoarthroses of both tibial solidation may finally be achieved after numerous surgeries.
bones, the sharp distal end of the proximal fibular fragment (2) Children operated on at an early age seem to have a higher
was inserted into the split formed at the upper end of the incidence of negative outcome.
distal tibial fragment. Microsurgery technique, using a free bone graft from
McFarland used a bypassing graft from the intact tibial the fibula and performing microvascular anastomosis, was
bone, fixing it to the affected tibial metaphyses on the con- another strategy. But according to Gilbert Hagan and
cave side. The structure functioned as a cross-bar such that Buncke [338], as well as Murray and Lovell [339], these
loading was transferred onto the graft in order to prevent operations required prolonged anesthesia and failed to
constantly aggravation of the antecurvation deformity. There eliminate the pathological symptoms complex of a short
was no invasion into the site of the pseudoarthrosis. and deformed leg. Moreover, the incidence of amputations
So-called delayed autografts, elaborated to improve the was 40–46%.
results of auto-plastic operations, showed high potential in More recently, several authors [340] have taken advan-
terms of healing. Treatment was carried out as follows: tage of the progress made in modern biological science in
2–3 weeks prior to pseudoarthrosis surgery, the auto-graft developing new approaches to the treatment of congenital
was taken from the tibia or iliac crest and implanted under pseudoarthrosis, in particular the use of osteal morphoge-
the femoral skin of the involved leg. After a 2-week waiting netic protein 7.
period, the pseudoarthrosis site was opened, the fragment Other authors for the purpose of bone formation stimula-
ends resected and the auto-graft placed in the inter-frag- tion in a zone pseudothrose applied an impulsive electro-
mental space. Plaster cast fixation lasted 8–10 months. magnetic field in a combination to osteal transplantation Ito
The accumulated experience of auto-graft usage indicated et al. pulsed ultrasound low intensity (LIPUS) Okada et al.
the difficulty in obtaining a sufficient quantity of auto-bone [341], high-energy shock wave Schatz [342]. However, at
in children, Therefore, parents and siblings became fre- least according to my own rather short analysis of the litera-
quently directly involved in the treatment process [334–336]. ture, the use of these techniques does not allow pseudoar-
In most cases, implants were taken from mothers since they throses healing to be combined with limb lengthening. Thus,
were more readily willing to undergo an operation to help the additional techniques of shortening or growth arrest of the
child. Nonetheless, the experience gained over time indicated intact bone are needed. Clearly, for many decades both sci-
that auto- and especially allografts from relatives did not entists and surgeons have focused their efforts on one aim in
meet expectations. Adding in the moral and psychological patients with congenital pseudoarthroses, to achieve consoli-
aspects of the problem lead one to conclude that this method dation, but they have failed to pay proper attention to the
even had a negative effect on further applications of bone correction of the accompanying deformity nor are they able
grafting. to settle the problem of shortening compensation.
Fig. 19.34 The surgical scheme

to achieve duplication of the
fragment ends with simultaneous
tibial elongation
Here too, transosseous osteosynthesis using the method Accordingly, different techniques to improve mechanical
of Ilizarov has found application, providing the optimum durability are currently under study.
mechanical and biological conditions for regeneration and Congenital pseudoarthroses account for 11.5% of the
bone formation processes in patients with congenital pseudo- patients with pseudoarthroses of the long bones. We have
arthroses. Moreover, these patients may be particularly suited treated 137 patients with congenital pseudoarthrosis of the
to this form of treatment because of the findings of bone atro- tibia. Specifically, the right tibia was affected in 72 patients
phy, osteoporosis, and thinning of the extremities of the bone (52.6%), and the left one in 65 patients (48.4%), Children
fragments. Given this chain of events, the fragile bone is between the ages of 4 and 18 accounted for 77.3% (106
unable to maintain the static-dynamic loads imposed on the patients) of the series. The incidence of congenital pseudoar-
extremities. throses was almost even in males and females.
Congenital pseudoarthrosis of the tibia was treated using It should be noted that increasing the mechanical strength
the Ilizarov method by Thabet et al. who employed a combi- of a bone union by augmentation of the bone mass is indi-
nation of periosteal and bone transplantation, intraosseous cated for patients with long thin and icicle-shaped fragment
osteosynthesis, a nail, and fixation with an Ilizarov appara- ends. Lengthening of one fragment using distractional epi-
tus, reporting this approach as an effective variant of physiolysis in children or partial corticotomy in adults is per-
treatment. formed. The appropriate segment can be lengthened for the
El-Gammal et al. [343], Alexandrov et al. [344], and required amount together with the restoration of bone
Mateev et al. [345] used a vascularized fibular graft and integrity.
Ilizarov distraction to correct a shortening and to treat a
non-union in a pseudoarthrosis zone. The combination of 19.5.5.1 Clinical Example
a free vascularized fibular graft and Ilizarov apparatus Patient K., 7 years old, was diagnosed with congenital
was also used by Toh et al., Cho et al. [346], Pozdeev pseudoarthroses of both tibia between the middle and lower
[347], Orlovskij [348], Sakamoto et al., and Mateev and thirds, varus/antecurvation deformity of 170°/140° and a
Imanaliev [345]. 6-cm tibial shortening (Fig. 19.35). Considerable thinning of
To increase the efficiency of congenital pseudoarthroses both proximal and distal fragments ends was observed on the
treatment, Shevtsov et al. [315] developed the concept of X-ray images. Osteosynthesis was performed using a three-
augmentation of the osseal mass in the zone of a pseudoar- ring Ilizarov frame to achieve lengthening by distractional
throsis but without transplantation. The goal is to increase epiphysiolysis and further overlapping of the fragment ends
the mechanical durability of the bone such that it acquires to increase bone mass as well as the mechanical strength of
the static-dynamic load capability of a normal extremity. the docking site (Fig. 19.34). The roentgenogram acquired at
a b
c d
Fig. 19.35 Roentgenograms of the tibia of patient К. (a) Before treat- (d) Insertion wires through the ends of the fragments (left). After that
ment; (b) after wire insertion through the epiphysis, for elongation by wire stoppers were formed. It allows pulling together the ends of bone
distraction epiphysiolysis; (c) duplication of the fragment ends. fragments (right)
the operating table confirmed the insertion of two wires wires and docking of the lateral surfaces of the fragments
through the epiphysis (Fig. 19.35b). resulted in their tight contact. Another image was obtained at
Seven days after osteosynthesis (Fig. 19.35b, c), epiphys- 30 days of distraction (Fig. 19.35d).
iolysis of the proximal tibial growth plate was obtained. The As seen in Fig. 19.36a, b, the length was compensated
first 20 days of distraction were intended for the creation of completely. Distraction took 55 days, followed by fixation
overlapping fragments. After a 3-cm duplication (Fig. 19.35c), for 132 days. On the left, the X-ray image shows frame
two wires were driven through the fragments ends. An X-ray removal and tibial fixation with the cast at 3 months and then
image (Fig. 19.35d) of the right side showed that the twisted follow-up at 3 months, 2 years, and 3 years.
a b c
d e f
Fig. 19.36 (a, b) The patient during treatment; (c) X-ray image after removal of the apparatus, followed by fixation using a plaster bandage;
(d) result at 3 months after apparatus removal; (e, f) at 2 and 3 years after treatment
If there is thinning throughout one fragment but a sufficient thus blocks a zone of the joint in the form of a ponticulus
thickness of the opposite fragment then overlapping of the (Fig. 19.37).
bone fragments can be accomplished by creating a trailer
fragment from one of them. In this method, after duplication 19.5.5.2 Clinical Example
of the ends, osteotomy thinning of the end of a sclerotic zone Patient T., 10 years old, was diagnosed with a congenital
is performed. The subsequent repositioning results in apposi- pseudoarthrosis of the left tibia, genu valgus, and 8 cm tibial
tion of the fragment ends. Longitudinal compression of the shortening (Fig. 19.38a). A significant width discrepancy
end of one fragment drives it into the spongiform tissue of was observed on the original X-ray image (Fig. 19.38b). The
the other. The cut end fragment is displaced sideways and proximal fragment was thin along its length and the distal
Fig. 19.37 Operative scheme for overlapping by the cut fragment (According to the method of Shevtsov and Maer)
one short and thick. During surgery, two distraction and occurred. After a closed osteosynthesis, consolidation with
crossing wires were driven through the proximal fragment to the correct axis was obtained, but after 1 year it relapsed
achieve epiphysiolysis. (Fig. 19.40a, b).
Figure 19.38c is the X-ray image obtained after 150 days As regeneration in the contact zone of the fragments was
of osteosynthesis. Overlapping of the fragments was per- completely absent, a longitudinal osteotomy of the fragment
formed at the docking site to increase the biomechanical ends was performed to allow their mutual immersion as well
strength but a tight contact of the lateral surfaces was not pos- as a larger zone of contact and augmentations of the osteal
sible due to the width discrepancy (Fig. 19.38c). This difficulty mass in the pseudoarthrosis zone (Fig. 19.40c). At 6 months,
gave rise to an alternative plan: to cut the distal end of the osteotomy in the top third was performed for segment length
proximal fragment (Fig. 19.38d), perform the reduction with restoration (Fig. 19.40d, e). Four months later, the distraction
the goal of achieving fragment contact, and drive the end of was complete, with removal of the apparatus after another
the distal fragment into the spongy tissue of the proximal one 6 months (Fig. 19.40f). Follow-up at 9 months and 10 years
(Fig. 19.38e). The cut fragment overlapped the docking site in (Fig. 19.40g) showed that the achieved position had remained
the shape of a bridge. The pseudoarthrosis subsequently stable.
healed with an increase in bone mass as well (Fig. 19.38f, g). In pseudoarthroses with thinning fragment ends without
In a segment of relatively normal length and moderately segment shortening it is possible to use an overlap technique
thin ends, consolidation can be improved and the bone thick- involving splinting of the cortical plate, with the splint
ened by driving the split fragments into each other obtained from the longer fragment. Splinting of the cortical
(Fig. 19.39). According to this technique, after exposure of plate by means of a wire with a stopper allows it to move
the fragments ends they are cut longitudinally for 3–4 cm before overlap in the pseudoarthrosis zone is achieved
depth using a chisel. The obtained sides are bent and the (Fig. 19.41). For more dense contact reduced splint the corti-
fragments are driven into each other. cal plate with fragments through it wire with stopper fol-
lowed by side-to-side compression, as shown below in the
19.5.5.3 Clinical Example clinical examples is carried out are perpendicularly spent.
K., 18 years old, was diagnose at the age of 6 years. At
age 8 years, osteosynthesis using the Ilizarov frame was 19.5.5.4 Clinical Example
performed and consolidation with valgus- antecurvation Patient D., 5 years old, was diagnosed with congenital
deformity was achieved. However, 3 years later a relapse pseudoarthrosis of both bones of the left tibia, a 160°
antecurvation deformity, 4 cm shortening, and a heel defor- of tibial lengthening and thickening at the docking site was
mity (Fig. 19.42). Thin ends of the fragments were observed achieved (Fig. 19.42c, d). The heel deformity was corrected.
on the X-ray taken before treatment. The total duration of treatment was 150 days. The residual
A split cortical plate was transported downwards using a antecurvation deformity corrected itself, in part due to the
distraction-guiding wire to achieve overlap, as confirmed on corrected position of the calcaneous.
X-ray images obtained after the operation, at different stages The application of these techniques improves the
of distraction, and at the end of fixation. The required amount mechanical strength of the bone by increasing the mass in
a b c
d e f
Fig. 19.38 (a, b) The patient and a roentgenogram made before treatment; (e) overlapping a zone of a contact of bone fragments; (f) after
ment; (c) roentgenogram obtained during elongation and duplication of removal of the apparatus
the fragment ends; (d) after cutting the distal end of the proximal frag-
g Moreover, despite pseudoarthrosis consolidation the

problem is by no means settled, as the final outcome mostly
depends on the accompanying foot deformity, where relapse
or refracture of the tibia cannot be ruled out. That is why we
pay close attention to the condition of the foot, with obliga-
tory correction of the deformity.
Pes calcaneus is a common deformity that can be cor-
rected using a closed method, with the creation of tension
stress inside the part of the frame applied to the foot. A pro-
nounced deformity of the foot when the calcaneal axis coin-
cides with the longitudinal axis of the tibia is an indication
for calcaneal osteotomy and further gradual correction of its
position.
19.5.6 Complications
The errors and complications observed during treatment of

the above-described patients were organizational, technical,
tactical, and general surgical ones.
Organizational mistakes include improper patient prepa-
ration for the expected treatment, incomplete instructions
Fig. 19.38 (continued) (g) 6 and 10 months after frame removal
prior to surgery, and maladjustments during treatment, such
as irregular control of the dressings, non-observance of the
the pathological area, in turn stimulating early functional dates of X-ray control, and insufficient functional weight-
reconstruction of the bone and thus patient recovery. The bearing during treatment.
improved strength has obviated the need for additional Technical errors are caused by lack of adherence to the
immobilization using a cast in the majority of patients (31) operation’s requirements, inappropriate frame assembly such
treated in this manner. However, in 14 patients with marked that it does not correspond to the treatment tasks, violation
osteoporosis a cast was applied for 3–4 months. (increase) of the rate and rhythm of distraction and deformity
Fig. 19.39 The split ends of

the bone fragments are driven
into each other (According to
the method of Shevtsov and
Shestakov)
a b c
d e f
Fig. 19.40 (a, b) The patient and a roentgenogram of the tibial bone for elongation; e fixation; (f, g) roentgenograms after removal of the
before treatment; (c) after longitudinal splitting of the fragments and apparatus at 9 months and 10 years of follow-up
their mutual immersion; (d) osteotomy at the proximal metadiaphysis

g
Fig. 19.41 Overlapping of a

zone of contact between
fragments using a slipping
fragment (According to
Ilizarov)
correction, and removal of the distraction-guiding wires from especially common. In the above series, it occurred in 42%
the splints. (57) of the patients but was successfully treated with local
Tactical errors include the wrong indication for the injections of antibiotics in 46 patients. Removal of one or
selected osteosynthesis technique, improper osteosynthesis, more wires was necessary in the remaining 11 patients.
and distorted centering of the frame, which can lead to the Secondary healing of the post-operative wound was observed
secondary translation of the bone fragments. in 8 patients (5.8%), most likely caused by local circulation
There is a much wider spectrum of general surgical disorders and rough manipulations during operative inter-
complication, but pin-tract infection of the soft tissues is vention, which resulted in extensive scarring of the skin.
a b c
d e
Fig. 19.42 (a, b) Photo of the patient and a roentgenogram before treatment; (c, d) roentgenograms after the operation (c) and before removal of
the apparatus; (d) the patient during treatment; (e) the patient after removal of the apparatus
Fig. 19.42 (continued) (f) roentgenograms at 3 and 6 months after removal of the apparatus
Soft-tissue swelling differing in severity was observed in We can claim, however, that in the entire time of treating
practically all patients during lengthening. We recommend patients with congenital pseudoarthrosis we have never
active and passive exercises of the adjacent joints, soft-tissue amputated a limb. We consider this to be the greatest achieve-
massages, and physiotherapy to reduce the volume. Eczematous ment of our techniques, and the basis of their advantage over
changes of the skin and marked swelling were observed in two all other existing ones.
patients during treatment and took 3–6 months to eliminate after
frame removal. These changes were likely related to metallosis
in these patients as a reaction to the chronic presence of metal. 19.5.7 Results of Treatment
The number of pseudoarthrosis recurrences is the most
challenging problem. Our statistics cover more than three From among our patients, 34 (24.8%) underwent treatment
decades of congenital pseudoarthrosis management. Initially, using closed methods following the use of compression, dis-
recurrence was not less than 50%. With improved techniques traction, or compression-distraction osteosynthesis. In
and new approaches that increased the mechanical strength at 103 (75.2%) patients techniques to improve the mechanical
the docking site, the rate fell to 25–30%, but we have as yet rigidity of docking site. Duplication of the ends of bone frag-
been unable to completely avoid recurrences. Interestingly, ments were used in 32 patients, different methods of overlap-
recurrence is more likely in patients with blue sclera and a large ping docking site by cut off fragment were done in 23 cases.
number of café au lait pigment spots on the skin. Moreover, it Mutual immersion of longitudinally splinted ends of bone
may well be the case that these are not relapses but the develop- fragments used in 33 cases, transporting a fibular split bone
ment of a fracture above or below the former pseudoarthrosis. for overlapping of pseudoarthrosis - in 4 patients, and the
In these patients, repeated osteosynthesis is indicated. combination of methods - in 13 patients.
In the process of pseudoarthroses treatment, 68 (49.6%) increased mechanical durability at the bone fragments’ dock-
patients underwent tibial elongation of 3–16 cm. Contractures ing site; restoration of segment length with elimination of a
of the knee and ankle joints were eliminated in 42 (30,6%) deformity of the longitudinal axis and the correction of
patients, foot elongation of 2–6 cm was performed in 14 abnormalities extending to the foot, as well as restoration of,
patients; and 42 (30.6%) patients could be treated in one stage. e.g., a tibiofibular syndesmosis. All of these biomechanically
It must be emphasized that at treatment of patients using promote the conservation of the static-dynamic function of
method of transosseous osteosynthesis according to Ilizarov, an extremity, while accelerating functional reorganization of
it is necessary to use principle of complex and, if it is possi- the bones and reducing the rehabilitation period.
ble, - one-stage restoration of anatomy and function of dam-
aged extremity. The procedures described herein are guided Note After the title of this chapter, all Authors, who have contributed
by complex principles; consolidation of the fragment ends to the chapter, are listed. The specific authorship of the individual para-
with simultaneous augmentation of the osteal substance and graphs is given after each section title.
Combined Strained Fixation
of the Long Bones 20
Combined strained fixation (CSF) is a variant of combined 7. Gradual tensioning of the axial compression wires in the
external fixation (CEF) (Figs. 20.1, 20.2, 20.3, 20.4, 20.5, transosseous module
20.6, 20.7, 20.8, 20.9, 20.10, 20.11, 20.12, 20.13, 20.14, 8. Implementation of the postoperative protocol
20.15, 20.16, 20.17, 20.18, 20.19, 20.20, 20.21, 20.22, 20.23, CSF is used to create a stop between the bone fragments
20.24, 20.25, 20.26, 20.27, 20.28, 20.29, 20.30, 20.31, 20.32, in cases of diaphyseal and metadiaphyseal fractures, slowly
and 20.33). In CSF, the fragments of the long bones are fixed joining fractures, false joints. It is also used for correcting
intraosseously by inserted thin fasteners (wire or wires), one
end of which is fixed to one of the fragments externally and
extra-articularly, while the other, under a controlled force, is
tensioned in the transosseous module mounted on another
bone fragment. Each compression wire during its insertion
and exit from the medullary cavity perforates one compact
layer at a site where the soft tissue volume is less and there
are no major neurovascular formations (Fig. 20.1).
The method is a combination of intramedullary compres-
sion and transosseous fixation. The term “strained” is used to
emphasize the dynamic nature of the compression forces
applied at the junction of the fragments. The effect is achieved
both by special devices for tensioning the axial compression
wires (calibrated springs, for example) and by elastic defor-
mation of the basic transosseous elements.
The general provisions of the CSF method are:
1. Identification of the indications and basic equipment for
the procedure
2. Preoperative preparation, including choice of both the
angle and the level of the axial compression wires in the
medullary cavity
3. Insertion of the axial compression wires in the medullary
canal
4. Insertion of the axial compression wires through both
fragments
5. Release of the axial compression wires from the medul-
lary cavity and their external fixation
6. Mounting of the transosseous module
Fig. 20.1 Combined strained fixation (CSF) of the femur. The

L.N. Solomin, M.D., Ph.D. intramedullary wires are axial compression wires. Their name empha-
R.R. Vreden Russian Research Institute of Traumatology sizes the biomechanical principle underlying this type of fixation. The
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia transosseous elements of the module for axial compression wire ten-
e-mail: solomin.leonid@gmail.com sioning are basic transosseous elements
896 L.N. Solomin
osteotomies and in the replacement of segmental bone defects compression wire results in a characteristic three-point
with osteoplasty material. Details of the indications are given single-plane deformity that we refer to as a “transient” or
in the following sections, dealing with CSF of the humerus, “mounting” deformity (Fig. 20.2).
femur, and the bones of the forearm and lower leg. The particular features of the axial compression wire
Contraindications to CSF are identical to those for CEF deformity in the medullary cavity create the need to
(Chap. 1.2). The other, specific contraindications are: individualize the parameters of wire insertion for every
1. Growth zones at sites where axial compression wires will situation. This is achieved by means of a special device
transit (Figs. 20.3 and 20.4).
2. Narrow medullary canal (<4 mm) To insert an axial compression wire in the medullary cav-
3. Marked osteoporosis with the risk of perforating the med- ity quickly and with minimal trauma (Fig. 20.7), the conduc-
ullary cavity wall with an axial compression wire in an tor (Figs. 20.5, 20.8, and 20.9) and special reamer (Fig. 20.6)
unplanned place are applied carefully at the calculated angle.
20.1 Equipment for CSF and Principles α

of Its Application a
In addition to the standard equipment for external fixation
described in Chap. 1.3, CSF requires the following special β
α<β
devices:
1. A device to determine the angle and level of insertion of a
a<b
the axial compression wires in the long bone
(Fig. 20.3) β
2. A conductor for the insertion of the axial compression

wires in the medullary cavity (Fig. 20.5) b
3. Wire reamers (Fig. 20.6)
4. Axial compression wires with stops (Fig. 20.7)
5. A conductor for the wire stops (Fig. 20.11) Fig. 20.2 Dependence of the intransosseous transit distance of the
6. External supports (Figs. 20.19 and 20.29). axial compression wire on both the wire insertion angle and the diam-
eter of the medullary cavity. It has been experimentally established that
These devices are described below, together with a dis-
the distance from the insertion point to the exit point of the axial com-
cussion and examples of their purpose and principles of use. pression wire depends on the properties of the wire (diameter,
A major component of CSF is the insertion of axial com- flexibility), its angle and level of insertion, and the diameter and shape
pression wires. When inserted at an acute angle into the med- of the medullary cavity. In particular, the narrower the internal diameter
of the bone and the larger the wire insertion angle, the shorter the dis-
ullary cavity, the wire reaches the opposite cortical plate,
tance from insertion point to the exit point. The specific features of
slides down it for some distance, and then returns to the axial compression wire insertion into the medullary cavity of the fore-
insertion side declining during its passage. Thus, the axial arm are shown in Fig. 20.17
Fig. 20.3 Device to determine the angle and level of

insertion of a flexible wire into a long bone. The device
enables experimental determination of the parameters for
axial compression wire insertion in the individual patient. It
consists of a rectangular elastic plate 1 with five holes on
each long side, The threaded rods 2 inserted into the plate are
equipped with domed nuts 3 on both sides of the plate 1. The
ends of the threaded rods are inserted into the holes of the
adjacent elastic plates 4, one on each side. The elastic plates
4 are fixed on the threaded rods in a manner similar to that of
plate 1 by means of domed nuts 3. The ends of the threaded
rods are secured by rigid strips 5 forming the top and bottom
of the device. A sliding bar with slots on its outer ends 6 can
be moved along the plate 4 in both directions. On one side of
the sliding bar 6, a guide tube 7 is fixed via a hinge, with a
calibrated screw 6 mounted so as to allow adjustment of the
angle of tilt of the tube
20 Combined Strained Fixation of the Long Bones 897
45º
30º 2 40º
6 5 4 35º
35º
40º
7
1
3
Fig. 20.5 The guide used to insert an axial compression wire into the
medullary cavity consists of two rigidly connected tubes 1 with diam-
eters of 1.7 and 3.5 mm. The inserted end of the guide is cut off at an
angle of 25°. A tubular fixator 2 with an inserted calibrated wire 3 is
rigidly connected to the opposite end of the guide at an angle of 60°.
Marks on the wire show the angle of the tubes. A strip 5 is connected to
the non-inserted end of the tubes and in the same plane at an angle of
30° by means of a threaded connection. A second tubular fixator 6 with
an inserted calibrated wire 7 is rigidly connected to the free end of strip
5 at an angle of 90°
progressively inserted by hammer taps to the pliers (Fig. 20.10).

If the wire is being inserted correctly there is insignificant
resistance to its passage. As the wire is further inserted, the
pliers are moved, keeping the wire at an angle of 5–10° larger
than the angle of the canal in the cortical plate. When the wire
enters the metaphyseal part of the bone, some resistance to its
passage can be felt. To avoid deformation of the wire, strict
control of the insertion force is necessary. The force required
Fig. 20.4 Determination of the parameters for axial compression wire to insert the wire increases as the angle of insertion increases
insertion. To allow for any apparent increase in the diameter of the med- and the diameter of the medullary cavity decreases.
ullary cavity on the radiograph, a scale marker (for example, a metal
In addition to the above considerations, there are also
ball 10 mm in diameter) should be visible on the radiograph. The
required radiography plane depends on the plane of insertion of the specific recommendations for the insertion of axial compres-
axial compression wire. A skiagram is made, reconstructing the actual sion wires:
dimensions of the medullary cavity. To identify the angle and level of • The skill needed to control the force applied in the inser-
insertion of the wire into the medullary cavity, the device is placed with
tion of the wire into the medullary cavity can be acquired
its lateral side on the skiagram. By bending the elastic plates, the curva-
ture of the cortical layers of the bone is simulated and the plates are by practicing on osteosynthesis models.
stabilized using the nuts. Then, by changing the angle and moving the • The wider the medullary cavity and the more marked
sliding bar, the necessary trajectory of the wire in the simulated medul- the osteoporosis, the flatter the angle of wire insertion
lary cavity is empirically determined, i.e., the trajectory that would
should be.
ensure the planned level of insertion of the axial compression wire
going beyond its limits during surgery • In the presence of osteosclerosis, perforation of the corti-
cal plate is achieved using a wire of larger diameter.
• In the presence of false joints, the canal of the medullary
cavity should be restored before wire insertion is attempted.
Before insertion into the conductor, the end of the axial • If one has not fully mastered the technique of CSF, radio-
compression wire that is to be inserted is bent at an angle of graphic monitoring (fluoroscopy) should be used at all
170–175° for a distance of 2–3 mm and an opposite bend in stages of wire insertion.
the same plane is made at the other end. The wire is inserted With proper insertion, the axial compression wire perfo-
until it rests against the opposite cortical plane. It is then rates the cortical plate in the metaphyseal area and becomes
grasped with flat-nosed pliers 3–5 cm from the conductor and accessible to palpation. A 10-mm incision is made in this
898 L.N. Solomin
Fig. 20.6 Wire reamers 3 mm in diameter and 20 cm long are used to screwed are screwed onto the end, at a specified distance from the outer
form a channel in the cortical plate for the insertion of the axial com- end of the conductor. These serve as a stop preventing further insertion
pression wire. Their specific feature is the threaded end. Two nuts of the reamer
30º
Fig. 20.7 For CSF of the clavicle, humerus, and ulna, axial compres-
sion wires 2 mm in diameter and 40 cm long are used. For osteosynthe-
sis of the femur and tibia axial compression, wires 2.5 mm in diameter
and 5.5 cm long are used. The inserted end of the wires is fitted with a
metric thread 5 mm long, with threaded stops screwed onto it. To avoid
over-twisting the wires when they are unscrewed, the stops for wire
fixation of the humerus and femur are provided with slots. For the same
reason, their threaded channel is positioned eccentrically (a). For osteo-
synthesis of the clavicle, ulna, and tibia, the stops for the axial compres-
sion wires must have a shearing angle of 25–30° (b). The use of threaded Fig. 20.8 Insertion of an axial compression wire into the medullary
stops facilitates removal of the wires if inflammation occurs at their exit cavity. Convenient bone landmarks (greater trochanter, epicondyles,
point, in which case the wire is screwed out of the stopper etc.) are used to locate the bone level identified experimentally. Then, a
guide with a wire preliminarily inserted in its 1.7-mm tube is inserted
through a skin puncture, making sure that the inserted end of the con-
area and the wire is withdrawn by punching. A conductor
ductor is placed exactly in the middle of the plane formed by the center
for a wire with a stop is inserted in the incision as far as the of the medullary cavity’s diameter. The conductor is inserted at an angle
bone (Fig. 20.11), the stop is screwed onto the wire and by of 40–45° to the long axis of the bone and a wire is inserted through the
pulling at the free end the stop is inserted as far as the bone. adjacent cortical plate by means of a drill, thus fixing the conductor. In
the tubular fixator, the controlling (calibrated) wire is fixed at the level
The incision is closed with one or two stitches.
of the mark designating installation of the conductor at the necessary
Assembly of the transosseous module for tensioning of angle. The reamer is inserted into the bone, into the second guiding tube
the compression wires is specific for every segment but is of the conductor as far as it will go, and the nuts at the end are screwed
subject to the general rule: deformational forces are most to a distance from the edge of the conductor equal to the thickness of
the cortical plate. Together with rotation of the reamer, the device is
effectively resisted by the tensioning of compression wires
smoothly lowered until the controlling wire meets the bone. Next, an
of minimum size. Special devices are used to monitor and adjacent cortical plate is perforated. The reamer nuts resting against the
regulate the tension in the wires, for example, distraction edge of the conductor restrict the drilling depth, thus preventing drilling
clips and calibrated springs. After wire tensioning, the con- into the opposite cortical tissue
dition of the soft tissues is examined: skin tension must be
eliminated by means of small incisions at the exit points of wires is maintained by tightening the nuts on the distraction
the transosseous elements and axial compression wires. In clip by an average 1 mm every 10 days, if measuring devices
the postoperative period, the tension of the axial compression are not available.
25º
Fig. 20.11 The conductor for the wires with stops can be a standard
nanoscope with a half-thinned and cone-shaped working forceps
Fig. 20.9 Insertion of an axial compression wire into the medullary

cavity of the forearm bones. If the wire is inserted near a joint, in the
direction opposite to it, a screw post is used. The difference in the con- 20.2 Humerus
ductor use is that the controlling calibrated wire is immediately installed
with a rest against the bone. The angle of the conductor’s installation is CSF is used when it is possible to ensure an end stop at the
reduced until the control mark appears at the tubular fixator of the post. junction of the bone fragments. Thus, the indications for the
The reamer is removed
use of CSF in cases of injury to the humerus and forearm are:
1. Transverse and short oblique fractures of the proximal
humerus and the upper third of its diaphysis (injuries
11-A2, 11-A3, 12-A3.1, according to the AO/ASIF
classification)
2. Slow-setting fractures and non-unions at the above-
mentioned locations with a transverse line of injury or a
line close to it and preservation of the coaxiality of the
bone fragments or the possibility of its restoration in a
single step
3. Traumatic dislocations provided they can be reduced in a
single step before fixation
4. Segmental defects (including joint defects) of the humerus
(for transplant fixation)
Note: Axial compression wires should not be inserted
through growth zones.
Fig. 20.10 The axial compression wire is inserted into the medullary
cavity using a “punching” technique. A drill should not be used as it In humeral fixation, the compression wires are inserted
will cause mixing of the medullary cavity and breakdown of the wire from the external aspect of the shoulder, guided by a frontal
900 L.N. Solomin
a b slightly more distally, to account for the thickness of the soft

tissues (Figs. 20.5 and 20.8). The reamer is temporarily
inserted in the humeral head and used as a lever. Then, using
a minimum approach, closed or open reduction of the bone
fragments is performed and they are fixed by two wires. The
quality of the reduction and orientation of the axial compres-
sion wires in the medullary cavity are determined from com-
parison radiographs.
To avoid insertion of the wire through the acromial pro-
cess of the scapula, the shoulder is maximally adducted. The
axial compression wire is then inserted by punching through
the central fragment, its exit oriented by means of controlled
counter-flexure of the external aspect of the segment. If the
comparison radiograph shows that the wire is apparently
emerging more medially (inserted through the acromial pro-
cess), bending of the guiding end of the wire is increased by
5°, the guiding end of the wire is pulled back by pulling (not
rotating!) at the opposite end of the wire as far as the fracture
level, and the wire is again withdrawn by punching. If the
wire is withdrawn more laterally than the designated zone
(past the fracture line), bending of the guide end of the wire
is decreased.
The stop is screwed onto the central end of the axial com-
pression wire (Fig. 20.7). The skin is dissected away with a
scalpel according to the size of the stop and a canal is formed
Fig. 20.12 (a, b) CSF of fractures, non-unions, and defects of the in the soft tissue with a clip. The stop is then driven as far as
humerus. Variant (a) is preferable: (1) if no marked osteoporosis is the bone by pulling at the opposite end of the wire. To reduce
present; (2) when the soft-tissue thickness at which the console length trauma to the soft issues, a guide for wires with stops is used
(the distance from the level of the half-pin closing in the bone to the
(Fig. 20.12). The skin is closed with a suture.
tensioning node of the axial compression wire) does not exceed
60–70 mm; and (3) if the diameter of the bone at the level of half-pin A transosseous module is then mounted for tensioning of
insertion is at least 30 mm the axial compression wire. The 5-mm half-pin VI, 8,120 is
inserted into the humerus and a connection plate bent in the
radiograph. After determination of the contour of the internal plane is fixed to the external end of the half-pin. The axial
cortical plate and the size and shape of the medullary cavity, compression wire is tensioned in the connection plate with
the shape of the wire is modeled with the plates of the device the help of a distraction clip (with a force of 245–294 N; in a
shown in Figs. 20.3 and 20.4. The optimal angle of wire inser- 12-A3.1, with a force of 294–343 N), compressing the
tion in humeral fixation is 140–150° with respect to the ana- junction of the fragments (Fig. 20.12a). The wire module
tomic axis of the distal fragment (the angle is proximally VII,9-3;VIII,3-9; VIII,10-4 can be used as the transosseous
open). By moving the bar of the device that changes the angle subsystem for tensioning the axial compression wire
of the guide tube, the course of the wire where it exits the (Fig. 20.12b).
medullary cavity at the top of the great tubercle is determined. The technique of CSF for non-unions of the humerus is the
This maneuver provides information on the optimal same as that for acute trauma. In case of indications to decor-
configuration of the axial compression wire, which can be tication or osteoplasty it facilitates control over axial compres-
expressed, for example, as follows: “For the axial compression sion wire insertion. The axial compression wire is tensioned
wire to penetrate the cortical plate in the area of the major with a force of 294–343 N. With traumatic deformation of the
tubercle on leaving the medullary cavity, it must be inserted proximal humerus, insertion of the axial compression wire
into the medullary cavity from the external aspect of the shoul- must be preceded by removal of a wedge of bone or a hinge
der at an angle of 150° at a distance of 19.5 cm from the tuber- osteotomy. The axial compression wire is inserted under
cle or at an angle of 145° at a distance of 17 cm from the visual control after restoration of the bone axis.
tubercle.” The narrower the medullary cavity, the larger the To restore segmental defects of the humerus (mostly in
wire insertion angle. the proximal part) of up to 40 mm, free autotransplants from
It is important to note that during formation of the canal at the wing of the ilium are used. For long defects, vascularized
the determined level, the reamer must perforate the skin autotransplants from the fibula are recommended. At the
a b c d
e f g
Fig. 20.13 CSF application in humeral defects. (a) The first stage is to mation: the proximal support has been removed; (f) the result. (g) The
eliminate a limb length discrepancy by distraction. (b) The defect is radiograph shows a CSF of an autograft in the case of a large defect of
replaced by an autograft; (c) the result. (d) A defect in the proximal the proximal humerus
third of the humerus is replaced by an autograft. (e) Module transfor-
ends of the bone fragments the internal cortical layer is completed by the installation of the additional module II,5-
removed to a depth of 3–5 mm, first with a reamer and then 11; II,8,90 or I,10,90; II,8,90, which is connected to the mod-
with a cutter. The ends of the transplant are pressed into the ule of the axial compression wire tension. The proximal
resulting slots. To prevent “telescoping” of the transplant due module is dismantled 2.5–3 months later providing that there
to a humeral diameter exceeding that of the transplant, block- are radiographic signs of bonding between the transplant and
ing wedges of bone graft are used. the fragments (Fig. 20.12b).
After stabilization of the transplant by CSF, a vessel suture In Fig. 20.13, clinical examples of CSF of the humeral
is inserted using microsurgical equipment. The operation is bone are shown.
902 L.N. Solomin
20.3 Femur specified angle with the help of a control (calibrated) wire
(Fig. 20.8). A canal is formed using a wire reamer in the
CSF is appropriate when it is possible to ensure an end stop adjacent cortical plate. An angle of 175° is formed in the
at the junction of the bone fragments. Thus, indications for guiding threaded end of the axial compression wire; a con-
CSF of injuries to the femur are: trol counter-angle is formed in the opposite end for proper
1. Transverse and short oblique intertrochanteric and orientation of the wire on insertion. The wire reamer is
subtrochanteric fractures (31-A3.2, 32-A3.1 according to extracted and the axial compression wire is inserted into the
the AO/ASIF classification), supracondylar fractures medullary cavity; the guide is removed. An awl is temporar-
(33-A1.3) ily inserted into the mass of the greater trochanter and is
2. Slowly setting fractures and non-unions of the above- used as the counter-stop. The axial compression wire is
mentioned locations with a transverse line of injury or a gripped with flat-nosed pliers 40–50 mm from the skin and
line close to it and preservation of the coaxiality of the inserted by hammer taps to the pliers through the medullary
bone fragments or the possibility of its restoration in a cavity to the level of the fracture. As the wire is inserted, the
single step pliers are moved distally.
3. Intra- or subtrochanteric, supracondylar correcting osteot- In the case of fractures, a reamer is inserted into the
omy after which the end stop between the fragments can greater trochanter and is used as a lever. Then closed or
be placed (transverse, hinge, according to Repke, Kryuk, open reduction of the bone fragments is performed using
McMarrey type, etc.). a minimum approach and they are diafixed with two wires.
Note: Axial compression wires should not be inserted The quality of the reduction and orientation of the axial
through growth zones. compression wire in the medullary cavity is determined
For CSF of the proximal femur, the axial compression on comparison radiographs. The femur is maximally
wire is inserted from the external aspect of the distal adducted. The axial compression wire is inserted by
fragment. For the fixation of fractures in patients weigh- punching through the central fragment, its outlet oriented
ing <50 kg, one axial compression wire is used; in other to the external aspect of the segment. The wire must pen-
patients, the insertion parameters are determined for each etrate the femur from the inside, at the top of the greater
of the wires using a frontal radiograph. If after osteotomy trochanter.
the spatial orientation of the proximal fragment can be If the wire has deviated towards the femoral neck, the
changed in a single step, this is shown on the radiograph. angle of bending of the guide end of the wire is increased by
The optimal angle of wire insertion for femoral fixation 5°, the guide end of the wire is pulled in by pulling (not rotat-
is 135–145° (the angle is proximally open). By moving ing!) the opposite end of the wire as far as the fracture level,
the bar of the device that changes the angle of the guide and the wire is again withdrawn by punching. If the wire
tube, the course of the wire where it exits the medullary emerges more laterally than the designated zone (past the
cavity at the top of the greater trochanter will be seen fracture line), the angle of bending of the guiding end of the
(Fig. 20.4). This evaluation provides information on the wire is decreased.
optimal configuration of the axial compression wire, After the wire emerges from the skin at the required
which can be expressed, for example, as follows: “For the point, a threaded stop is screwed onto it (Fig. 20.7). If osteo-
axial compression wire to penetrate the cortical plate in porosis is present, an allogeneic bone pad of a larger diam-
the area of the greater trochanter on leaving the medul- eter is placed under the stop. An amount of skin equivalent
lary cavity, it must be inserted into the medullary cavity to the stop is dissected away with a scalpel and a canal is
from the external aspect of the femur at an angle of 135° formed in the soft tissue with a clip. The stop is driven as far
at a distance of 17 cm from the trochanter. The second as the bone by pulling on the opposite end of the axial com-
axial compression wire should be inserted at an angle of pression wire. To reduce soft-tissue trauma, a guide for
145° at a distance of 21 cm from the trochanter.” The nar- wires with stops is used (Fig. 20.12). A suture is placed on
rower the medullary cavity, the larger the angle of inser- the skin. The second axial compression wire is similarly
tion of the axial compression wire. inserted.
The operation is performed on the orthopedic traction A transosseous module is then mounted for tensioning
table with a pelvis bench and the patient supine. Fixation the axial compression wires. Two 6-mm half-pins are
starts with marking off the proximal axial compression wire. inserted in the femur connected by the bar IV,8,120;
The reference point is marked on the skin and a step is made V,8,120(Fig. 20.14a). By means of the distraction clip the
distally to take account of soft tissue thickness. The guide axial compression wire is tensioned with a force of 245–294
for insertion of the axial compression wire is taken through N, thus creating compression at the junction of the
the skin puncture to the bone, fixed, and installed at the fragments.
Fig. 20.14 CSF of fractures (a) and

correcting osteotomies (b) of the
femur. When an acute change of the a b
spatial orientation of the proximal
fragment of the femur is either not
possible or inappropriate, a half-pin
should be inserted in the neck. It is
connected by hinges to the external
supports for gradual correction
The technique of CSF in the case of non-unions of the proximal wire that ensure its curved passage through the
femur generally corresponds to that described for acute medullary cavity, such that it exits at the top of the exter-
trauma. In the case of indications for decortication or osteo- nal epicondyle, are determined. The angle and level for
plasty, it facilitates control over the insertion of axial com- insertion of the second wire are determined experimen-
pression wires. The axial compression wires are tensioned tally. This wire must emerge from the medial cortical
with a force of 294–343 N. plate 1–2 cm proximal to the level of the femoral injury
If deformities of the proximal part of the femur are pres- (fracture, osteotomy).
ent, insertion of the axial compression wire must be pre- The operation starts with insertion of both wires to the
ceded by a correcting osteotomy with single-step placement bone injury level. After reduction or correcting osteotomy,
of the fragments in the necessary positions. For conve- the fragments are stabilized by diafixation. The punching
nience of the manipulations, the half-pin I,9,90 is inserted. technique is used to insert the proximal axial compression
It is also used (instead of an awl) as the counter-stop in wire through the distal fragment until it penetrates the
axial compression wire insertion through the proximal frag- skin in the area of the external epicondyle. The second
ment. After tensioning of the wire the half-pin I,9,90 is wire is rotated by 180° and also inserted by punching
connected to the basic device (Fig. 20.14b). A wire module through the distal fragment until it perforates the skin in
basis on two supports VI,9-3;VI,8-2 – VII,3-9 can be used the area of the internal epicondyle. It is permissible to
as the transosseous subsystem for tensioning the axial com- insert the second wire by means of a drill from the side of
pression wire. the internal epicondyle. Stops are screwed onto the distal
In CSF for the repair of the femoral epicondylar ends of the wires and inserted as far as the bone. Both
region , a frontal radiograph of the injured bone is used to axial compression wires are tensioned with a force of
determine the parameters for insertion of the axial com- 196–294 N in the transosseous module III,9,70; IV,9,70
pression wires. Both wires are inserted from the side of (Fig. 20.15).
the external cortical plate. Working with the device Figure 20.16 provides clinical examples of CSF of the
shown in Fig. 20.3 , the angle and insertion level of the femur.
904 L.N. Solomin
Fig. 20.15 CSF of fractures of the distal femur
Fig. 20.16 CSF application in an intertrochanteric osteotomy (a, b) and a supracondylar osteotomy (c)
20.4 Forearm line close to it and preservation of the coaxiality of the

bone fragments or the possibility for its single-step
CSF is used when it is possible to ensure an end stop at the restoration
junction of the bone fragments. Thus, the indications for 3. Traumatic deformities in which the dislocation can be
CSF in injuries of the humerus and forearm are: eliminated in a single step before fixation
1. Transverse and short oblique fractures of the diaphyses 4. Segmental diaphyseal and metadiaphyseal defects as well
and metadiaphyses of the ulna and radius (22-A1.2, as joint defects of the forearm bones, e.g., for transplant
22-A2.2), including Monteggia (22-A1.3) and Galeazzi fixation
(22-A2.3) fractures Note: In false joints, insertion of the axial compression wire
2. Slowly setting fractures and non-unions of the above- should not be attempted before restoration of the patency of
mentioned locations with a transverse line of injury or a the medullary cavity (Fig. 20.17).
906 L.N. Solomin
temporary immobilization of the proximal radioulnar joint

L and tensioned in the support used for tensioning the axial
compression wire. Half-pin (I,10,90) can be used instead of
wire (I,11-5)I,11-5.
If external fixation for a false joint is combined with a
Fig. 20.17 In CSF of the forearm bones, the wire is inserted by punch- decortication operation, after restoration of the patency of
ing to ensure its progressive motion. It then returns due to its bend to the the medullary canal, plasty according to the method of Albi-
cortical plate on the same side as its insertion. Therefore, first, the angle Khakhutov facilitates control over the insertion of the axial
of insertion of the axial compression wire must be minimal, i.e., up to
30° in CSF of the radius, and >150° in ulnar fixation (with the angle
compression wire. If the ends of the bone fragments are
open proximally). Second, the bone destruction zone must be located exposed, the axial compression wire is inserted retrogradely.
between the compression wire stop on the opposite cortical plate and This is done by inserting a wire with a ski-shaped bend at its
the point of its return to the cortical plate on the side of its insertion (the end in the distal fragment and placing it on a holding device.
interval L). Non-observance of this condition will result in the wire pen-
etrating between bone fragments during surgery
The wire is inserted by punching and its exit is oriented
towards the posterior aspect of the bone in the area of the
styloid process.
20.4.1 Ulna An axial compression wire is also inserted by punching
through the medullary cavity of the central fragment, its exit
For the repair of injury to the ulnar diaphysis, the axial com- oriented towards the top of the olecranon. During open inter-
pression wire is inserted in the posterior aspect of the distal ventions, the wire can be inserted through the central frag-
fragment and exits through the top of the posterior aspect of ment using a low-speed drill. Before perforation of the skin
the olecranon. To determine the angle and level for wire with the wire, the forearm is placed in flexion at 120–130°. A
insertion, a lateral radiograph is used. With the aid of the threaded stop is screwed onto the peripheral end of the wire
device shown in Fig. 20.3, the trajectory of the axial com- (Fig. 20.7) or, in the case of osteoporosis, a stop is formed in
pression wire is determined such that the position of the frac- the shape of a hook or spiral. The stop is inserted as far as the
ture is between the location of the wire stop on the anterior bone by pulling on the central end of the wire through an
cortical plate and the point at which the wire emerges from incision/puncture in the soft tissue. A transosseous module is
the posterior cortical plate (Fig. 20.4). then installed for tensioning the axial compression wire
The optimal angle of wire insertion for ulnar fixation is (Figs. 20.18, 20.19, and 20.20). The wire is tensioned with a
150–155° with respect to the anatomic axis of the distal frag- force of 245–294 N (25–30 kgf) for fractures and 343–393 N
ment (the angle is proximally open). The narrower the med- for false joints, and is fixed to the support with a traction
ullary cavity, the smaller the wire insertion angle. clip.
The operation starts with the use of a special guide to In defect diastases with anatomic shortening of the ulna,
insert the axial compression wire (Figs. 20.5 and 20.9) into the first stage involves restoration of the proper relations in
the medullary cavity and its insertion by punching as far as the distal radioulnar joint with the help of external distrac-
the level of the bone injury. It is important to note that to tion fixation; the ulna is then lengthened by 3–4 mm. The
form the canal at the determined level, the reamer must per- device is subsequently dismantled, with the exception of
forate the skin slightly more distally, to take the soft-tissue wireVIII,6-12(VIII,6-12). The forearm is fixed in a plaster
thickness into account. The axial compression wire is inserted splint. After 7–14 days, if there are no clinical or labora-
into the canal. At the guiding end of the wire, a ski-shaped tory signs of inflammation, osteoplastic substitution of the
bend of 170–175° and 2–3 mm long must be formed, together defect is performed. In defect diastases without anatomic
with an opposite bend at the other end of the wire. shortening of the ulna, this surgical treatment stage is not
The wire is gripped with flat-nosed pliers 30–50 mm from required.
the skin and is inserted by hammer taps on the pliers to the The operation starts with visual evaluation of the ends of
level of the bone injury, with the guiding end of the wire the fragments. In the available configuration, they are treated
oriented to the posterior aspect of the forearm. As the wire is so that the end stop with the transplant can exit with mini-
inserted through the medullary cavity, the pliers are moved mum damage to the bone tissue. If the prominences of the
away from the skin. receiving bed interpenetrate with the transplant, the rota-
In fractures of the ulna, the fragments are reduced by tional rigidity of fixation and the surface area of contact are
closed manual reduction, using reduction plates, or by open increased, thus promoting earlier engraftment and remodel-
reduction with the minimum approach. In Monteggia frac- ing of the transplant. The medullary cavity is restored. An
tures, the head of the radius is reduced after repositioning axial compression wire is inserted in the medullary cavity of
the ulnar fragments. Wire (I,11-5)I,11-5 is inserted for the bone fragment orthogradely or retrogradely.
Fig. 20.18 The variant of tensioning the compression wire based on the 5-mm half-pin I,6,40 is preferred in patients with a large volume of soft
tissue, a bone diameter at the level of insertion of the half-pin of not less than 20 mm, and without marked osteoporosis
The defect length is carefully measured. For defects up to inserted through the transplant and the proximal fragment.
40 mm, a free autograft from the wing of the ilium is used. The half-ring is dismantled. The subsequent stages of
The graft must be 3–5 mm larger than the size of the defect the operation are similar to those for ulnar fractures.
and must exceed the ulnar diameter by 3–4 mm. A 2-mm The compression wire is tensioned with a force of 294–343
canal is made in the projection of the anatomic axis of the N. If the bone replacement of the defect is performed during
transplant. Instead of an autograft, ceramic or porous tita- the second stage of the operation, the device is installed
nium nickelide or other bone-replacement materials are pos- according to the configuration shown in Fig. 20.20 after res-
sible. For defects >40–50 mm in length, a vascularized toration of the length of the ulna.
autograft from the fibula should be used. The length of a cor-
tical autograft must be 2–3 mm more than the length of the
defect. 20.4.2 Radius
Wire VIII,5-11 is inserted through the ulna and fixed into
the half-ring. By pulling the wire, the distance between the The axial compression wire is inserted into the radius from
bone fragments can be increased to allow more convenient the external or anteroexternal aspect of the proximal frag-
introduction of the autograft. The axial compression wire is ment. As the wire will be in a plane close to the frontal plane,
908 L.N. Solomin
Fig. 20.19 The axial compression wire can be tensioned by means of Fig. 20.20 In Monteggia injuries, the radius is abducted and the wire
a transosseous module based on wires. Two wires with stoppers, I,4-10 (VIII,1-7) is inserted through its distal metaphysis and then tensioned in
and II,10-4, are inserted at the level of the base of the ulnar process and the ring support. This support is connected by two rods to the tran-
50–60 mm distal from it in a plane close to the frontal plane in the sosseous module for compression wire tensioning. The distal support is
opposite direction. The wires are tensioned in the original external sup- moved the necessary distance by distraction and, after radiographic
port or in a support based on a half-ring lengthened by connection confirmation that the joint surfaces are at the same level, the wire with
plates. The free ends of the connection plates are joined with a rod a stop (I,11-5)I,11-5 is inserted. If displacement is edgewise, the use of
wire (I,3-9) or (I,9-3) is recommended. The stop eliminates the edge-
wise displacement of the proximal part of the radius. Then the wire is
the calculations must be based on a frontal (anteroposterior) bent backwards and inwards. The dislocation is eliminated by simulta-
neous traction at both ends of the wire. After this manipulation, wire
radiograph. The level of the bone injury must be between the (I,3-9) is replaced by wire (I,11-5)I,11-5 at the half-pin I,9,90. Another
axial compression wire stop on the internal cortical plate and wire is inserted VIII,6-12(VIII,6-12) through both bones at the level of
the point of its return to the external cortical plate (Fig. 20.4). their distal metaphyses. Six weeks later, the distal support and the tran-
The optimal angle of insertion of the axial compression wire sosseous element inserted at the first level in the radius are removed
for ulnar fixation is 25–30° with respect to the anatomic axis
of the proximal fragment (the angle is proximally open). The more proximally in order to take into account the thickness
narrower the medullary cavity, the larger the angle of inser- of the soft tissue. The wire is inserted into the canal, its guid-
tion of the axial compression wire. ing end has a ski-shaped bend of 170–175°, and a length of
The operation starts with insertion of the axial compres- 2–3 mm and an opposite bend in the same plane at the other
sion wire into the medullary cavity using the special guide end of the wire.
(Fig. 20.9), by punching to the level of the bone injury. It is The wire is gripped with flat-nose pliers 30–50 mm from the
important to note that during formation of the canal at the skin and then inserted by hammer taps to the pliers to the level
determined level, the reamer must perforate the skin slightly of the bone injury. The guiding end of the wire is oriented to the
Fig. 20.21 The axial compression by 3–5°, the wire is inserted to the level of the distal radial
wire can be tensioned by a metaphysis, and is again distally inserted by punching. A
transosseous module based on the
5-mm half-pin VIII,12,120 or three threaded stop is screwed onto the central end of the wire
2-mm console wires (Fig. 20.7) or a stop is formed in the shape of a hook or spiral
in the case of a patient with osteoporosis. The stop is inserted
as far as the bone by pulling the peripheral end of the wire
through an incision puncture in the soft tissue. The tran-
sosseous module is then constructed for wire tensioning
(Figs. 20.21, 20.22, and 20.23). The axial compression wire
is tensioned with a force of 245–294 N (25–30 kgf) for frac-
tures and 343–393 N for false joints and is fixed to the sup-
port using a traction clip.
The protocol for CSF of defect-diastases of the radius is
generally identical to that described for radial defects. If
required, proper relationships are restored in the radioulnar
joints during the first stage by external fixation. The axial
compression wire is inserted in the medullary cavity under
visual control, moving the soft tissue in the proximal direc-
tion. If osteoplastic replacement of the defect is performed
as the second stage, the axial compression wire is tensioned
in the ring supports shown in Fig. 20.23. In defect-diastases
without anatomic shortening of the radius the module for
tensioning the compression wire is mounted as for fractures
and false joints of the radius (Figs. 20.21 and 20.22).
20.4.3 CSF of Both Forearm Bones:

Combined Fixation1
In general, CSF involves identification of the parameters for

compression wire insertion, and their insertion through both
bone fragments. The Fixation in the transosseous modules
posterior aspect of the forearm. As the wire is inserted into the does not differ from that described for the fixation of isolated
medullary cavity, the pliers are moved away from the skin. injuries of the ulna and radius.
In fractures of the radius, the bone fragments are reduced The combined fixation of an injury to both bones of the
using reduction plates or under visual control in a minimum forearm can be performed if the indications for ulnar or radial
approach. If the fixation of a false joint is combined with a CSF are fulfilled. If the injury is such that an end stop cannot
decortication, restoration of the patency of the medullary be provided, the splinters of the paired bone are stabilized
canal is followed by plasty according to the method of Albi- using a transosseous or an implanted fastener. In oblique dia-
Khakhutov as this facilitates control over axial compression physeal fractures, either plates, intramedullary nails, or tita-
wire insertion. The axial compression wire should not be nium nickelide fasteners are used. In splinter injuries or
inserted before the patency of the medullary cavity has been already compromised osteogenesis (non-unions, false joints),
restored. In open operations, the proximal edge of the skin external fixation is needed.
wound is cut back 2.5–3 cm from the level of bone destruc- The most appropriate installations for the combined
tion, a canal is formed, and the axial compression wire is fixation of forearm fractures are shown in Figs. 20.24, 20.25,
inserted into the medullary cavity under visual control. and 20.26. The operation always starts with CSF. The axial
The axial compression wire is inserted by punching compression wire is tensioned only after reduction of the
through the medullary cavity of the distal fragment, orient- fragments of the paired bone.
ing its exit towards the top of the styloid process. Before the Figure 20.27 provides several clinical examples of CSF of
skin is penetrated by the wire, the patient’s hand is placed in the forearm bones.
ulnar deviation of 25–30°. If the wire has penetrated the skin
in the wrist projection, the bend at its guiding end is increased 1
Combined fixation is described in Chap. 3.
910 L.N. Solomin
Fig. 20.22 If osteoporosis is

present, the transosseous module
is mounted by means of two
wires tensioned in the lengthened
half-ring VII,1-7; VIII,7-1
Fig. 20.23 The CSF of Galeazzi fractures is basically performed using

a method similar to that described for isolated radial fractures. The ring
support is used for tensioning the basic wires. After reduction and sta-
bilization of the bone fragments, proper relationships are usually
restored in the distal radioulnar joint. For its temporary immobilization, Fig. 20.24 In CSF of both bones of the forearm, the operation starts
the stabilization wire with a stop VIII,6-12(VIII,6-12) is inserted with the insertion of an axial compression wire through the radius. An
through the distal metaphysis of the forearm bones axial compression wire is then inserted through the ulnar fragments.
The modules for compression wire tensioning are mounted and then
connected by two rods. The compression wire is tensioned after the
fragments of both bones of the forearm have been adapted. The com-
pression force by the connection rods must match the tensioning force
of the axial compression wires. Three or four weeks prior to the planned
date of device removal, the rods connecting the modules for compres-
sion wire tensioning are removed, which allows the patient to begin
developing rotational movements
912 L.N. Solomin
Fig. 20.25 (a, b) A mandatory condition in using

implants in combined fixation is the possibility of a b
ensuring “stable functional” (not requiring a plaster
bandage) fixation, which allows the restoration of all
types of movements in the adjacent joints, including
rotation
Fig. 20.26 In a combined radial CSF and external fixation of the ulnar destruction of the radius and transverse destruction of the ulna, com-
fragments (a), to ensure rotational function, reference positions desig- bined fixation will involve the use of fewer transosseous elements than
nated in the atlas with the sign “→” are used for the insertion of tran- in external fixation and ensure the optimal biomechanics of fixation of
sosseous elements in the ulna. In the case of oblique, spiral, or splintered every forearm bone (b)
a b
c
914 L.N. Solomin
Fig. 20.27 CSF for a Monteggia fracture (a–c), in non-unions of the forearm bones (d–i), and in an ulnar defect (j, k)

916 L.N. Solomin
d e

f g

918 L.N. Solomin


920 L.N. Solomin
20.5 Clavicle b c
Structurally, the clavicle is a spongy bone since its internal

lumen is filled with cellular bone and there is no intermedul-
lary canal. Our research [349] has shown that an axial wire in
a
the spongy bone provides sufficient rigidity for the fixation
of splinters, even in cases of minimum axial compression.
Moreover, this technique prevents displacement in transverse
and short oblique fractures (91.2-A3 type according to the Fig. 20.28 Insertion of axial compression wires in fractures of the
AO-ASIF classification) and oblique (91.2-A2), spiral (91.2- internal (a), middle (b), and external (c) third of the clavicle
A1), and splintered (91.2-B1, 91.2-B2) fractures. The indica-
tions for CSF are non-unions and segmental defects of the
clavicle (for bone graft fixation). with the transplant can exit with minimum damage to the
The axial compression wire in CSF of the clavicle is bone tissue. It should be kept in mind that if prominences of
inserted through both fragments retrogradely with the help the receiving bed penetrate the transplant, the surface area
of a drill. Therefore, each end of the wire must be provided of contact is increased, thus promoting a higher stability of
with a triquetral grind. Where the wire penetrates the cortical fixation. Especially important is the presence of these promi-
plate of the bone fragments depends on the fracture level nences at the junction of the transplant with the central frag-
(Fig. 20.28). ment, as the largest displacing forces arise here.
Regional anesthesia or sedation is generally used for CSF After reduction, the axial compression wire is inserted
of the clavicle. The operation is performed (Fig. 20.29) with using a drill through the peripheral fragment until it appears
the patient supine. A cushion is placed along C7–D7 and the above the skin.
patient’s arm behind his or her back on the side of the injury. In the fixation of non-unions and defects of the sternum,
The head is turned in the direction opposite to the injured and when a longer fixation period is considered necessary, a
clavicle. In the successful closed reduction of fractures, stop is screwed on the central end of the axial compression
insertion of the axial compression wire in the CSF of non- wire (a bend-type stop is formed) and the wire is inserted as
unions without angular deformity in which there is displace- far as the bone. The wound is drained and sutured. The mod-
ment of fragments along the periphery, is done orthogradely ule for tensioning the axial compression wire is then
from the side of the central fragment. In open reductions, installed.
after separation of the bone fragments, the direction of wire The coracoid process of the scapula is located by palpa-
insertion into the fragments is marked with an awl on the tion and a wire is inserted in its base so that its guiding end
side of the bone wound. The central bone fragment is is oriented in the direction of the scapular spine. Importantly,
deflected backwards and the wire is inserted using a drill first the direction of insertion of the wire is established, and
until it appears above the skin and then further. The end of only then is the skin pierced with the wire. If after insertion
the wire should be immersed into the bone to not prevent of the wire along the base of the coracoid process–scapular
reposition of the fragments. spine axis the soft tissue under the wire appears to be com-
For short (20–30 mm) central fragments, the axial compressed, the wire must be extracted and inserted at a different
pression wire is inserted through the fragment by punching. angle. Only then is the wire fixed in the chuck of the drill and
A bend of 165–170° is formed in the central end of the wire inserted until its guiding end lies in the projection of the
and an opposite bend at the other end for orientation control. scapular spine. The second basic wire must be provided with
The wire is inserted in the prepared canal, gripped with flat- a stop. It is inserted through the acromial process of the scap-
nosed pliers, and pushed using hammer taps, such that it is ula (peripheral fragment of the scapula) in the direction from
oriented towards the exit to the anterior surface of the clavi- back to front.
cle (sternum). After the wire has penetrated the skin, its ends The external support consists of a half-ring and connec-
are straightened. tion plates. It is placed at an angle of 120–130° to the ana-
The operation to replace a clavicular defect starts with tomic axis of the shoulder so that it will not further prevent
visual evaluation of the ends of the fragments. Based on the abduction in the humeral joint. The distance between the
available configuration, they are treated so that the end stop support and the skin surface at the front should be at least
a b
Fig. 20.29 (a–k) Combined strained fixation (CSF) of the clavicle (a) splinter should be fixed by cerclage suture before ACW insertion
The patient is placed on an operational table. (b) An axial compression through the peripheral fragment. If there is a defect, the length of the
wire (ACW) is inserted through the central fragment. (c) If the central autograft should be 2–3 mm longer than the defect. In both the autograft
bone fragment is short or the defect is in the central part of the clavicle, and the peripheral fragment, a channel with a diameter 0.2 mm lager
an ACW is inserted through the sternum. (d) The ACW is inserted than that of the ACW should be made
through the peripheral bone fragment. (e) In splintered fractures, the
922 L.N. Solomin
f g
Fig. 20.29 (continued) (f) In the fracture shown here, the ACW is (prepared in advance!) is inserted into the acromion process of the scap-
fixed by means of a curved stopper. The first bend fixes the wire on a ula. (h) A basic console wire is fixed in a plate, followed by tensioning
bone. Its length should be <3–4 mm. The part of the bend that is parallel and fixing of the ACW in the basic support. (i) In cases of non-unions
to the clavicle is inserted under skin, and the external bend over skin. and bone defects, the basic support should be fixed by two K-wires, one
This facilitates removal of the ACW. If the fixation period is potentially through the acromion process of the scapula and the other through the
longer than 4–6 weeks (non-union, defect) it is expedient to use an coracoid process and spine of the scapula
internal stopper for ACW fixation. (g) A 2-mm basic console wire
j k
Fig. 20.29 (continued) (j) Basic wires are tensioned in a half ring. external surface upwards. The guiding end of the wire is oriented to the
The ACW is tensioned with the help of a traction clip. (k) In disloca- upper surface of the acromial extremity of the clavicle. A stop is formed
tions of the acromial end of the clavicle, the operation described by at the central extremity of the wire and inserted as far as the bone. The
Ilizarov and Barabash starts with mounting of the transosseous module wire is tensioned in the external support with a force of 147–176 N. In
based on one (shown) or two wires. The clavicle is then reduced by chronic injuries (“non-reducible” dislocations), the joint surfaces are
single-stage manual reduction and is held with a single-tooth hook. A openly aligned. When indicated, ligamentoplasty is also performed
wire is inserted in the acromial process of the scapula from its postero-
1.5 cm and the distance at the back 2 cm. Only then are the 6. In fracture-dislocations of the acromial end of the clavi-
basic wires tensioned simultaneously (Fig. 19.29). The axial cle, the console wires are inserted in the acromial end of
compression wires should be tensioned in the external sup- the clavicle only as far as the opposite cortical layer.
port with a force of 176.4–196 N (18–20 kgf). Console wires are not inserted in the acromial process of
Figure 20.30 provides a clinical example of CSF of the the scapula but rather Kirschner wire acr.,6-12 is used,
clavicle. with its ends bent in a U-shape towards each other.
7. The minimum distance between the skin surface and the
external supports must be 1.5–2 cm.
20.5.1 External Fixation of the Clavicle Indications for external fixation are: fractures of various
severity levels (91.2-A, 91.2-B, 91.2-C according to the AO/
A pioneer in the development of external fixation of frac- ASIF classification), fractures that have joined with an
tures and dislocations of the clavicle was Sushko [350]. improper position of the bone fragments, fracture-dislocations
The recommendations for the method published by the and dislocations of the acromial end of the clavicle. False
Russian Ilizarov Research Center [351] form the basis of joints and clavicle defects are better treated with CSF.
the fixation method requirements that are generally still When an original Sushko device is not available, the
applicable: fixation frame can be assembled from the parts of an Ilizarov
1. At least two 2-mm console wires at an angle to each other device. This will require two plates (direct or radius), posts,
are inserted in each bone fragment. wire fixators, and a connection rod; 3-mm half-pins can be
2. The points of wire insertion must be near the epiphyses of used instead of wires.
the clavicle. The patient is administered regional anesthesia or placed
3. The points of wire insertion must be on the upper surface under sedation. The operation is performed with the patient
of the clavicle. supine, with a cushion along C7–D7 and his or her forearm
4. The direction of wire insertion must coincide with the behind the back (Fig. 20.31). The patient’s head is turned in
anatomic axis of the bone fragments. the direction opposite to the injured clavicle but it should not
5. In diaphyseal fractures, wires are inserted through both be thrown back; the side of the face must be level with the
cortical layers. anterior aspect of the chest.
924 L.N. Solomin
a b
Fig. 20.30 (a–g) CSF of a screw-hole fracture (a) A clavicular frac- processus and scapular spine. (c) Both basic wires are fixed to the plate.
ture at one of the plate screws (screw-hole fracture). (b) The plate is The ACW is tensioned with the help of a traction clip. (d) Upper arm
removed and CSF performed. One of the basic wires is led through the function at postoperative day 5
acromion processus of the scapula and the other through the coracoid
e g
Fig. 20.30 (continued) (e) The roentgenogram 6 weeks postoperatively. (f) Upper arm function 6 weeks postoperatively. (g) The device is dis-
mantled 8 weeks after the operation
926 L.N. Solomin
b
a
c d
e f
Fig. 20.31 (a–e) External fixation of the clavicle (a) The patient is Wires are inserted in the peripheral fragment and the peripheral support
placed on the table. (b) The insertion sites of the transosseous elements is assembled. (f) The final step consists of reduction and connection of
are marked. (c) Console wires are inserted (parallel to the thoracic sur- the supports
face) in the central fragment. (d) The central support is assembled. (e)
First, the wire insertion points are determined from radio- fragments at the insertion levels of the transosseous
graphs in two projections. Radio-opaque markers are placed elements.
2 cm from the joint surfaces of the acromial and sternal Mounting of the device starts from the medial support.
extremities of the clavicle, perpendicular to the anatomic The wires are manually fixed in the extreme holes of the con-
axes of the bone fragments. Injection needles are also placed nection plate and using wire fixators, so that their guiding
to mark the anterior and posterior boundaries of the bone ends only slightly protrude over the edge of the plate. The
plate is applied onto the skin and the wire directed towards moved away from the skin by 1.5–2 cm. The second wire is
the sternal extremity of the clavicle and manually inserted to inserted until it touches the bone and, after making sure that
the bone. One should again make sure that the wire is located it is located in the center of the clavicle diameter, the first
from the upper aspect of the clavicle and in the center of the wire is fixed rigidly to the support. After the second wire is
bone diameter. A reference point is marked on the wire show- inserted and fixed, the support is similarly mounted on the
ing the depth of its insertion and indicating the depth at which peripheral fragment.
it will exit from the lower cortical plate. The wire is drilled at External fixation in fractures and dislocations of the acro-
low speed, monitoring its insertion depth. The bar is then mial end of the clavicle is shown in Fig. 20.32.
Fig. 20.32 (a–g) External fixation of fractures and fracture-disloca- (parallel to the thoracic surface) in the clavicle. (b) Wire acr.,6-12 is
tion of the acromial end of the clavicle (a) Console wires are inserted inserted through the acromion process and is bent
928 L.N. Solomin
Fig. 20.32 (continued) (c) The support is assembled on the inserted stop 5–6 mm in diameter is used. In chronic injuries, this wire is fixed
wires. (d) A console wire with a stopper is inserted. To avoid cutting to the external support by a traction clip. (e) After the dislocation is
during the fixation of chronic injuries and in osteoporosis, a flexural eliminated, the reduction wire is fixed to the support
Fig. 20.32 (continued) (f) A clinical example of external fixation for A console wire with a stop is then inserted into the acromial end of the
a dislocation of the acromial end of the clavicle is shown (Case of A.N. clavicle. The wire is fixed to the basic support by posts and a distraction
Chelnokov). (g) In the method of Barabash and Solomin [352] the basic clip
support is mounted in a manner similar to that used in CSF (Fig. 20.29).
20.6 Postoperative Protocol Active–passive movements in the adjacent joints and gen-
tle massage are prescribed from postoperative day 2. At
The principles of the postoperative management of patients 5–12 days, the patients are managed as outpatients. With
with external fixation are given in Chap. 32. The specific fea- clinical and radiographic monitoring, the load on the extrem-
tures of CSF are discussed herein. ity is increased, reaching 70–85% of the functional norm by
In the operating room, after the axial compression wires the end of the fixation period.
have been tensioned, the skin around the wires is examined. In elderly patients with weak muscles of the shoulder and
If the skin is compressed, either in the neutral position of the forearm, subluxation of the humeral head can occur follow-
extremity or during passive movements, the skin and, if nec- ing CSF. To prevent this complication, we recommend use of
essary, the fascia are dissected and sutured. A pressure ban- a cravat bandage for 1–2 weeks and measures to strengthen
dage in the form of a sling is applied to the area of the axial the shoulder girdle muscles.
compression wire insertion for 2–3 h (Fig. 7.37). The wires Throughout the fixation period (and not less than
exit points are covered with gauze dressings soaked in 70% every 1.5–2 weeks), tensioning of the axial compression
ethyl alcohol. During the first 3–4 days, the dressings are wires is monitored by a calibrated spring or wire fixator.
changed daily, then as required but not less frequently than Interfragmental compression is reduced by 30–50% from
every 7–10 days. The ACW exit sites are to be checked thor- the initial value over the 2 weeks prior to the planned
oughly on a daily basis. dismantling of the structure, and tension is completely
Following CSF of the femur, the patient is placed on the removed 5–7 days prior to dismantling. Bear in mind that
bed and a soft cushion is placed under the knee joint to ensure the fixation schedule is established individually based on
leg 80–100° flexion. After fixation of the clavicle or the the dynamic results of clinical and, in parallel, radiographic
humerus, a wedge-shaped cushion is placed between the monitoring. For example, normal skin color, the absence
shoulder and the body to abduct the extremity by 45°. of soft-tissue edema, and painless movement in adjacent
930 L.N. Solomin
joints are negative indications for restoring the mechani-

cal strength of the bone; conversely, a lack of discontinuity
of the shadow of the periosteal regenerate and a changing
radiological picture, even with the preserved tracked space
between the fragments, are indications for completion of
the fixation period.
In fractures of the diaphysis and metadiaphysis of the
femur/tibia, the structure is generally dismantled within
7–12 weeks, in corrective osteotomies within 6–9 weeks, in
fractures of the humeral diaphysis within 6–7 weeks, in frac-
tures of the humeral metaphysis and metadiaphysis within
4–6 weeks, after CSF of false joints within 8–10 weeks, after
CSF of clavicular fractures within 3.5–5 weeks, and after
corrective fixation of orthopedic pathologies within a
11–14 weeks.
The CSF structure is dismantled in the outpatient setting
(Fig. 20.33). Local infiltration anesthesia is combined with
the administration of promedol (trimeperidine), Relanium
(diazepam), or Dimedrol (diphenhydramine). First, the
transosseous module for tensioning the axial compression
wires is dismantled. To remove the compression wires from
the humerus or femur, the extremity is maximally adducted.
The tensioning ends of the compression wires are thoroughly
treated with an antiseptic. The wire is gripped with sterile
flat-nosed pliers and pushed proximally with a hammer until
the stops appear under the skin. The skin is punctured and
the stops are released and unscrewed (or cut off). The wires
are extracted by pulling at the opposite end. The skin is
sutured. b
If it becomes necessary to remove a compression wire
prematurely, for example due to soft-tissue inflammation not Fig. 20.33 (a–f) Dismantling of the device for CSF of the clavicle (a)
controlled by conservative measures, then first a transosseous The basic support is dismantled. (b) Local anesthesia is administered in
a projection of a wire stopper
module is mounted on the opposite bone fragment and con-
nected by connection rods to the wire tensioning module.
Next, the wire is screwed out of the threaded stop with mod-
erate pulling and finally removed.
c d
Fig. 20.33 (continued) (c) The external end of the ACW is fixed using wire stopper then led out. (e) The wire stopper is cut and the wire is
flat-nose pliers. The wire is moved in the central direction using ham- removed. Sutures are placed on the skin
mer blows. (d) Soft tissue over a stopper should be dissected and the
Pelvic Injuries
21
Aleksey Vladimirovich Runkov
To precisely identify the character of the deformity and the grade The condition of the anterior pelvis can be determined
of adhesion of the bone fragments radiographically, images are using routine radiographic imaging, but in the posterior pel-
obtained in the frontal and internal oblique planes (Fig. 21.1). vis a tomographic study may be necessary to more precisely
a b
Fig. 21.1 Radiographic imaging of the pelvis: frontal projection (a) and internal oblique projection (b)
A.V. Runkov, M.D., Ph.D. () L.N. Solomin, M.D., Ph.D.

Department of Traumatology and Orthopedics, External Fixation Department, R.R. Vreden Russian Research Institute
Ural Scientific Research Institute of Traumatology and Orthopedics, of Traumatology and Orthopedics,
7 Bankovsky Str., Ekaterinburg 620014, Russia 8 Baykova Str., St. Petersburg 195427, Russia
e-mail: rounkov@e1.ru e-mail: solomin.leonid@gmail.com
934 A.V. Runkov and L.N. Solomin
determine the location of the injury, the direction of the dis- 6-mm diameter with a spongy thread. The use of half-pins
placement, and the presence or absence of bone union. with a cone-shaped cutting end and limiting stay nuts
enhances the strength of the bone–metal block. Prior to
insertion of the half-pins into the bone, a hole is made with
21.1 Equipment a stiletto in the adjacent cortical plate.
We recommend using half-pins with a 4-mm screw part
Generally, the equipment for external fixation in pelvic inju- and a shank end provided with an M6 thread. The screw part
ries corresponds to that listed in Chap. 1.3. In the following, of a half-pin and half-pin shaft are connected by a cone-
the particular features of the equipment are described. shaped neck (Fig. 21.2a). The tail of this half-pin is inserted
In external fixation of the pelvis (Figs. 21.1, 21.2, 21.3, 10–20 mm into the bone (Fig. 5.257). This approach is
21.4, 21.5, 21.6, 21.7, 21.8, 21.9, 21.10, 21.11, 21.12, 21.13, equivalent to using a half-pin with a stepwise change in
21.14, 21.15, 21.16, 21.17, 21.18, 21.19, 21.20, 21.21, diameter. This enables the length of the pin in the bone to be
21.22, 21.23, and 21.24), 2-mm wires with a stop and wires increased, which also enhances its stability.
without a stop are used, as well as console transosseous ele- In inveterate damage, half-pins with a shank-end diameter
ments comprising console wires and half-pins of 4-, 5- and of 8 mm are used. Accordingly, nuts, posts and washers of
Fig. 21.2 (a–c) External fixation

equipment for pelvic osteosynthesis
21 Pelvic Injuries 935

c
the corresponding diameter are necessary for their fixing to

supports (Fig. 21.2b). External supports consist of half-pin
arches and combined wire arches (Fig. 21.2c) [353, 354].
21.2 Principles of External Device Assembly

for the Fixation of Pelvic Injuries
Safe positions for the insertion of transosseous elements in

pelvic bones are presented in Chap. 5.7. The “closed” inser-
tion of transosseous elements facilitates the use of probes
(needles, wires) to determine the limits of the internal and
external cortical plates, at both the insertion and exit sites,
when placing the wires as well as fluoroscopy or X-ray imag-
ing with radio-opaque markers.
In difficult cases, one should resort to open insertion of Fig. 21.3 The location of the pelvic support relative to bone
the half-pins. An incision should be made in the soft tissues landmarks
so that the direction of insertion of the transosseous element
can be controlled visually. In any case, final radiographic use of cumbersome circular devices in unstable rotational
confirmation of the correct positioning of the transosseous pelvic injuries (and even in stable injuries) is inappropriate.
elements is mandatory. The orientation of both arched and bow supports is shown
For osteosynthesis of the pelvis, open (arched, anterior in Fig. 21.3. For circular devices, large femoral arches, col-
frame) and closed (circular) devices have become the most lected from two one-half arches, are used. This facilitates
widely accepted. The biomechanical properties of semicir- device reassembly if needed during treatment. The distance
cular devices are similar to those of arched devices but they from the skin surface to the frontal support is 2.5–3 cm, and
are more cumbersome. The external device is assembled to the rear support 2–3 cm more [88]. The “dismountability”
from the parts of the standard Ilizarov set. To reduce the sep- of the support facilitates module transformation and possible
arate components of an injured pelvic ring, the modules device reassemblies [99, 355].
fixing the bone fragments are mutually displaced (Figs. 3.4,
3.5, 3.6, 3.7, 3.8, and 3.9). In the arched device, the supports
are those of half a femoral arch (Fig. 21.2c). 21.2.1 Surgical Technique
Assembly of the external frame and the choice of tran-
sosseous elements depend on the clinical objectives and the The details of the intervention depend on the type of pelvic injury
type of injury. An isolated assembly of the anterior frame and on the general condition of the patient: in unstable vertical
type is ineffective in vertical unstable injuries; instead, the injuries and in rotational injuries of the “open book” type, exter-
posterior parts can be fixed in a ring device. By contrast, the nal fixation is one element of the anti-shock measures.
External fixation is performed with the patient under general semi-bow supports are positioned using threaded bars.
or regional anaesthesia, supine, and with the bladder catheter- Reduction of the fragments now occurs. The apparatus is sta-
ized. A table with a recess is used for applying a ring device. bilized (Fig. 21.7).
Figures 21.8 and 21.9 present the variant of external
fixation at fractures 61-B2.2. This type of partially stable
21.2.2 Osteosynthesis in Stable and Partially (rotationally unstable) pelvic damage is characterized by
Stable Pelvic Injuries (61-A, 61-B) crumpling and subluxation of the sacroiliac joint, rupture of
the symphysis pubis, and torsion displacement of the
In stable pelvic injuries, external fixation is used for frac- hemipelvis: the “crumpled book” type of damage.
tures of the iliac wing with displacement of the broken
fragment, and for injuries involving considerable destruc-
tion of the anterior semi-ring; for example, bilateral frac- 21.2.3 Osteosynthesis in Vertically Unstable
tures of both pubic bones and ischial bones, i.e., “butterfly” Pelvic Injuries (61-C)
type fracture (injuries 61-A2 by the AO/ASIF classification)
(Fig. 21.4). In these fractures (Fig. 21.4), the apparatus of The 61-C type of damages differs from the rotationally
the anterior frame type is applied, and half-pins are inserted unstable type by the presence of a vertical shift of one or both
into the bodies of the pubic bones. At the first stage, the halves of the pelvis, i.e., the injuries are rotationally and ver-
iliac bone wings should be brought apart to form a diasta- tically unstable. Anterior damage can represent rupture of
sis on the fracture level. As the displacement of the the symphysis, fracture of branches of the pubic bones, an
fragment-butterfly will, as a rule, also comprise a rotation acetabular fracture, or a combination thereof. Posterior
component, the half-pins inserted into the pubic bones injury may consist of an iliac fracture (61-C1.1), dislocation
should be turned anteriad and backward, and the displace- or fracture-dislocation of the sacroiliac joint (61-C1.2), or
ment then eliminated in its height. Next, the half-pins fracture of the sacrum (61-C1.3). A rotationally unstable
inserted into the pubic bones are fixed to the basic sup- injury on one side and a vertically unstable injury on the
ports, the diastasis is eliminated, and the apparatus other is classified as 61-C2. A bilateral vertically unstable
stabilized. injury, which is the most complex injury, is classified as
In partially stable (rotationally unstable, vertically stable) 61-C3. These injuries are accompanied by stretching or rup-
injuries to the pelvic ring, the ligaments of the pelvic poste- ture of the sacral plexus roots and damage to the pelvic dia-
rior segment are partially preserved, as the vertical displace- phragm, bladder, vagina, and rectum.
ment of the hemipelvis is absent. In these cases, sufficient Fixation and repositioning of the anterior pelvic segments
stability of the osteosynthesis may be achieved by fixation of alone in this kind of injury will not restore the anatomic
the pelvic anterior segments using a “fore frame.” interrelationships in the posterior segments of the pelvic
In injuries of the “open book” type, the hemipelvis is ring, neither will it provide sufficient stability for early mobi-
rotated outward (Fig. 21.5). The device is assembled in a lization of the patient. Successful treatment of these injuries
hypercorrection position with the arches turned towards each involves early repositioning and fixation of the posterior
other at an angle of 10–15°, with the angle open cranially. parts of the pelvis.
Under fluoroscopic control, a single-step reduction of a In unilateral injuries (Fig. 21.12), skeletal traction is
rough displacement is performed using supports. Following applied in order to reduce displacement of the injured half of
the alignment of these supports relative to each other, the the pelvis. An anterior frame device is then applied and the
final reduction is carried out. pelvis stabilized in this newly achieved position. The patient
In partially stable fractures, lateral compression (61-B2 is then turned on his or her side. The arch of the anterior
by the AO/ASIF classification) results in damage to the ante- semi-frame must be located in the recess of the orthopedic
rior parts of the pelvis in the form of rupture of the pubic table. Anterior and posterior semi-bow devices are connected
joint or fracture of the pubic and ischial bones with the frag- to form a circular pelvic support. Into each posterior third of
ments overlapping each other. Persistence of the damaging the iliac crests, a half-pin is inserted. In obese patients and
force causes damage to the lateral mass of the sacrum or a when there is considerable displacement, up to three half-
vertical fracture of the posterior segments of the ilium. The pins can be inserted on each side in the space between the
ligaments of the sacroiliac joint will remain intact whereas posterior-upper and the posterior-lower spines of the ilium.
the hemipelvis will be displaced inward and backward. The The half-pins are attached by arms to the respective supports
total volume of the pelvis will not increase. of the device.
In the first stage, supports should be applied to the iliac The posterior supports should be connected to each other
wings, positioning them at an angle of 10–15°, opened cau- by plates and threaded bars, enabling further correction of
dally. The pelvic wings are then moved apart 2–3 cm and the any remaining pelvic displacement. First the supports should
Fig. 21.4 (a–e) External fixation at fractures 61-A2.3 (a) Insertion of half-pins and assembly of the supports. (b) Reduction hinge assembly,
distraction, and detorsion. (c) Insertion of half-pins into pubic bones
Fig. 21.4 (continued) (d) “Butterfly” reduction using half-pins. (e) Diastasis elimination and device stabilization
be moved apart until a diastasis is obtained, then the injured If both sacroiliac joints are damaged, half-pins are inserted
half of the pelvis is brought down in the vertical and antero- into the lateral masses of the sacrum. If bone needs to be
posterior direction. Radiographs in two planes are obtained, lowered, for example the left hemipelvis, then reduction is
and the posterior and anterior parts of the pelvis are brought facilitated by attaching the support mounted on the right
together. After reduction, supportive compression is applied hemipelvis to the operation table with a special add-on device
to the posterior and anterior semi-ring devices. (Fig. 21.10).
2 3
1
Fig. 21.5 (a–e) Reduction of unilateral injuries to the pelvis of the enable elimination of both the diastasis and the rotational component of
“open book” type: 61-B1 (a) General scheme of carrying out an osteo- the deformation (4). (b) Half-pins insertion, support installation
synthesis (1, 2, 3) and schemes of the reduction unit. Together they
Fig. 21.5 (continued) (c) Installation of the second support. (d) Reduction hinge assembly. (e) Diastasis elimination and device stabilization
Reduction of acute injuries is completed on the opera- Therefore, if only the anterior pelvis is injured
tion table. The reduction using a device may be considered (61-B1.1), i.e., rotational damage of a posterior half ring
satisfactory if: (1) the remaining displacement in the pos- (61-B1.2), then arched and semicircular devices should be
terior parts is not >0.5 cm; (2) the remaining displacement used. Biomechanical studies have shown that devices of
in the anterior parts is not >1.5 cm, including displacement this type do not prevent pathological mobility of the sacro-
at the level of the pubic joint, which should not be >1 cm; iliac joint [94]. Therefore semicircular configurations can
(3) the asymmetry of the hip joints relative to the sacrum be applied only in the absence of vertical instability (61-
is not >2 cm. B1.3, 61-B2).
Fig. 21.6 (a, b) Scheme for reduction of unilateral injuries to the pelvis elimination. Therefore, these reduction units can be used by turns. (b)
of the “open book” type: 61-B1 (a) This reduction unit does not enable Depending on bone structure (presence of osteoporosis), the amounts
the elimination of a rotational component of the displacement. However of time from the moment of damage for fixing each support with 2–5
it possesses the best, compared with Fig. 21.5, possibilities for diastasis half-pins should be used
Fig. 21.7 (a–d) Reduction of unilateral pelvic injuries of the “lateral compression” type: 61-B2 (a) The general arrangement of the osteosynthe-
sis. (b) Half-pin insertion, installation of the supports. (c) Reduction unit assembly. (d) Closed reduction and device stabilization
In vertically unstable injuries (61-C), only ring devices 21.2.4 External Fixation of Acetabular Fractures
should be used. In addition, the greater the time since the
injury, the more rigid the assembly must be, which is achieved As an urgent osteosynthesis or for transport immobilization,
using additional wires and half-pins in the assembly. the simplest apparatus is used (autonomous skeletal trac-
Vertically unstable injuries should be reduced gradually tion), as shown in Fig. 21.15f.
and in the following order [355]: In the first stage, the pelvic ring configuration is restored
1. Diastasis is created in the posterior segments. by moving the pelvic half-supports relative to each other in
2. Vertical (cranial) displacement of the posterior segments accordance with the procedures described above. Closed
is eliminated. reduction of the fracture is performed under fluoroscopic or
3. Displacement in the sagittal plane (anteroposterior) is radiographic control. Reduction of the acetabular fragments
eliminated. in simple fractures, in which there is one large fragment, is
4. Rotational displacement in the anterior pelvic segments is achieved by traction on the respective part of the hip joint
eliminated. capsule, by pulling the femur (Fig. 20.23).
5. Diastasis in the posterior segments is eliminated. In displacements of the posterior column of the acetabu-
6. The apparatus is stabilized. lum, traction is applied in the position of maximal internal
Fig. 21.8 (a–d) The osteosynthesis scheme in bilateral rotational this simplifies installation of the reduction unit. The stability of the
damage with differently directed displacements: 61-V2.2: the “crum- reduction unit can be increased by placing an additional plate at the
pled book”. (a) Supports and reduction unit assembly. In this basis of the U-shaped reductional unit. In this case, this unit will resem-
configuration, the supports should be located in a horizontal plane, as ble a parallelogram
c
b
Fig. 21.8 (continued) (b) Displacement elimination and device stabi- the supports. However, in this case all hinges of the reduction unit
lization. (c) In contrast to the scheme shown in (a), the base supports should be two-plane. (d) Displacement elimination and device stabili-
are located at a 20–30º angle to the horizontal plane. This slightly zation, similar to (b)
reduces the bulkiness of the frame and simplifies fixing the half-pins to
a b
c
d
Fig. 21.9 (a–f) Closed reduction of bilateral rotationally unstable pelvic internal oblique projection before reduction (e) A-P roentgenogram after
damage (a) Bilateral rotationally-unstable pelvic damage (b) The exter- reduction. (f) Roentgenogram obtained in an internal oblique projection
nal fixation device with the original reduction unit has been applied. (c) after reduction
A-P roentgenogram before reduction. (d) Roentgenogram obtained in an
3 rotation. In displacements of the anterior column, the hip is

maximally abducted with up to 90° of flexion and maximally
2 rotated outwards. In complex fractures with displacement of
dissociated posterior and anterior columns (T-form and two-
column fractures), successive repositioning and fixation of
the acetabular columns is performed. First, with the aid of
half-pins and traction on the hip, the anterior column is reset
and fixed, and then the direction of traction is changed to
reset the posterior column. In fractures of the anterior col-
umn of the acetabulum, the fracture line may have spread to
1
the iliac wing. In these cases, two half-pins are inserted into
the intact parts of the ilium near the sacrum. The fragment of
the anterior column is separately fixed after a preliminary
repositioning (Fig. 21.16) [356].
To transfer the reduction force directly onto the fragment,
the femoral head and the displaced acetabular fragment are
attached to each other with wires to form a single block.
A half-pin is inserted into the acetabulum and temporary reduc-
tion is achieved by moving the femur/fragment block in the
necessary direction. Following successful reduction, the frag-
ments are fixed to each other with half-pins, wires, and screw
inserted under fluoroscopic control through a small incision.
Fig. 21.10 The add-on device for attachment of the apparatus to the
Next, the repositioning wires are removed and the hip is put
operation table comprises two bars (1, 2) and connecting half-pins (3).
Bar 1 is attached to the operation table, half-pins 3 are connected to the into the physiologically neutral position (Fig. 21.17), i.e., 20°
apparatus’ external support, and bar 2 is moved relative to the latter. of flexion in the hip joint, 0° of abduction and rotation [357].
(From [93])
Fig. 21.11 (a–d) The general arrangement of a 61-C1 injury osteosynthesis (a) The general arrangement of the osteosynthesis. (b) Assembly of
the supports
Fig. 21.11 (continued) (c) Installation of the reduction unit. (d) Displacement elimination and device stabilization
Fig. 21.12 (a–d) General arrangement of a 61-C1 injury osteosynthe- transferred to a ring type, followed by displacement elimination and
sis (a) The general arrangement of the osteosynthesis. If a one-stage stabilization of the frame. If transfer to a ring type is realized, the sup-
reduction is not possible (serious condition of the patient, inveterate ports of the fore semi-frame should be initially assembled in a horizon-
injury), the first stage is pelvic stabilization with the aid of an anterior tal plane, unlike in the scheme presented in Fig. 21.10
semi-frame, similar to that in Fig. 21.10. The device should be
Fig. 21.12 (continued) (b) Assembly of the supports and reduction bilization. The fore semi-frame should be stabilized by means of two
units. Note that at this stage the anterior reduction unit is not completed threaded rods, with the rear one positioned at the expense of placing the
with threaded rods, unlike in Fig. 21.10. (c) Reduction. (d) Device sta- traction rod at an angle of 90º to the plate of the reduction unit
Fig. 21.13 (a–l) Osteosynthesis in a 61-C1 injury. (a) General arrangement of the steps of the osteosynthesis
Fig. 21.13 (continued) (b) Insertion of half-pins in the iliac wings and This stage is carried out as antishock action if it is not possible to assem-
assembly of the anterior supports. (c) Skeletal traction is applied, fol- ble the full frame. (d) Installation of the anterior reduction unit. Partial
lowed by partial installation of the anterior reduction unit (similar to a2). elimination of torsion and vertical displacement, (similar to a3)
Fig. 21.13 (continued) (e) Insertion of half-pins in the rear thirds of the iliac bones. (f) Installation of the rear segments of the supports.
(g) Installation of the rear reduction unit
Fig. 21.13 (continued) (h) The biomechanics of reduction in the dif- will be an internal rotation of the support (and a hemipelvis fixed to it).
ferent variants of installation of the rear reduction unit. If the lever is If the lever is fixed medial of the half-pin (3) together with lifting there
fixed in a plane of insertion of a half-pin (h1, g), in its operation there will be an external rotation of the support (and a hemipelvis fixed to it).
will be plane-parallel movement of one support relative to another. If (i) Creation of the diastasis in the posterior part (similar to a4)
the lever is fixed lateral to the half-pin (2), together with lifting there
Fig. 21.13 (continued) (j) Elimination of vertical displacement (similar to a5). (k) Elimination of displacement in the area of an anterior pelvic
half-ring
Fig. 21.13 (continued) (l) Elimination of the “posterior” diastasis and stabilization of the device
Fig. 21.14 (a–f) External fixation of vertically-unstable pelvic damage. (c) A-P roentgenogram after reduction. (d) View of the posterior
age (a) A-P roentgenogram showing vertically unstable pelvic damage reduction unit. (e) A-P roentgenogram showing the result of treatment.
(b) Internal oblique roentgenogram of vertically-unstable pelvic dam- (f) Result of treatment as seen on an internal oblique projection
a b
c d
f
a b
c d
Fig. 21.15 (a–f) External fixation at 62-B (a) Insertion of half-pins 70–75° and the application of traction force at an angle of 110–115° to
and assembly of the pelvic support. (b) Assembling the support on the the anatomic axis of the femur decrease the risk of forcing out the half-
femur: VII,3-9; VII,10-4. (c) Connection of the supports and distrac- pin and is biomechanically superior in bringing the proximal part of the
tion. (d) Insertion of half-pin I,9,70, which is fixed with the aid of a femur outwards
traction clip to a remote bar. Insertion of the half-pin at an angle of
Fig. 21.15 (continued) (e) Elimination of the dislocation of the proximal part of the femur and stabilization of the device. (f) The reduction of
transverse acetabular fractures and ruptures of the sacroiliac and pubic joints (the posterior repositioning unit is not shown)
a b
Fig. 21.16 The reduction of high (a) and low (b) fractures of the anterior column of the acetabulum
a b c
Fig. 21.17 Repositioning acetabular fragments with a “single-block” external fixation device. (a, b) Prior to and after manipulation; (c) internal
fixation of the fracture with a screw inserted transcutaneously
a b
c d
Fig. 21.18 (a–d) Closed reduction of the acetabulum by “single- nal fixation frame. (c) Synthesis of the fractures by screws, using a
block” fixation (a) Transversal fracture of the acetabula, pubic bones, minimally invasive method (through punctures under fluoroscopy con-
and femoral necks. (b) Closed reduction of a transverse acetabular frac- trol). (d) Result of treatment at 1 year
ture by “single-block” fixation and synthesis of the pelvis by the exter-
The operation is completed by releasing the soft tis- Table 21.1 Classification of pelvic post-traumatic deformities (From [359])
sues around the transosseous elements: the skin is incised, Type of disorders in the posterior pelvis
displaced relative to the wires (or half-pins), and then Unilateral Bilateral
resutured.
When it is impossible to perform full fixation, e.g., in a Simple Combined
patient with massive casualties on admission, or because of
the seriousness of the victim’s condition, the “fixation” vari- Vertical-rotational
(vertical) Rotational
ant of external fixation is performed (Figs. 21.11, 21.4, and
21.6). In these cases external fixation should be combined Stable Unstable Stable Unstable
with conservative treatment: lying by Volkovich (“frog”
The grades of hip-joint displacement:
position), “hammock,” skeletal traction. In the second stage
I. Asymmetry of the hip joints up to 1 cm or no asymmetry
frame should be fully completed or internal fixation should be II. Asymmetry of 1–2 cm
done. III. Asymmetry >2 cm
The aim of surgical treatment is to eliminate the asym-

21.3 External Fixation of Malunited Pelvic metry of the hip joints and to stabilize the pelvic ring in the
Fractures and Pelvic Deformations correct position. If the deformity is evaluated as stable, then
application of the device is preceded by osteotomy. As a rule,
In patients with traumatic deformities of the pelvis, particular an unstable deformity requires an additional stage of open
attention should be paid not only to their orthopedic status but intervention in the zone of poor consolidation after correc-
also to their neurological and urogenital status. It is advisable tion in the device, especially when the deformity includes
to find out the reason for any pain or inability in weight-bear- old ruptures of joints.
ing and to take the patient’s wishes into consideration [358]. In rotational deformities, the asymmetry of the hip joints
Instability of the pelvic ring can be determined clinically by does not, as a rule, exceed 2 cm and the instability is most
pressing upon the pelvic wings in different directions. However, often associated with an old rupture of the pubic joint or
it is important that the instability is confirmed by functional incomplete consolidation of the fragments in the anterior
radiographic tests, which include standing in turn on each leg, pelvis. This makes closed elimination of the pelvic defor-
or lying with the legs apart with weights attached and bent at mity possible by means of a slight turn of the hemipelvis in
the knees and hips. Relative movement of the pelvic halves the device at the level of the sacroiliac joint. In vertical defor-
more than 5 mm indicates instability of the pelvic ring. mities, the asymmetry of the hip joints often exceeds 2 cm
The direction of the displacement of the hemipelvis indi- and is due not only to rotation of the innominate bone but
cates whether the deformity is vertical or rotational (Table 21.1; also to cranial displacement of the posterior pelvis. Therefore,
Fig. 21.19). restoration of the extremity length by correction of the
Rotational deformity implies a change in the shape of the hemipelvis might prove ineffective without also correcting
pelvic ring as a result of rotational displacement of the innom- the displacement of the posterior pelvis.
inate bone relative to the sacrum in one of the three planes; for Hence, asymmetries less than 2 cm can be eliminated by
example, an old rupture of the sacroiliac and pubic joints fol- correcting the rotational displacement of the innominate
lowing injury of the “open book” type. Vertical deformity bone, and in greater asymmetries by correcting the vertical
implies a change in the shape of the pelvic ring when, along displacement of the posterior half of the pelvis. Stable verti-
with rotation, there is cranial displacement of one of the cal deformities can be corrected with the aid of osteotomy of
innominate bones at the level of the posterior pelvis; for exam- the lateral mass of the sacrum laterally relative to the sacral
ple, an incorrectly consolidated fracture of the sacrum lateral foramens and the pubis and ischium. In unstable injuries,
masses with cranial displacement of the hemipelvis, or an ipsi- osteotomy of the posterior segments may be omitted if there
lateral false joint of the pubis and ischium. is an obvious (>5 mm) vertical mobility in the pelvis’ poste-
The degree of pathological mobility of the hemipelvises can rior segments, as confirmed by functional testing.
indicate whether a deformity is stable or unstable. Instability may Mainly the frame configurations presented in Chap. 21.3 are
be associated with joint rupture, false joints of the innominate used. The feature of the devices employed in the osteosynthesis
bone and the sacrum, and with incomplete consolidation of incor- of inveterate pelvic damage is the use of a greater number of
rectly consolidated fractures within 6–8 weeks of the injury. half-pins. In urgent fractures of the anterior third of the wings
The indications for surgical treatment in old injuries of the iliac bones, 2–3 half-pins are inserted, and into the pos-
include: vertical deformities of the pelvis of grade II or III terior third one half-pin. In patients with inveterate damage,
irrespective of the stability grade; unstable rotational defor- accordingly, 3–4 and 2–3 half-pins should be used. In addition,
mities of the pelvis of grade II or III; and stable rotational stabilizing half-pins in the anterior-inferior spine and supra-
deformities of the pelvis of grade III. acetabular area are inserted. When deformation is eliminated
closely, without osteotomies, the use of half-pins with a shaft rotation in the sagittal plane) or abduction or adduction (rota-
diameter of 8 mm is necessary. Supports should be applied in tion in the frontal plane) relative to the sacrum. The actual
the “hypercorrection” position. These assemblies must be position will be a combination of these various types of dis-
equipped with reinforced reductional units. placement, but it is always possible to determine the most
Surgical treatment is performed in several steps. In unsta- obvious components of the deformity in order to successively
ble deformities of the pelvis, the first step involves closed eliminate them.
restoration of the shape of the pelvic ring with the aid of an The external supports of the device should be positioned
external fixation device. in hypercorrection relative to the present displacement of the
Rotational deformities of the pelvis result from rotationally hemipelvis, and then connected to each other with a reposi-
unstable fractures of the pelvic ring as well as from vertically tioning node in order to eliminate the rotational displacement
unstable fractures of the pelvis if, during treatment, the cranial in the sagittal plane, which makes it possible to eliminate the
displacement of the hemipelvis was eliminated. Furthermore, leg length discrepancy (Fig. 21.5).
the innominate bone may also be rotated inward or outward Displacement of the hemipelvis is started on the second
(in the horizontal plane) in flexion (basket-handle type injury: postoperative day at the rate of 1 mm four times a day, at the
Fig. 21.19 (a–e) Examples of variants of pelvic deformations. (a) Unilateral vertical. (b) Bilateral combined
Fig. 21.19 (continued) (c) Rotationally unstable. (d) Rotationally stable
same time as mobilization of the patient without loading the destroyed. There is vertical displacement of the pelvic
injured side. Therapeutic exercises are prescribed and phys- half ring with stretching or rupture of the sacral plexus
iotherapy if there is pain. After the anterior parts of the pelvis roots.
have been lowered, as confirmed by serial radiographs, the In the absence of obvious vertical mobility of cranially
repositioning node is reassembled to bring the parts together displaced posterior parts of the pelvis, in the first stage,
and to provide compression in the horizontal plane. osteotomy of the sacrum is performed (described below) and
Elimination of the deformity is followed by the rigid connec- half-pins are inserted into the posterior spines of the iliac
tion of the supports of the anterior and posterior parts, thus bones. The patient is then turned on his or her side and half-
enabling full loading of both lower extremities. pins are inserted into the anterior parts of the pelvis. The
In old ruptures of the pubic joint, synthesis is achieved supports of the device are installed with hypercorrection
using a tendon allograft or a plate, without disassembling the relative to the present displacement of the hemipelvis, and
external fixation device. If there is limited contact between then attached to each other with reduction nodes in the front
the pubis and ischium, osteosynthesis is achieved using a and in back for creation of a diastasis in the osteotomy area.
plate. The fixation device must remain in place for not less If vertical mobility is present in the posterior parts, then
than 3 months after the final stabilization of the fragments, osteotomy is not required.
until consolidation is confirmed radiographically. Gradual distraction at a rate of 1 mm four times a day is
In unstable vertical deformities of the pelvis, the integ- started after the elimination of pain on postoperative day
rity of the posterior bone–ligament complex is completely 3–5, at the same time as mobilization of the patient without
Fig. 21.20 Elimination of cranial displacement
Fig. 21.21 Elimination of anterior-posterior displacement
loading the injured side. Therapeutic exercises and physio- displacement, as described above. Compression is applied
therapy are prescribed. If obvious pain or signs of irritation between the fragments, while the device is stabilized
of segments S1–S3 roots develop, the rate of displacement (Figs. 21.13k, l and 21.22).
must be reduced to 1 mm/day or the distraction temporarily Internal fixation of the pubic bones and symphysis is
halted. Traction of the posterior parts is performed until a achieved using plates. Final stabilization of the position
diastasis of 10–15 mm is produced. achieved is maintained by forming an ileosacral block with
In the next stage, the posterior reduction node is pulled one or two compressing screws inserted under fluoroscopic
into a vertical position for gradual elimination of the cra- control via the ilium into the sacrum.
nial displacement of the hemipelvis. The distraction rate In stable deformities, the surgery proceeds in three
is 0.25 mm four times a day (Fig. 21.13i, j and 21.20). stages:
Following the vertical alignment of the posterior ilium 1. Mobilizing osteotomy in the areas of incorrect
relative to the sacrum, if necessary the anteroposterior consolidation.
displacement is eliminated (Figs. 21.12 and 21.21). The 2. Gradual correction of existing displacements using an
final stage of correction involving the anterior reposition- external fixation device.
ing node is elimination of the remaining rotational 3. Internal fixation.
Fig. 21.22 Creation of compression between fragments after elimination of rotational displacements
For osteotomy of the anterior pelvis and lateral areas of is made 2–3 cm lateral to the symphysis over the horizontal
the sacrum, the open method is applied or a minimally inva- branch of the pubis. Its anterior upper aspect is exposed by
sive approach under fluoroscopic control. Prior to osteotomy, blunt and acute dissection. Osteotomy is performed with a
the device is installed or, as a minimum, the transosseous chisel under the protection of elevators inserted along the
elements are inserted. anterior and posterior aspects of the pubic bone. The wound
Osteotomy of the sacrum is performed with the patient is sutured.
lying prone. Under fluoroscopic control in two planes, X-ray In stable vertical deformities of the pelvis, immobility of
contrast marks (injection needles) are inserted to mark the the cranially displaced hemipelvis is due to incorrect con-
upper and lower margins of the lateral mass of the sacrum, and solidation both in the anterior and in the posterior pelvis. In
the incision line is drawn with the aid of the marks. An inci- some cases, in spite of consolidation of the anterior pelvis
sion of 1.5–2 cm is made parallel to the posterior iliac spines and the absence of clinical or radiographic signs of instabil-
0.5–1 cm inwards. The posterior- superior part of the lateral ity of the pelvic ring, there is a false joint of the lateral mass
mass of the sacrum is opened bluntly and sharply. Sacral proof the sacrum that can be revealed only by tomography. To
tectors are placed in front and behind. Between the protectors, eliminate this type of deformity, osteotomy is necessary not
osteotomy of the sacrum lateral of the sacral foraminas, under only of the sacrum but also of the pubis and ischium, gener-
two-planed fluoroscopic control, is done. The chisel must not ally on the side of the greater displacement.
protrude onto the anterior surface of the sacrum for more than The operation is performed in three steps under general
2–3 mm. Finally, evident mobility of the dissociated frag- anesthesia on an X-ray-negative operation table using
ments must be achieved. The wound is sutured layer by layer. fluoroscopy. In the first step, with the patient supine, osteot-
Osteotomy of the ischium is also performed with the omy of the pubic bone is done. The second step involves
patient lying prone. The ischial tuberosity is found by palpa- turning the patient to the prone position for successive
tion. An incision of 1–2 cm is made along the gluteal fold osteotomy of both the ischium and the lateral mass of the
1–2 cm medially from the ischial tuberosity apex. The sacrum. Once clear mobility of the hemipelvis is achieved,
ascending branch of the ischium is isolated by blunt dissec- half-pins are inserted into the posterior spines of the iliac
tion. Osteotomy is performed medial to the ischial tuberosity bones. In the third step, with the patient lying supine and a
for 1–2 cm. The wound is sutured. recess at the level of the pelvis, half-pins are inserted into the
Osteotomy of the pubis is performed with the patient lying anterior parts of the innominate bones, and the device is
supine, with a catheter in the bladder. An incision of 1–2 cm assembled.
Fig. 21.23 Ileosacral blocking

with a compression screw
Assembly of the device, the beginning and the rate of dis- determined. The wire should be oriented perpendicular to the
traction, the order of displacement elimination, final stabili- sacroiliac joint, remaining outside the projections of the
zation of the pelvic ring with internal half-pins, and the sacral foramina and not exiting beyond the limits of the con-
amount of time the device remains in place are analogous to tour of the sacral vertebrae.
those for stable vertical deformities. The incision is situated 1–2 cm distal from a position at
Internal fixation of the bones and joints is performed the border of the middle and lower thirds of the line connect-
using reconstruction plates. The use of allotendoplastics for ing the anterior upper and posterior upper iliac spines.
fixing the pubic symphysis is possible. Through an incision of 10–15 mm, with the use of a protec-
In old ruptures of the pubic joint, after the pubic bones tor, a canal parallel to the guide-wire is formed using a chisel,
are joined, an ultrasound examination is necessary as is an and into this canal a compressing spongy screw of 7–7.3 mm
examination of the bladder after administration of contrast diameter is inserted (Figs. 21.23 and 21.24). The wound is
agent, in order to rule out its entrapment. Subsequently, sutured. The use of cannulation spongy screws considerably
osteosynthesis is performed with the immersed construc- facilitates the performance of this task.
tions (plates, implants with shape memory). The device is It is important to note that in old ruptures of the joints,
not disassembled and the fixation is continued for another after removal of the constructions, a loss of reduction will
3 months. occur even after prolonged fixation. Therefore it is recom-
One of the most difficult tasks in the treatment of mended that internal fixation be performed after reduction is
patients with post-traumatic deformities of the pelvis is achieved. Analogously, internal fixation should be done in
the elimination of the pathological mobility of the poste- situations of probable non-union at the fracture level, i.e., in
rior segments that can occur at the sacral level, or at the the presence of a considerable diastasis or a longstanding
level of the sacroiliac joint or the ilium. If there is a non-union.
malunion or a non-union of the ilium, osteosynthesis is Situations in which pelvic deformation leads to unit
done with plates and screws. In instability at the level of shortening (seeming shortening) of the lower limb are fre-
the sacroiliac joint or lateral mass of the sacrum, an ileo- quent. Currently, there is no unequivocal strategy to correct
sacral block is formed by the insertion of a compressing this kind of limb discrepancy not at the expense of pelvis
screw via the ilium and the sacroiliac joint into the body of deformity correction but by lengthening of the femur or
the first or second sacral vertebra. This operation is per- lower leg. We cannot rule out that in some cases “non-pel-
formed at the final stage of treatment, when all the dis- vic correction of pelvic deformities” may be an alternative
placements have been eliminated with the aid of the to orthopedic footwear or when pelvic deformity correction
external fixation device. is impossible for any reason. However it is necessary to
The operation is carried out with the patient lying supine remember, that similar corrections do not solve the problem
on an X-ray-negative table with a recess for the ring support of a compensatory (secondary) spinal deformity. Therefore
of the apparatus. Under general anesthesia, under fluoroscopic this “treatment” of a pelvic deformity can be compared to
control in two projections and with the aid of a preliminarily the attempted treatment of a scoliosis using lower limb
inserted guide-wire, the place for half-pin insertion is lengthening.
a b
c d
e
f
Fig. 21.24 Stages of treatment of a traumatic deformation of the pelvis. (a) The initial roentgenogram. (b) After device arrangement and osteot-
omy of the right ilium, pubic bone, and ischium. (c, d) Deformity correction. (e, f) Change to internal fixation
21.4 Postoperative Recommendations joint can be started depends on the character of the injuries
and the completeness of the surgical restoration of the joint
Following osteosynthesis of the pelvis with ring devices, a anatomy. In full reduction with stable fixation of the acetabu-
special trolley and bed with a recess for the assembly are lar fragments with a pelvic support and half-pins, movement
required. If the assembly consists of anterior half-rings alone, training can be started after removal of the femoral support,
there are no special recommendations for the patient’s 3 or 4 weeks after device stabilization. The time for fixation
recovery in a bed. The bed must allow the patient access to of pelvic fractures is 6–8 weeks. In “clean” ruptures of the
personal items and the prophylaxis of bed sores. Also, it joint with no internal fixation, the device cannot be disas-
must be equipped with a Balkan frame to which the assem- sembled before 3 months.
bly can be temporarily attached with damper springs to Partial weight-bearing on the injured side is permitted
enable comfortable therapeutic physical exercise. If in very after completion of all the interventions, with a gradual
unstable injuries (61-C3) the assembly did not include the increase, in the presence of extra-articular damage, to full
insertion of half-pins into the posterior lower spine or the weight-bearing within a month.
sacrum, then to avoid secondary pelvic displacement skeletal The fixation device must remain in place 8–12 weeks
traction via the femoral condyles must be applied [94]. after final stabilization of the fragments, until consolidation
The transosseous elements should be maintained in the is confirmed radiographically following functional clinical
same way as described for the Ilizarov apparatus. Dressings testing.
are changed using antiseptic agents, daily during the first On the planned day for removal of the assembly, a func-
2 weeks and then once a week. tional test is performed. The reduction nodes are removed or
Any remaining fragment displacement is eliminated start- loosened, and the patient is asked to walk with a full load for
ing on postoperative day 2 or 3 at a rate of 1–4 mm/day 30–60 min. If there is no pain and the hemipelvises show no
(0.25–1 mm four times daily). mobility, the assembly is removed. Following disassembly,
The patient starts mobilization as the pain subsides, and in crutches (or a cane) are recommended again for walking. If
relation to the seriousness of the injury and the stability of there is no pain, weight-bearing should be increased to the
the fixation. Mobilization can start on the second day in sim- functional load within 3 weeks. Partial weight-bearing of the
ple injuries, and by the end of the third week in serious inju- extremity operated upon in acetabular fractures should take
ries. First the patient is encouraged to sit, and then to walk place not before 3 months after osteosynthesis, and full
with crutches. If repositioning of the displaced bone is good weight-bearing not before 4 months. Clinical restoration of
and the fixation is sufficiently rigid, the patient should be the pelvic anatomy is confirmed radiographically. The appro-
able to walk painlessly with a cane in 3–8 weeks. In acetabu- priateness of using support belts, braces, or bandages is
lar fractures, the time at which movement training of the hip addressed on an individual basis.
Foot and Hand
22
Alexander Kirienko, Leonid Nikolaevich Solomin,
Natalya Grigorjevna Shikhaleva, Vladimir Ivanovich Shevtsov,
Mikhail Jur’evich Danilkin, and Konstantin Andreevich Ukhanov
This chapter presents the fundamentals of external fixation in allow a specific frame configuration to be constructed for
fractures, fracture-dislocations of the foot and hand, and in the reduction and stabilization of a particular fracture type
the correction of foot and hand deformities. in a particular part of the foot and hand. The following sec-
The Ilizarov external fixation technique, being mini- tions illustrate various external fixator configurations
mally invasive, does not add any surgical insult to the employed for the treatment of different types of foot and
patient. It therefore allows control of pain, is associated hand injury and deformity. Important features of surgical
with less bleeding, and facilitates nursing care particu- technique are described in a comprehensive step-by-step
larly in patients with polytrauma including of the foot and manner.
hand. It provides efficient fracture stabilization and the
possibility of indirect fracture or fracture-dislocation
reduction based on the principle of ligamentotaxis. It can 22.1 Reference Lines and Angles of the Foot
be used as a temporary foot-stabilizing device in com-
pound fractures until the condition of the surrounding soft Leonid Nikolaevich Solomin
tissue allows major reconstructive procedures to be per- and Konstantin Andreevich Ukhanov
formed [360].
In the presence of acute or chronic foot and hand infec- The reference lines and angles (RLA) of the foot are pre-
tions, Ilizarov external fixation may be the ultimate method sented in Figs. 22.1, 22.2, 22.3, 22.4, 22.5, 22.6, 22.7, 22.8,
of stabilizing an infected fracture or non-union, as the pins 22.9, 22.10, 22.11, and 22.12. They help in the assessment of
are inserted away from the infection focus. Ilizarov external fractures and dislocations, and are essential for the correc-
fixation is a versatile system, with different components that tion of foot deformities.
A. Kirienko, M.D. (*) V.I. Shevtsov, M.D., Ph.D.

External Fixation Division, Istituto Clinico Humanitas, Department of Orthopedics,
Via Manzoni 56, Rozzano, Milano 20089, Italy The Russian Academy of Medical Sciences,
e-mail: alexander@kirienko.com, alexander.kirienko@humanitas.it Soljanka Str., Moscow 14109240, Russia
L.N. Solomin, M.D., Ph.D. M.J. Danilkin, M.D., Ph.D.
External Fixation Department, R.R. Vreden Russian Department of Hand Surgery,
Research Institute of Traumatology and Orthopedics, Russian Ilizarov Scientific Center “Restorative
8 Baykova Str., St. Petersburg 195427, Russia Traumatology and Orthopedics”, M. Uljanova Str., 6,
e-mail: solomin.leonid@gmail.com Kurgan 640014, Russia
N.G. Shikhaleva, M.D., Ph.D. K.A. Ukhanov
Department of Hand Surgery, Russian Ilizarov Scientific Center Department of Orthopedics,
“Restorative Traumatology and Orthopedics”, Central Regional Hospital,
M. Uljanova Str., Kurgan 6640014, Russia Urotskogo Str., Gatchina 188300, Russia
970 A. Kirienko et al.
a b
24,5°
22° 24,5°
28° 22°
28°
130° 130°
c
125-130°
Fig. 22.1 (a–c) Normal foot morphology. (a, b) The angle between dinal axis of the talus and the anatomic axis of the tibia in a vertical
the longitudinal axis of the calcaneus and the forefoot is 130°; the peak position (From [469]). (c) To find the angle of the longitudinal arch of
of this angle is at the proximal part of the Chopart joint. The angle the foot, according to F.R. Bogdanov two lines should be drawn: the
between the horizontal plane and the metatarsal/forefoot axis is 22°. first on the bottom contour of the calcaneus, the second lengthways
The hindfoot angle between the horizontal plane and the axis of the heel from the head of the 1st metatarsal. The average crossing angle of these
is 28°. The angle between the talar axis and the horizontal plane is lines should be 125–130° (From [362])
24.5°. This inclination results in an angle of 115° between the longitu-
25°
a 15-20° b
c 5-15°
Fig. 22.2 (a–c) Normal foot morphology. (a) The angle between the head of the first metatarsal and the lower edge of the navicular bone, and
axis of the first metatarsal and the horizontal plane is 15–20° (From the horizontal plane is 25° (From [363]). (c) The angle of supination of
[361]). (b) The angle between a line tangent to the plantar surface of the the forefoot according to M.I. Kuslik should be 5–15° (From [362])
22 Foot and Hand 971
a b c
20−40°
25−28° 15−20°
Fig. 22.3 (a–c) Normal foot morphology. (a) Calcaneal-bearing angle. angle) is evaluated on lateral radiographs. It is indicated by a line drawn
The axis of the calcaneus crosses the horizontal plane at an angle of from the highest point of the anterior process of the calcaneus to the
25–28°. (b) Angle of the calcaneus. The angle between the line tangent highest point of the posterior facet and a line drawn tangentially to the
to the plantar surface of the calcaneus and the line of the horizontal superior edge of the tuberosity. The angle is normally 20–40° (From
plane is 15–20° (From [244, 363]). (c) The Böhler angle (tuber-joint [244])
a b c
110°(106−114°)
24,5°
50°
Fig. 22.4 (a–c) Normal foot morphology a The angle between the ver- between the talar axis and the horizontal plane is 24.5° (From [469]).
tical line and the talar axis in the sagittal plane is 110° (106–114°) (c) The talo-calcaneal angle formed by the two axes of the talus and
(According to Sinai Hospital of Baltimore, 2010). (b) The angle calcaneus is 50° (From [363])
a b
88°(85-91°)
5°(1-9°)
c d
84°(79-89°) 76°(70-82°)
78°(73-83°)
Fig. 22.5 (a–d) Normal foot morphology (According to Sinai Hospital first proximal phalanx in the sagittal plane. The anatomic proximal dor-
of Baltimore, 2010). (a) The angle between the talar axis and the first sal angle is 84 (79–89)°. The anatomic distal dorsal angle is 78 (73–
metatarsal bone in the sagittal plane is 5 (1–9)°. (b) The anatomic prox- 83)°. (d) The anatomic proximal dorsal angle of the first proximal
imal dorsal angle of the first metatarsal bone is 88 (85–91)°. (c) The phalanx is 76(70–82)°
a b
d e
Fig. 22.6 (a–e) Normal foot morphology. (a) The calcaneus and also on the same line. (d) The dorsal edges of the medial cuneiform and
cuboid bone are aligned along the same lateral border line. (b) The the first metatarsal around the joint are on the same line. (e) In the talo-
medial edges of the talonavicular joint, the first cuneonavicular joint, navicular joint, the two centers of the joint surfaces correspond (From
and the Lisfranc joint are on the same line. (c) Their dorsal edges are [364])
a b c
80°(78-82)°
89°(86-92)°
90°(7-11)°
Fig. 22.7 (a–c) Normal foot morphology (According to Sinai Hospital (78–82)°. (c) The axis of the ankle joint passes through the tips of the
of Baltimore, 2010). (a) The anatomic distal lateral angle of the tibia is medial/lateral malleolus. The angle between the axis and joint line of
89 (86–92)°. (b) The anatomic distal anterior angle of the tibia is 80 the talus in the coronal plane is 9 (7–11)°
a b
10 mm
Fig. 22.8 (a, b) Posterior view of the calcaneus. (a) The anatomic axis
of the calcaneus passes 5–10 mm lateral to the longitudinal axis of the
tibia (From [102, 361]). (b) The valgus angle between the two axes of
the tibia and calcaneus is <6° (Marx [244])
Fig. 22.9 (a, b) Normal foot

morphology. (a) The angle
a b
between the two axes of the talus
and calcaneus is 20° in the
transverse plane (From [244]).
(b) The angle between the axis of
the talar body and the line along
the lateral surface of the
calcaneus is 21(14–28)° in the
horizontal plane (According to 21°(14-28)°
Sinai Hospital of Baltimore,
2010)
20°
14.5°
a 14,5° b
12°
12°
3°
3°
3° 3°
3° 21°
7° 21°
7° 14° 3°
87° 14°
7,5° 87° 7.5°
2°
2°
98° 98°
90.5°
37°
90,5° 104° 104°
37° 22°
14°
22°
Fig. 22.10 (a, b) Basic 14°

reference lines and angles of the
foot (Kirienko A, unpublished
data)
c 8-10°
b
5-8°
142°(136-148°)
e
d
8-10°
15°(10-20°)
Fig. 22.11 (a–e) Reference lines and angles of the foot. (a) The metatar- 8–10° (From [365]). (d) The axis of the tarsal bones is defined as the
sal parabola angle is 142 (136–148)°, which is defined by the lines from bisector line perpendicular to the line connected by the two-half points of
the top of the second metatarsal to the tops of the first and fifth metatarsals the medial/lateral sides of the tarsal bones. The angle between the ana-
(According to Sinai Hospital of Baltimore, 2010). (b) The axis of the first tomic axis of the second metatarsal and the axis of the tarsal bones is 15
metatarsal is 5–8° varus compared to the second metatarsal (From [365]). (10–20)° (According to Sinai Hospital of Baltimore, 2010). (e) The fifth
(c) The angle between the axes of the first and the fifth metatarsals is metatarsophalangeal varus angle is 8–10° (From [365])
96°(92°−100°)
a b 5-6° c 88°(84−92°)
1°(0−2°) 96°(92−100°)
3−5°
d e f
8−16°
3°(1−5°)
Fig. 22.12 (a–i) Normal foot morphology. (a) The joint line conver- angle is 88 (84–92)° (According to Sinai Hospital of Baltimore, 2010).
gence angle of the first proximal interphalangeal angle is 1(0–2)° (d) DASA (distal articular set angle): The angle between the anatomic
(According to Sinai Hospital of Baltimore, 2010). The anatomic proxi- axis of the first proximal phalanx and the line perpendicular to the first
mal medial angle of the first phalanx is 96 (92–100)° (According to metatarsophalangeal articular surface is 3–5° (From [365]). (e) The first
Sinai Hospital of Baltimore, 2010). (b) The first interphalangeal valgus metatarsophalangeal valgus angle. The angle between the axes of the
angle. The angle between the axes of the proximal and distal phalanges first metatarsal and proximal phalanx of the first toe is 8–16° (From
of the first toe is 5–6° (From [365]). (c) The anatomic proximal medial [365]). (f) The joint line convergence angle of the first metatarsophalan-
angle of the first phalanx is 96 (92–100)°. The anatomic distal lateral geal joint is 3 (1–5)° (From [365])
g h i
91°(87−95°)
92°(88−96°)
2°(0−4°)
3−6°
Fig. 22.12 (continued) (g) The anatomic proximal medial angle of and the line perpendicular to the first metatarsophalangeal articular sur-
the first metatarsal bone is 92 (88–96)°. The anatomic distal lateral face is 3–6° (From [365]). (i) The joint line convergence angle between
angle is 91 (87–95)° (According to Sinai Hospital of Baltimore, 2010). the first metatarsal and the medial cuneiform bone is 2 (0–4)° (According
(h) PASA (proximal articular set angle) and DMAA (distal metatarsal to Sinai Hospital of Baltimore, 2010)
articular angle): The angle between the anatomic axis of the metatarsal
22.2 Foot Injuries recommend external fixation as the method of choice in the
treatment of compound fractures or fracture-dislocations, for
Leonid Nikolaevich Solomin the treatment of old malaligned fractures and non-reduced old
dislocations, and for the correction of various foot deformities.
External fixation of injuries of the forefoot, midfoot, and The treatment of phalangeal fractures or fracture-
hindfoot is discussed in the following three sections. dislocations and metatarsal fractures employing the external
fixation technique begins with the insertion of two 1.8–2 mm
K-wires that cross each other through the calcaneus in calc.,2-8
22.2.1 Forefoot Injuries and calc.,4-10. Both K-wires are fixed in a half-ring support
and tightened using a wire tensioning device. A third 1.8–
Forefoot injury includes phalangeal fractures, fracture-disloca- 2.0 mm olive wire is introduced through the proximal metaphy-
tions, fractures of the metatarsals, and tarsometatarsal (Lisfranc) sis of metatarsal 1 and 5: m/tars.V-m/tars.I. The wire is fixed in
joint injury. Most forefoot injuries are treated conservatively, a half-ring support and tightened using a wire tensioning device.
with walking cast or hard-soled-shoe immobilization. Only in Half-ring supports are connected to each other using connect-
cases in which there is significant displacement of the frag- ing plates. In compound injuries of the foot, in the area of the
ments are surgical reduction and internal fixation indicated. In ankle joint, temporal spanning fixation of the ankle is indicated.
old malaligned fractures or fracture dislocations, single-stage It can be achieved by extending the foot external fixator module
reduction may become technically difficult due to the acquired to the lower leg. The ring is positioned at level VIII of the lower
soft-tissue stiffness and scar tissue formation. In these situa- leg: (VIII,8-2)VIII,8-2; VIII,4-10 and connected to the foot
tions, gradual distraction of the fragments using the Ilizarov frame by means of three rods (Fig. 22.13).
external fixator becomes the only alternative, allowing ana- In multiple maluniting metatarsal fractures, traction
tomic reduction of the fracture-dislocation. As soon as the frag- applied to the distal phalanx of the toe is inefficient. In these
ment alignment is corrected, open reduction and internal situations, fragment alignment can be corrected only by
fixation can be performed as a definitive treatment method. We traction applied directly to the distal metatarsal bone
a b
Fig. 22.13 Longitudinal axial traction is essential for the reduction of sagittal plane (b), with the insertion point 2–3 mm distal from the prox-
phalangeal and metatarsal fractures. (a, b) Traction is applied to a imal end of the nail bed in order to prevent migration of the K-wire
K-wire inserted through the distal phalanx of the toe in the frontal through the bone. (c) As an alternative to the above technique, traction
plane. Both ends of the wire are bent 3–4 mm away from the skin to can be applied using a console wire. Apart from longitudinal axial trac-
create a triangle (b). The top of the triangle is formed into a hook where tion, accurate fragment reduction requires interfragmentary compres-
the traction (a) is applied. If radiographs of the foot reveal marked sion. This can be achieved by the insertion of additional 3-mm half-pins
osteoporosis, the K-wire is introduced through the distal phalanx in the or console wires into the main fragments of the metatarsal bone
fragment. A K-wire inserted through the distal metaphysis of ity. In these fractures, accurate reduction of the tarsal bones
the metatarsal bone will provide the required control over is essential. External fixation based on the principles of
fracture reduction. Unequal longitudinal displacement of the gradual distraction and ligamentotaxis can restore the mid-
metatarsal bone fragments is not a contraindication for the foot anatomy and maintain the achieved fragment reduc-
above technique. Initially, the most displaced metatarsal tion until the bone has healed. External fixation of
fragment is reduced. As soon as the original length of the compound tarsal fractures or fracture-dislocations of a tar-
bone has been restored, the external fixator is adjusted as sometatarsal joint is a valuable technique for foot stabiliza-
required to reduce the adjacent metatarsals. tion, while open reduction and internal fixation may be
Figure 22.14 shows the Ilizarov mini external fixator used associated with a higher risk of postoperative complica-
in the treatment of juxta-articular phalangeal and metatarsal tions related to soft-tissue healing, such as skin necrosis
fractures. and wound infection. In neglected cases, when attempted
primary reduction has failed, gradual distraction may be
the only method to correct fragment alignment in order to
22.2.2 Midfoot Injuries restore foot function.
Injuries to a tarsometatarsal joint are renowned not only
Severely comminuted displaced fractures of the navicular, for their association with immediate, often disabling, pain
cuneiform, and cuboid bones can cause significant disabil- and swelling, but also for later problems due to the alteration
a b
Fig. 22.14 (a, b) Features of the Ilizarov mini external fixator, which uses 1.8–2.0 mm console wires. For external fixation of metatarsal bone
fractures, three wires should be inserted in each fragment; two wires are usually sufficient for the fixation of phalangeal fractures (From [366])
of foot mechanics and degenerative change. If, despite treat- to the ring support, which is connected to the foot module by
ment, there is severe loss of foot function as a result of pain, three threaded rods.
midfoot fusion can be performed using the Ilizarov external Fractures of the navicular, cuneiform, and cuboid bones
fixator. can be treated by external fixation. Two crossing 1.8–2 mm
Patients with midfoot injury are divided into four groups K-wires are inserted through the calcaneus. The wires are
depending on the time since injury [360]: tightened with a wire tensioning device and fixed in a half-
1. Acute injury (up to 3 days): single stage open/closed ring support: calc., 2–8; calc.,4-10. A third wire is inserted
reduction. through the first and second metatarsal bones. A fourth wire
2. Subacute injury (up to 6 weeks); single-stage open/closed is inserted through the third and fifth metatarsal bones. The
reduction using a distraction device. wires are tightened and fixed to a half-ring support posi-
3. Old injury (up to 8 months): two-stage procedure. The tioned vertically: m/tars.I–m/tars.II; m/tars.V–m/tars.III.
distractor is applied and gradual distraction is continued The half-ring supports are connected to each other with two
for 1–3 weeks. As soon as fragment alignment is achieved, threaded rods, which establish the direction of gradual dis-
open reduction and internal fixation can be performed as traction. If accurate fracture reduction and fixation are nec-
a definitive method of fracture fixation. essary, additional console wires with stops can be installed.
4. Old injury (>8 months). Advanced post-traumatic degen- These provide better control of the fragments and more sta-
erative changes of the midtarsal or tarsometatarsal joints bility to the fixation, particularly in osteoporotic bone frag-
are evident. Reconstructive surgery consists of various ments (Fig. 22.15).
corrective osteotomies depending on the type of The reduction of Lisfranc joint dislocations or fracture-
deformity. dislocations by external fixation is technically demanding
Comminuted fractures of the tarsal bones make primary and requires an expert level of surgical skill. Successful ana-
reconstruction of joint surface congruency technically tomic reduction can be compromised by soft-tissue interpo-
demanding and not always possible. Due to a high inci- sition (torn tarsometatarsal ligaments, joint capsule). In these
dence of post-traumatic osteoarthritis described for these circumstances, after fragment distraction is accomplished,
types of midtarsal and tarsometatarsal fractures, primary open reduction combined with transarticular K-wire fixation
arthrodesis may be advisable. It is essential to restore and is advised [360].
maintain the lengths of the lateral and medial foot columns Primary fusion of the tarsometatarsal joint is indicated if
in order to prevent planovalgus/varus deformity. The gap articular surface reconstruction is unsuccessful (severely
between the fragments is filled with autogenous cancellous comminuted fracture type). It should not result in shorten-
bone graft. ing of the internal or external surfaces of foot. A bone
Extension of the foot external fixation module to the lower defect arising after the resection of articulate surfaces
leg is not compulsory although it provides more control over should be replaced by autograft. Additional information is
foot position, avoiding the need for permanent foot support. provided in Sect. 22.5. The technique for the external
Two 1.8–2.0 mm K-wires are inserted through the tibia at fixation of post-traumatic foot deformities is discussed in
level VIII (VIII,8-2)VIII,8-2;VIII,4-10 and then connected Sect. 22.4.
a b
Fig. 22.15 For reduction of dislocations or fracture-dislocations of the reduction of longitudinal fragment displacement (one-stage reduction
tarsometatarsal (Lisfranc) joint (a) K-wires are inserted through the dis- in acute injuries and gradual distraction in old injuries). During later
tal metaphysis of the dislocated metatarsals. The K-wires are fixed and stages, the direction of traction is adjusted (medially, laterally, dorsally
tightened in a half-ring support. The divergent type of Lisfranc joint or in the plantar direction) corresponding to the direction of fragment
dislocation requires separate fixation of the K-wires, which allows displacement. The external fixation foot module is adjusted accord-
adjustment of the amount of axial traction applied to each fragment ingly. (b) After the desired fragment alignment has been achieved, the
depending on the displacement. Applied axial traction is helpful for the fragments are stabilized by the insertion of additional wires
22.2.3 Hindfoot Injuries the main talar fragments in the frontal plane under fluoroscopic
control. Joint distraction is released leaving a gap of 2–3 mm.
22.2.3.1 External Fixation of Talus Fractures If indirect closed fracture reduction is unsuccessful, open
Lee and Bashirov [368] recommend starting external fixation reduction of the bone fragments is performed and the frag-
of talus fractures with construction of the frame on the distal ments are fixed with screws. It is advisable to leave the exter-
third of the lower leg. Two ring supports are fixed to the nal fixator in place to provide temporary support for the
tibia: V,3-9;V,4-10 and (VIII,8-2)VIII,8-2;VIII,4-10 ankle joint (Fig. 22.17).
(Fig. 22.16). A combination of wires with half-pins on the
lower leg allows modification of the lower leg module from 22.2.3.2 External Fixation of Calcaneal Fractures
two ring supports to one without compromising fixation sta- The procedure begins with construction of the ring support
bility: VII,1,120; (VIII,8-2)VIII,8-2;VIII,4-10. After the VII,3-9; (VIII,8-2)VIII,8-2; VIII,4-10 on the lower leg
tibial module has been constructed, two 1.8-mm crossing (Fig. 22.18a). The first wire is inserted through talus,3-9 in
wires are inserted through the calcaneus. The wires are fixed the frontal plane. It is fixed and tightened in an additional
and tightened in the half-ring support. The lower leg ring three-hole support which is firmly fixed to the ring support.
supports are connected to the hindfoot module by three The optimal position for wire insertion is below the tip of the
threaded rods. Under fluoroscopic control, distraction is medial malleolus so that the wire passes through the talus
applied to create a diastasis of 3–4 mm between the tibia and and through the middle of the lateral malleolus. Alternatively,
talus. it can be inserted through both malleoli. A second olive wire
Reduction of the talar fragments is achieved by distraction is inserted through the metatarsal bones m/tars.V–m/tars.I. It
combined with manual maneuvers. As soon as satisfactory is tensioned and fixed to a half-ring support. The forefoot
reduction is obtained, two wires with stops are inserted through half-ring module is connected to the lower leg module using
Fig. 22.16 Frame construction for the

reduction of talar fractures, as described by
Lee and Bashirov [368]
Fig. 22.17 Frame construction for the

reduction of talar fracture-dislocations, as
described by Shigarev and Zyryanov [368].
The device is based on the principle of
“two-level distraction” applied to the
subtalar and ankle joints combined with
manual fragment reduction. The directions
of the olive K-wires depend upon the
fracture plane and the direction of
displacement of the main fragments
a b
Fig. 22.18 (a–c) A two-thirds ring calcaneal support is connected to displacement. If the fragment is in the valgus position, gradual distrac-
the main module by three hinges, two on the medial and lateral aspects tion is applied along the lateral hinge until the fragment is reduced. For
of the foot and one in the midline. It is important that the rotational axis correction of the Böhler angle, distraction is applied along all three
of the lateral and medial hinges corresponds to the top of the calcaneal hinges. Rotational alignment of the calcaneal fragment can be achieved
deformity (CORA). This assembly allows reduction of any kind of cal- by changing the position of the hinged connecting rod in the two-thirds
caneal fragment displacement. If the fragment is in the varus position, ring support
then distraction applied along the medial hinge will reduce the
Fig. 22.19 It may be that distraction created along the connecting additional one or two wires are inserted through the impacted calcaneal
hinged rods increases the subtalar joint gap so that reduction of the fragment. The wires are tensioned and fixed to the newly added half-
impacted calcaneal fragment fails. In such cases an additional half-ring ring support. Gradual distraction at a rate of 0.25 mm three to four
support is installed. Moderate distraction is applied to the subtalar joint times a day is applied to the impacted fragment until it is reduced and
to widen the joint gap and restore the longitudinal arch of the foot. An the Böhler angle is restored (From [366])
an additional support and a threaded rod of appropriate performed. Gradual distraction of the fragments should be
length. started after 5–7 days at 0.25 mm three of four times per day.
The main (basic) module can be constructed combining It is mandatory to monitor the condition of the skin through-
wires and half-pins in a hybrid construction: VII,12,120; out the period of distraction at the hindfoot area in order to
VIII,9-3; talus,1,90 (Fig. 22.18b). A half-pin is inserted prevent soft-tissue-related complications. Additional infor-
into the talus in the oblique-sagittal plane from front to mation is provided in Sect. 22.4.
back, either lateral or medial to the tibial anterior muscle If a primary hindfoot injury has led to the development of
tendon (position 1 or 2), or in the oblique-sagittal plane post-traumatic flat foot deformity and subtalar joint arthritis,
from front to back, from outside to inside and more lateral then simultaneous correction of the longitudinal arch of the
than the long extensor muscle of the toes (position 10 or foot can be combined with arthrodesis of the subtalar joint
11) [2]. Two crossing wires are then inserted through the (Sect. 22.5).
calcaneal tuberosity at an angle <45° to the frontal plane.
The wires are tensioned and fixed in a two-thirds ring
support. 22.3 Closed Correction of Foot Deformities
External fixation of post-traumatic deformities of the cal-
caneus can be achieved by applying gradual distraction to the Leonid Nikolaevich Solomin
displaced malunited fragments. The frame construction is
similar to that described above and is illustrated in Fig. 22.19. In this section we introduce only the basic principles rele-
The proximal and distal wires must be inserted through the vant to the correction of a foot deformity by external fixation.
calcaneus as far apart as possible. Calcaneal osteotomy is Due to the variety and complexity of congenital and acquired
foot deformities, it is practically impossible to describe in In clinical practice, methods for changing the shape of
one section all the methods of deformity correction using all parts of the foot based on the gradual distraction of
Ilizarov external fixation. Instead, the main idea is to dem- bone fragments to induce new bone formation in the
onstrate that complex foot deformities can be successfully osteotomy zone are widely used [361, 369–371], as dis-
corrected by the external fixation techniques developed at cussed below.
the Russian Ilizarov Research Center. Before reading this
section, the reader is referred to the previous sections in
which the principles of construction of external fixation Table 22.1 Main types of foot deformity
devices for the treatment of foot and ankle joint injuries Type of deformity
were introduced. Pes equinus Pes calcaneus
There are eight major kinds of foot deformity [244]. These Pes adductus (metatarsus varus) Pes abductus (metatarsus valgus)
can be united into four pairs (Table 22.1). Pes excavatus Pes planus
In practice, the various main types of foot deformity are Pes supinatus (pes varus) Pes pronatus (pes valgus)
often combined in a complex foot deformity. An example is
club foot deformity, in which foot equinus is combined with
forefoot adduction. Distinguishing the main components of a
complex foot deformity allows proper planning of deformity
correction and the construction of appropriate external
fixation modules.
The main principles of equinus foot deformity correction are
discussed in Chap. 23.6 (Figs. 23.62 and 23.63). Figs. 22.20,
22.21, 22.22, and 22.23 shows principles of external fixation at
some other foot deformities.
As described above, the external fixation device for the
correction of a complex foot deformity is constructed of
modules designed to correct the individual components of
the deformity. Foot deformity correction by external fixation
always requires stabilization of the ankle joint by connecting
the foot module to the lower leg ring support.
In children, the correction of a congenital foot deformity
may also require soft-tissue release, involving lengthening of
the Achilles tendon, plantar fasciotomy, or capsulotomies.
In adults, the correction of a foot deformity by external
fixation should be followed by foot stabilizing procedures
(arthrodesis) after the desired correction has been achieved.
Otherwise there is a risk of recurrence after the external
fixation device is removed. Accordingly, surgery is planned
in two stages: initially the foot deformity is corrected, and
then the foot is stabilized in a second step. Alternatively, the
surgery can be planned as a one-stage procedure: after
removal of a wedge-shaped or falciform piece of bone
Fig. 22.20 The external fixator for correction of pes calcaneus is simi-
(following the method of Kuslik) the external fixation device
lar to the frame described for equinus foot correction. It is important
can be used to stabilize the fragments or for the gradual cor- that the axis of the hinged connecting rods corresponds to the talar tro-
rection of the residual deformity. chlea center
Fig. 22.21 Excessive forefoot adduction is corrected using two sup- to achieve the desired correction. If the forefoot deformity is rigid or the
ports. One half-ring support is placed on the hindfoot. Wires are inserted metatarsal bones are osteopenic then two wires are inserted: m/tars.I–
through the calcaneus: calc., 2-8; calc., 4-10. Alternatively, instead of m/tars.II; m/tars.V–m/tars.III. This provides better control over the
the wires, a half-pin hybrid configuration can be used: calc.,4-10; forefoot and prevents loosening of the wires by allowing a more equal
calc,7,90. The second half-ring support is placed on the forefoot. A distribution of the distraction force. Hinged connecting rods are attached
wire is inserted through the metatarsal bones: m/tars.I–m/tars.V. If the to each half-ring support (a). (b) Alternative configuration using two
forefoot deformity is relatively mobile then only one wire is sufficient olive wires for the correction of excessive forefoot adduction
Fig. 22.22 The external fixator for correction of pes cavus consists of
two supports, one fixed to the calcaneus and the other to control the
forefoot position. Half-ring supports are connected to each other by
hinged rods. The rotational axis of the hinges should correspond to the
top point of the forefoot deformity
a b
Fig. 22.23 External fixator for correction of varus foot deformity. The talus: talus,2,90. The transosseous element stabilizing the ankle joint is
frame is constructed using two modules, one placed on the distal lower fixed to the ring support on the lower leg. The foot and lower-leg mod-
leg and the other mounted on the foot. The ankle joint is stabilized ules are connected to each other by two threaded rods with hinges ((a)
either by a wire talus,3-9 inserted through the talus in the frontal plane: view from the back). (b) A similar technique is used for the correction
talus (or through the lateral malleolus) or by a half-pin inserted into the of forefoot supination
22.4 Foot Osteotomies executed after device application, the manual and mutual
displacement of the device modules proves the completeness
Alexander Kirienko of bone destruction. Osteotomies should be monitored (level,
direction) and the transosseous elements inserted preferably
22.4.1 Introduction with the aid of fluoroscopy.
Table 22.2 provides a classification of the osteotomies of
The Ilizarov method differs from “traditional” methods by the the foot bones using Ilizarov’s method.
introduction into surgical treatment of the concept of defor- Practically all configurations used in foot osteotomies
mity correction over time. In other words, the traditional include a transosseous module fixing the lower leg. It can be
approach in surgery assumes a final exact correction of the two supports on the basis of wires: V,3-9; V,4-10 – VII8-2;
deformity in the operating room. However, in this case, the VII, 4–10, or a hybrid wire/pin support: VI,12,120; VII,3-9;
technical and biological opportunities to achieve this goal are (VII,8-2)VII,8-2.
frequently limited. In the Ilizarov method, the operative action
is a prologue for subsequent therapy, which will terminate
after a certain time interval. Therefore, the Ilizarov method 22.4.2 Osteotomy of the Heel
possesses the following opportunities and advantages:
1. After a resection resulting in shortening of the foot (for The indications for calcaneal osteotomy are: calcaneal defor-
example, in a resection of cuboid bone in pes varus), dis- mities in the frontal plane (varus or valgus); deformities in
tractional osteosynthesis allows the formation of a regen- the horizontal plane (adduction or abduction); calcaneal
erate of the necessary size, thus avoiding a secondary deformities in the sagittal plane (equinus or vertical heel);
deformation (foot shortening) as a consequence of pri- and hypoplasia of the heel in complex congenital and post-
mary deformity correction. traumatic deformities.
2. During deformity correction, by changing the configuration There are osteotomies, such as that of Dwyer, in which
of the device, it is possible to supervise and eliminate the plane of the bone section is located more or less obliquely
possible errors of correction following the basic plan of in relation to the frontal plane. Besides curved and straight
treatment; osteotomies, those extending from the bottom to the top sur-
3. Using the plastic properties of regenerate along with face of the heel and anterior to the attachment of the Achilles
modifying the direction and influence of the external force tendon are described. Thus, quite a large posterior apophy-
developed by the device, the desired form and size of the sis connected with Achilles tendon is released (Figs. 22.24
deformed foot can be created. and 22.25).
4. The constant and prolonged distraction of the bone and Osteotomy assumes a small (1–3 cm) external skin inci-
soft tissue extend them and permit to obtain lengthening sion, sufficient to allow access of the chisel.
of the foot. Subtalar osteotomies of the heel are done in the subtalar
Indication for application of the foot deformity correction zone, either horizontal to or bordering its plane. The proce-
with osteotomies is limited to the treatment of rigid postrau- dure is started slightly distal to the site where the Achilles
matic or congenital foot deformities; to the foot that was tendon is fixed (Fig. 22.26).
treated previously with the classical soft tissue surgeries,
other osteotomies or arthrodesis. Osteotomy tecnique for
elastic, instable and neurologic foot is less indicated than Table 22.2 Classification of osteotomies performed according to the
Ilizarov method
arthrodesis.
In the treatment of foot deformities, Ilizarov used tradi- 1. Osteotomy of the calcaneus
1.1 Osteotomy of the body of the calcaneus or the posterior
tional osteotomies of the calcaneus, the middle part of the
apophysis
foot, and the metatarsals. In addition, he developed talocal- 1.2 Osteotomy of subtalar area
caneus osteotomies. To preserve a maximum blood supply 2. Astragalocalcanean osteotomy
and to guarantee good regeneration, the osteotomy should be 2.1 Anterior astragalocalcanean osteotomy
carried out as a “closed” or “half-closed” procedure, with 2.2 “Dome” or “crescent” osteotomy
minimal damage to the soft tissues. Skin incisions should be 2.3 V-shaped osteotomy
parallel to the direction of the subsequent distraction to avoid 2.4 Y-shaped osteotomy
divergence of the wound edges. 3. Osteotomy of the middle part of the foot
Osteotomies can be executed either before the insertion of 3.1 Osteotomy of cuboid and navicular bones
the transosseous elements and device application or after 3.2 Osteotomy of the cuboid and cuneiform bones
device assembly. Any osteotomy can be considered as com- 4. Osteotomy of the anterior foot
pleted if at the turn of the chisel there is a clinical move- 4.1 Metatarsal osteotomy
ment of the bone fragments, as seen by eye. If osteotomy is 4.2 Osteotomy of the phalanges of the toes
a b
Fig. 22.24 (a, b) Rectilinear osteotomy to correct equinus with an increase in the height of the heel
a b
Fig. 22.25 (a, b) Correction of the vertical position of the heel, with lengthening
Another variant of heel osteotomy in the subtalar area is the future distraction. Movements of chisel in the internal
the L-shaped Pisani’s osteotomy. The short part of it is verti- cortical layer must be limited in order to avoid damage to the
cal and calcaneocuboid, involving the front of the heel and vessels and the posterior tibial nerve.
thereby sparing the calcaneocuboid joint. The long part is Figure 22.29 shows the configuration of the device used
horizontal, crossing the bone distal to the Achilles tendon in osteotomies of the calcaneus, in the subtalar area.
fixation site (Fig. 22.27).
Subtalar osteotomies of the calcaneus along with subtalar
joint fusion and triple joint fusion are used to correct a post- 22.4.3 Astragalocalcaneal Osteotomies
traumatic flat foot and a foot with a sharp Böhler’s angle as
well as hemimelic foot (Fig 22.28). The line of an anterior astragalocalcaneal osteotomy extends
For subtalar osteotomy of the calcaneus, two external rectilinearly from a front projection of the heel to the talar
incisions, 1.5 cm each and located on the same line, are neck (Fig. 22.30). This osteotomy is used for treatment of
made. One of them is more anterior to the body of the heel, cavus foot and deformities located proximal to Chopart’s
in the subtalar area; it allows access to a zone close to the joint. Carrying out the osteotomy requires protection of the
calcaneocuboid joint. The other is more posterior, providing talar neck on its dorsal surface by means of an orthopedic
access to a zone close to the calcaneal tuber. Both incisions elevator, such as Hohmann’s, to avoid damaging the dorsal
are made in the vertical direction, parallel to the direction of arteries of the foot and the tendons of the lower limb.
a b
Fig. 22.26 (a, b) Subtalar osteotomy in the oblique plane is performed distal to the site of Achilles tendon fixation. This allows both correction
of the flatness and an increase in the height of the heel
a b
Fig. 22.27 (a, b) A subtalar L-shaped osteotomy is used for correction of heel height and a flat foot
a b
Fig. 22.28 (a, b) Horizontal subtalar osteotomy in combination with triple joint fusion is used in the treatment of post-traumatic flat heel and
hemimelic foot
a b
Fig. 22.29 (a) Device configuration for subtalar joint fusion and sub- ring for heel correction has a system of hinges and rods that connect
talar osteotomy of the heel. The subtalar joint, after resection of the with the ring of the lower limb. Instead of a proximal support, half-pin
joint surfaces, is fixed in a 5/8 ring support using the mutual compres- VII,1,120 fixed to an “epimalleolar” support can be used. (b) Device
sion of the bent wires. This support is connected in a neutral position, configuration and the regenerate after deformity elimination with the
without compression, with the distal ring of the lower limb. The half- aid of a subtalar osteotomy
a b
Fig. 22.30 (a, b) Rectilinear osteotomy of the anterior appendix of the foot and neck of the talus is used to eliminate a cavus foot and to lengthen
the anterior part of the foot
The line of a crescentic or hinge astragalocalcaneal correction of an equinal deformation accompanied by supi-
osteotomy begins at the cranial surface of the foot 1–1.5 cm nation or pronation of the foot at the expense of additional
from the posterior astragalocalcaneal joint and passes progressive “opening” of the osteotomy with its internal or
through the base of the metatarsal cavity before continuing external surface.
to the talar neck. Osteotomy divides the foot in two parts: Dome osteotomy is carried out using a special curved 5–6 cm
(1) the talus without its head and the osteotomied proximal chisel. Access is lateral. Special attention should be given to the
part of the heel connected with the malleolus and (2) the internal cortical layer because of the risk of damage to the neu-
other bones of the foot, which freely move under the rovascular bunch. Osteotomy can be done too by a chisel of
influence of the device on the curved surface of the osteot- 1–1.5 cm width. Thus, the curved line of the osteotomy will be
omy (Fig. 22.31). a combination of small rectilinear osteotomies (Fig. 22.32).
Indications for a dome astragalocalcaneal osteotomy are A V-shaped osteotomy is a combination of a rectilinear or
equinus deformity of the foot in an inactive malleolus and oblique osteotomy of the posterior large apophysis of the
a b c
Fig. 22.31 (a–c) Performing a “crescent” osteotomy using a rectilinear chisel and a small lateral incision under the external malleolus
a b
Fig. 22.32 (a, b) Dome astragalocalcaneal osteotomy is used in the correction of equinus foot with difficult mobility of the talocrural joint.
Simultaneously, supination or pronation of the foot can be corrected
heel and a direct anterior astragalocalcaneal osteotomy. The calcaneus below the subtalar joint, almost parallel to it. The
two lines of the osteotomies cross at a sharp angle (60–70°), bottom beam runs almost vertically and dissects the anterior
the top of which is located on the plantar surface of the heel part of the body of the heel, parallel to the calcaneocuboid
(Fig. 22.33). joint, 1.5–2 cm posteriorly. The anterior beam begins at the
Indications for V-shaped osteotomy include the necessity sulcus calcanei and passes through the sinus tarsi, then dis-
of simultaneous correction of a heel deformity and deformi- sects the collum tali (Fig. 22.34). These three beams together
ties located in the proximal part of the Chopart joint. form adjoining angles of approximately 120°.
The Y-shaped osteotomy of Kirienko, unlike the V-shaped The indications and opportunities for a Y-shaped
osteotomy, consists of three “beams,” with the center of their osteotomy are the same as those of the V-shaped osteot-
divergence at the level of the bottom of the sulcus calcanei. omy. Its advantage is that less time is needed for the cor-
The posterior beam of the osteotomy dissects the body of the rection of the deformity since a smaller distraction is
a b
Fig. 22.33 (a, b) V-shaped osteotomy is used for the simultaneous treatment of complex deformations of the anterior and posterior parts of the
foot. Here treatment of a flat valgus deformity with pronation is shown
a b
Fig. 22.34 (a, b) The Y-shaped osteotomy has the same indications as the V-shaped osteotomy but less time is needed for deformity correction
and lengthening of the foot is prevented
a b
c d
Fig. 22.35 (a–d) Configuration of the device used in astragalocalca- lus and talus in the frontal plane, is also possible: (XI,9-3)talus,9-3.
neal V and Y-shaped osteotomies. Wires talus, 1–7 and talus, 11–5 are Instead of the proximal support, half-pin VI,1,120 fixed to the “epimal-
used to stabilize the talus. With the aid of “arms” they are fixed in the leolar” support can be used
base support. The use of one wire, inserted through the external malleo-
required. In addition, superfluous lengthening of the foot adducted, supinated, or pronated foot when the deformity is
is prevented. located in its middle part.
In Fig. 22.35, models and configurations used in astra- In operating on a cavus or equinocavus foot, it is neces-
galocalcaneal osteotomies are shown. sary to combine device-supported osteotomy with dissection
of the plantar aponeurosis. If the aponeurosis has already
been dissected and there is no evident strain, distractional
22.4.4 Osteotomies of the Middle Part external fixation makes it possible “to extend” the aponeuro-
of the Foot sis in a closed procedure.
Figure 22.38 shows the device configuration used in
All of these osteotomies are rectilinear. osteotomies of the cuboid and navicular bones. With this
Both the cubo-navicular osteotomy (Fig. 22.36) and the configuration, deformities can be successfully eliminated
cubocuneiform osteotomy (Fig. 22.37) are used for “plus” when the talus bone is in an equinus position and there is
corrections of an anterior cavus foot and an abducted, cavus of the middle foot.
a b
Fig. 22.36 (a, b) Rectilinear osteotomy of the cuboid and navicular bones is used in the correction of an anterior cavus foot
a b
Fig. 22.37 (a, b) Rectilinear osteotomy of the cuboid and cuneiform bones
a b
e f
For correction of abduction, adduction, supination, and along the interior and anterior surfaces are fixed by hinges
pronation of the anterior foot, depending on the deformity located in the horizontal plane (Fig. 22.38).
level, rectilinear osteotomy of the cuboid and cuneiform Deformity correction is carried out by distraction of the
bones (Fig. 22.39a, b) or osteotomies of the navicular and rod of the internal hinge such that the internal part of the
cuboid bones (Fig. 22.40a, b) are performed. osteotomy is extended by 1 mm/day. For a small shortening
At pes adductus one (“wire-pin”) or two (“wire”) base using one of the rods of the external hinge, a virtual hinge at
rings on the ower leg, a half-ring on the heel, and a half-ring the level of the external part of the osteotomy is formed.
at the level of the metatarsus are used. Supports on the foot Otherwise, or by contrast, in the case of distraction, the
a b
Fig. 22.39 (a, b) Device assembly to correct an adduction of the ante- calcaneocuboid and talonavicular joints from stretching. Under these
rior part of the foot with the aid of an osteotomy of the cuboid and conditions, the stability of the anterior part is increased due to the third
cuneiform bones. The calcaneal half ring is lengthened using two direct metatarsal wire. Correction is achieved by the formation of a cunei-
plates and an additional wire with a stopper from the side of the cuboid form-shaped regenerate whose base is inverted medially
bones is inserted to increase the stability of the device and to protect the
Fig. 22.38 Kinematic charts (a–d) and device configurations (e, f) for position due to the closed correction of the subtalar joint, either in one
the correction of a deformity, the top of which is located at the level of the stage or gradually. Correction of equinus and cavus deformities of the
middle part of the foot. Osteotomy can be executed through either the middle foot is carried out by means of distraction on two parallel, exter-
cuboid and navicular bones (a, b, e, f) or the cuboid and cuneiform nal and internal plantar pins and by means of shortening at an anterior
bones (c, d). Connection of the heel with the lower leg by means of central pin. Instead of a proximal support, half-pin VI,1,120 fixed to the
three two-plane hinges enables placement of the heel in the correct “epimalleolar” support can be used
a b
Fig. 22.40 (a, b) Correction of an adduction of the foot through an osteotomy of the navicular and cuboid bones. The wire with a stopper is more
proximal and passes through both the cuboid bone and the base of the navicular bone
virtual hinge is displaced outwards, resulting in lengthening rotate on the spiral plate, are mounted. Thus, the plate and
of the middle part of the foot (Fig. 22.41). two tags form a unit with a “T” shape. Two vertical threaded
Treatment of abduction of the foot (pes abductus) is also rods are inserted into the outermost apertures of the tags.
carried out by means of a rectilinear osteotomy of the cuboid They connect to the anterior half-ring on the foot by means
and cuneiform bones or of the navicular and cuboid bones. of two-plane hinges, thus promoting deformity correction in
Distraction on the lateral side is performed to obtain a wedge- the sagittal (equinal, cavus foot) and frontal planes and the
shaped regenerate whose base is outwardly inverted. At the correction of supination and pronation. Supination is cor-
same time, lengthening of the middle foot is possible rected by differentiated traction on the two vertical rods,
(Fig. 22.42). with faster traction on the external rod than the internal rod.
In the correction of supination (after osteotomy), the Thus, there is simultaneous correction of the equinus of the
configuration is similar to those shown in Figs. 22.23 and anterior foot, cavus, and supination. These manipulations
22.43. Note that a half-ring applied to the anterior foot should should be done simultaneously with distraction using two
be oriented such that its edges are in a plane parallel to the lateral plantar rods connecting the anterior and posterior
plantar surface. half-rings.
The anterior half-ring with a support on the lower leg is Pronation is corrected according to the same principles
connected by means of a T-shaped unit. The spiral plate joins that guide the correction of supination. The inclination of the
the ring of the lower leg and is fixed using an aperture pro- half-ring fixing the anterior part of the foot also should
jected at the level of the base of the 5th metatarsal. On the resolve the position of the pronated metatarsal bones and
distal end of the plate, two tags, male and female, able to toes. For deformity correction, distraction on the external
Fig. 22.41 In the correction of a b

an adduction by means of
lengthening on the internal side
and shortening of the rod of the
external hinge, a virtual hinge at
point O (a) is formed. The size of
the base of the wedge is
calculated using the formula of
proportional triangles (b). To not
shorten an external rod or to
lengthen it, the virtual hinge O is
outwardly displaced (c). In this
case, the regenerate has a
trapezoidal form and lengthening
B
of the foot becomes more
D
significant (d)
F
A C O
E
c d
B
D
O
A C O
a b
Fig. 22.42 (a, b) Ilizarov device assembly to correct an abduction of the anterior foot through an osteotomy of the navicular and cuboid bones.
Lengthening is carried out on an external rod until a wedge-shaped or trapezoidal regenerate forms
vertical rod is accompanied by compression on the internal Use of the computer-navigated Ortho-SUV Frame for the
vertical one. correction of complex deformities is discussed in detail in
Quite often, foot deformities are combined with severe Chap. 17.
metatarsophalangeal and interphalangeal contractures,
which are amenable to correction. The deformity is cor-
rected in one stage as closed as possible and fixed with 22.4.5 Osteotomy of the Anterior Part of the Foot
wires transarticularly. Capsulotomies increase the efficiency
of the correction. Complete cutting of the flexor tendons, Fixation after correcting osteotomies of the anterior foot
despite the evident cosmetic effect (straightening of the can be carried out by mini-devices (Figs. 22.14, 22.48,
toes), dramatically reduces the support function of the 22.49, and 22.51) and plunge designs: plates, screws, and
toes. wires.
Along with the plantar aponeurosis, discussed above, the Joint fusion between the medial cuneiform bone and the
Achilles tendon can be lengthened as well. first metatarsal (Fig. 22.45) is used in the correction of
In Fig. 22.44, an example of the treatment of a patient with overextension and adduction of the first metatarsal (Lapidus
a complex foot deformity is shown. Osteotomy of both the heel procedure). This operation is frequently performed also in
and the cuboid and talus bones was carried out. The level and cases of hallux valgus, caused by a deviation of the first ray
type of the osteotomy were determined by the level of the of the anterior foot.
deformity, involving the posterior and middle parts of the Osteotomy of the proximal metaphyses of the first meta-
foot. tarsal is used to correct superfluous flexion (cavus
a b
Fig. 22.43 (a, b) In the correction of supination, the front half-ring tion of the metatarsal bones and the toes. Shortening of two vertical
should be perpendicular to the longitudinal axis of the anterior part of rods in the differentiated mode (greater for the external rod) allows the
the foot. In addition, the edges of the half ring are necessary to arrange correction of both equinus and supination
the plantar surface of the anterior foot in a plane, to resolve the supina-
configuration) or, conversely, overextension in pes planum Inserting another console wire in the cuboid bone or the first
(Fig. 22.46). cuneiform bone increases the stability of the proximal module.
Distal osteotomy of the first metatarsal (Figs. 22.47 and For lengthening of the more massive first metatarsal or
22.48) is also used in the correction of hallux valgus. simultaneously lengthening two (or more) metatarsals, the
Metatarsal lengthening is indicated in congenital proximal module is assembled on the basis of a half-ring,
shortening of the 4th, less often the 3rd and 4th, or the 5th arranging it perpendicular to the longitudinal axis of the
metatarsal bones. Shortening of the first metatarsal is anterior foot. One of the proximal base wires is inserted at
seen in congenital defects, such as congenital pigeon- the level of the base of the metatarsals, and the other through
toedness and varus deformation of anterior foot. the cuboid and cuneiform bones (Fig. 22.51).
Shortening of the 4th metatarsal is frequently found in Corticotomies are done in the proximal metaphysis, close
Turner syndrome. to the proximal groups of wires. Here, the bone has the wid-
Monolateral, sectorial, and semicircular devices are the est diameter and the greatest biological reserves, thus favor-
most commonly used. With the sectorial LAKI fixator ing the formation of the distraction regenerate (Fig. 22.50).
(Fig. 22.49) two or three mutually intersecting console The rate of distraction for the first 7–8 days should be 1 mm/
wires or half- pins are inserted in each bone fragment. day (0.25 mm × 4). In the subsequent period, the rate of
Smooth console wires are fixed with a small inclination lengthening is 0.75–0.8 mm/day. The difference is explained
relative to the bone’s longitudinal axis so as to exclude by the fact that, initially, deflection of the wires causes a dis-
expulsion of the wires from the fragment during crepancy between the distraction rate and the length of the
lengthening. regenerate. Thus, a small, 2–3 mm overlengthening is
a b
c d
Fig. 22.44 Treatment of a patient with a complex foot deformity. (a–f) Before treatment
g h
i j
Fig. 22.44 (continued) (g) X-ray examination during the operation: bone fragments after osteotomy. X-ray images of the foot prior to (i)
osteotomies of the calcaneus and of the navicular and cuboid bones. (h) and at the end of (j) deformity correction. View of the foot and the
A console wire with a stopper is inserted for additional fixation of the device from the inside at the beginning (k)
l m
Fig. 22.44 (continued) View of the foot and the device from the inside at the end (l) of correction. View of the plantar surface of the foot at the
beginning of (m) and after (n) correction. (o–t) Treatment results
p q
r s

a b
Fig. 22.45 (a, b) Open joint fusion between the internal cuneiform bone and the base of the first metatarsal bone correcting for flexion and
abduction
a b
Fig. 22.46 (a, b) Dome osteotomy of the base of the first metatarsal
a b c
Fig. 22.47 Rectilinear transverse percutaneous osteotomy of the distal К-wires. (c, d) The head of the first metatarsal is lifted upwards and
part of the first metatarsal. (a, b) The distal fragment should be dis- does not participate in supporting the anterior foot. At correction, the
placed outwards to remove the protrusion at the head of the bone, with distal fragment of the first metatarsal is displaced from top to bottom to
its simultaneous turn together with the first toe. Fixation is done by two enable loading
Fig. 22.48 (a) Relapse hallux valgus

after a classical operation using the
a b
Shevron method. (b) X-ray images
obtained during surgery show the
osteotomy and the correction achieved.
(c, d) Stable osteosynthesis with a
Kirienko-Lazzarini external mini-fixator
c d
a b
Fig. 22.49 The LAKI external mini-fixator of the sectorial type (LAKI). Its two modules are connected by a threaded rod, with an upper flat slid-
ing surface to prevent rotation during lengthening (a). The wires are bent in advance to keep them from slipping out during distraction (b, c)
a b a b
Fig. 22.51 (a, b) Lengthening of the first metatarsal. Additional

fixation of the phalanges is carried out using a K-wire
Fig. 22.50 Lengthening the 4th metatarsal at the level of the proximal
metaphysis
desirable in order to avoid shortening of the bone after arch that includes the heads of all the metatarsals
dynamization of the device. (Fig. 22.52).
Lengthening should occur over the long axis of the ray of Usually, at distraction, patients report pain, due to the
the anterior foot until the head of the metatarsal contacts the resistance of the soft tissues. During fixation, the pain sub-
sides and patients are able to walk with gradually increas-
ing loading. Restructuring of the regenerate is usually
reached after 2–3 months of fixation. Loosening the nuts of
the device’s distractional rods results in its dynamization.
The device is removed under local anesthesia in an outpa-
tient setting. Return to normal loading is typically in a
month.
Osteotomy of the proximal phalanx of the first toe
(Fig. 22.53) is required when the deformity of halux occurs in
this level. The procedure can be performed either together
with an osteotomy of the metatarsal or separately. There are
various methods of correction. In one variant, the deformity is
eliminated by cuneiform resection of the phalanx, but this
leads to toe shortening. In an osteosynthesis done using wires,
correction involves a rectilinear osteotomy and displacement
to restore the anatomic axis.
Osteotomies of the phalanges of toes 2–5 are usually car-
ried out to treat the claw toes deformities that accompany
various deformities of the anterior foot, for example, those of
the second and third toes in extreme forms of hallux valgus,
or those of the toes in neurological conditions such as
Charcot-Marie-Tooth. Osteotomy can be done at the level of
the base of the proximal or distal phalanx, depending on the
Fig. 22.52 Restoring the anatomic length of the 4th metatarsal and the deformity type. Fusion of the proximal interphalangeal joint
physiological arch of all metatarsal heads is not excluded.
a b c d
Fig. 22.53 (a, b) Correcting a valgus deformity of the first toe by valgus with simultaneous restoration of the axes, carried out with the
cuneiform resection of the proximal phalanx results in shortening of the inward displacement of the toe
latter. (c, d) Rectilinear osteotomy of the proximal phalanx to correct a
22.5 Fusion of the Joints of the Foot 22.5.1 Fusion of the Ankle Joint
Alexander Kirienko and Leonid Nikolaevich Solomin Initially, two base rings on the wire-based support or a com-
bined wire-pin support are placed on the lower limb. This is
The technique of joint fusion using the Ilizarov method is indi- done to facilitate all subsequent manipulations, as after that
cated in severe post-traumatic arthrosis of any of the foot it will be easier to attach the foot module to the supports
joints, especially in the presence of associated deformities and (support).
stable contractures. In such cases, a one-stage resection of the After the blood has been drained from the lower leg, a
joint surfaces and stabilization by the device are carried out. pneumatic tourniquet is placed on the inferior third of the
Other use of the joint fusion are in the cases when an external upper leg with the aid of an Esmarch bandage or sterile
fixation device is required in the begining with the first surgery elastic bandage. Access to the ankle joint according to
for closed progressive stretching of the soft tissues and elimi- both the indications and the experience of the surgeon is
nation of the rigid contractures of the joints and after that by obtained. The most popular access route is the external
the second surgery subsequent stabilisation of the foot. This is side. An incision 7–8 cm in length and curving around the
necessary to avoid partial or full return of the foot to its former external malleolus is made. Inferiorly, the incision should
position, in other words, to prevent relapse. External fixation not be made too low, to avoid damaging the sural nerve.
also allows the formation of a bone regenerate between the The tendons of the peroneal muscles should be dislocated
bone surfaces subjected to joint fusion, the correction of an posteriorly. All taloperoneal ligaments are cut and an
accompanying deformity, the filling in of defect at the level of oblique osteotomy of the fibula of 2–3 cm above the slit of
the resected joints, and the correction of axial deviations. Thus, the talocrural joint is done. Syndesmoses between the
resection of the foot bones, as in classic cases, is excluded and fibula and tibial are dissected. The distal fragment of the
the volume of the bones is thereby preserved. fibula is then abducted outward and upward, maintaining
During treatment in the device, its external manipulation as much as possible the vascularity of the proximal part.
allows the correction any mistakes and thus the achieve- The joint surfaces are resected according to the deformity.
ment of an absolutely correct position between the bone To establish good contact in the medial part of the joint, it
fragments. Dosed, joint-specific compression between is frequently necessary to use the same access to perform
bones in a zone of joint fusion during treatment is another an osteotomy of the internal malleolus, displacing the
advantage. bone cranially. The need for additional medial access with
Together with joint fusion, lower limb operations (length- partial resection of the internal malleolus cannot be
ening, axial correction, pseudoarthroses, infection, defects) excluded.
can be carried out. The foot is placed in a functionally advantageous posi-
Stabilization in the device favors early loading, based on tion: 80–105° in males and 95–110° in females. The surfaces
its positive effects on changes in the tissues and the short in contact with each other may need additional adaptation
period of consolidation (usually 45–60 days). The absence depending on the consequences of the foot displacement.
of a plaster cast avoids the formation of bedsores in patients We do not recommend placing the foot at an angle <90°
with neurologic diseases targeting the feet. Unlike joint because this will lead to extra weight-bearing by the heel and
fusions involving the use of blocking nails and compress- forced flexion of the knee joint. The foot is temporarily fixed
ing screws, external devices allow residual correction, pro- using two K-wires inserted from the plantar surface through
viding more reliable fixation and dynamic monitoring of the heel into the talus and tibia. The external malleolus is
the bones, which is especially important in patients with shortened so that its length is sufficient to block the forma-
osteoporosis. In the presence of infectious processes, how- tion of a contact zone between talus and tibia, but at the same
ever, the use of internal fixation is subject to certain time short enough, to avoid contact with the calcaneus and
restrictions. not limit movement of the subtalar joint. Joint cartilage is
In this section, fusion of ankle, subtalar joints are consid- then removed from both the external malleolus and the exter-
ered along with triple joint fusion, panarthrodesis of the foot, nal surfaces of the talus and tibia. The external malleolus is
Lisfranc joint fusion, and talotibial joint fusion (after then placed at the junction of the joint surfaces and fixed by
astragalectomy). a wire with a stopper, which is inserted obliquely from out-
Practically all configuration used in these joint fusions side inward and from below upwards through the tibia but
include an external fixation module fixing a lower limb. It not touching the talus. The wire is fixed in the distractional
may consist of two wire-based supports V,3-9; V,4-10 – rod for subsequent compression in the area of syndesmosis.
VII(8-2)8-2; VII,4-10 or a hybrid wire/pin support: Thus, the external malleolus serves in the formation of the
VI,12,120; VII,3-9; (VII,8-2)VII,8-2. original bridge between the tibia and the talus.
Fig. 22.54 Assembling the device used

in a ankle joint fusion. Two intersected
wires in the talus and two in the
calcaneus are attached and stretched in a
horseshoe-shaped support, without
creating compression in the subtalar
joint. Pay attention that the wire with a
stopper, inserted through the external
malleolus, does not exert compression
on the lateral surface of the talus and in
the area of the syndesmosis. Wires in the
calcaneus, in its middle part and in the
metatarsal bones, only play a foot-
stabilizing role, without compression
of the joints
Before level-by-level stitching, the wound is drained, as an arch inverted to the side of the joint fusion provides
postoperative bleeding from the zone of the resected foot stability and ensures correct compression. Its functioning is
bones is always observed. objectively confirmed by a progressive reduction of pain
For stabilization of the foot, a closed horseshoe-shaped sup- and hypostasis.
port, assembled from a half-ring, two plates, and two arms and
connected by threaded rods is used (Fig. 22.54).
The module fixing the foot is connected to the module of 22.5.2 Subtalar Joint Fusion
the lower limb at four places: anterior, posterior and the two
lateral surfaces. All rods should be supplied with hinges Indications for subtalar joint fusion are post-traumatic arthro-
located in the sagittal plane, as this allows subsequent moni- sis, paralytic varus or valgus deformities of the heel, incom-
toring of the angle of the foot equinus. Compression on all plete dislocation of the subtalar joint after large lengthenings of
rods is immediately carried out on the operating table manu- the lower limb, and valgus heel with incomplete dislocation in
ally as well as by means of nuts and “shortening” connecting the subtalar joint of a hemimelic foot.
rods. The two temporal wires inserted in on the plantar sur- The operation begins with the installation of a tran-
face of the heel are then removed. sosseous module on the lower leg. The preferred route of
Walking with gradually increasing weight-bearing is access to the joint is external and in the projection of the
allowed and even encouraged beginning at postoperative sinus tarsi. Cartilage in the posterior subtalar joint, and
day 2 or 3. A soft insole with a small heel for protection of whenever possible in the medial and anterior parts of the
the equinus, adjustable according to the response and com- joint, is resected. Extreme caution must be exerted in the
fort of the patient, is used. During the fixation period, sup- anterior part so as not to injure the calcaneocuboid and talo-
porting compression of 1 mm/day for 10 days is carried out. navicular joints.
It must be emphasized that superfluous compression causes Wires inserted through the talus should be located not in
necrosis. In the talus, a small curvature of wires forming the plane of the horseshoe-shaped support, but 8–10 mm
Fig. 22.55 Assembling the device for a

subtalar joint fusion. Compression is
achieved by tensioning of the calcaneal
and talar wires, which should be located
below and above the horseshoe-shaped
support at a distance of 8–10 mm. These
wires are fixed directly to a support
forming an arch inverted to the side of
the joint fusion. Their tension guarantees
compression in the subtalar joint
proximally, and wires inserted through the calcaneus the K-wires in order to reduce the risk of pin tract sepsis.
8–10 mm distally. During wire insertion, the skin should be After restoration of the longitudinal arch of the foot, the
displaced to the side, opposite the wound. Compression in distraction process is continued until the subtalar joint gap
the subtalar joint is carried out using the talar and calcaneal is 5–7 mm. Simultaneously, a varus/valgus heel deformity
wires attached directly to the horseshoe-shaped support and is corrected by applying additional distraction along the
forming an arch with the base inverted to the side of the joint medial/lateral hinged connecting rods (as described
fusion. After tensioning of the wires, the size of this arch above).
decreases, creating compression in the subtalar joint If during distraction the soft tissues around the wires
(Fig. 22.55). become inflamed, distraction should be stopped. The reac-
The connection between the modules of the lower limb and tion generally subsides within 3–4 days, after which distrac-
the foot is similar to that described for a ankle joint fusions. tion is resumed. If anti-inflammatory treatment is not
Naturally, no compression in the ankle joint is needed. successful, then the wires should be removed from the area
Adjustment of the angle of equinus during treatment is neces- of soft-tissue inflammation and re-inserted in an adjacent,
sary only for the convenience of weight-bearing by the foot. non-affected area. Alternatively, half-pins can be used instead
Figure 22.56 shown an alternative configuration of the of wires: calc.,7,90 or calc.,5,90 [2, 98].
device for subtalar joint fusion. The second stage of the surgical procedure consists of
If a primary hindfoot injury has led to the development harvesting bone from the iliac wing. The size of the graft
of a post-traumatic flat foot deformity and subtalar joint should be wider than the subtalar joint gap by 3–5 mm.
arthritis, then simultaneous correction of the longitudinal The subtalar joint is debrided by removal of the degen-
arch of the foot can be combined with fusion of the subtalar eratively altered articular surfaces. The bone graft is
joint. To achieve this complex goal, the external fixation placed between the calcaneus and the talus vertically as
device is constructed as illustrated in Fig. 22.57. Distraction illustrated in Fig. 21.8. The external fixation device is
begins 3–4 days after the operation according to the stan- adjusted to generate moderate compression between the
dard protocol (0.25 mm three to four times/day). It is always talus and calcaneus, thus facilitating reliable graft
important to monitor the condition of the soft tissue around fixation.
Fig. 22.56 (a, b) In this device configuration , wires inserted through the talus and calcaneus are fixed in different supports. The advantages are
the opportunity for movements in the talocrural joint and supporting compression at the level of the joint fusion
22.5.3 Fusion of Ankle The operation begins with installation of a transosseous

and Subtalar Joints module on the lower limb. The module may consist of two
rings and be wire based or a module with one support
In double joint fusion, the configuration is similar to that rec- based on half-pins. Access to the metatarsus is lateral.
ommended for fusion of the ankle joint (Fig. 22.58). Cartilage is removed first from the calcaneocuboid joint,
then from the talonavicular joint, and finally from the sub-
talar joint.
22.5.4 Triple Joint Fusion Two wires with stoppers are inserted from opposite sides
through the talus and two more through the calcaneus.
The indications for triple joint fusion are: post-traumatic Another wire is inserted in the cuboid bone and one more in
arthrosis of the subtalar and Chopart joints; stabilization of a the navicular bone, parallel to the plantar surface. Before the
paralytic foot after poliomyelitis or other neurological dis- wires are inserted, the skin should be moved distally, towards
ease, such as spina bifida and Charcot-Marie-Tooth; foot sta- the anterior part of the foot. Another two wires are inserted
bilization after correction of complex deformities with through the metatarsus.
subsequent joint fusion, as occurs in diabetic arthropathies The horseshoe-shaped support is placed between the
or post-traumatic neurological deformities of the foot; and wires such that those in the talus and navicular bones are
stabilization of the foot in congenital pigeon-toedness if the cranial to it. Wires inserted through the calcaneus and cuboid
operation is carried out in the adult patient. bone should point cadually. Those inserted medially through
a b
Fig. 22.57 (a, b) Preoperative X-rays. (c) Before treatment

Fig. 22.57 (continued) (d–f) Bone-plasty makes it possible to restore wire inserted through the external malleolus fixes the talus as well.
the arch of the foot by correcting a pathological position of the calca- Instead of wire m/tars.V-m/tars.I the half-pin talus,1,90 (or talus, 11,90)
neus with simultaneous joint fusion of the subtalar joint. Note that the can be used
Fig. 22.57 (continued) (g) Changing external fixation for internal one
Fig. 22.58 Configuration of the device

used to achieve fusion of the ankle and
subtalar joints
VI,12,120; VII(8-2)8-2; VII,4-10; (IX,8-2)talus,8-2 calc.5–m/tars.V; calc.7–m/tars.I
the metatarsus must be over the support, and the “lateral” At the end of the assembly, the horseshoe-shaped support
wires under it (Fig. 22.59). is connected to the module on the lower limb by means of
Wires inserted through the talus and calcaneus should be four rods.
duly tensed to provide proper compression in the subtalar
joint. These wires, because they are on different sides of the
support and at some distance from it, are initially bent to 22.5.5 Panarthrodesis of the Foot
form an arch. The same can be done to achieve compression
in the talonavicular and calcaneocuboid joints. With the Panarthrodesis is a combination of a talocrural joint fusion
ends of wires, which have been inserted through the navicu- and a triple joint fusion.
lar and cuboid bones in the apertures of the horseshoe The configuration of the device is similar to that recom-
-shaped support, an arch opening posteriorly is made. mended for fusion of the ankle joint. To exert compression in
Pulling on the wires generates compression on the talus and the area of the subtalar and Chopart (calcaneo-cuboid and
calcaneous. Sufficient compression is ensured by displacing talonavicular) joints, wires preliminarily bent to form an arch
the wires backwards by at least 1 cm from their primary are used (Fig. 22.60).
position. Additional correction of the foot after a joint fusion
Wires in the metatarsal bones are necessary only to stabi- operation may be necessary. If so, the device configuration
lize the anterior foot. may be more complex, for example the configuration
Fig. 22.59 Device configuration for a

triple joint fusion
used in “V”- and “Y”-shaped osteotomies (Fig. 22.35). In In the diabetic foot, base rings are used on the lower leg to
these patients, correction begins 12–14 days after the for- guarantee maximum stability. In a post-traumatic pathology
mation of a primary bone callous at the level of joint in which the muscles of the lower leg have kept their func-
fusion. tion, the support is not necessary.
Figure 22.61 illustrates a clinical example of a panarthrod- We prefer a dorsal access to the joint, through one trans-
esis. The indications were a traumatic dislocation of the knee verse or two short longitudinal incisions to approach its
joint and tibial epiphyseolysis , injury of the sciatic nerve and internal and external parts. This is followed by resection of
popliteal artery, as well as compartment syndrome. the joint surfaces, repositioning of possible incomplete dislo-
If the segment is also shortened, the lower leg can be cations, and diafixation of the anterior part by means of tem-
lengthened with the Ilizarov device shown in Fig. 22.62. It is porary К-wires.
mounted prior to the arthrodesis. The device is assembled from a posterior half-ring length-
ened by two plates with 3–4 apertures and from an anterior
half-ring mounted perpendicular to the long axis of the foot.
22.5.6 Fusion of the Lisfranc Joint During wire insertion, the skin is moved to the side opposite
the joint. The posterior half-ring is fixed on two wires with
The indications for this type of joint fusion usually are post- stoppers, inserted through the heel. One or two wires are led
traumatic arthrosis; the consequences of a poliomyelitis through the cuboid and cuneiform bones. The anterior half-
when other types of stabilization have already been carried ring is fixed on two or three wires inserted through the meta-
out but there is a deformity and instability of the middle part tarsals. Two medial and two lateral rods connect the
of the foot; and an incomplete dislocation in the Lisfranc half-rings. The rods are located one above the other
joint, as a consequence of diabetic arthropathy. (Fig. 22.63).
Fig. 22.60 The device configuration

used for panarthrodesis. The transosseous
elements of the proximal support are not
shown
a b c
d e f
Fig. 22.61 (a–f) Before treatment

g h
i j
Fig. 22.61 (continued) (g–j) After a panarthrodesis operation. The foot equinus was corrected gradually because of the risk of trophic
disorders
k l m
n o p
Fig. 22.61 (continued) (k–p) Treatment results

Fig. 22.62 Compression panarthrodesis

of the foot with simultaneous mounting of
the device for lower leg lengthening.
Corticotomy with osteoclasis of the
proximal metadiaphysis of the tibia is
performed as the final stage of the
operation. At the end of the distraction
period, reduction-fixation wire IV,3-9 is
inserted at the level of the intermediate
support
I,8-2; I,4-10; II,1,90 – IV – VI,1,100; (VII,8-2)VII,8-2; VII,4-10; (IX,8-2)talus,8-2

calc.,2-8; calc.,4-10; m/tars.IV - m/tars.I
Fig. 22.63 Configuration of the

device used in a Lisfranc joint
fusion. The posterior long
half-ring fixes the posterior and
middle parts of the foot. The
anterior half-ring fixes the
metatarsals. Compression is
carried out between these two
supports by shortening of a pair
of medial rods and a pair of
lateral rods
22.6 Basics of External Fixation the hand is between 1.34 and 1.94 per 1000 born. Disability
in Hand Surgery in the hand resulting in damage reaches 30–32%, and physi-
cal inability after hand traumas 25–28%. Therefore, as noted
Natalya Grigirjevna Shikhaleva, by Rozov in 1956, hand surgery is not small surgery, but big
Vladimir Ivanovich Shevtsov, surgery on a small scale. Bunnel [374] underlined the impor-
and Mikhail Jur’evich Danilkin tance of this problem in his ranking of hand surgery at the
top of orthopedic surgery skills.
22.6.1 Introduction
22.6.2 Indications and Contraindications for
Restorative treatment of hand diseases and injuries remains Transosseous Osteosynthesis of the Hand
problematic in spite of significant surgical advances. This is
due, first of all, to the anatomic and physiological properties Transosseous osteosynthesis using a mini-fixator for short
of the hand. Although a small part of the human body in tubular bones is indicated in closed and open fractures of the
terms of its area (only 2%), the hand nonetheless com- phalanges and metacarpals of the fingers, replantation of the
prises 27 bones and 28 joints. Muscular control of hand fingers and wrist, in non-united fractures, malunions and
function is performed by 45 muscles [372]. The length of the pseudoarthroses, in post-traumatic stumps, in hypoplasia
arm of a 20-year-old adult accounts for 44.6% of body length and congenital anomalies of the bones of the hand for their
in men and 44.1% in women. The hand makes up 24–28% of elongation, in congenital syndactyly, and in joint contrac-
the arm length in adults. The average size of a man’s hand is tures [233, 324, 375–385]. Contraindications to osteosynthe-
18.4 cm, and a woman’s 17.4 cm. Physiologically, all joints sis are related to the apparatus and include widespread
of the hand function as a uniform joint. A complex network pyoderma, angiopathies, and the inappropriate behavior of
of vessels, nerves, and ligaments creates an elegant shape the patient.
and provides perfect function. Through its functional abili-
ties and as a tactile organ, the hand is an intermediary
between a person and his or her surroundings. In blind peo- 22.6.3 Equipment
ple, the hand essentially acts as a visual organ, and in those
who are mute as an organ of speech [373]. For the osteosynthesis of short tubular bones the mini-fixator
At the same time, the hand, like any other organ is vulner- can be individually installed on the dorsum of a finger or a
able to disturbances in pre-natal development and to metacarpal. Each device contains two units for wire fixation.
the influence of external traumatic factors, as evidenced by Knots are maintained by a longitudinal threaded rod
the following data: the frequency of congenital diseases of (Fig. 22.64).
a 22.6.4 Osteosynthesis of Fractures of the Hand

Bones with the Mini-fixator
Nowadays, traumatologists and orthopedists are able to

treat a given pathology using nailing, mini-plates, and
transosseous osteosynthesis. The chosen method frequently
defines the result. Satisfactory results following intramed-
ullary osteosynthesis were reported in 4.6% of the cases
compared to unsatisfactory results in 1.5% [372, 378,
386–390].
Indications for osteosynthesis using the mini-fixator, as
b mentioned above, are closed and open fractures of the meta-
carpals and phalanges of the fingers. Open and intra-articular
fractures with small bone fragments are also well-suited for
osteosynthesis, as are cases in which there is damage to the
tendons and neurovascular formations of the bottom third of
the forearm [378, 379]. At osteosynthesis, the plane of wire
insertion in the bone fragments should be perpendicular to
the longitudinal axis of the fragment.
Due to the angular displacement of the bone fragment
fixation sites, the wires are set at an angle, but after they are
connected to the core they will occupy a parallel position,
repositioning the axis of the bone of the hand. Similarly,
when the wires fixings in the fixating units perpendicular to
the bone fragments displaced with an angle, after the con-
nection of the units by threaded rod they will occupy a paral-
lel position and thereby reposition the axis of the bone.
Fig. 22.64 (a, b) Wire fixation units of the mini-fixator and the The following case illustrate the possibilities of osteosyn-
device’s position after an osteosynthesis of a metacarpal bone thesis for fractures of the bones of the hand. Patient Sh.,
35 years old, fell on his left hand, resulting in closed diaphy-
seal fractures of the 2nd and 4th metacarpals with a shift of
the fragments, and an intra-articular fracture of the base of
the 1st metacarpal. The next day, closed osteosynthesis with
external fixation of all damaged bones was carried out using
mini-fixators. Five weeks later, after clinical testing, the
apparatus was removed. Seven days later, a complete recov-
ery of hand function was demonstrated (Fig. 22.66).
The actions of the surgeon in response to massive dam-
age to the tendons and neurovascular formations follow a
developed algorithm. The operative measures begin with
identification of the tendons and neurovascular fascicles,
which are indicated by different color threads in an appara-
tus applied to the bottom third of the forearm and to the
hand. To bond the extremities in damaged formations, the
hand is immobilized in the position of palmar or dorsi-
flexion, depending on the damage. This pulls together the
Fig. 22.65 Scheme for the introduction of wires in a bone of the hand extremities of the damaged formations without their ten-
and their fastening in the fixation unit of the apparatus
sioning. Initially, bridge ligatures are made on the tendons
of the extremities, after which microsurgery can be per-
For the fixation of bone fragments, console wires allow formed. To bond the damaged nerves, the deep layers are
freedom of movement of both the tendons and the muscular joined to the superficial ones, initially with transneural inter-
flexors and extensors while neurovascular formations remain bundle sutures, then epineural and finally epiperineural
undisturbed (Fig. 22.65). sutures.
Fig. 22.66 (a–e) Roentgenograms a

and photos of the patient’s hand
before (a) and during (b, c)
treatment and the final result (d, e)
b

c
d

e
These techniques were applied in the following clinical In traumatic amputations of the fingers, the first stage of
example. Patient D., 21 years old, had an incision wound of treatment consists of restoration of all soft tissues with the
the bottom third of the right forearm, with damage to all use of microsurgical techniques. In the final stage, osteosyn-
flexor tendons for fingers 2–5, the ulnar artery, and the thesis is carried out using a mini-fixator, which provides
ulnar and median nerves. The damaged formations were good support of the damaged finger(s) and of the circulation,
restored according to the following algorithm, which we thereby improving restorative treatment efforts (Fig. 22.69).
developed: The hand was placed in a position of 50° flexion.
After 3 weeks, gradual extension of the hand was instituted
to achieve 20° of dorsiflexion. After 7 days of fixation, the 22.6.5 Deformity Correction of the Bones
frame was disassembled and rehabilitation initiated. At of the Hand Using External Fixation
8 months follow-up, a good result of treatment was
confirmed, including complete restoration of motor func- The principal causes of malunions of the bones of the hand
tion with a muscle strength score of 4 points. At 14 months, are: the interposition of soft tissues between fragments,
electromyography and dynamometry confirmed the posi- incomplete repositioning of bone splinters and a lack of sta-
tive dynamics of the restorative processes (Fig. 22.67). ble fixation of the bone fragments, insufficient time
In incomplete amputations, following restoration of the allowed for immobilization (necessary for consolidation),
soft tissues the damaged bones can be fixed using a mini- and premature mechanical loading in the absence of a strong
fixator. Patient B., 29 years old, presented with a deep callus.
slash wound of the left hand, with damage to the flexor Depending on the form of the bone and the function, all
tendons of fingers 3–5 and to the 4th and 5th metacarpals. malunions can be grouped as follows:
After restoration of the integrity of the tendons and soft 1. Absence of clinically visible deformity and of a functional
tissues of the palmar surface, a mini-fixator was used to disturbance of the hand and fingers: operative treatment is
create a hand brace for the damaged metacarpals. In the not indicated.
postoperative period, the condition of the hand was moni- 2. Malunions with angular deformity of the carpal region or
tored. After 2 weeks, restorative treatment was started changings of the transverse and longitudinal arches of the
(Fig. 22.68). hand due to transverse and subcapital fractures of the
a b
Fig. 22.67 Photos and X-rays of the hand and forearm of patient D. (a–c) Before the operation; (d, e) during treatment
e f h
Fig. 22.67 (continued) (f–h) 8 months after the trauma

a b
c d
e f
Fig. 22.68 Photo and roentgenograms of a hand of patient B. (a, b) Before and (c, d) during treatment; (e, f) 8 months after the trauma
a b
Fig. 22.69 Roentgenogram and photos of the hand of patient B. (a, b) Before treatment; (c) after surgery; (d, e) 2 months after the trauma
metacarpal bones not interfering with the function of the a

fingers: operative treatment is optional.
3. Disturbance of the form and function of the hand and
fingers after diaphyseal and intra-articular fractures, with
both dislocation and bone shortening: operative treatment
is indicated.
The application of mini-plates is limited to diaphyseal b
fractures, because of the development of rigidity at juxta-
articular fractures, thus furthering the damage due to the
trauma by operative measures involving the capsule and
the traumatic rupture of the ligaments. Transosseous osteo-
synthesis not only can eliminate a wide range of deformi-
ties, but also provides for the stable fixation of the
fragments, thus conserving active function of the interfac-
ing joints.
Depending on the clinical and radiological condition of
the bone, deformity correction will require different tech- c
niques [391].
Currently, in bone deformities, osteotomy should be car-
ried out with simultaneous axial correction. Figure 22.70
shows the basic stages of an operation to correct a malunion.
It begins with the introduction of wires into the bone above
and below the angle of the deformity (Fig. 22.70b). The wires
are introduced in a plane perpendicular to the longitudinal
axis, with the knots formed for bracing of the wires estab-
lished at an angle opening opposite to the deformity angle.
Through a 5-mm incision, the oseotome cuts into the cortical
plate on its concave aspect (Fig. 22.70c), followed by osteo- d
clasis, before the axis is corrected, according to a triangular
shape on the concave side of the diastasis. The knots of the
bracing wires are established parallel to each other, then the
connecting hinge is entered into the central aperture
(Fig. 22.70d). The duration of bracing depends on the defor-
mity angle but is usually 30–45 days, depending on the size of
the diastasis after axial correction and the formation of the
regenerate.
As a clinical example, a 22-year-old patient was admitted Fig. 22.70 (a–d) Deformity correction using a mini-fixator
with a malunion of the 4th and 5th metacarpals of the left
hand. Dissection of the cortical plates on the concave side
enabled a one-stage correction of metacarpal axes using the 1 and 2, osteosynthesis is carried out for abduction of the
mini-fixator (Fig. 22.71). first beam. This is followed in the second stage by an osteot-
Oblique malunions with segment shortening and the pres- omy of the first metacarpal, with simultaneous elimination of
ence of rough cicatricial changes in the tissues can be treated the deformity.
with corrective osteotomy with subsequent graduated In pseudarthroses of the phalanges or metacarpals of the
distraction. fingers, closed or open osteosynthesis is carried out using a
If a malunion is combined with expressed contractures of mini-fixator. As a clinical example: Patient Z., 23 years old,
the joints then osteotomy of the damaged beam is indicated. was diagnosed with non-unions of the proximal phalanx of
To eliminate residual rigidity of the joints, additional sup- the 1st finger and metacarpals 2–5 as well as combined con-
ports are applied on the interfacing segments. tractures of the joints of the right hand. Through incisions of
Malunions of the first metacarpal bone, as a rule, are com- 5–7 mm, new fragment ends were obtained, followed by
bined with an adduction contracture of the first beam. In osteosynthesis using a mini-fixator for each pseudoarthrosis
these patients, treatment involves two stages: first, for beams (Fig. 22.72).
a b
c d e
Fig. 22.71 (a–e) Post-traumatic deformity of the 4th and 5th metacar- was carried out. The deformity resolved simultaneously on the operat-
pals of the right hand in a 22-year-old patient with a malunion. ing table. After removal of the apparatus, finger function recovered in
Corrective corticotomy and osteosynthesis using the Ilizarov mini-fixator full
Fig. 22.72 (a–d) Osteosynthesis

a b
using mini-fixators in the
treatment of multiple pseudoar-
throses of the bones of the hand
d
22.6.6 Transosseous Osteosynthesis a

in the treatment of Post-traumatic
Stumps of the Hand
In patients with post-traumatic finger stumps, restoring the

length of the shortened segments, particularly when there
has been complete loss of all fingers of both hands, can be
attempted. In such cases, it is not a reconstruction of the
hand, but rather of the lost fingers, using their remaining
parts or the metacarpals. The aim of treatment should be to
restore basic tongs and plucking actions, as well as the
strength, of the reconstructed fingers as these properties
determine the functionality of the hand [380, 382]. b
In the presence of an accompanying deformity, standard
osteotomy and deformity correction should be performed,
with subsequent lengthening at the same level.
For finger stumps <2 cm in length, the base support of the
mini-fixator consists of two wires inserted in the distal part
of the interfacing bone of the more proximally extended seg-
c
ment. Then, through the base of the elongating segment an
S-shaped wire is inserted and, like a bridge, is slung over the
nearby joint, then fixed in the same support. The operation
ends with the insertion of console wires through the elongat-
ing distal fragment and the attachment of the wires to the
distal support, as depicted in Fig. 22.73.
As an example, patient A., 32 years old, was treated for a
post-traumatic stump of the distal phalanx of the 3rd finger, Fig. 22.73 (a–c) Elongation of a short distal phalanx
long-standing damage to the extensor tendon of the 2nd
finger, and flexion contracture of the distal joint of the 2nd
finger (Fig. 22.74). The short stump of the distal phalanges Currently, the surgical approaches to these conditions are:
of the 3rd finger was lengthened using the osteosynthesis (a) restoration of the fingers by local tissues: filling of finger
method described above. Treatment restored the proportions 1 by finger 2 (pollicization), and phalangization of the first
of the finger lengths and resolved the flexion contracture of metacarpal; (b) restoration of finger 1 by bone-skin plasty
the nail phalanx of the second finger. using a bucket-handle graft; (c) microsurgical grafting of a
To restore the tong and plucking functions of the amputa- tissue complex (including the toes); and (d) lengthening of
tion stumps of all fingers of both hands, it is sufficient to the existing hand segments by external fixation.
lengthen metacarpals 1–3, with deepening of the first inter- Clinodactyly is typical of the shortening of one of the
digital space, as was done in patient K., 64 years old. As a phalanges. The therapeutic task involves elongation of the
result of deep frostbite all his fingers had been amputated at phalanges and correction of the deformity while reducing the
the level of the metacarpal heads, resulting in the formation interdigital length disproportion. An example is patient M.,
of non-functional hands (Fig. 22.75). 5 years old, who had a congenital malformation of the left
Elongation of the 1st, 2nd, and 3rd metacarpals provided hand consisting of hypoplasia and clinodactyly of the middle
functional improvement. At elongation of the 1st metacarpal, phalanx of the third finger. The therapeutic goal was to
its abduction was established for subsequent excavation of restore both the axis of the finger and the ratio of the fingers
the first interdigital interval. by producing an average lengthening of the phalanx
(Fig. 22.76).
In hypoplasia of the metacarpals or phalanges of the
22.6.7 Congenital Anomalies of the Hand fingers, the mini-fixator can be used for elongation, in order
to eliminate a cosmetic defect and restore interdigital pari-
These disorders include syndactyly, brachydactyly, clinodac- ties. Figure 22.77 shows, as an example, a 19-year-old patient
tyly, deformations of the hand because of amniotic strangula- treated for hypoplasia of the 3rd and 5th metacarpals.
tions, ectrodactyly, hypoplasia of the metacarpals and phalanges Graduated extension usually begins 5–7 days postopera-
of the fingers, and other congenital diseases of the hand. tively. Fractional distraction is carried out 3 × 0.25 mm/
a b
c d
Fig. 22.74 (a–d) Patient A., 32 years old: elongation of a distal stump of the third finger
day(=0.75 mm/day). The rate of elongation during distraction One of the problems in the treatment of syndactyly is the
varies depending on the intensity of the bone and soft-tissue creation (growth) of skin stocks in the interdigital space for
regeneration. subsequent skin plasty with local tissues and the formation
The apparatus is removed after the desired elongation of fingers [392]. To this end, the proximal and distal meta-
has been reached (50–153% of the initial segment size) or physes of each phalanx of the involved fingers and the distal
if there is a risk of trophic disorders involving the stump ends of the metacarpals are held by two wires with stoppers
end. in the form of a corkscrew (Fig. 22.69c). The corkscrew bend
in the wires is made on the operating table. The wires are
then inserted through a phalanx from the palmar surface out-
22.6.8 Syndactyly wards. Directly under the skin, the curved wire is inserted all
the way to the bone. On the dorsal surface of the fingertips
In 1986, for every 2,000–3,000 births there was one case of the wires are fixed in two plates, placed along the longitudi-
syndactyly, accounting, at that time, for half of all congeni- nal axis of the fingers.
tal anomalies involving the upper extremities [383]. The plate ends are interconnected by two transversely
According to the regional register on congenital malforma- directed rods. Distraction starts on day 3 postoperatively: for
tions for the Moscow region, in 2001, this number had the proximal rod at a rate of 0.25 mm twice a day, and at the
increased to 100 for every 10000 births. Quite often, syn- distal rod (near the ends of the fingers) four times a day for
dactyly is inherited. the first 15–20 days and then two to three times a day.
a b
d e
Fig. 22.75 (a–f) Elongation of the metacarpals of the hand with deepening of the interdigital space of the first interdigital interval
f Our approach represents an improvement over earlier

configurations of the apparatus, which were too large and
massive to be used for syndactyly elimination in young
patients. Based on 20 years of experience with this tech-
nology, we were able to improve on the original design in
1999 [393]. The new apparatus is available in two vari-
ants, one with two supports and the other with three, that
allow treatment of all forms of syndactyly. The apparatus
with two supports is applied when the patient has a syn-
dactyly of one or two adjacent interdigital intervals. For a
syndactyly of three adjacent interdigital intervals, both
the apparatus with three supports and the one with two
supports are used. Syndactyly of four interdigital intervals
is treated with two of the three-support apparatuses.
Unlike the designs presented by other authors, in which
the wires are inserted in the sagittal or frontal planes, in
our apparatus the wires are inserted at an angle of 45°
(Fig. 22.79).
For fixation, we use corkscrew-bent wires inserted such
that there is minimal trauma to the soft tissues
(Fig. 22.79c).
Fig. 22.75 (continued) Special attention should be paid both to the establishment
of an adequate supply of skin and to the geometric character-
istics of the incisions for plasty in the treatment of the affected
interdigital space.
Distraction is carried out for 30–45 days, depending on the After elimination of the interdigital bonding, the location
severity of the pathological changes, followed by fixation for of the bottom-most interdigital space must be carefully con-
12–15 days. This period is necessary to adapt the skin and sidered, as it affects the cosmetic appearance and function of
reduce stress on the involved elements. The device is removed the span of the fingers. To define this location, we used
and plastic surgery, including the formation of fingerprints, anthropometric and radiographic studies of the relevant
is performed. parameters in healthy individuals. Based on these data, the
Syndactyly is associated not only with an altered cos- bottom of the 1st interdigital interval was assigned to the
metic appearance of the hand but also, because of the asso- level of the large metacarpophalangeal joint. The bottoms of
ciated cutaneous changes in the joints at different levels, the 2nd, 3rd, and 4th intervals were determined from
contractures. The later the syndactyly is corrected, the roentgenograms of the hand that were taken in direct projec-
more pronounced and persistent the dysfunction of the tions of the normally separated fingers of 90 individuals ages
hand. This is evident in the following clinical example. A 5–72 years. The average arithmetic lengths of the two meta-
10-year-old female patient presented with a bone-skin carpals or the basic phalanges adjacent to the studied inter-
syndactyly involving the third interdigital interval of both digital interval was defined, and the relation of this size to
hands. The mini-apparatus was applied for distraction of the distance from a line extending from the heads of the
the fingers and creation of a skin stock. Transverse traction given metacarpals to the bottom of the interdigital interval
proceeded for 20 days, followed by fixation for 25, and was calculated [394]. These studies revealed that the geo-
then plasty of the third interdigital interval using local tis- metric dimensions of the bone and soft-tissues proportion-
sues. However, despite appreciable improvements in the ally vary with growth and that they are valid for patients of
cosmetic and function of the patient’s hands, due to distur- all ages.
bances in the phalanges of the fingers and their articulating The results indicated the possibility of eliminating the
extremities, contractures in the interphalangeal joints clinical implications of syndactyly and restoring not only the
remained (Fig. 22.78). cosmetic form of the hand but also the hand’s function, as
To improve the functional result, treatment must begin at demonstrated in the following clinical example: Patient Z.,
an early age, with the advantage of earlier treatment of the 12 years old, was treated for syndactyly using an apparatus
“held down” joints. The smaller the size of the hand, with two supports. Transverse traction was carried out for
the smaller the stock of soft tissues required for plasty and 30 days followed by fixation for 15 days. The final stage con-
the shorter the treatment time [383]. sisted of plasty of the interdigital interval. The cosmetic
a b c
d e f
Fig. 22.76 (a–f) Patient M., 5 years old: clinodactyly of the third finger with a deformity of its axis
appearance of the hand was good and function was restored Contractures are often caused by ischemic disturbances
(Fig. 22.80). associated with mechanical, thermal, or chemical trauma to
Thus, the mini-fixator can be successfully used in the the hand. The contractures are either due to the trauma itself
treatment of syndactyly as it allows the creation of a skin or to the prolonged immobilization of the hand in a plaster
stock in the interdigital interval and the restoration of both cast. Other causes of contractures of the hand and fingers are
cosmetic form and hand function. systemic diseases involving the connective tissue or the cen-
tral and peripheral nervous systems, or infectious, allergic, or
congenital conditions.
22.6.9 Contractures of the Joints of the Hand Among the degenerate-dystrophic diseases of the hand,
chronic progressing cicatrical degeneration of the palmar
Among the consequences of damage to the hand, one of the aponeurosis accompanied by flexion contracture of the
most frequent is contractures of the joints of the fingers. fingers deserves particular mention. Dupuytren was the first
Fig. 22.77 (a–d) A19-year-old

patient with hypoplasia of the 3rd
a
and 5th metacarpals of the right
hand
b c
d
b e
Fig. 22.78 A 10-year-old with syndactyly of the third interdigital interval. (a, b) Before treatment; (c, d) during treatment; (e) result
a b
Fig. 22.79 (a–c) A newly designed two- and three-support apparatus for syndactyly treatment. The direction of the wires through the phalanges
and of the corkscrew-bent wire are shown in (c)
to described the condition, in 1832. He also suggested scar tissue with subsequent dermal plasty is indicated. If the
aponeurotomy as a method of operative treatment. expressed flexion contractures of the fingers are accompa-
Most of the patients are men (92–96%). The progressive nied by dislocations in the joints, we recommend a two-
nature of Dupuytren’s contracture leads to appreciable dis- stage treatment. In the first, the mini-fixator is used to
turbance of hand function to the extent that it restricts profes- eliminate flexion of the fingers, after which the dislocations
sional work in 67% of patients [395]. are set and all dystrophically altered tissues are excised. At
The choice of treatment depends on the degree of disease 3–4 weeks after the operative measure, if healing of the
expression and the nature of the tissue involvement. For the postoperative sutures allow, then physical therapy is initi-
treatment of light post-traumatic fixating and non-homoge- ated [384].
neous contractures without an associated functional An example of this approach is provided in the following
deficiency >30%, conservative treatment with medicinal clinical cases. Patient C., 29 years old, suffered complication
agents to promote resorption of the developed adherent pro- following a gun-shot wound in the right hand: non-union of
cess, together with physical therapy, electroprocedures, the 1st metacarpal, flexion contracture of the 2nd finger
water- and fangotherapy, is usually sufficient. joints, and adduction contracture of the 1st ray. Surgery con-
For more significant contractures, with joint functions sisted of an open osteosynthesis of the 1st metacarpal fol-
deficiency of 60% or more, surgical treatment to excise the lowed by closed osteosynthesis of the 2nd finger on the right
Fig. 22.80 A 12-year-old male patient treated for syndactyly of the 3rd interdigital interval. Appearance and roentgenogram of the hands (a)
before, (b) during (bracing regimen), and (c) after treatment. Functionality was restored
hand using the Ilizarov apparatus. After abduction of the 1st 56 years old, presented with third-degree scarring of the pal-
finger, plastic repair of the scars with local tissues was done mar aponeurosis of both hands. The scars were excised and
(Fig. 22.81). the Ilizarov apparatus was installed on ray 5 of the left hand
An example of a serious form of Dupuytren’s contracture and on rays 4 and 5 of the right hand, followed by gradual
treated with the mini-fixator is the following: Patient P., extension of the fingers (Fig. 22.82).
a b
c e
Fig. 22.81 (a–e) Roentgenograms and photos of the hand of patient C. before and during treatment, and the result
Fig. 22.82 (a–c) The hands of

patient R. before and during
a
treatment and the result
c
Table 22.3 Distribution of patients and hands according to the 22.6.11 Result of Treatment
pathology
Pathology Number of patients Number of hands The long-term anatomic and functional results were studied
Fractures 546 592 in 62 (58.9%) patients. Based on a three-point system,
Post-traumatic 105 124 excellent results, defined as complete recovery of the ana-
deformities
tomic and functional condition of the hand were obtained
Post-traumatic stumps 181 259
in 51.8%; satisfactory results, defined either as a weakly
Congenital anomalies 349 571
of development expressed bone deformity not influencing function or as
Congenital syndactyly 164 229 restoration of the anatomic form of the bones but varying
Joint(s) contractures 51 54 persistence of the contracture was noted in 37.5% and
Total 1,386 1,822 10.7%, respectively. Unsatisfactory results did not occur.
Restoration of pinch function in one or several of the fingers
was defined as a good treatment result (156 patients,
22.6.10 Complications 78.8%), improvement of pinch function in one or several
fingers was considered to be a satisfactory result (42
Our experience based on the treatment of 1386 patients (1822 patients, 21.2%). There were no unsatisfactory results
hands) is described in Table 22.3. (failed lengthening or lengthening without functional or
In the treatment of 95 patients with malunions and pseudo- cosmetic improvement).
arthroses involving the bones of the hand there were 7 com- Analysis of early and late outcomes showed that all exam-
plications (7.3%): soft-tissue inflammation in the vicinity of ined patients had stable treatment results, with maintenance
the wires (2), delayed consolidation (2), secondary shift of of the achieved lengthening, reconstructed pinch, and cos-
the fragments (2), and allergic dermatitis (1). These compli- metic appearance. It should also be noted that not only was
cations were eliminated in the course of treatment and did initial movement in the neighboring joint achieved but also
not influence the final consolidation or the anatomic and an increase in movement amplitude of 10–15°. Patients
functional results. reported an increase in pinch force; the improved cosmetic
The complications observed in the postoperative period appearance was the result of stretching and redistribution of
can be divided into three groups: the skin on the operated segments.
1. Those related to improper application of the method, i.e., Thus, the use of external fixators in hand surgery is the
skin cutting by the wires in rays undergoing lengthening (21 method of choice in the treatment of a wide variety of hand
cases, 3.68%) and skin cutting by the bone (12 rays, 2.1%) pathologies: open injuries with extensive destruction of the
2. General surgical complications: pin-tract infection (18 structures of the hand or traumatic amputation of any of its
rays, 3.15%) parts, lengthening of the segments, heavy acrocontracture
3. Specific complications: deformities of the regenerate after accompanied by dislocations, amputation stumps of fingers
removal of the device (8 patients, 1.4%) and complications with dysfunction of the hands, and severe congenital anoma-
encountered during lengthening (59 segments, 10.3%) lies, including total syndactyly. All of these conditions are
All complications except skin cutting by the bone frag- amenable to correction using the mini-apparatus, as long as
ment were identified and eliminated in a timely manner and there is no alternative indication.
did not increase the treatment time. To address the bone cut-
ting of the skin at the stump end, we performed skin-bone Note After the title of this chapter, all Authors, who have contributed
grafting to model its shape. The regenerate deformity was to the chapter, are listed. The specific authorship of the individual para-
eliminated by plaster splint application for 3 weeks. graphs is given after each section title.
Large-Joint Pathology
23
Leonid Nikolaevich Solomin, Elena Aleksandrovna
Volokitina, Jury Petrovich Soldatov,
and William Dean Terrell
In its general form, the external fixation device used for the Two wires are inserted through the acromial process and
treatment of large joints pathology consists of (1) a transosseous scapular spine; they are fixed after tensioning to the half-
module fixing the proximal joint segment; (2) a transosseous ring acr.,7-1; acr.,11-5. Additional stability for the support is
module fixing the distal joint segment; and (3) a hinge subsys-
tem connecting the transosseous modules. The assembly of
each component of the device has its own specific features.
23.1 Shoulder
In this section we consider the fundamentals of external

fixation of chronic dislocations of the shoulder joint and
arthrodesis of the shoulder joint (shoulder joint fusion)
(Figs. 23.1, 23.2, 23.3, 23.4, and 23.5).
External fixation of chronic dislocations of the shoulder
involves three stages [396]: (1) abduction of the head under the
edge of the glenoid cavity of the scapula by means of axial dis-
traction; (2) adduction of the head outwards; (3) approximation
of the joint surfaces. The operation is performed with the patient
supine and supported by a cushion throughout C7–D7. The gle-
nohumeral joint must project beyond the operating table.
L.N. Solomin, M.D., Ph.D. (*)

E.A. Volokitina, M.D., Ph.D.
Department of Traumatology and Orthopedics, Ural State
Medical Academy, Repina Str., 3, Ekaterinburg 620028, Russia
e-mail: volokitina_elena@rambler.ru
J.P. Soldatov, M.D., Ph.D.
Fig. 23.1 Distraction between the external supports starts on day 3–5
Department of Orthopedics, Russian Ilizarov Scientific Center
at a rate of 1.5–2 mm/day in 6–8 stages. The distraction rate is decreased
“Restorative Traumatology and Orthopedics”,
and the number of stages increased if pain or neurotrophic disturbance
M. Uljanova Str., 6, Kurgan 640014, Russia
occurs. Correct insertion of wires VII,9-3 and VII,10-4 (i.e., perpen-
W.D. Terrell, M.D. dicular to the anatomic axis of the fragment) helps to bring the proximal
Department of Orthopedics, Pinnacle Orthopedics and Sport Medicine humerus outwards during distraction. Depending on the duration of the
Specialists, 300 Tower Road, Suite 200, Marietta, GA 30060, USA dislocation and the rigidity of the soft tissue, this stage takes from 5 to
e-mail: wdterrell@comcast.net 18 days
Fig. 23.2 After radiographic confirmation of abduction of the rim of Fig. 23.3 After radiographic confirmation of adduction of the proxi-
the humeral head by 3–5 mm more caudally than the lower edge of the mal humerus outwards, gradual closure of the external supports is
fossa glenoidale, the device is reassembled. This is done by installing a started for final reduction of the dislocation. After 4 weeks of fixation,
long connection plate with threaded ends between the external supports the device is removed and restoration of movement in the shoulder joint
near the half-pin. To exclude further rotation of the connection plate is started
due to pulling of the half-pin, a stabilizing derotational unit is mounted
on its distal end by connection plates with posts. The free end of the
half-pin is connected to the connection plate so that it can be pulled at
an angle of 110–115° to it (the angle is proximally open) as shown,
rather than perpendicular to the anatomic axis of the humerus. Insertion
of a half-pin at an angle of 70–75° and the application of traction force
at an angle of 110–115° to the anatomic axis of the humerus decrease
the risk that the half-pin will be forced out and ensure better biome-
chanics of adduction of the proximal humerus outwards. Traction at the
half-pin is performed at a rate of 0.25 mm four to six times a day. The
direction of the angular transposition of the humerus is monitored
radiographically: only outwards, outwards and forward, and outwards
and backwards are allowed. This stage usually takes from 3 to 8 days
23 Large-Joint Pathology 1049
a b c
d e f
Fig. 23.4 (a–f) External fixation in a chronic dislocation of the shoul- Frame removal and temporal fixation by wires for about 3 weeks. (f) In
der. (a) Applying the frame. (b) Distraction of the upper arm. (c) dislocations lasting >3–5 months and in case of osteoporosis, abduction
Abduction of the proximal humerus. (d) Dislocation elimination. (e) of the proximal humerus can be accomplished with two half-pins
Fig. 23.5 The external supports

of the girdle and shoulder are
positioned perpendicular to the
compression force vector at
which only mutual compression
of the surfaces occurs, i.e., the
shoulder does not slide relative to
the scapula. Alignment of the
direction of the compression
force and a straight line
connecting (conventional) the
points of decussation of the basic
transosseous elements is also
beneficial. A clinical test
(compression of an unsutured
operative wound) ensures correct
installation of the device from a
biomechanical point of view
provided by the insertion of a half-pin into the scapular the humeral head will not slide from the joint surface of the
spine. This is done by marking the anterior and posterior scapula. A wire is then inserted through the head in the cen-
cortical plates of the scapular spine with two needles. A ter of the fossa glenoidale in a direction strictly coinciding
canal is made with an awl between them and the half-pin is with the optimal direction of the compression force. One or
inserted to a depth of 35–45 mm. The alternative is a support two more diafixing wires are inserted for the convenience of
based on two half-pins inserted in the scapular spine [397]. installing the device.
Wires VII,9-3 and VII,10-4 are then inserted through the Two crossing wires are inserted through the neck of the
humerus and fixed after tensioning to the ring support. In scapula, 1.5–2 cm below the top of the coracoid process. One
anterior dislocations, half-pin II,8,70 with a spongy thread is of them passes through the scapular spine, the second one
inserted; in inferior dislocations, half-pin II,9,70; and in pos- under the scapular spine. The external support (lengthened
terior dislocations, half-pin II,10,70. In the presence of half-ring or arc) is installed on the shoulder girdle so that:
marked osteoporosis or if the dislocation occurred more than • It is located perpendicular to the wire inserted in the plane
4–5 months previously, an additional half-pin is inserted at of the compression force vector.
level III. The supports are connected by three bars. At this • The wires cross at the center of the support.
stage, the half-pin remains unfixed to the supports of the Only then are the wires tensioned and fixed to the sup-
device (Fig. 23.1). port. As the half-ring is not parallel to the insertion plane of
For compression arthrodesis of the shoulder joint (shoul- the wires, fixation clamps are used for their fixation.
der joint fusion), the position of the patient on the operating Additional rigidity is provided by one or two half-pins
table depends on the approach planned for removal of the inserted into the scapular spine. The transosseous module is
joint surfaces: supine with a cushion between the scapulas then mounted on the shoulder: IV,8-2; V,10,70. This ring
and the shoulder girdle projecting beyond the table edge, or support is also placed perpendicular to the wire inserted in
on the healthy side [398]. The synovial membrane is not the plane of the compression force vector. The humerus must
excised; the cartilage on the humeral head is removed only in be located in the center of the ring. Both supports are con-
where it contacts the glenoid cavity of the scapula. The nected by three or four threaded rods that are strictly parallel
shoulder should be placed in 60° abduction, 30° anterior to the wire inserted in the plane of the compression force
deviation, and 15° inward rotation [399]. To increase the area vector (Fig. 23.5).
of contact between the scapula and humerus, it is also pos- After the operation, the arm is placed on an abduction
sible to use elements of the surgical procedures of Goht, splint or two telescopic half-pins connected to a broad belt
Watson-Jones, Movshovich, and others. are fixed to the distal support of the device. Supporting com-
The most important part of compression arthrodesis is pression is applied at a rate of 1 mm every 10–14 days. Joint
identification of the vector of the compression force at which fusion usually emerges 2.5–3 months after the operation.
23.2 Elbow cycle of flexion–extension has been completed, it is repeated,

which usually takes less time. After 10–15 passive flexion
Leonid Nikolaevich Solomin and Jury Petrovich Soldatov and extension cycles, the time for a full cycle is reduced to
several minutes. Passive movements are then supplemented
In this section we consider the fundamentals of external by the development of active movements, for which the arms
fixation of chronic dislocations of the forearm, elbow joint of the swivel hinge are disconnected. Over 3–7 days, a grad-
stiffness, and arthrodesis of the elbow joint (Figs. 23.6, 23.7, ual transition is made to the priority development of active
23.8, 23.9, 23.10, 23.11, 23.12, 23.13, and 23.14). movements. Then the device is dismantled and restorative
The first stage of the closed reduction of chronic dislocations treatment continues.
of the forearm involves installation of a double-support module The procedure for using the external fixation devices pre-
based on a ring and a two-thirds ring on the shoulder. The sup- sented is intended for patients with stiffness without a bone
port is either based on wires (Fig. 23.6a) or a hybrid device component. If the joint surfaces are congruent, installation of
(Fig.23.6b). The second module fixing the forearm can also be the device is preceded by arthroplasty, which may include,
a wire or hybrid wire/half-pin device: II,6,90; III,9-3; IV,6,90 according to the indications, partial removal of the ulnar pro-
(as shown in the figure) or III,9-3; IV,6,70. A hinge-distraction cesses, excavation of the olecranon fossa, and the removal of
subsystem is mounted between the modules. After reduction of ossified material (Figs. 23.10 and 23.11).
the dislocation, the elbow joint is fixed in the mid-physiological In patients with post-traumatic intra-articular elbow-joint
position for 2–3 weeks, after which the device can be used for fusion of >1 year duration, the following method is used.
the development of movement in the elbow joint. Initially, a cup-and-ball (hinged) osteotomy of the area of
There are two conditions for successful external fixation joint fusion is performed using medial and lateral approaches.
for stiffness in the elbow joint. The first is to use the reference The ends of the humerus and the elbow bones should be pro-
positions shown in the atlas for insertion of transosseous ele- cessed by mills. In this procedure, the humeral condyle takes
ments. The second, indispensable condition of frame assem- on a semi-cylindrical form and the trochlear notch an ellipti-
bly for elbow-joint stiffness elimination is the installation of cal one (Fig. 23.12). Thus, a resection of the ends of the
axial hinges (one axial hinge is used in monolateral devices, humerus and ulna should be 0.5–1 cm. New elbow-joint
Fig. 23.9) strictly according to the axis of rotation of the elbow movement is acquired by means of a hinged frame (Figs. 23.8
joint (Fig. 23.7). Figure 23.8 shows the assembly developed at and 23.9).
the Russian Ilizarov Research Center [400]. Alternative hybrid For the first three postoperative days, the osteotomy gap is
wire - half-pin assembly can be used: II,10,90; III,8,90 – washed with cooled novocaine. Drainages are removed
VII,9-3 –o– II,10-4 – VI,7,90; VII,6,90. Figure 23.9 shows the 1–2 days after the operation. Hyaluronidase is infiltrated
monolateral configuration of the device. peri-articularly at 64 U/ml once a day for a total of ten injec-
A diastasis of 2–3 mm is created between the joint sur- tions. Betamethasone is infiltrated at 1 ml/week for a total of
faces. Introducing water in the joint under pressure (using three injections. Joint movements start 1–2 days after the
the arthroscopic technique) is beneficial. operation. The total duration of the procedure is usually
A swivel hinge is used to gradually increase flexion of the 1.5–2 months.
elbow joint beginning at an average of 2–6°/day in four to six In patients with inveterate (old) traumatic dislocations of
stages. The flexion rate must be reduced if pain occurs or if the radial head and ulnar deformations, cure comprises three
there are signs of irritation of the great vessels and nerves. The stages. In the first, the hinged frame is installed and ulnar
manipulations must not cause any pain. The decision as to osteotomy applied at the CORA level (Fig. 23.14a). In the
whether the amount of movement of the swivel hinge causes second, the hinged frame is used to restore the length and
no pain must be made in the morning. Only after a night with- axis of the elbow. In the third, residual displacement of the
out analgesia should an increase in the rate of joint movement radial head is eliminated and the bone is fixed in the correct
be recommended. The systematic prescription of analgesics position (Fig. 23.14b). The device configuration is similar to
to accomplish movement “at any cost” is impermissible. that in Monteggia injury (Chap. 11.2.1 – Fig. 11.14).
After forearm flexion to an angle of 130–140° has been Figure 23.15 provides an example of the treatment of an
achieved, extension starts at the same rate. After the full inveterate Monteggia injury.
Fig. 23.6 Schemes for an Ilizarov

device (a) and combined external a
fixation device (b) for the reduction
of chronic dislocations of the forearm.
Distraction starts on day 3–5
postoperatively at a rate of 0.25 mm
six to eight times a day. The rate of
distraction is decreased if pain or
signs of hyperextension of the great
vessels and nerves occur. After lateral
radiographs confirm the presence of
the necessary diastasis for unhindered
horizontal movement of the ulnar
epiphysis, the subsystem connecting
the modules is remounted. Its
construction (Figs. 2.4, 2.5, 2.6, 2.7,
2.8, and 2.9) depends on the type of
dislocation: anterior, posterior,
medial, or lateral
IV,10-4; IV,8-2 – VII, 3-9 o III,3-9 – VI,4-10; VI,6-12(V,6-12) (a)

130 3/4 130 3/4 120 120
IV,8,90; V,10-4 – VII,3-9 o II,6,90; III,9-3; IV,6,90 (b)

130 3/4 130 3/4 120
a b
Fig. 23.7 An axis of rotation of the elbow joint in the frontal (a) and axis of the elbow joint goes through the humeral head and the starting
horizontal (b) planes a Finding the frontal plane rotation axis: (1). A point of the humeral trochlea. This rotation axis is located at an angle of
line through the center of the humeral head and the transition point of 96° to the mid-diaphyseal line of the humerus. (b) Finding the horizon-
the medial epicondyle of the humerus and the starting point of the tal plane rotation axis: (1) A line connecting the apexes of the medial
huneral trochlea is drawn (line 1). (2) A line perpendicular to the mid- and lateral epicondyles is drawn (line #1). (2) A line from the apex of
diaphyseal line of the humeral bone is drawn (line #2). Lines #1 and #2 the internal epicondyles at an angle of 5º to line #1 is drawn (a line #2).
should cross at an angle of 6°. In other words: the frontal plane rotation Line #2 is the rotation axis of the elbow joint in the horizontal plane
a b
Fig. 23.8 Range-of-movement

hinged frames. (a) Frame
assembly according to the
Ilizarov Russian Research Center
[400]. (b) Two-plane hinge: 1 II,6-12; II,11-5 – VII,9-3 –o– II,4-10 – (VII,12-6)VII,12-6; VII,5-11 (a)
proximal part, 2 distal part, 3 line
between ulnar processes II,10,90; III,8,90 – VII,9-3 –o– II,10-4 – VI,7,90; VII,6,90 (b)
a b
III,9,90; VII,9,90 --o-- II,9,90; VI,9,90
Fig. 23.9 Monolateral configuration of the device for increasing the range of movement in the elbow joint. The wire is inserted in the projection
of the axis of elbow joint rotation
Fig. 23.10 Restriction of elbow-joint extension of the because of a

lack of conformity between the ulnar process and the ulnar fossa,
decentralization, or hypertrophy of the top of the ulnar process can be
corrected by modifying the curvature of the trochlear notch. This is
done, in accordance with the results of specific calculations, by remov-
ing a wedge of bone at the base of the ulnar process [230]. Osteosynthesis
of the ulnar process is then performed as for fractures (Figs. 11.3, 11.4,
and 11.5). The supports for tensioning the compression wires are used
as the module of the device for the subsequent development of move-
ments in the elbow joint
Fig. 23.11 Roentgenograms

from a patient with post-trau-
a
matic elbow-joint stiffness,
caused by deformities in the
block of the humerus. (a) Before
treatment, with maximum
possible extension; (b) during
treatment; (c) after device
removal
c
a b
c d
Fig. 23.12 Roentgenograms from a patient with elbow-joint fusion. (a) Before treatment; (b) during treatment; (c) 4 months postoperatively, with
maximum flexion and extension; (d) 9 years after treatment
V,10,120; VI,7-1 0,4-10; I,10-4 — V,6,90

130 2/3 130 120
Fig. 23.13 For compression arthrodesis of the elbow joint, installation only mutual compression of the humerus and ulna without risk of sliding.
of the device is preceded by removal of the joint surfaces and their adap- Then, for convenience in mounting the device, one or two diafixing wires
tation by placing the forearm in the position 80/80. A wire is then inserted are additionally inserted. Note that the device supports are located per-
through the base of the ulnar process. The direction of the wire must pendicular to the compression force vector rather than to the anatomic
precisely coincide with the vector of the compression force, providing axes of the bone fragments. Support VI,6,90 is of auxiliary significance
a b
c d
I,10-4; I,2-8; II,4-10 0 IV,4-10 -- (VII,12-6)VII,12-6; VII,5-11 (a)

I,10-4; I,2-8; (I,11-5)I,11-5; II,4-10 -- IV,4-10 -- (VII,12-6)VII,12-6; VII,5-11 (b)
I,10-4; I,6,90; II,7,90 0 IV,6,90 -- (VII,12-6)VII,12-6; VII,5-11 (c)
I,10-4; I,6,90; II,7,90 0 IV,6,90; (IV,11,90) -- (VII,12-6)VII,12-6; VII,5-11 (d)
Fig. 23.14 Configuration of the Ilizarov device for repositioning of an inveterate dislocation of the radial head according to [400] (a, b). The
alternative is a combined (“wire–half-pin”) assembly (c, d)
a b
Fig. 23.15 Roentgenograms from a patient with a post-traumatic dislocation of the radial head and an ulnar-shaft deformity before treatment (a),
during treatment (b), and 5 years after device removal (c)
23.3 Wrist device is removed immediately after the anatomy of the

wrist joint has been restored and diafixation by the wires is
Leonid Nikolaevich Solomin complete.
In non-acute injuries (3–4 weeks post-trauma), a single-
In this section we consider the fundamentals of external step reduction of the dislocation is possible; however, if there
fixation of chronic dislocations of the hand, stiffness of the is insufficient experience in the treatment of such patients the
wrist joint, and arthrodesis of the wrist joint (Figs. 23.16, recommended first stage is to apply a distraction device
23.17, and 23.18). based on two supports: VI,6-12(VI,6-12); VI,4-10 ←→
In dislocations and fracture-dislocations of the wrist joint m/carpV–m/carpII. Distraction at a rate of 0.25 mm four to
(wrist bones), provided there are indications for open reduc- six times a day starts from the second postoperative day. Five
tion, the use of a distraction device must be considered as to 7 days are usually enough to “stretch” the joint, thus pro-
the first mandatory stage of surgical treatment [401]. If up to viding more convenient conditions for open intervention.
2 weeks has passed since the trauma, the device is applied In chronic injuries (8–9 months old) with osteoporosis
by means of an incision, to ease reduction. The device is and marked rigidity of the soft tissues, the distraction device
based on two wires with stops tensioned in two half-ring must include a large number of transosseous elements. The
supports: VI,6-12(VI,6-12) ←→ m/carpV–m/carpII. This distraction period usually lasts 7–12 days. After open
(V,3-9); VI,6-12(VI,6-12); VI,4-10 o V,6-12(V,6-12); V,4-10 − VIII,6-12(VIII,6-12)

120 120 120
m/carpII–m-carpIV; m/carpV–m/carpIII o m/carpII–m-carpIV; m/carpV–m/carpIII
2/3 120 2/3 120
Fig. 23.16 Distraction device for the wrist joint. A wire is inserted Fig. 23.17 In the device used for the elimination of wrist-joint stiff-
through the 2nd and 5th metacarpals; a second wire is inserted through ness, the axial hinges are installed according to the axis of movement of
the 5th and 3rd metacarpals. After tensioning, the wires are fixed to a the wrist joint; that is, along the lower edge of the styloid process of the
two-thirds or three-quarter ring support. The transosseous module on radius (From [80]). A diastasis of 2–3 mm is created between the joint
the forearm is based on three wires fixed to one ring support surfaces. Introducing water in the joint under pressure (using the
arthroscopic technique) is beneficial
reduction, the device can be left in place not only for immo-
bilization but also to remove the load from the injured struc- paresthesia. The manipulations must not cause any pain. The
tures in order to prevent aseptic necrosis. decision as to whether the amount of movement of the swivel
The Russian Ilizarov Research Center has developed hinge does not cause pain must be made in the morning.
methods for the use of the Ilizarov mini-device for the treat- Only after a night without analgesia should an increase in the
ment of fractures of the wrist bones and metacarpals that also rate of joint movement be recommended. Systematic pre-
involve the use of a large device to facilitate reduction. After scription of analgesics for the development of movement “at
5–7 days, the large device is removed and further fixation of any cost” is impermissible.
the bone fragments involves only the mini-device. After dorsal flexion of the hand to an angle of 40–45° is
One of the conditions for successful external fixation for achieved, the device is stabilized for 2–3 days. Returning to the
the elimination of stiffness in the wrist joint is to use the ref- initial position of palmar flexion does not usually cause any
erence positions described in the atlas for the insertion of difficulties. After 10–15 cycles of passive flexion and exten-
transosseous elements. The device shown in Fig. 23.17 is sion, the time for a full cycle will be reduced to several minutes.
recommended. Passive movements are then supplemented by the development
Flexion stiffness is the most frequently occurring wrist- of active movements, for which the arms of the swivel hinge
joint problem in clinical practice. A swivel hinge is used to are disconnected. Over 3–7 days, a gradual transition is made
gradually increase extension, starting at an average rate of to the priority development of active movements. Then, the
2–6°/day in four to six stages. Flexion must be decreased if device is removed and restorative treatment is continued.
pain occurs or if there are signs of irritation of the vessels For arthrodesis of the wrist joint, the hand is placed in
and nerves. The latter are manifested as finger blanching or dorsal flexion of 20°. The device is analogous to that shown
a b c
d e f
Fig. 23.18 Scheme for reconstruction of the forearm in defects of the wrist bones and combined osteosynthesis are performed (b). After
ulna and radius, chronic osteomyelitis, or extensive defects of the soft arthrodesis is achieved, typically in 9 weeks, the distal support is
tissues (a). A non-free graft is transplanted from the radius to the ulnar removed (c–e). The device is removed 5 months after surgery (f)
defect, and arthrodesis of the distal part of the ulna with the first row of
in Fig. 23.17. If, after removal of the traumatic defect of the However, this method was not widely adopted due to its
radial epiphysis, the excess length of the ulna does not exceed complexity. Imperfections of external and internal bone
2 cm, its distal epiphysis is resected and used as grafting fixators and the plaster bandages widely used at the time
material. If the defect of the distal end of the radius is >2 cm, resulted in straightening of the formed angle, slow consoli-
it must be replaced with bone graft or by lengthening the dation, or the formation of pseudoarthrosis at the osteotomy
remaining part of the bone according to the method of level, which significantly lowered the efficacy of the inter-
Ilizarov. This subject is discussed in more detail in Chaps. 19 vention and prolonged the terms of treatment.
and 20. In 1986, Ilizarov developed an original technique of hip
reconstruction by creating an additional supporting point in
the pelvic bone, which allowed, in addition to the increased
23.4 External Fixation of the Hip Joint support of the extremity, normalizing its axis and length
[404–408]. This operation further served as the basis for the
In the following, the basic principles of external fixation of development and improvement of the techniques used to
defects, deformities, developmental anomalies, and the con- treat congenital hip dislocation in adults [409–411], proxi-
sequences of traumas of the proximal femur are considered mal hip defects [412], coxarthrosis [413], congenital hip dis-
(Figs. 23.19, 23.20, 23.21, 23.22, 23.23, 23.24, 23.25, 23.26, location in children [413, 414], and supra-acetabular
23.27, 23.28, 23.29, 23.30, 23.31, 23.32, 23.33, 23.34, 23.35, neoarthrosis [525, 526] (Fig. 23.19).
23.36, 23.37, 23.38, 23.39, 23.40, 23.41, 23.42, 23.43, 23.44, A significant number of patients were operated on at the
23.45, 23.46, 23.47, 23.48, 23.49, 23.50, and 23.51). External Russian Ilizarov Scientific Center “Restorative Traumatology
fixation of a “central dislocation” of the hip was discussed in and Orthopedics” (RISC “RTO”) and expressed satisfaction
Chap. 21.6 – Fig. 21.15. with the obtained result, such that the Ilizarov reconstructive
support hip osteotomy became one of the main organ-pre-
serving techniques of non-supportive hip treatment [418– 421].
23.4.1 Support Osteotomies Using the Ilizarov Indications for the technique are:
Technique • Congenital hip dislocation in adults and adolescents (after
termination of the active growth period in patients not
Elena Aleksandrovna Volokitina younger than 16–18 years) in case of marked dysplasia of
and Leonid Nikolaevich Solomin the pelvic bone and femur when the anatomic conditions
(flat thinned pelvic bone, total deficiency of the anterior,
23.4.1.1 Introduction posterior margin of the acetabular arch, thinned femur
Supportive osteotomy techniques have been developed to with narrow or curved medullary canal) do not allow hip
improve extremity function in case of a non-supportive hip. replacement
Kirmisson suggested subtrochanteric osteotomy in 1894 to • Post-traumatic and postoperative defects of the head,
eliminate adduction contracture and lordosis in patients with neck, and proximal part of the femur when the patient
long-standing congenital hip dislocation (cited in [402]). The refuses hip replacement or there are no possibilities to
technique was further developed by several orthopedists, perform it
such as Froelich [435], Lorenz [711], Haas [712], and • Post-traumatic or post-resectional defects of the head,
Golland [436]. However, the most popular technique, due to neck and proximal part of the femur after a pyoinflammatory
its relative technical simplicity and functional effect, was the process in the coxofemoral joint or femur when, due to the
Schanz osteotomy [434], in which a transverse osteotomy of risk of re-infection, hip replacement is contraindicated
the femur was performed at the level of the middle upper The contraindications are identical to those described in
third of the ischial branch, with abduction of the distal frag- Chap. 1.2. It should be emphasized that osteomyelitis of the
ment by 45–60°. pelvis, femur, tibia, and foot bones on the operated side are
In later modifications of the Kirmisson and Schanz osteot- contraindications only in case of relapse.
omies, angulation of the femoral abduction was increased or
decreased, and the location where the additional support was 23.4.1.2 Biomechanical Basis of the Technique
created was modified. Extremity lengthening issues and axial and Preoperational Planning
corrections were not taken into account. In case of dysplasia, pyoinflammatory conditions, and lesions
In 1949 Berliner [403] suggested treating congenital dis- in the area of the coxofemoral joint, with proximal hip dislo-
locations associated with limb shortening by combining the cation in the middle and smaller gluteus and iliopsoas mus-
Schanz osteotomy (oblique osteotomy at the level of the cles, there are persistent degenerative dystrophic changes
ischium to form the angulation) with the Bogoraz technique that prevent the use of the traditional biomechanical calcula-
(osteotomy of the diaphysis for lengthening, performed using tions of Pauwels [422–424] and Janson [425]. Specifically,
lateral and longitudinal skeletal extension during 4–6 weeks). the affected muscles are not able to balance the body in
Fig. 23.19 External fixation performed

a b
with a double reconstructive support
osteotomy of the hip with correction of the
extremity axis: (a) frontal view, (b) lateral
view
pelvic balancing nor are they able to withstand weight-bear- supporting joints’ coaxiality and symmetric positioning
ing. The formation of an additional support redistributes with respect to the contralateral side
gravity-loading on the affected side. Accordingly, we believe Based on the principle of static body balance reconstruc-
that the biomechanical basis of this technique, first of all, is tion in the upright standing position, Shevtzov Volokitina,
to define the site where an additional support in the pelvic and Makushin developed a method of preoperative planning
bone will be created, depending on the stage of the proximal of femoral bone reconstruction (RF patent no. 96123503/14).
femoral dislocation. The method presented below relies on geometric construc-
The main task of orthopedic treatment is reconstruction of tions made from the skiagram created from the patient’s pel-
the patient’s ability to stand upright and to walk, by provid- vic X-ray in frontal view with maximal adduction of the
ing not only significant functional and cosmetic effects but involved extremity (Fig. 23.20). The algorithm is the
also by ensuring minimal consumption of the muscular following:
energy necessary for keeping the body balanced in the verti- 1. Mark the projection of the total mass center (TMC)
cal position. (T-point) in the upright standing position. The TMC is
The biomechanical basics for reconstruction of an extrem- located at the intersection of the body midline (TTR) and
ity with a decentered coxofemoral joint are the following the direction of the frontal rotation axis of the healthy
Volokitina [417, 426]: coxofemoral joint.
• In case of neoarthrosis, making use of the present func- 2. Define the points of maximal gravity loading of the intact
tional adaptation reactions (passive closure of the joint in extremity (V-point) at the intersection of the TC-sections
loading on the extremity due to the femur bearing against with the acetabular contour.
the pelvis during its maximal adduction) 3. Based on the equality of the angles of action (Pd = Ps,
• Planning femoral reconstruction considering the biome- ad = as) of the right and left gravitational components in
chanical properties of the contralateral coxofemoral joint the upright standing position, a TVTv right triangle is
• Correcting the biomechanical axis and length of the constructed on the healthy side and symmetric to it a
involved extremity, up to the reconstruction of the TV1Tv triangle on the affected side, with TTv as the
posterior branch of the ischium. The needed location of the

support (Vo-point) (from the above-mentioned areas) is
found at the intersection of the circumference (the center is
in the V1-point, radius r = V1Vn) with the lower external
contour of the pelvic bone. Thus, after formation of the bone
support, gravity-loading is redirected from the affected site
to the center of the general support line (V1-point) between
the Vo-point of support formation and the neoarthrosis cav-
ity’s maximal gravity-loading Vn-point (V1Vn = V1Vo).
Hence, the higher the femoral dislocation and the
higher the neoarthrosis cavity, the lower should be the
formed additional support within the anatomically avail-
able area of the pelvic bone. Redistribution of the maxi-
mal gravitational loading of the affected side from the
Vn-point to the V1-point enables evenly distributed load-
ing on the pelvic bones.
6. The required angle of g-abduction of the intermediate
fragment equals the angle between the straight line drawn
from the T- and Vo-points and the vertical line drawn
through the Vo-point. As a result of hip reconstruction,
the rotation axes of the neoarthrosis and bone support
intersect in the TMC with the rotation axis of the healthy
coxofemoral joint, and there is no overturning moment in
the upright standing position.
7. Then, on the skiagram, the inter- or subtrochanteric
osteotomy is modeled, as is the formation of the pelvic
support, by displacement of the osteotomized distal frag-
ment to the Vo-point with its abduction at the g-angle.
Then, distraction of the distal femoral fragment is per-
formed and angulation is corrected at the level of the cor-
ticotomy. The control position of the distal femoral
fragment is the position at which the distances obtained
between the TTR gravity-loading line and the centers of
the knee joints (K, K1) and ankle joints (Q, Q1) of the
intact and affected extremities (KTK = K1TK,
QTQ = Q1TQ) are equal. The pelvic bone may contact
either the lesser trochanter or the surface of either the
metadiaphysis or the diaphysis depending on the level
Fig. 23.20 Preoperational planning of a femoral bone reconstruction where the support point in the pelvic bone is formed and
the femoral osteotomy is done.
common cathetus. The V1-point is the optimal point for In a support reconstruction osteotomy of the femur per-
maximal gravity loading of the affected side. formed according to this technique of preoperative planning
4. Then the Vn-point of maximal gravity loading is defined it is helpful to reconstruct the conditions for static balance in
for the present coxofemoral joint (neoarthrosis) located at the upright standing position by referring to the TMC.
the intersection of the TCn-vector (from the TMC to the
center of the neoarthrosis rotation). The neoarthrosis’ 23.4.1.3 Features of Wire Insertion and Setting,
rotational center is defined as the intersection of the per- and Assembly of the Ilizarov External
pendiculars dropped from the neoarthrosis cavity contour Fixator
tangents. External fixation performed before support reconstruction
5. The site where the additional support point on the pelvic osteotomy of the femur makes use of standard parts taken
bone will be formed is anatomically limited by an area that from the Ilizarov external fixator set, such as two arches and
includes the acetabulum, its inferior margin, the upper pos- a ring, threaded and telescopic rods, connecting plates, 1- to
terior external margin of the locking foramen, and the 4-hole male and female posts, wire-fixation bolts, M-bolts
a b
I,6-12; I,11-5; I,9,90 o III,7-1; III,6-12; III,9,90 o VI,3-9; VII,2-8; VII,4-10
Fig. 23.21 Basic assembly of the external fixator for osteotomies: (a) External view; (b) internal view
6 × 12 and 6 × 18, M6 nuts, hemispherical paired washers, keeps the femur and pelvic bone wing free and allows wires
smooth and stop wires with a diameter of 1.8–2 mm and a to be inserted in the frontal and posterior surfaces.
length of 460–500 mm. The arches and rings are fitted based Through the distal femoral metaphysis in its transversal
on the appropriate size. The following aspects must be taken plane, three or four mutually intersecting wires are inserted.
into account: A skin “store” is created for lengthening also during flexion
• The size of the arches and half-rings (rings) are fitted indi- and extension of the knee joint (the wire must pass through
vidually according to the level of the planned installation the stretched soft tissues). The wires are fixed and tightened
on the segment (upper, middle, or lower third of the in the ring support of the Ilizarov external fixator, which is
femur) so that the distance between the skin and the inter- installed perpendicular to the femoral axis in two planes
nal edge of the arch or half-ring along the whole circum- (Fig. 23.22).
ference is 1.5–2.0 cm. To fix the proximal fragment through the area of the greater
• The telescopic rods must be long enough to fit the calcu- trochanter and lateral part of the femoral neck in the adducted
lated distance between the ring and the middle arch. and maximally extended extremity, two wires with stoppers
• The number of external fixator instruments should include are inserted backwards from the front, outside from within, and
reserves and will depend on the construction. bottom-up, and two wires with stoppers in the opposite direc-
After the fixator is chosen, its parts are placed in a metal tion, forward from behind, out from within, and down from
container for sterilization before surgery. above. The wires are fixed and tightened in the arch installed
The basic assembly of the Ilizarov external fixator for almost in the sagittal plane considering the forthcoming maxi-
reconstruction support osteotomies is shown in Fig. 23.21. mal valgization of the proximal fragment with hypercorrection
In the operating room, the patient is anesthetized and then by 10–15° from its varus and anticurvature displacement. The
placed supine on the orthopedic table with head and shoulder pattern of wire insertion results in the creation of a store of soft
elevated. To provide the optimal conditions for external tissues. Insertion of the wires on the frontal surface in the
fixation, the distal panel of the table should be set horizontally above-mentioned direction maximally displaces the soft tis-
and maximally lowered. The healthy extremity is abducted at sues outwards and downwards; wires inserted on the posterior
an angle of 110–115° and fixed by foot support. The patient’s surface displace the soft tissues inwards and upwards.
sacrum is on the pelvic support; the affected extremity lies in To fix the intermediate fragment in the upper third of the
free position with the shin on the operating pillow, which femoral diaphysis in its transverse plane beyond the Hunter’s
a b on the border of the upper and middle thirds of the

diaphysis.
Through a 2.5–3 cm transverse incision of the skin, the
fascia lata of the femur is dissected transversely. The muscles
are bluntly retracted by the elevator along the anterior and
posterior surfaces, exposing the femur. To prevent splitting
of the bone especially at the subtrochanteric level, it is perfo-
rated by a wire along the line of the planned osteotomy. A
1.5–2 cm wide osteotome is used in a transversal consequent
dissection of the external, anterior, and anterior-posterior
cortical plates. The osteotomy is terminated according to the
initial direction of the osteotome, positioned inwards from
the outside. Next, using a wide chisel, installed between the
osteotomied fragments, medialization of the proximal mar-
gin of the distal fragment is performed until the support in
the pelvic bone is reached, simultaneously extending and
abducting the femur up to the biomechanically calculated
angles of the support point. The proximal femur must be
positioned with maximal valgization. The arches with almost
parallel planes after the femoral abduction are fixed together
by four threaded rods directly or by hinge units, creating
compression in the osteotomy area. A test must then be made
Fig. 23.22 Wire insertion and double reconstruction support
to check the consistency of the formed support by smooth
osteotomy of the femur: (a) frontal view, (b) lateral view
adduction of the femur.
Support formation during 15–40° of femoral abduction
canal projection, three wires with stoppers and with a dia- leads to significant deviation of the biomechanical axis of the
physeally shaped cutting end are inserted, two from the femoral segment. That is why an additional corticotomy is
anterior and one from the posterior surface. A skin store is made at the calculated level, which is usually in the upper
created for lengthening and forthcoming abduction of the third of the diaphysis. To do so, the telescopic rods connect-
femur (in valgization osteotomy and pelvic bone support ing the middle and distal supports are disassembled. In an
formation). The wires are fixed and tightened in the second anterior external approach through a 1-cm skin incision, cor-
arch of the Ilizarov external fixator, installed with hypercor- ticotomy of the diaphysis is carried out on the anterior exter-
rection to the opposite side from the first one so that the nal surface of the femur, distally from the wires, and fixed in
planes of the arch supports will form an angle open out- the middle support. The middle arch and the ring are again
wards and backwards. Before the osteotomy is performed, fixed together by telescopic rods. The positions of the femo-
the arches must not be connected. To increase the stability ral fragments are controlled by taking an X-ray of the cox-
of the intermediate support, two or three console wires are ofemoral joint and femoral bone in two projections. The
additionally inserted along the anterior semicircle of the operative wound is sutured layer-by-layer. Aseptic dressing
upper third of the femur, with their sharp ends not transcend- is applied at the exit sites of the wires and a pressure dressing
ing the border of the second cortical (medial dorsal) layer. is places on the osteotomy and corticotomy areas.
Two-plane hinge units are used to connect the middle sup- Figure 23.23 shows the stages of support osteotomy using
port with the distal one by four telescopic rods that must be the Ortho-SUV Frame.
directed corresponding to the longitudinal axis of the femur.
In assembling the connection of the arch with the ring in 23.4.1.4 Features of the Postoperative Period
case of correction angulation of the distal support, hemi- In the postoperative period, the dressings around the wires
spheric washers are used. are changed as needed but at least once every 10 days. The
After insertion of the wires and the external fixator patient is instructed to walk on crutches and is given exer-
assembly, the operative field is thoroughly disinfected sev- cise therapy. Distraction at the level of the corticotomy is
eral times and the sterile sheet under the operated extremity started on postoperative day 5 at a rate of 1 mm/day.
is changed. The surgeon can then begin the osteotomy. Its Simultaneous with lengthening (advanced distraction
level is verified based on an X-ray of the affected joint along the external rods by 0.5 mm), correction of the angu-
taken in a position of maximal adduction of the femur and lation of the femoral bone fragments is made on the dis-
using radio-opaque markers, i.e., 2–3 wires, inserted in the traction regenerate until the extremity’s mechanical axis is
projection of the inter- and subtrochanteric area as well as normal.
a b c
d e f
Fig. 23.23 Stages of Ilizarov support pelvic osteotomy: (a–f) surgery line drawn through the support point of the femoral bone to the pelvis
planning, (g–k) stages of the surgery. (a) Initial X-ray; (b) maximal must correspond to the mechanical axis of the extremity; (f) modeling
adduction to define the level of the proximal osteotomy; (c) modeling of transosseous element insertion
abduction of the distal fragment; (d, e) the perpendicular to the bispinal
g h i
j k
Fig. 23.23 (continued) (g) insertion of the transosseous elements and (i) connection of the middle and distal supports by the Ortho-SUV
fixation of the external supports; (h) the proximal osteotomy with sin- Frame; (j) eliminating the limb length inequality with simultaneous res-
gle-stage correction of the fragments’ position, connection of the proxi- toration of the axis; (k) for the fixation period, the Ortho-SUV Frame
mal and intermediate supports. The second osteotomy: struts are replaced by hinges
Between 10 and 12 days prior to the planned disassembly Female patient A., 16 years old, with a congenital left hip
of the external fixator, the tension between the supports is dislocation associated with a partial defect of the left femoral
eased by loosening the nuts on the connective rods by head and neck, shortening of the left extremity by 4 cm, and
0.25 mm twice a day. The indication for external fixator dis- valgus deformity of the left knee joint was admitted to the RISC
assembly is the absence of mobility during axial and lateral “RTO”. The congenital left-hip dislocation had been diagnosed
loadings in the area of the osteotomy and regenerate, as when the patient was 5 years old but at that time an open reduc-
confirmed in a functional test. tion was not possible; 2 years later re-operation, consisting of
In the following clinical example a patient with a supra- arthrotomy and arthrolysis of the left coxofemoral joint with
acetabular neoarthrosis that resulted from an open reduction excision of the commissures and ossifying elements, was nec-
of a hip dislocation was treated as described above essary. By the age of 15, a neoarthrosis had developed in the
(Fig. 23.24). supra-acetabular area on the patient’s left side.
a c
a
Vn
V VI
Cn
C C0
B
β
Y
Fig. 23.24 Use of support

osteotomy in the treatment of a
supra-acetabular neoarthrosis.
(a, b) Before treatment;
(c) skiagram made from the
pelvic X-ray for preoperational
planning of the extremity
reconstruction
Fig. 23.24 (continued) (d, e) external fixation

Fig. 23.24 (continued) (f, g) treatment results

On admission, she complained of moderate pain, limita- The following is a clinical example of the treatment of a
tion of femoral abduction and rotation, low supportiveness of postresectional defect of the proximal femur that arose after
the extremity, and marked limping. Examination revealed removal of an infected hip joint prosthesis (Fig. 23.25).
limitation of flexion up to 100°, extension up to 165°, femo- On first admission to the RISC “RTO,” patient K., 42 years
ral abduction up to 105°, fixed external rotation equal to 15°, old, underwent left hip replacement for stage III left-sided
a positive Duschen-Trendelenburg symptom, and a valgus post-traumatic coxarthrosis. The postoperative period was
deformity of the right knee joint by 25°. complicated by a deep operative wound infection. Numerous
X-ray imaging of the pelvis showed neoarthrosis in the sanitizing operations were inefficient and the inflammatory
area of the acetabular arch. The femoral head was oval- process was controlled only after removal of the hip prosthe-
shaped and somewhat reduced in size; the interrelation char- sis. To increase the supportiveness of the left lower extrem-
acteristics of the joint were elliptical. The neoarthrosis space ity, a double reconstruction osteotomy of the femur was
was narrowed and sclerosis of the contact areas was observed. performed, with the support point formed by the medialized
Dislocation of the point of gravitational loading on the diaphysis under the inferior margin of the acetabulum. In the
affected side was 35 mm. The Shenton line was deviated and lower third of the femur, osteotomy was carried out to
the greater trochanter was located 5 cm over the Rosel- lengthen the extremity. As a result of the Ilizarov left femoral
Nelaton line. support osteotomy, the supportiveness and length of the left
The patient and her parents refused hip replacement con- lower extremity were restored. The patient was satisfied with
sidering the young age of the patient (16 years); instead, the treatment.
decision was made to undergo Ilizarov reconstructive sup- Figure 23.26 shows a clinical example of femoral recon-
port osteotomy of the hip. struction for a defect in the proximal femur and chronic
In projections of the reconstructed femur, ad was deter- osteomyelitis.
mined to be 40°; the Vn- and V1-points were found and then
the optimal location of the offloading support was chosen, 23.4.1.5 Complications
under the inferior margin of the acetabulum. The optimal Errors that can lead to severe complications and unsatisfac-
abduction value of the intermediate fragment was g = 35°. tory results of treatment can most often be traced to the pre-
In the clinic, the patient underwent subtrochanteric recon- operational planning period and the surgical intervention
struction support osteotomy and corticotomy on the border itself. These are errors in defining the indications for support
of the upper and middle thirds of the femoral diaphysis. osteotomy and in choosing the optimal site of support point
External fixation was performed using the Ilizarov external formation.
fixator. Additional support was formed by the surface of the As an example, patient M., 29 years old, presented with a
femoral diaphysis under the inferior margin of the acetabu- high congenital dislocation of the right hip and a neoarthrosis
lum, with an intermediate fragment abduction angle of 35°; at the level of the wing of the ilium. She underwent Ilizarov
the distance from the osteotomy to the corticotomy was reconstruction support osteotomy of the femur, with the addi-
12 cm. On the fifth postoperative day, distraction was started tional support formed in the acetabulum (Fig. 23.27).
at a rate of 1 mm a day for 49 days. The obtained distraction Following surgery, the patient still had asymmetrically
regenerate was 5 cm long. To correct the biomechanical axis distributed gravity-loading on the right and left sides of the
of the extremity, the regenerate was transformed in the fron- pelvis. On the affected side, the maximal gravity-load was in
tal (30°) and sagittal (15°) planes. the middle between the neoarthrosis cavity (Vn) and the sup-
The external fixator was disassembled after 168 days port localization (Vo), and on the intact side on the arch of
postoperatively. Conditions for static balance in the upright the acetabulum (V-point). Hence, when the patient tried to
standing position of the body were reconstructed. The bio- stand upright, the h-overturning moment appeared.
mechanical axis became normal and the length of the left At the completion of treatment, the patient still had an
extremity was reconstructed. The axis and position of the left asymmetrically distributed gravity-loading of the pelvic
lower extremity were normal. Coxofemoral motion was the bones. Body balance in the vertical position was achieved by
following: flexion, 80°; extension, 180°; adduction, 90°; displacement of the TMC projection towards the intact
abduction, 115°, and rotation, by 5°. extremity. The limping remained as well as a positive
In short- and long-term follow-up after surgery, the patient Trendelenburg syndrome, which significantly affected the
did not have any complaints. She walked with no additional treatment result.
support and had no residual limping. The Trendelenburg In adolescents with an anatomically altered form of the
symptom was negative, right and left. The patient was proximal femur, when the joint surfaces are not fully devel-
satisfied with the treatment result. At the time of this writing, oped and there are segments of open growth zone after a sup-
the good functional result has been stable for more than port osteotomy, during further growth of the femur the
14 years. configuration of the joint surfaces will change unpredictably.
a b
c d
Fig. 23.25 Support osteotomy was used to treat a defect in the proxi- lateral views; (c) after removal of the hip prosthesis; (d, e) after support
mal femur. (a) Before hip replacement; (b) fistulography in frontal and medializing osteotomy and supracondylar lengthening osteotomy
For example, patient G., 12 years old, presented with a the bone) can result in fibular-type neuritis of the sciatic
pathological dislocation of the right hip and a defect of the nerve and inflammation of the soft tissues around the
neck and head of the right femur due to suppurative coxitis wires.
suffered in childhood. A double reconstruction support Errors of postoperative management include premature
osteotomy of the right femur was performed before the active disassembly of the external fixator, before union termination,
growth period had terminated (Fig. 23.28). or inadequate loading on the operated extremity after the dis-
As a result of the continuing growth of the femur, there assembly, which can lead to fracture of the contact regener-
was a decrease in the frontal angle of its diaphyseal transfor- ate and deformity of the distraction one. In such cases,
mation and a change in the joining surfaces’ configuration, external fixation must be repeated, which significantly pro-
which led to a cranial shift of the support point such that the longs in-patient treatment. Insufficient patient control during
previously formed support became inconsistent. The extrem- exercise therapy can result the development of persistent
ity became shorter by 4 cm and obtained a fixed faulty posi- extension contracture of the knee joint.
tion of external rotation by 15°. To improve the faulty position Thus, the features of Ilizarov reconstruction support
and shortening of the extremity, reoperation was required in osteotomy are defined by the type of the proximal femoral
the final period of the patient’s active growth. defect, the level of the proximal femoral displacement, and by
The errors during surgery were mainly technical and the presence or absence of a formed neoarthrosis in the supra-
implied insufficient medialization of the femur and incon- acetabular area. Preoperational planning of a support osteot-
sistency of the support in the pelvic bone, which resulted in omy must include definition of the optimal level of support
a lower efficiency of the intervention and a rapid progres- formation on the pelvic bone and angulation of the femoral
sion of arthrosis, associated with the absence of prolonged abduction to restore the symmetry of the gravity-loading dis-
decompression of the joint. Insufficient contact between tribution on the pelvic bones. The long-term effectiveness of
the fragments at the level of the proximal osteotomy in one support osteotomy is improving. Effectiveness is also related
case increased the term of union and in-patient treatment. to the full functioning of the formed support point, when the
The insertion of wires close to the sciatic nerve in addi- number of movements in the coxofemoral joint increases and
tion to not following the method of wire insertion (burn of limping becomes reduced or fully disappears.
Fig. 23.26 (a–h) Support

osteotomy in the treatment of a
defect in the proximal femur.
After reconstruction of the
mechanical axis and equalizing
the lengths of the extremities,
module transformation of the
external fixator was performed.
Note that simultaneous with the
femoral reconstruction the
equinus position of the ankle was
eliminated
b

e f

g h

a b
Fig. 23.27 Error in defining the point of support of the femur. (a) X-rays of the pelvis before the surgery; (b) after surgery; (c) explanatory
skiagram
Fig. 23.28 Support osteotomy a

in the period of incomplete
b
growth. (a) Before surgery; (b)
after reconstructive osteotomy
of the femur, during the period
of Ilizarov external fixation; (c)
a month after disassembly of the
external fixator; (d) 9 months
after disassembly of the external
fixator
d
23.4.2 Femur Lowering Before If there is a deficiency of bone tissue, plasty involving the
Hip Replacement resected femoral head as the transplant is required. Preference
should be given to cups that have a low profile, are free from
Elena Aleksandrovna Volokitina cement and have an antireluxational gasket. In this category
and Leonid Nikolaevich Solomin of patients, apart from underdevelopment of the acetabulum,
there is a relative hypertrophy of the sciatic bone and sciatic
23.4.2.1 Introduction tuber. Therefore, the femoral component of the prosthesis
The successful use of endoprosthetics of hip-joint disorders is should have quite a large offset.
one of the most difficult and persistent problems in orthopedics.
These disorders include congenital femoral dislocation, patho- 23.4.2.2 Femur Lowering in a Two-Stage
logical dislocation and incomplete dislocation of the femur, Implantation of Pelvic and Femoral
chronic post-traumatic femoral dislocation, chronic post-trau- Prosthetic Components
matic pseudarthrosis of the femoral neck, and hypoplastic cox- The RSC “RTO” has developed a method for the implanta-
arthrosis and varus deformation of the femoral neck, accompanied tion of a total hip joint endoprosthesis. The first stage con-
by high proximal displacement of the thigh. sists of resection of the femoral head, implantation of the
One-stage endoprosthetics of the hip joint in this category pelvic component, and installation of the Ilizarov distrac-
of patients is plagued by the development of tractional tional device for gradual, dosed femur lowering. The second
neuropathy of the femoral and sciatic nerves, pain inten- stage is implantation of the femoral component and the head
sification, and the formation of severe postoperative contrac- of the prosthesis with its repositioning in the cavity. After
tures in joint muscles. In addition, during surgical that, the device is dismantled [426, 427].
intervention, injuries are often incurred during distraction of Access to the hip joint is through its anterior lateral aspect.
the femur to reposition its head in the cavity of the prosthe- The degeneratively altered capsule in the joint resection area
sis. There are difficulties in suturing together the dystrophi- of the femoral neck is removed as is the femoral head from
cally changed and deteriorated muscles because of their the acetabulum or neoarthrosis cavity. The final step is pro-
structural inferiority and evident deficiency. Two-stage endo- cessing the acetabular cavity and implanting the pelvic com-
prosthetics implantation in the hip joint, as described in this ponent of the prosthesis (Fig. 23.29).
section, decreases the number of traumas, avoids neurologi- Femur lowering is performed through mobilization of
cal complications, and promotes favorable results during the the muscles surrounding the proximal femur, following a
postoperative period. transverse section of the iliotibial tract along a slope of the
The main purpose of the first stage is lowering of the lower major trochanter. The iliopsoas tendon from the lesser tro-
extremity (femur) by using external fixation. The second stage chanter is partly cut. At the same time, rotational, flexi-
is implantation of the prosthetic. Thus, based on the features extensive, and abductive-adductive movements of the
of the clinical situation, the first stage, except for external femur (in the hip joint?) are carried out to decrease the ten-
device application, can include mobilizing operations of the sion on the muscle fascia in the joint area. The wound is
soft tissues, osteotomies, and the implantation of the sutured in layers.
prosthesis. In the wing of the pelvic bone 4–5 wires, in the middle
The indications for the technique are those situations in third 3 wires, and in the inferior third of the diaphysis 3–4
which endoprosthetics are called for; however, the develop- wires with stoppers facing towards one another are inserted.
ment of a tractional neuropathy of the sciatic nerve during Wires are fixed on arches and the ring of the Ilizarov device.
repositioning of the head of the prosthesis into its cavity can The arches and the ring are connected by telescopic rods
be predicted. with hinges (Fig. 23.30). A hybrid device (using half-pins)
Contraindications consist of known contraindications to can also be used, as shown in Fig. 21.15.
the use of endoprosthetics and external fixation. It is impor- The day after surgery, femoral distraction between the
tant to be aware of the fact that in patients with osteoporosis supports is started gradually, at a rate of 2–3 mm/day
there is a great danger of releasing the wires, including those (0.5 × 4–6 times/day). The rate and amount of distraction
inserted through the wing of the ilium. depend on the tolerance of the patient. If there are neurologi-
Careful selection of patients with sufficient and well cal symptoms involving the sciatic nerve, the rate is reduced
structured bone flesh in the acetabular area, favoring the or distraction is even temporarily stopped. Otherwise, dis-
maintenance of a stable fixation of the pelvic component, traction is usually completed in 2–3 weeks.
improves the results of treatment with the respective tech- Distraction should be finished at moment when the top
nique. Implantation of the cup of the prosthesis should be of the trochanter will be opposite the center of the cavity
carried out in the true acetabular zone. implanted and Shenton line will be restored.
Fig. 23.29 The first stage of a b c

operative intervention. (a)
Condition before the operation:
dislocation of the thigh,
supra-acetabular neoarthrosis; (b)
resection of the femoral head. (c)
implantation of the pelvic
component of the prosthesis
Wire removal and device disassembly are done in the

operating room. The joint should be free, to allow access.
The femoral component including the head of the prosthesis,
to be placed in the cavity, is implanted according to the tech-
nology of the chosen endoprosthetics (Fig. 23.31). Functional
tests on the femur are conducted: 90° flexion, 180° exten-
sion, 60° adduction, 110–120° abduction, 15–20° external
and internal rotation, and 60° adduction with maximum
external rotation. The wound is sutured with the prosthetic
head in a stable position in the cavity and aseptic bandages
are applied.
In the postoperative period, special attention should be
paid to range-of-movement development.
Clinical Example
Patient B., 36 years old, suffered from bilateral congenital
dislocation of the thigh (Fig. 23.32). Although the diagnosis
was made when she was 4 months of age, the condition had
not been treated.
In 2003, at the age of 31, she had applied for medical
treatment at one of orthopedic clinics of the Russian
Federation, where an endoprosthetic of the left hip joint, a
cement-free prosthesis was implanted in one stage. In the
early postoperative period, an evident painful syndrome and
neuropathy of the femoral and sciatic nerves developed.
Two weeks later, surgeons removed the shaft and the head
of the prosthesis. After that, under conservative therapy, the
pain subsided and sensitivity improved. Nonetheless,
1.5 years later, weight-bearing on the left lower extremity
was not possible. In 2005, the shaft and head of the prosthe-
Fig. 23.30 Configuration of the device for femur (lower limb) sis of the left hip joint were implanted again. Ten days later,
lowering dislocation of the head occurred. The head was repositioned
a b rotation were determined. Basic limb function was confirmed.

The patient was pleased with the outcome. Neurological
complications were absent.
Clinical Example
Patient U., 42 years old, entered the clinic with bilateral
hypoplastic stage III coxarthrosis, varus deformities of the
femoral necks, and rigidity of the hip joints. During clini-
cal examination, a sharp restriction of hip joint movements
was determined: flexion 105º, extention 130º, and fixed
adduction of 75º and external rotation of 15º. In addition,
she had hypotrophy of the thigh muscles and a positive
grade 3 Trendelenburg sign on both sides. She could walk
only with the help of a cane. After X-ray examination of
the right hip joint, 3 rd degree osteoarthrosis with varus
deformities of the femoral necks, infringement of the
Shenton line, and a high position of the major trochanter on
both sides were found.
The first stage of treatment consisted of resection of the
femoral neck and head and implantation of the pelvic com-
ponent of the prosthesis. The distractional device was then
applied. Beginning at postoperative day 2, dosed distraction
Fig. 23.31 The second stage of the operative procedure: (a) femur
(lower limb) lowering in the external fixation device; (b) implantation was carried out between the supports over 2 weeks at a rate
of the femoral component of the prosthesis and repositioning of the of 2–4 mm/day. After femur (lower limb) lowering to
head in the cavity achieve the necessary level and to restore the Shenton line,
the femoral component and head of the prosthesis, with
under narcosis with subsequent fixation of the leg in a plas- repositioning in the cavity, were implanted. There were no
ter bandage for 3 weeks. Five years after reimplantation of complications after the operation. Range-of-movement was
the shaft of the prosthesis, the patient reported a moderate restored. Six months later, the right hip joint was success-
pain syndrome and neuropathy of the femoral and sciatic fully operated on.
nerves.
In 2008, she was hospitalized at the “VTO” with a diag- 23.4.2.3 Femur Lowering in a One-Stage
nosis of: congenital dislocation of the right hip, a pain Implantation of Pelvic and Femoral
syndrome, contracture of the right hip joint, shortening of Prosthetic Components
the right lower limb by 4 cm, a stable endoprosthesis of The second stage of operative treatment can include implan-
the left hip joint, and neuropathy of the sciatic nerve on tation of both the pelvic and the femoral components of the
the left side. prosthesis. This method is especially indicated in cases
The first stage of treatment comprised arthrotomy, resec- when, based on the functional roentgenograms, femur low-
tion of the head and neck of the right femur, implantation of ering without mobilizing operations can be considered, or
a cement cavity from the Ceraver prosthesis, and mobiliza- the procedure can be executed in a minimal approach, i.e.,
tion of the proximal part of the femur with partial tenotomy adductomy and osteotomy of the femoral neck. The clinical
of the adjoining muscles. The standard-configuration Ilizarov experiences presented in Figs. 23.34 and 23.35 serve as
device in a position of flexion (155o), adduction (75o), and examples. In the presence of soft-tissue rigidity and osteopo-
internal rotation (15–20o) was applied to the right iliac bone rosis, except for the half-pins inserted into the wing of the
wing and femur. The postoperative period consisted of a ilium, supra-acetabular half-pins should be used.
dosed distraction of the femur.
Three weeks after the first stage, the Ilizarov device was 23.4.2.4 Complications
removed. A non-cement shaft and the metal head of the An excess rate and size of the distraction can lead to a per-
Ceraver prosthesis were implanted. The result of treatment sistent, painful syndrome, neuritis of the sciatic and femo-
was positive. Movements in the right hip joint was painless. ral nerves. Prescribing systemic analgesics to increase the
Active (150o, muscular force score of 4–5 points) and passive distraction is by all means inadmissible. There is only one
(>110° and more) flexion, active (180o, muscular force score criterion of correctness for the chosen rate and size of
of 4–5 points) extension, 100o abduction, and 5° internal distraction: that the patient has a good night’s sleep.
The chosen amount of the distraction should not be carried tain situations, removal of the wire or half-pin is preferable.
out in a single step, but rather divided in 4–6 stages. If this may lead to destabilization of the device, a tran-
Before the second stage of operative treatment, sosseous element should be inserted at a different site. At the
inflammation of the soft tissues (if any) within the closed latest, at the closing stage of distraction, the device can be
area of transosseous elements should be resolved. In uncer- replaced with skeletal extension using a heavy weight.
Fig. 23.32 Two-staged endoprosthetic implantation. (a) At admission; (b) after the first stage; (c, d) after femur lowering
Fig. 23.32 (continued) (e, f) after the 2nd stage

Fig. 23.33 Two-stage endopros- a

thetic procedure. (a, b) At
admission
b d
c e
Fig. 23.33 (continued) (c) after the 1st stage; (d) after distraction of the thigh; (e, f) after the 2nd stage

a b
c d
Fig. 23.34 (a–k) Adult case study. A 72-year-old female with a 1-year femoral head. (c) One possible configuration for hip distraction with an
history of a neglected femoral neck fracture. Household ambulatory external fixator. A pre-constructed frame with Orthofix TrueLok com-
with a walker and constant pain. Minimal community ambulatory abil- ponents is shown. (d) One full turn of the right telescopic rod equals
ity. Technique: Leonid Solomin M.D. Case & Presentation: William D. 1 mm of distraction, as does 1.5 full turns of the oblique telescopic
Terrell M.D. (a) Preoperatively. (b) Lesser trochanter at the level of the rods
e f
g h
i j
Fig. 23.34 (continued) (e) Sizing the frame to the patient. (f) The alu- rosis. (i) Day of surgery. The distraction rate during the 1st week: is
minum components can be modified easily at the bedside with a Gigli 2–3 mm/day, depending on the amount of tension; during the 2nd week:
saw, without stressing the frame. (g) After frame assembly. Note that 1.5–2 mm/day; the 3rd week: 0.5–1 mm/day, depending on the amount
there are NO half-pins near the operative site in the posterior approach of tension on the frame. (j) This radiograph was taken 2.5 weeks post-
to the hip. Supra-acetabular pins should ALWAYS be inserted with a operatively. The patient was confined to bed rest and was anticoagu-
trochar and drill sleeve. (h) The distal support should be assembled as lated to prevent deep-vein thromboses. She was monitored for stretch
follows: VII,3-9; VIII,8,80. Wire VII,10-4 or half-pin VIII,4,90 should injury to the peroneal nerve and is ready for hip arthroplasty
be inserted in case of severe rigidity of the soft tissues and/or osteopo-
Fig. 23.34 (continued) (k) Length and function restored with hip k
arthroplasty. The fixator was removed in the operating room just
prior to hip arthroplasty. Pin sites are draped with an adhesive iodi-
nated skin barrier. The posterior wall was reinforced at initial sur-
gery due to erosion of the trochanter during the year of conservative
treatment. The patient is now ambulatory at home without an assis-
tive device and in the community with a cane
a b
Fig. 23.35 Two stage endoprosthetics. (a) At admission; (b, c) after the1st stage of the procedure
d e
Fig. 23.35 (continued) (d) after distraction of the thigh; (e) after the 2nd stage
23.4.3 Deformity Correction of the Proximal Indications for the suggested method are late stages of
Femur Before Total Hip Replacement coxarthrosis of various etiologies and of deformity osteoar-
thritis in a neoarthrosis of the supra-acetabular area with
Elena Aleksandrovna Volokitina marked pain syndrome, contractures, and rigidity of the hip
joint associated with deformities of the proximal femur and
23.4.3.1 Introduction femoral diaphysis by >20° due to previously performed
Hip replacement surgery following inter- and subtrochant- juxta-articular correction, medialization, or support osteoto-
eric medialization and support osteotomies of the femur is a mies [403, 424, 434–437].
technically complex and non-standard surgical intervention, Contraindications are: (a) marked congenital underde-
especially the implantation of the shaft of the prosthesis velopment of the pelvic and femoral bones on the side of
[428–431]. A deformity in either the proximal femur or the the planned surgery (narrow medullary canal, flat acetabu-
femoral diaphysis does not allow implantation of the stan- lar cavity); marked scar changes of the juxta-articular mus-
dard femoral component of the hip prosthesis without previ- cles and soft tissues in the femoral area; lower limb spastic
ous osteotomy, which in turn requires dissection of a bone paraparesis; chronic osteomyelitis of the pelvis, femur, and
wedge and excision of the greater trochanter and its modeling, tibia or the bones of the feet on the side to be operated on;
followed by fixation to the proximal femur [432, 433]. pyoinflammatory processes in the area of the soft tissues of
Ilizarov external fixation dramatically broadens the range the gluteal region and of the operated extremity in
of indications for and technical capacities of hip replace- general.
ment in such patients. This section describes a method of
hip replacement that, when combined with correction 23.4.3.2 Method Variations
osteotomies of the femur, allows the stable implantation of Depending on the anatomic changes in the implantation zone
a hip prosthesis with non-cement fixation [426, 432, 433]. following valgization support and correction osteotomies,
This method was developed at the RISC “RTO.” there are three variations of the surgical intervention.
Fig. 23.37 Osteotomies in the treatment of a diaphyseal deformity in

its middle third by 20° prior to hip replacement: (1) osteotomy of the
neck continued on the medialized diaphysis, excision of the greater tro-
chanter for subsequent transfer and modeling; (2) osteotomy of the dia-
physis at the apex of the deformity, with excision of a bone wedge. The
Fig. 23.36 Osteotomies used in the treatment of a diaphyseal defor- latter is performed at the second stage following hip replacement
mity in its upper third by 20°, carried out before hip replacement: (1)
osteotomy of the neck continued on the medialized diaphysis, (2)
osteotomy of the diaphysis on the apex of the deformity with incision of
a bone wedge and excision of the greater trochanter for subsequent of the middle or lower third of the diaphysis, followed by
transfer and modeling angular transformation of the distraction regenerate. In such
cases, the surgeon’s task is also to eliminate the proximal part
Variation 1 is the most complex since it is performed fol- of the deformity. Modeling of the proximal femur and greater
lowing an intertrochanteric valgization osteotomy with fem- trochanter is required as well. However, the anatomic struc-
oral medialization under the inferior margin of the acetabular ture of the upper third of the diaphysis is not affected, which
cavity, corticotomy, and lengthening of the upper third of the allows implantation of the shaft of the hip prosthesis without
diaphysis, followed by angular transformation of the distrac- prior osteotomy. The diaphysis deformity in such cases should
tion regenerate [433]. In such cases, the surgeon’s task is to be located distal to the implanted hip component. This enables
eliminate the deformity in both the proximal and the distal elimination of the deformity and improvement of the femoral
femur. Modeling of the proximal femur and the greater tro- axis during the second stage, 3–4 weeks after hip replacement,
chanter is required (Fig. 23.36). thus reducing surgical traumatic invasiveness (Fig. 23.37).
Variation 2 is used following an intertrochanteric valgiza- Variation 3 is technically the simplest since it is used fol-
tion osteotomy with femoral medialization under the inferior lowing a subtrochanteric valgization osteotomy and cortico-
margin of the acetabular cavity, corticotomy, and lengthening tomy at the border of the upper and middle thirds or in the
a b inserted at three levels: the proximal femur, the middle third

of the diaphysis, and the supracondylar area. At each level,
all wires should be O-wires inserted in opposite directions to
provide safe fixation of the bone fragments in the external
fixator supports. Console wires and extracortical clamp
devices are an alternative (Chap. 12.5 – Figs. 12.24, 12.25
and 12.26).
In the proximal femur, four or five wires (two of which
are O-wires inserted in opposite directions) are inserted into
the bone tissue area free from the implant (the area of the
greater trochanter clivus and basal part of the neck) under
visual control and before the wound is closed, i.e., just after
implantation of the shaft and reduction of the joint into the
joint cavity.
In the middle third of the femoral bone, two or three
O-wires are inserted in opposite directions just under the dis-
tal part of the prosthesis shaft into the diaphysis area free
from the implant. To define the precise insertion points of the
wires, X-ray control is performed using radio-opaque
markers.
Four wires are inserted in the supracondylar area, two of
Fig. 23.38 X-ray of the right coxofemoral joint with the femur in fron- which are O-wires inserted in opposite directions in the plane
tal and lateral views, showing the typical femoral deformity after sub- of the transverse section of the metadiaphysis.
trochanteric valgization support osteotomy. A deformity in the upper The wires are fixed and tensioned in the Ilizarov external
third of the femoral diaphysis by 20° necessitates a correction osteot-
omy of the diaphysis as a prerequisite (variation 3 of the method) of hip
fixator supports, consisting of two arches (proximal level and
replacement the level of the middle third of the femur) and one ring
(supracondylar area) (Fig. 23.39).
In variation 3, to fix the femoral bone fragments it is
enough to install an Ilizarov external fixator unit consisting
middle third of the diaphysis, at the level where the excess of two supports: an arch on the proximal part of the femur
femoral adduction was eliminated. In such cases, the ana- and a ring in the supracondylar area (Fig. 23.40).
tomic structure of the proximal femur is intact, the joint
remains mobile, and the support point is not always func- 23.4.3.4 Preoperative Planning
tional. This factor facilitates further hip replacement: model- Prior to a surgical procedure for any of the three variations
ing of the proximal femur and greater trochanter is not of the suggested method, preoperative planning is essen-
required. The surgeon must improve only one deformity, at tial using the skiagrams and X-rays: of the pelvis in the
the level of the previous corticotomy, in order to implant the frontal view, of the femur including the coxofemoral joint,
shaft of the hip prosthesis (Fig. 23.38). and the knee joints, in both cases in frontal and lateral
It should be noted that a femoral diaphysis deformity views.
<20° at any level does not interfere with implantation of The pelvic component must be implanted in the proper
either standard or revision femoral components, since while acetabular area (the Ranavat triangle) [438], where the mid-
the implantation canal for the shaft of the hip prosthesis is dle of the hypotenuse defines the true rotational center of the
being prepared, including rasping the canal from the inside hip joint. The center of the pelvic component template of the
using special rasps, such insignificant deformities are elim- prosthesis is positioned relative to the true rotational center
inated. However, a deformity of the diaphysis by >20° at of the hip (Fig. 23.41). Fitting of the pelvic component
any level cannot be improved by internal rasping of the according to the skiagram requires that the contour of the
canal alone. In such cases, before hip prosthesis shaft internal cortical plate of the femoral canal would fit the con-
implantation, the surgeon must perform a repeat correction tour of the hip prosthesis shaft on the X-ray template.
osteotomy of the femur, using the suggested method. In variations 2 and 3 of the method used in case of a prox-
imal femur deformity, the direction of the cervical osteotomy
23.4.3.3 Features of External Fixation line for resection of the femoral head must be preoperatively
In osteosynthesis of the femur using the Ilizarov external defined as must the line demarcating the excision of the
fixator and variation 1 or 2 of the method, the wires must be greater trochanter, for its further modeling and transfer. The
a b
Fig. 23.39 Basic assembly of the Ilizarov external fixator, used in method variations 1 and 2: (a) External view, (b) internal view
resection line of the greater trochanter and its transfer and Preoperative projections on the skiagram enable the size
fixation to the femoral bone are projected so that its apex of the pelvic and femoral components to be fitted correctly as
would coincide with the rotational center of the prosthesis well as the planning of any necessary bone plastic surgery,
cup. The excess part of the bone, i.e., the amount breaking modeling and transfer of the greater trochanter to normalize
the external contour of the femur and preventing the transfer the offset value, and a repeat correction osteotomy of the dia-
of the modeled greater trochanter, is further removed in a physis with excision of a bone wedge.
wedge-shaped or trapezoidal excision (Fig. 23.42).
Then the level of the planned diaphysis osteotomy is 23.4.3.5 Surgical Technique
defined on the apex of the deformity. According to the X-rays In the variation 1, the patient lies supine and an extensible
of the femur in two views, skiagrams are used to model the external approach is made to access the joint and visualize the
correction of the femoral segment axis. The apex of the dia- zone of the formed femoral support of the pelvic bone (usu-
physis deformity is defined at the point of intersection of the ally, the lower margin of the acetabular cavity). A diathermy
bone fragments’ axial lines. The osteotomy procedure is knife or rasp is used to excise both the coxofemoral joint cap-
modeled on the skiagram, abducting the distal fragment until sule from the adjacent connective and scar tissue, and the
the diaphyseal axis becomes normal. Thus, the shape and size anterior surface of the intertrochanteric area, including the
of the femoral fragment to be excised are defined (Fig. 23.43). site of the previous femoral osteotomy. In such cases, the
This stage completes the projection of the variations 1 and 2. lesser trochanter and medial surface of the proximal femur
For variation 3, the projection of the prosthesis cup implan- valgization are approximated to the pelvic bone and through
tation is standard since the proximal femur is intact. Implantation the scar tissue, making contacting with it under the inferior
of the hip prosthesis shaft and the level of the diaphyseal margin of the acetabular cavity. The thickened and degener-
osteotomy at the apex of the deformity are projected in the ated joint capsule is excised. Underneath, the capsule protec-
same way as described above for variations 1 and 2. tors are installed above the upper and under the lower margins
Fig. 23.40 X-ray image of the right femur in frontal view following
hip replacement, correction osteotomy of the diaphysis and osteosyn-
thesis of the femoral bone using an Ilizarov external fixator module Fig. 23.41 X-ray image (a) and skiagram taken from the pelvic X-ray
consisting of two supports (variation 3) (b) of patient G., 56 years old, 20 years after valgization support osteot-
omy of the right femur prior to hip replacement. The skiagram shows
the scheme of the geometric constructions used to define the true
acetabular cavity (Ranawat triangle)
of the neck and under the support point (freed from the scar
tissue), directly contacting the pelvic bone.
An osteotome and electric saws are used according to the To prepare the implantation canal for the femoral compo-
preoperative planning, with osteotomy of the greater trochanter nent, the femur must be maximally adduct and rotated out-
inclining inwards and downwards and then moving to the upper wards, until the intercondylar line is vertical. Simultaneous
margin of the wound together with the muscles connected to it. with creating the approach, the lateralized trochanter is
A cervical osteotomy is then made at an angle of 45° while at excised, thus decreasing the tension on the femoral fascia
the same time the osteotomy line of the neck is continued to the lata and significantly facilitating pulling of the sawn femoral
end surface of the medialized femoral fragment, which enables surface into the operative wound.
the medullary canal to be immediately opened. The protectors are installed under the external margin of
The femoral head is removed from the cavity using the the proximal femur and behind the sawn area of the femoral
extractor. With various cutters, the acetabular cavity is treated neck, in the medial part of which the medullary canal is
down to spongy bone with blood drops, with sufficient deep- opened. As determined using a rasp inserted into the canal
ening by the cutter. The pelvic component is inserted using a until it meets the bone at the level of the deformity, the direc-
special instrument at an angle of 45–50° to the frontal plane tion of the intermediate fragment of the femur is defined. For
and 10–15° to the sagittal plane of the pelvis. the sake of visual control, incision of the skin and femoral
fascia is continued distally, the muscles are bluntly retracted

over the apex of the femoral diaphysis deformity at the bor-
der of the upper and middle thirds, and protectors are installed
over and under the bone in the deformity area.
A wedge-shaped piece of bone, including the deformity
area and coinciding with the shape and size preoperatively
projected, is excised using a saw. The bone chisel is then
used to modify the sawn surfaces of the diaphysis until good
mutual contact is achieved. The drill is removed and the
canal is treated with special rasps to install the femoral com-
ponent of the artificial hip joint. During rasping, the femoral
fragments are held in contact with each other by a surgical
assistant, who uses two bone-holding clamps. When the
position of the femoral fragments on the rasp is stabilized, a
test is performed with the module’s heads (short, middle,
long) to define the optimal offset and to position the stability
of the prosthetic head in the cavity. The rasp position is
controlled by X-ray visualization. The rasp is removed and
Fig. 23.42 Geometric constructions on the skiagram taken from the the non-cement shaft of the hip prosthesis is tightly pulled
pelvic X-ray, with the projecting osteotomy line on the neck, resection
of the head (shaded region), and resection of the greater trochanter, the into the proximal fragment; the component should coincide
apex of which after the transfer must be located on the same horizontal with the size of the rasp. In such cases, the most optimal
line as the hip prosthesis’ rotational center. The excess bone (shaded shaft type is triclinic with press-fit fixation.
region) is removed from the proximal part in a wedge-shaped or trape-
zoidal excision
a b
Fig. 23.43 Geometric construc-

tions on the X-ray skiagram of
the hip and femur, projecting the
line of the repeat correction
osteotomy of the diaphysis with
excision of a bone wedge and
followed by transplantation of the
hip prosthesis’ shaft. Anatomic
axes of proximal and distal
fragments are drawn, the wedge
for removing is found
Contact between the femoral fragments at the bone-wedge Ilizarov hip support osteotomy of the femur with formation
excision site and the rotational position of the distal femoral of the additional support under the lower margin of the cav-
fragment should be visually controlled. At the junction site ity and lengthening of the middle third of the diaphysis by
of the fragments, due to the remaining mobility, femoral cor- 5 cm; in the supracondylar area, an additional osteotomy was
rection is performed. The stability of the hip prosthesis in the performed for genu valgum correction. During the following
cavity is checked with a functional test that includes the 12 years, the extremity remained supportive. However, pain
module’s heads. The proper size head is chosen for the and movement limitation had appeared in the hip joint over
implantation, comparing the obtained findings with preop- the previous 2 years, which led the patient to again seek med-
erative ones. Implantation of the fitted head on the femoral ical advice in our clinic (Fig. 23.44).
shaft of the prosthesis is followed by the component’s At the RISC “RTO,” she underwent right hip replacement,
reduction. in which an Altimed non-cement cavity and non-cement
Then, with the femur in abduction and inward rotation, shaft were implanted. In the middle third of the diaphysis, at
the excised greater trochanter is distracted such that its apex the level of the deformity apex, a bony wedge was excised;
is at the same level as the rotational center of the artificial hip osteosynthesis between the fragments was provided by the
joint. This step is guided by the skiagram showing the preop- hip prosthesis shaft and reinforced by the Ilizarov external
erative planning [432, 433]. The trochanter is temporarily fixator. The greater trochanter was excised before dislocation
fixed to the femur by three wires and a control X-ray is taken. of the femur. Following implantation of the prosthetic shaft,
When the trochanter’s apex is located at the same level as the the trochanter was modeled and fixed again to the femur by a
rotational center of the hip prosthesis, marks are made on the wire or cerclage wire. External fixation lasted 3 months.
femur and trochanter using a diathermy knife, to indicate Six months after surgery, the X-ray images showed clear
the exact degree that the excised trochanter must be distracted. signs of consolidation in the osteotomy zone of the diaphy-
Then, the temporary fixing wires are removed and a chisel is sis, thus confirming the good functional result obtained with
used to model the trochanter, forming a groove in it so as to the suggested method: the length inequality of the legs was
obtain a press-fit of the trochanter on the remaining bone area eliminated, there were no movement limitations in the right
of the external surface of the femur. The excess femoral bone, hip, and the right leg became supportive and pain-free.
i.e., that disturbing the external contour, is resected. The mod- In variation 2 of the suggested method, the surgical tech-
eled trochanter is fixed with two or three spongy bone screws nique is generally the same as in variation 1. Due to the prior
or wire cerclage suture to the femoral bone. high peri-arthric osteotomy and the formation of the func-
All resected areas of the bone tissue (femoral head, trap- tional support point by transformation of the proximal femur,
ezoid or wedge-shaped piece of the proximal femur, excised invasive procedures are required such as an extensible exter-
wedge of the deformity apex of the diaphysis) are used as nal approach to the joint in order to visualize the zone formed
autografts to reconstruct the pelvic and femoral defects. by the support of the pelvic bone by the femur, osteotomy of
The wound is carefully rinsed with saline solution and the the greater trochanter, which is relocated to the upper wound
wound margins are closed by temporary, widely placed skin margin together with the muscles connected to it, and cervi-
sutures. Wires are then inserted into the femur at three levels cal osteotomy at an angle of 45°, continued on the medial-
and Ilizarov external fixation is performed. The still-existing izated metadiaphysis to open the medullary canal. Then, the
deformities of the femoral segment axis are improved. Under hip prosthesis cup is implanted in the proper acetabular cav-
visual control, compression is exerted in the zone of the dia- ity. The femoral component is implanted with enough deep-
physeal osteotomy until complete contact and immobility of ening in the femur because the femoral deformity level is
the bone fragments on the hip prosthesis shaft are achieved. distal to the shaft end. A functional test is performed to check
The final position of the hip prosthesis and the femoral frag- the stability of the hip prosthesis in the cavity, using the mod-
ments is controlled by taking X-rays of the femur in frontal ule heads. The fitted head is implanted on the femoral shaft
and lateral views. The temporary skin sutures are removed, of the hip prosthesis followed by a final reduction step.
the wound is rinsed with saline solution, final hemostasis is In the position of femoral abduction and inward rotation,
performed, and layer-by-layer sutures are placed on the the excised greater trochanter is reduced downwards until its
wound up to the drainages (subcervical and subfascial) and apex is located at the level of the rotational center of the
covered by aseptic dressings. artificial hip joint. According to the preoperative projection,
The following clinical case is an example of the variation its inner surface is modeled to improve its contact with the
1 of the suggested method (Fig. 23.44) femur, followed by fixation using two spongy bone screws or
As a child, patient L. underwent repeated operations for a wire cerclage suture.
congenital dislocation of the right hip. Since age 18, she had During the second stage, after wound healing (2–3 weeks
experienced severe pain in the joint. At the RISC “RTO,” later) a correction osteotomy of the diaphysis is performed
6 years later, when she was 24 years old, she underwent on the apex of the deformity to improve the femoral segment
a b
c d
Fig. 23.44 A patient who underwent variation 1 of the suggested artificial hip joint, modeling of the greater trochanter, osteotomy, and
method: (a, b) 12 years after a support osteotomy; (c) operation plan- excision of the bone wedge in the middle third of the diaphysis, Ilizarov
ning; (d–f) after right hip replacement using a non-cement Altimed external fixation
e f g
Fig. 23.44 (continued) (g, h) after disassembly of the Ilizarov external fixator
Fig. 23.44 (continued) (i) 3 months later
axis. The wires are inserted into the femur at the same three the lesser trochanter and the proximal femur remains intact
levels as described in the variation 1 and Ilizarov external and anatomically unaltered. The approach to the joint, osteot-
fixation is performed. Postoperative management does not omy of the neck, resection of the femoral head, treatment of
differ from that in patients on operated according to the vari- the acetabular cavity, and implantation of the hip prosthesis
ation 1. The following clinical case demonstrates variation 2 cup are performed using traditional methods.
of the suggested method (Fig. 23.45). When the rasp is used on the femoral bone, its end reaches
Patient G., at the age of 36, was diagnosed with a dysplas- the cortical layer of the diaphysis at the deformity level. To
tic coxarthrosis, for which she underwent valgization sup- visualize the rasp’s position, the operative approach is
port osteotomy of the left femur, corticotomy of the diaphysis expanded distally or an additional incision is made in the
on the border of the upper and middle thirds to lengthen the projection of the diaphysis deformity apex. Then, a saw or
femur and further correction of the extremity axis, and chisel is used to excise a bone wedge, including the defor-
lengthening according to the Ilizarov method. During the mity area, and the distal fragment of the femoral bone is fine-
following 20 years, she suffered gradually progressive treated using a rasp. The size and shape of the wedge are
osteoarthritis and was thus readmitted to the clinic for hip determined during preoperative planning,. When the correct
replacement. According to variation 2, the first stage con- position of the femoral fragments is achieved with the rasp, a
sisted of left hip replacement using the Ceraver non-cement test using the module heads is performed. Then the rasp is
artificial hip joint followed by modeling and then osteosyn- removed and the fitted non-cement shaft of the hip prosthesis
thesis of the greater trochanter using spongy bone screws, is tightly pulled into the femur. The head of the hip prosthe-
according to the preoperative projection. sis is implanted, followed by its reduction.
The second stage, performed 2 weeks after the hip replace- In the next step, wires are inserted into the femur at two
ment, consisted of a correction osteotomy of the diaphysis, levels (proximal femur and supracondylar area) and Ilizarov
made distally from the hip prosthesis shaft, and Ilizarov external fixation is performed. At the site where the two fem-
external fixation. The postoperative course was uneventful. oral fragments contact each other, final correction of the axis
After 8 weeks of fixation the Ilizarov external fixator was is made. Postoperative management does not differ from that
disassembled. A good functional result was achieved. of patients undergoing the variations 1 and 2. The following
In variation 3, the surgical technique is the simplest clinical case demonstrates the variation 3 of the suggested
because the level of the prior support osteotomy is distal to method (Fig. 23.46).
Fig. 23.45 Variation 2 of the suggested method: (a) 20 years after a with modeling and osteosynthesis of the greater trochanter by spongy
valgalization support osteotomy of the right femur; (b, c) after left hip bone screws. There is varus deformity and shortening of the femur
replacement using the Ceraver non-cement artificial hip joint, together
Fig. 23.45 (continued) (d, e) the second stage: correction osteotomy and Ilizarov external fixation
e f
Fig. 23.45 (continued) (f, g) treatment result

a b
Fig. 23.46 Variation 3 of the suggested method: (a) before surgery, (b) after implantation of the non-cement hip prosthesis, bone wedge excision
at the deformity level followed by Ilizarov external fixation; (c) treatment result
The bandages around the wires are changed at least once

every 3–5 days; supporting compression between the frag-
ments of 1–2 mm once every 7–10 days is applied until there
is union at the level of the osteotomy, followed by disassem-
bly of the external fixator.
23.4.3.7 Complications
Inflammation of the soft tissues surrounding the wires can
occur anytime after surgery. The cause can be insufficient ten-
sion of the wires or their undiagnosed breakage. The exit sites
of the wires must be carefully inspected by the physician dur-
ing the dressing procedure. In case of pain and hyperemia
around a wire, it must be removed and antiseptic dressing
(antiseptic solutions and ointments) applied on the affected
site. We have not had a single case of deep, marked infection
threatening the hip prosthesis (19 patients observed).
Traction neuropathy of the sciatic nerve involving the
lesser trochanter is a short-term postoperative complication
caused by the surgery itself, as a traumatic factor. It results in
soft-tissue edema, compression on the nerve stems, as well
as femoral traction during both the test and final reduction of
the prosthetic head into the cavity, which can cause ischemia
of the nerve stem.
To prevent the development of such complications, reduc-
tion of the head of the prosthesis and insertion of its shaft are
performed extremely carefully, using smooth motions with-
Patient G., at the age of 24 years, underwent surgery for a out jerking or roughness.
congenital dislocation of the right hip: valgalization support Dislocation of the hip prosthetic head due to prior femoral
osteotomy and Ilizarov external fixation were performed. At osteotomies can occur because of the scar changes in the
the age of 37, she began to experience pain in the hip and muscles and soft tissues surrounding the joint. In the postop-
marked limping. After admission to the RISC “RTO,” she erative period, these patients should follow a special move-
underwent right hip replacement with implantation of a ment regimen. They are to lie in bed with the involved thigh
SLPS Altimed (Belorussia) non-cement cavity and a non- abducted at an angle of 110–120°, rotation at 0°, and exten-
cement hip prosthesis shaft. On the border of the upper and sion 160–170°. This position is created by forming a space
middle thirds of the diaphysis, in the deformity area, a bone for the Ilizarov external fixator, using special medical pulls
wedge was excised; osteosynthesis between the fragments or mattresses. In the postoperative period, exercise therapy
was performed on the shaft and reinforced with the Ilizarov and electrostimulation of the abducting muscles should be
external fixator. External fixation lasted 2 months. prescribed.
23.4.3.6 Features of the Postoperative Period 23.4.3.8 Conclusion

In the postoperative period, standard anti-platelet therapy is In cases in which in combination with hip joint replacement
usually prescribed, consisting of one of the direct anticoagu- a recurrent correction osteotomy of the femur is required, the
lants, such as fraxiparine 0.3 or 0.6 mg subcutaneously once Ilizarov external fixator has significant advantages over
a day, or clexane 40 mg subcutaneously once a day in either traditional extra- and intraosseous fixators. Perhaps most
case during 5–6 weeks. To prevent infectious complications, important is its low traumatic effect because the procedure of
cephalosporin antibiotics are administered, such as claforan wire insertion and removal is not technically difficult. The
1 g twice a day intravenously and intramuscularly during Ilizarov external fixator provides reliable and controlled
7 days after surgery. Laboratory control of blood and urine osteosynthesis and enables correction of the femoral frag-
should be done on a daily basis during the first 5 days after ments’ position after surgery. Moreover, Ilizarov external
surgery and then once or twice a week. The sutures are fixation allows a standard (not revision) hip prosthesis com-
removed on day 10–14 postoperatively. The patients are ponent to be implanted, thus keeping the femur intact in the
trained to walk on crutches and exercise therapy is provided. middle and lower thirds of the diaphysis. This is especially
important in young and middle-aged patients. Dosed com- Several surgical options have been proposed, each with
pression at the osteotomy level facilitates successful repara- its own possible complications. Varus osteotomy of the hip
tive regeneration of the bone tissue. shortens the leg and may increase the acetabular incongru-
ency. Valgus osteotomy of the hip may unload the deformed
portion of the femoral head but it may also increase luxation
23.4.4 Arthrodiatasis without influencing the basic avascular process. Finally,
acetabular osteotomies aimed at reorienting or increasing
William Dean Terrell the size of the acetabulum may increase the support
provided to the femoral head but often fail to reduce the
23.4.4.1 Introduction pressure on it or change its shape [452]. Articulated hip dis-
The term “arthrodiastasis” was coined to describe a regime traction is minimally invasive and its positive effects on bone
of articulated distraction and open surgery of the hip and cartilage on both sides of the joint have been demon-
employed since the 1970s [102, 439, 440]. Arthrodiastasis is strated. This method reduces the pressure on the femoral
derived from the Greek arthro (joint), dia (through), and sta- head and can improve joint congruency by reducing supero-
sis (to stretch out). lateral luxation. Articulated hip distraction does not change
Arthrodiastasis is one option for many challenging hip the joint anatomy, unlike some osteotomies, thus allowing
diagnoses. These hip problems range from Perthes disease in ease of later conversion to a total hip arthroplasty if neces-
adolescents to the sequelae of trauma in adults. Hip distrac- sary [451, 452].
tion can be performed utilizing a variety of methods based on Pin sites are a potential site of bacterial colonization,
various external fixator devices. This section describes the although pin-tract infection is not a contraindication. The
advantages and exact technique of this method. risk must be considered when contemplating a total joint
arthroplasty. Since the results of articulated hip distraction
23.4.4.2 Indications and Contraindications for arthritis in patients over 45 years of age and in those with
Hip distraction with an external fixator has been used for inflammatory arthropathy are poor, these are relative con-
many indications, including but not limited to the follow- traindications [444]. Another cautionary note is that patients
ing: osteoarthritis, hip dysplasia, avascular necrosis with slipped capital femoral epiphysis as the etiology for
(AVN), epiphysiolysis, chondrolysis in patients under AVN seem to have less improvement in pain than patients
45 years of age, the repair of acetabular fractures, with other etiologies [457].
Girdlestone patients before revision hip arthroplasty, in
combination with proximal femoral resection in spastic 23.4.4.3 Surgical Techniques
quadriplegia, mobilization of joint contractures, and for Figure 23.47 shows the stages of the arthrodiastasis proce-
the treatment of benign aggressive tumors located around dure for improvement of hip range-of-movement. In this
the hip joint [442–457]. patient, the Sheffield device (Orthofix) was used.
One of the more common indications for this procedure in The patient is placed supine on a transparent operating
the pediatric population is AVN, which is caused by isch- table. A hip arthrogram is performed to assess cartilage
emia from a variety of etiologies, including Perthes disease, architecture and the extent of hinge abduction. An adduc-
sickle cell anemia, epiphysiolysis of the femoral head, stor- tor and iliopsoas tenotomy may be performed. Under the
age diseases, complications arising from the treatment of guidance of an image intensifier, a 1.6-mm K-wire is
developmental hip dysplasia, fractures of the femoral neck, inserted into the femoral head at the center of rotation of
and septic arthritis. The ischemia leads to a process of resorp- the hip while the leg is kept in 15° of abduction, with the
tion, collapse, and repair that may result in a painful, poorly patella pointing forward. The articulated body for the hip
functioning hip [448]. (in this case from Orthofix) is then placed on the K-wire
Late-onset Perthes disease is one of the more common and a standard body template is attached to the hinge dis-
diagnoses associated with the use of articulated distraction. tally. The proximal part is fixed to the supra-acetabular
The condition is defined as AVN of the femoral head and is area with a T-clamp template using two or three half-pins
diagnosed in patients older than 9 years of age. The later a (5 or 6 mm depending on patient size). The distal portion
patient presents with this disease, the worse the prognosis for of the fixator body is then affixed to the femoral shaft using
the joint. Currently, there is no consensus of opinion regard- two or three half-pins. The templates are then replaced by
ing the absolute best treatment for late-onset Perthes. the appropriate fixator body and T-clamp. The joint space
Conservative treatment is not an attractive option because it is immediately distracted 4–5 mm under image control.
does not change the congruency of the joint or the shape of Distraction is continued at 1 mm/day until Shenton’s line is
the femoral head. overcorrected.
a a´
b b´
Fig. 23.47 Surgical steps of arthrodiastasis. Technique: D. Paley, and 15–20° of abduction. (a’) Hip extension. (b) A Steinman is inserted
M.D; case and presentation: S.C. Standard, M.D., Baltimore Limb pin 5–10 mm below the center of the femoral head, perpendicular to the
Length and Deformity Center. (a) The hip is placed in full extension anatomic axis. (b’) Hip flexion
c Horizontal pelvis c´
Coronal mid axis
Sagittal mid axis
Perpendicular line at the

level of the femoral head
d d´
e f
Fig. 23.47 (continued) (c) Reference points for the insertion of an axial half-pin. (c’) Hip flexion. (d) The Steinman pin/hinge axis is placed.
(d’) Hip extension. (e) Support guide pin with T construct. (f) The hinge fixator is placed over the guide pin (view 1)
g h
i j
k l
Fig. 23.47 (continued) (g) The hinge fixator is placed over the guide (k) The 1st pin below the arch, anterior to the hinge–1-hole cube and a
pin (view 2). (h) The hinge fixator is placed over the guide pin (view 3). washer (view 1). (l) The 1st pin below the arch, anterior to the hinge–1-
(i) The hinge fixator is placed over the guide pin (view 4). (j) Two hole cube and a washer (view 2)
supra-acetabular pins are placed using the cannulated pin technique.
m n
o p
q r
Fig. 23.47 (continued) (m) The 2nd pin is placed below the arch, (p) The 2nd pin is placed below the arch, posterior to the hinge–1-hole
posterior to the hinge–1-hole cube (view 1). (n) The 2nd pin is placed cube (view 4). (q) Place two distal half pins – leave pins long (view 1).
below the arch, posterior to the hinge–1-hole cube (view 2). (o) The 2nd (r) Two distal half pins are placed, leaving the pins long (view 2)
pin is placed below the arch, posterior to the hinge–1-hole cube (view 3).
s t
u v
w x
Fig. 23.47 (continued) (s) Two distal half pins are placed, leaving (view 1). (w) The final proximal half-pin is placed anterior to posterior
the pins long (view 3). (t) Final distal half-pins off the Sheffield proxi- in the pelvis, followed by construction of the anterior extension bar
mally (view 1). (u) Final distal half-pins off the Sheffield proximally (view 2). (x) The final proximal half-pin is placed anterior to posterior
(view 2). (v) The final proximal half-pin is placed anterior to posterior in the pelvis, followed by construction of the anterior extension bar
in the pelvis, followed by construction of the anterior extension bar (view 3)
y z
Fig. 23.47 (continued) (y) The complete frame with anterior hip extension bar and cemented ball joints (view 1). (z) The complete frame with
anterior hip extension bar and cemented ball joints (view 2)
Figure 23.48 provides an example of arthrodiastasis use 23.4.4.5 Postoperative Protocol

in the treatment of Legg-Calve-Perthes disease. The patient There are several general principles that should be heeded
was a 10-year-old girl with a 6-month history of Perthes, hip in the postoperative routine for patients with Perthes
flexion and adduction contracture, and painless limp. disease: (1) distraction at 1 mm/day until Shenton’s line is
overcorrected in the postoperative period; (2) the patient is
23.4.4.4 Procedure Complications kept non-weight-bearing; (3) flexion and extension exer-
The most common complications include pin-tract infections cise are encouraged; (4) the fixator is left in place until lat-
and pin breakage, both of which are treated in a routine man- eral pillar reossification appears (usually 4–5 months);
ner. Specific complications for the articulated monolateral routine pin care (surgeon’s preference) is performed during
fixator are locking connector failure and migration of the this time.
cam positioning of the ball. This may cause loss of the 15° The fixator is removed under general anesthesia and a hip
abduction position. arthrogram is performed. Some authors recommend a cus-
Multiple studies have shown that the ball joint is the most tomized hinged abduction orthosis. Gradual weight-bearing
common site of mechanical failure. Cementing this connec- is accompanied by physical therapy. Hydrotherapy has also
tion with PMMA at the time of surgery is therefore com- been used. Many patients continue in physical therapy for
monly recommended [458–460]. 6 months [451, 452, 460].
a b
c
d
Fig. 23.48 Pediatric case study. Technique: D. Paley, M.D.; case and presentation: S.C. Standard, M.D.; Baltimore Limb Length and Deformity
Center. (a) Herring C/Shenton’s line broken. (b) Ludloff position. (c) Mild flattening with extrusion. (d) Anterior defect
e f
Fig. 23.48 (continued) (e) Core decompression. (f) After frame application (view 1). (g) After frame application (view 2). (h) Two weeks
postoperative
i j
l m
Fig. 23.48 (continued) (i) Six weeks postoperative. (j) Fourteen weeks postoperative. (k) Arthrogram at external fixator removal. (l) One week
post-removal. (m) Four months post-removal
o p
Fig. 23.48 (continued) (n) Four months post removal. (o) Six months post-removal. (p) Six months postoperative. (q) Six months
postoperative
s t
u v
Fig. 23.48 (continued) (r) Six months postoperative. (s) Six months postoperative. (t) Six months postoperative. (u) Preoperative.
(v) Postoperative
23.4.5 Hip-Joint Fusion The operation of compression arthrodesis of the hip joint
(Figs. 23.49, 23.50, and 23.51) starts with the removal of the
Leonid Nikolaevich Solomin joint surfaces and adaptation of the stump of the femoral
neck to the acetabulum. The hip is placed abducted at 10°
Surgery is carried out with the patient on an orthopedic trac- and flexed at 30° for patients in sedentary occupations and
tion table with a pelvic support and perineal rest. Both legs 20° for those whose occupation mostly involves standing and
are abducted at 15–20° with moderate traction to the feet. walking [139]. To increase the contact areas in the acetabu-
Fig. 23.49 (a) The device for

compression arthrodesis of the hip
joint generally corresponds to the one
used in the elimination of hip
dislocations and includes three
external supports. It is recommended,
especially in the presence of osteopo-
rosis, that two half-pins I,8,120;
II,10,90 are inserted at the level of the
intermediate supports. To avoid hinge
connections, the proximal basic
support is installed parallel to the
distal basic support mounted at level
VI of the femur: V,8,120; VI,3-9.
Compression is created on the
operating table by approximation of
the basic supports and through medial
transposition of the intermediate
support. In patients of “muscular” type
and weighing >80 kg, due to the
tendency of lower limb adduction
during compression, an additional
b
pelvic support should be mounted (b)
a b
Fig. 23.50 To lengthen a shortened femur, the segment can be length- to restore the length of the extremity half-pin V,8,90 or V,9,90 is
ened at the same time as the arthrodesis. The support fixing the coxal inserted. This helps to correct (if required) the position of the distal
bone is unchanged. The femur is fixed by device I,8,120; II,8,120 – IV fragment and to stabilize the device, fixing it to the reductionally fixing
←→VI,8,120; VII,3-9. Insertion of half-pins at two proximal levels in support. If joint fusion has taken place (usually in 2–3 months) and the
the projection of position 8 (or 9) is necessary to create a compression femur requires further fixation, half-pin II,11,90 is inserted and fixed to
force, its vector maximum coinciding with the anatomic axis of the the proximal support of the femur. The support is then removed from
femoral neck (a). After the femur has been lengthened by up to 1–2 cm, the pelvis (b)
mounted on the lower leg. A hinge-distraction system is

installed between the modules. If dislocation of the shin
is a complication of femoral lengthening, an additional
transosseous module is mounted on the lower leg and con-
nected by a hinge subsystem to the basic frame.
There are two mandatory conditions regarding the device
configuration for increasing the knee joint’s range of move-
ment. First, for knee-joint stiffness the reference positions
described in the atlas for the insertion of transosseous ele-
ments (Chap. 5) should be used. The assembly shown in
Fig. 23.52b can be adopted. Second, the axial hinges should
be installed strictly according to the rotational axis of the
knee joint (Fig. 23.54).
In addition, there is a widely accepted opinion that knee-
joint movements have a more complex trajectory than
can be provided by one-axial hinges. The trajectory of move-
ments in a knee joint can be presented as the superposition of
points on certain segments of arches on a circle of the femoral
condyles and on segments on the tibial condyles. Due to a dif-
ference in the radiuses, the lengths of the arches of the femoral
condyles, and the segments of the tibial condyles, movement
in the knee joint are carried out over several trajectories with
a change in the centers of rotation. Thus, the trajectory of
knee-joint movement represents a complex curve that is dif-
ferent for the external and internal condyles. This provides the
rotational component of movement [461] (Fig. 23.53).
There are devices that better incorporate the biomechan-
ics of knee-joint movements; for example, that of Volkov
Fig. 23.51 In females with a defect of the proximal femur and joint [80] and Oganesyan [462], and the modified device of
fusion in an inappropriate position, a reconstructive operation is per- Ilizarov [9]. The use of hexapods, for example, the Ortho-
formed to improve sexual function
SUV Frame (Chap. 17) is of potential value in this field
because it allows any form and direction of movement of one
support relative to the other, based on the calculations made
lum, a slot is made corresponding to the diameter of the by the software.
femoral neck. If there is a defect in the proximal femur or an It is important to recognize that treatment of knee-joint
insufficient area of the aligned surfaces, a slot is made in stiffness is a very complicated problem that cannot always
both the greater trochanter and the roof of the acetabulum be solved by external fixation alone [465]. One should have
and a spongy transplant is placed in it from the acetabular a clear idea of the functional and anatomic-topographic char-
area or the wing of the ilium. Before the device is installed, acteristics of the femoral muscles and the degree of develop-
two or three diafixing wires are inserted. ment of the cicatricial process in the knee joint and
para-articular tissues. Preoperative examination includes
electromyography, ultrasonography, computed tomography,
23.5 Knee magnetic resonance imaging, and especially contrast roent-
genography of the muscles [466]. The data from the clinical/
Leonid Nikolaevich Solomin functional examinations allow five groups of patients to be
identified (Table 23.1).
In this section the fundamentals of external fixation of dislo- Reconstruction of muscle sliding involves several vari-
cations of the lower leg and knee joint arthrodesis are con- ants and modifications of operations to mobilize and recon-
sidered (Figs. 23.52, 23.53, 23.54, 23.55, 23.56, 23.57, struct the quadriceps [102, 467–470]. Lengthening of the
23.58, 23.59, 23.60, and 23.61). distal tendon of the quadriceps in adults is undesirable as it
For the closed reduction of lower leg dislocations, the first will result in restricted active extension of the lower leg.
stage involves mounting a transosseous module, based either Furthermore, external fixation allows a gradual increase in
on wires or a hybrid module (Fig. 23.52), on the femur. A flexion of the lower leg to the necessary angle in the postop-
second module, also based on wires or a hybrid module, is erative period.
a b c
III,12-6; III,7-1 – VII,3-9; VII,8-2 ←o→ II,3-9; II,10-4 – VII,2-8; VII,4-10 (a)
arc 210 180 3/4 150 150
II,8,90; III,10,90 – VI,8,120; VII,3-9 ←o→ II,3-9; II,10-4; IV,12,70 (b)

1/3 210 180 3/4 150
Fig. 23.52 The Ilizarov device (a) and a combined external fixation of the necessary diastasis for unhindered movement of the lower leg in
device (b) for reduction of the lower leg. The external supports of the the horizontal plane, the subsystem connecting the modules is
module fixed to the femur are located parallel to the axis of the femoral remounted (Figs. 2.4, 2.5, 2.6, 2.7, and 2.8). Remounting depends on
condyles. Distraction starts on postoperative day 3–5 at a rate of the type of dislocation: anterior, posterior, medial, or lateral. After
0.25 mm six to eight times a day. The distraction rate is decreased if reduction of the dislocation, the knee joint is fixed in the mid-physio-
pain or signs of hyperextension of the great vessels and nerves occur. In logical position for 2–3 weeks; the device can then be used to develop
lateral (external, internal) dislocations and subluxations, distraction movements in the knee joint (c)
must first be uniform on all three hinges. After radiographic confirmation
Fig. 23.53 Movements in a knee joint [461]

Fig. 23.54 Orientation of the a b

axis of knee flexion-extension in
the frontal (a), sagittal (b), and
transverse (c) planes (Adapted
from Paley [102]). The axis of
rotation of the knee in sagittal
plane is located in crossing of
posterior cortical lines of femur A
and tibia (at knee extension these
lines coincide). In order to find
the axis of rotation of a knee
joint, it is necessary to make the B D
roentgenogram of contralateral
(intact) joint. Axial hinges are
installed between the tran-
R
sosseous modules fixing the
femur and the lower leg, 2 cm W Y
from the joint surface, and at the
Tm C
junction of the middle and
posterior thirds of the femoral
condyle (From [463, 464]) (d)
E
Ta Z
c d
0°
20 mm
3°
23
Table 23.1 Groups of patients with knee joint stiffness and its treatment
Large-Joint Pathology
Group Reason for stiffness Clinical/laboratory data Treatment

I (a) Aftermath of plaster immobilization of femoral Stiffness is not associated with a cicatricial process in the Passive-active development of movement using an external
fractures; less frequently, fixing of the knee by knee joint; there are no rough unions or malunions between fixation device
bandaging in fractures of the lower leg muscle and bone (myofasciodeses). Conservative
(b) Complication of lengthening of the femur (extension treatment, including redressment attempts over
stiffness) or lower leg (flexion stiffness) 2–3 months, have failed
II Aftermath of an inflammatory process in the knee joint or The femoral muscles are intact or have no marked Arthroscopic release of the knee joint with subsequent
intra-articular fracture secondary fibrous changes or atrophy. The points of passive-active development of movement using an external
pathological fixation of the muscles to the femur are not fixation device
available or not marked. A cicatricial process occurs in the
knee joint cavity and para-articular tissues
III United fractures of the distal third and distal part of the Stiffness is not associated with a cicatricial process in the “Semi-closed” with a local process or open myolysis with
femur knee joint or it is not marked and is secondary in character. reconstruction of muscle sliding. If required, release of the
Marked signs of myofasciodesis: cicatricial union of knee joint. Subsequent development of movement in the
muscles and tendons with bone, union of tissues knee joint using an external fixation device
IV United open fracture, after extensive injury of the soft Stiffness is associated with a cicatricial process in the Open arthrolysis, myolysis with reconstruction of muscle
tissues of the distal femoral muscle; osteomyelitis in para-articular tissues; polylocal myofasciodeses sliding followed by passive-active development of
remission movement using an external fixation device
V Malunions and non-unions of the distal third and distal part Stiffness is associated with a cicatricial process in the One-stage operative treatment: Open arthrolysis, myolysis
of the femur para-articular tissues; polylocal myofasciodeses with reconstruction of muscle sliding; fixation of rigid
bone fragments with subsequent passive-active develop-
ment of movement using an external fixation device.
Two-stage treatment (preferable): Stage 1 is union of the
bone fragments with restoration of the anatomic axis of the
segment (even if shortening is kept). Stage 2 is open
arthrolysis, myolysis with reconstruction of muscle sliding
followed by passive-active development of movement
using an external fixation device
1125
a b
Fig. 23.55 (a–c) The swivel hinge is installed on the anterior and posterior surface or on both sides

c
In neurogenic stiffness of the knee-joint, lengthening of the These factors form the basis for drawing up the informed
biceps femoris, semitendinosus, and semimembranosus mus- consent to be signed by the patient before the operation, so
cles by external fixation is comparatively rarely indicated; in that he or she is aware of both the real chances of success and
case of a continuous process, there is a tendency to spasticity. the limitations of restorative surgery. It is known that major
Apart from the indicators given in Table 23.1, it is neces- stiffness of the knee joint may result in a state of decompen-
sary to take into account: sation, even with a normal axis and length of the lower
1. The degree and duration of the stiffness and the patient’s extremities [471]. Therefore, one should use all means to
age. improve, if not restore, the function of the knee joint. Signs
2. The patient’s attitude to treatment and his/her desire to of gonarthrosis are not a contraindication.
restore the amplitude of knee-joint movement. Some If extension stiffness occurs during femoral lengthening,
patients insist on a maximum possible restoration of joint especially during regenerate formation in the distal third of
movement; for others, restoration of 30–45% of move- the segment and when closed redressment has failed, external
ment amplitude is sufficient for their social rehabilitation. fixation can be used. For this purpose a transosseous module
3. The intensity of changes to the articulating surface of the is mounted on the lower leg as shown in Fig. 23.52 or the
femur; for example, in extension stiffness, a 40% shorten- module is based on two half-pins and a wire (Fig. 23.56b).
ing of the belly of the rectus and median muscles, due to The module is connected by a hinge subsystem to the basic
their atrophy and to fibrous changes, prejudices the pos- support. This approach should be used if extension stiffness
sibility of restoring full active extension of the lower leg. forms during the treatment of femoral fractures, especially
4. The presence and characteristics of a chronic inflammatory open injuries to the distal third of the segment, as it ensures
process of the femur or knee joint. that the emergence of rough cicatricial unions of tendons and
5. The presence of another orthopedic pathology: non- muscles with the bone at the fracture site is avoided.
unions or deformities, including shortening of the femur In most cases all supports of the device fixing the femur are
or lower leg. located perpendicular to the anatomic (mid-diaphyseal) axis
Fig. 23.56 (a, b) Alternative

supports for the femur and tibia
a b
VI,8,120; VII,3-9; VIII,4,90 (a)
I,1,90; II,3-9; III,12,120 (b)
of the bone. Accordingly, the distal basic ring (as well as all shortening of the femur. Simultaneous restoration of the
supports) is not parallel to the knee-joint plane. Therefore, to anatomy and function of the injured extremity is the priority in
install axial hinges, an additional support fixed at the necessary planning the patient’s rehabilitation. The operation for single-
angle to the distal basic femoral support must be introduced stage restoration of knee-joint function must be performed with
into the assembly. Another possibility is to use complex the participation of a surgeon experienced in these types of
hinges, one part serving for fixation to the distal basic support interventions. Otherwise, treatment should be divided into two
of the femur device and the other the axial hinge itself. or three stages. The opinion that following external fixation of
The formation of persistent flexion stiffness of the knee the femur (particularly lengthening) there necessarily emerges
joint that does not respond to conservative treatment can be a marked restriction of knee-joint movement currently needs
complication of lengthening of the lower leg. The absence of revision. This problem can be avoided by the use of a combined
loading on the extremity can negatively affect the distraction external fixation device and observance of the recommenda-
regenerate; thus, the stiffness needs to be eliminated as soon tions for postoperative management of the patient.
as possible. For this purpose, a transosseous module is A single-stage operation to treat a traumatic injury simul-
mounted on the femur as shown in Fig. 23.52 or a ring sup- taneously with mobilization of the knee joint involves the
port based on a wire and two half-pins is used (Fig. 23.56a). following:
If patellofemoral synostosis or fibrous union of the patella 1. In angular and rotational deformity exceeding 15–20°,
with the femoral bone has occurred, its open or arthroscopic with shortening of 20–40 mm, osteotomy is recommended,
mobilization is required. A wire is then inserted through the with subsequent gradual correction of the deformity.
patella in the frontal plane and tensioned in the additional 2. In hypertrophic defect pseudoarthroses and anatomic
half-ring support. The support is fixed to the basic support, shortening of the femur by 2–3 cm, microdistraction is
thus creating diastasis between the patella and femur. performed to eliminate the inequality in the lengths of the
In clinical practice, extension stiffness of the knee joint is extremities and to restore the anatomy of the bone simul-
often present together with a non-union, deformity, defect, or taneously with restoration of knee-joint movement.
Fig. 23.57 External fixation of a traumatic femoral deformity with severe extension knee-joint stiffness. (a, b) Before treatment

(c, d) after deformity correction,
external fixation using a hinged
frame
d

(e, f) after module
transformation of the frame,
and the final X-ray result
e
3. If external fixation of a femoral non-union involves an of contact. If axial compression is at the junction of the frag-
intervention with an open stage (removal of a metal struc- ments, it is easier to achieve a rigid external fixation.
ture, osteoplasty), it is combined with an operation to Therefore, in correcting osteotomy for fragment adaptation,
mobilize the knee joint. the bone wound should be located in a plane close to the
4. In atrophic non-unions of the femur and shortening of the transverse plane.
segment by 40 mm, the bone fragments are openly reduced An alternative to lengthening a shortened femur is to
using, according to the indications, osteoplasty; cortico- lengthen the lower leg, providing unevenness of the knees is not
tomy is performed with osteoclasis of the femur to elimi- rejected by the patient for aesthetic reasons. Differences in the
nate inequality in the lengths of the extremities [472]. levels of the knee joints up to 5 cm do not significantly influence
5. The operation to treat shortening of a lower extremity that the biomechanics of gait [471]. If the femur is shortened by
is accompanied by severe stiffness of the knee joint after more than 5–7 cm, some of the shortening can be addressed by
the malunion of intra-articular fractures not more than lengthening the femur and the rest by lengthening the lower leg.
1.5 years after trauma starts with surgery on the knee This allows an improvement in knee-joint function and reduces
joint. The congruity of the joint surfaces is restored and both the rehabilitation period and the unevenness of the knees.
the joint is mobilized. The second stage involves length- In replacement of a segmental defect of the femur by the
ening of the segment [471]. Ilizarov method, operative approaches to improve knee-joint
It is known that the closer the osteotomy is performed to the function must be postponed at least until adaptation of the
knee joint, the greater the danger of stiffness. Therefore, if transposed fragment to the basic fragment and their stabili-
the top of the deformity is located in the distal femur or proxi- zation. Arthrolysis and myolysis can be performed in a single
mal lower leg, a correcting osteotomy is performed as far as step with open adaptation of the transposed and basic bone
possible from the knee joint. This issue is considered in more fragments. Multiple severe myofasciodeses, filling the knee-
detail in Chap. 16. joint cavity with scar tissue, osteomyelitis are the reason for
Passive development of knee-joint movement may ulti- two-stage treatment for restoration of the weight-bearing
mately result in the destabilization of fragments in their zone ability of the extremity and improved knee-joint function.
Fig. 23.58 External fixation of a traumatic left femoral

shortening by 12 cm; severe knee-joint extension
contracture (patella-femur fusion); femoral osteomyelitis.
(a, b) Before treatment
a
Fig. 23.58 (continued) (c–g) The patient, after arthrolysis, myolysis, and quadriceps plasty, developed movements in the knee joint. The femur
and lower leg were simultaneously lengthened
e

g h
Fig. 23.58 (continued) (h–k) The length discrepancy of the lower legs was eliminated, the function of the knee joint considerably improved.
Treatment was carried out over 1.5 years
i j


a c
Fig. 23.59 External fixation in the treatment of severe flexion knee-joint contractures caused by cerebral injury. (a–d) Before treatment
Fig. 23.59 (continued) (e, f)

after arthrolysis, myolysis, and
lengthening of the Achilles
tendon
e
f h
Fig. 23.59 (continued) (g–m) extension of the knee joint with the aid of hinged frame, and simultaneous elimination of the patellar disposition
(patella baja)

m o
Fig. 23.59 (continued) (n, o) the patient before the second stage of treatment
Fig. 23.59 (continued) (p, q)

after arthrolysis, myolysis, and
applying the software-based
Ortho-SUV Frame
q
Fig. 23.59 (continued) (r, s) gradual

elimination of contracture, stabilization of the
device after strut removal
r
Fig. 23.59 (continued) (t, u) result

of treatment
s t
u
Fig. 23.60 Devices for compression

arthrodesis of the knee joint (a, b). Note that
in arthrodesis there is no need to use
reference positions for the transosseous
elements. The choice can be expanded
through the use of safe positions. For
lengthening the extremity or for bone defect
replacement, lengthening arthrodesis is
used. (c) This procedure involves gradual
separation of the modules on the femur and
lower leg at a rate of 0.25 mm three times a
day starting after 2 weeks, or moving the
intermediate bone fragment (From [473])
a b
c
3 4 1 2 5 6 7 8
V,8-2; V,1-7 – VII,2-8; VII,4-10 →← I,2-8; I,4-10 – III,9-3; III,4-10 (a)
180 180 160 160
2 1 3 4 5 6
VI,2,120; VII,4-10; VIII,8,90 →← I,2-8; I,10-4; III,12,120 (b)
180 160
Fig. 23.61 If the extremity is to be lengthened,

bilocal osteosynthesis can be used. The device is
mounted so as to allow compression at the junction
of the fragments after removal of the knee joint and
distraction at the level of the corticotomy with
osteoclasis of the tibia (a). The newly inserted
transosseous elements are further fixed to the
intermediate support; the distal support can be
removed 2–3 weeks prior to the end of the fixation
period (b). It is possible to obtain a distraction
regenerate at the level of contact of the femur and
tibia and at the level of the lower leg
a b
2 1 3 4 5 6 7
V,2,120; VII,4-10; VIII,8,90 →← I,9-3; II,12,90 ←→ IV –– VII,8-2; VII,4-10 (a)
180 160 160 160
2 1 3 4 5 6 7 8
V,2,120; VII,4-10; VIII,8,90 →← I,9-3; II,12,90 — V,3-9; V,4-10; VII,11,70 (b)
180 160 160
After closed operations, the knee joint is stabilized in the On day 2 or 3 after closed osteosynthesis and after
position achieved by maximum elimination of the stiffness. arthroscopic release, gradually increasing flexion (extension in
However, to reduce pain, the position in the joint achieved by the presence of extension stiffness) of the lower leg starts by
the end of the operation must be decreased by 30–50%. It means of a swivel hinge, at an average rate of 2–6°/day in four
often happens that, after open arthrolysis and myolysis, to to six stages. The rate is reduced if pain occurs or if there are
avoid excessive skin stretching the skin is taken in with the signs of irritation of the great vessels and nerves. The manipula-
knee joint flexed to a lesser extent than was achieved during tions must not cause any pain. The decision whether the amount
the operation. To reduce the risk of postoperative soft-tissue of movement of the swivel hinge causes no pain must be made
necrosis, the knee joint is stabilized in a position that ensures in the morning. Only after a night without analgesia should an
an adequate blood supply to the wound edges. If a marked increase in the rate of joint movement be recommended. The
cicatricial process occurs in the area of the joint, the knee is systematic prescription of analgesics for the development of
stabilized in a position close to full extension. movement “at any cost” is impermissible. After the skin has
A diastasis of 5–6 mm is created between the joint sur- healed following open arthrolysis and myolysis, redressment of
faces in two or three stages. It is important to note that due to the knee joint under raush-anesthesia is recommended.
flexure of the transosseous elements the amount of separa- Lower leg flexion to an angle of 120° (or less if planned
tion by the hinges will not correspond to the joint space. preoperatively) is followed by extension, initially at the same
Therefore, the effectiveness of the distraction should be rate. This is also the protocol for flexion stiffness. When the
monitored radiographically. Radiographic monitoring of the full cycle of flexion extension is completed, it is repeated.
installation of the axial hinges is also necessary. The repeat cycle usually takes less time. After 10–15 cycles
of passive flexion and extension, the time for a full cycle is cause persistent relative shortening and changes of the
reduced to several minutes. Passive movements are then sup- gastrocnemius muscle (for example, due to previous
plemented by the development of active movements, which poliomyelitis) or in the presence of marked osteoporosis, the
requires disconnecting the arms of the swivel hinge. Over external fixation operation is performed simultaneously with
3–7 days, a gradual transition is made to the priority devel- lengthening of the Achilles tendon. In stiffness emerging
opment of active movements. The device for movement after intra-articular fractures of the ankle joint after a previ-
development can be removed after the patient can achieve ous infectious process, arthroscopic release is performed
flexion–extension of the knee joint in 10–20 min [468]. (provided there are no contraindications) in one stage, at the
Restorative treatment involving massage, exercise therapy, same time as installation of the external fixation device.
and myostimulation is continued. The procedure starts with mounting the transosseous
Arthrodesis of the knee joint starts with the removal of the module on the lower leg. If lengthening of the lower leg is
joint surfaces and adaptation of the prepared bone ends with complicated by the presence of talipes equinus, the basic
the lower leg in 10° of flexion and 10° of outward rotation. device is used. In other cases, two pairs of wires are inserted
The fragments are stabilized with two or three wires. If the and are fixed after tensioning to two ring supports. The sup-
placement of the extremity is correct, a long thread passing ports are connected by three rods: V,2-8; V,4-10 – (VII,8-2)
from the anterior upper spine of the ilium to the first inter- VII,8-2; VII,4-10. The lower leg module can be a combined
digital space runs across the middle of the patella [1]. Unless single-support module: VI,12,120; (VII,8-2)VII,8-2; VII,4-
lengthening arthrodesis is planned, a rectangular autograft is 10 (Fig. 23.62a) or VI,12,120; (VII,8-2)VII,8-2; VIII,1,90
formed from the patella. A slot is made through both bones (Fig. 23.62c, d). A module based on a lengthened closed
2–3 mm smaller than the autograft, which ensures a tight fit. half-ring (“horse-shoe” support) is mounted on the foot.
The wound is cleaned and stitched. By means of swivel hinges, gradual extension of the foot
The external fixation device is then mounted. In Ilizarov is started at an average of 2–6°/day in four to six stages on
external fixation, crossing wires are inserted into the epicon- postoperative day 2 or 3. The rate is reduced if pain occurs or
dylar area. Another pair of wires is inserted 8–10 cm more if there are signs of irritation of the great vessels and nerves.
proximally. The wires are tensioned and fixed to two ring The manipulations must not cause any pain. The systematic
supports connected by three rods. A similar module is prescription of analgesics for the development of movements
mounted on the lower leg. The modules are connected with “at any cost” is impermissible.
bars and compression is applied at the junction of the bones After 15–20° extension has been achieved, the foot is sta-
(Fig. 23.60a). Figure 23.60b shows a hybrid variant of the bilized for 3–5 days. Flexion is then started, its rate limited
device for compression arthrodesis of the knee joint. only by the occurrence of pain or a neutrophic disorder. After
a full cycle of flexion–extension is completed, it is repeated.
The repeat cycle usually takes less time. After 10–15 passive
23.6 Ankle flexion and extension cycles the time for a full cycle is reduced
to several minutes. Passive movements can be developed
Leonid Nikolaevich Solomin using a special automatic pneumatic attachment [103]. Passive
movements are then supplemented by the development of
The fundamentals of external fixation of malleolus fractures active movements. For this purpose, the arms of the swivel
are considered in Chap. 13.4; chronic ankle injuries in Chap. hinges are disconnected. Over 3–7 days, a gradual transition
13.5. Treatment of pes calcaneus is considered in Chap. 22.3 is made to the priority development of active movements.
(Fig. 22.20), and compression arthrodesis in Chap. 22.5 (Fig. The device for movement development can be removed
22.54). In this section we consider external fixation for ankle- after the patient has achieved confident movements in the
joint stiffness, that is, pes equinus (Figs. 23.62 and 23.63). ankle joint. Restorative treatment involving massage, exer-
The device is assembled from two transosseous modules cise therapy, and myostimulation is continued.
fixing the lower leg and foot. The modules are connected by External fixation is used when dorsal flexion of the foot
a hinge subsystem. by 25–30° was not achieved after lengthening of the Achilles
Flexion stiffness of the ankle resulting in talipes equinus tendon. The foot is fixed by the device for 1–2 weeks, after
is frequent in clinical practice. The most common reason for which the hinge subsystem is used in accordance with the
persistent flexion stiffness is that the rules concerning plaster above descriptions.
immobilization and lower leg lengthening have been broken. In a patient with forefoot equinus, the hindfoot should be
These complications are grounds for using external fixation fixed to the base frame. In this case the support fixing the
by “closed” methods. In stiffness resulting from diseases that forefoot is a mobile one (Fig. 23.63).
a
b
Fig. 23.62 (a–d) A hinge subsystem is installed between the tran- spond to the value of the distraction force at the joint space. Therefore,
sosseous modules fixing the lower leg and foot. The center of rotation the effectiveness of the distraction should be monitored radiographi-
of the axial hinges on the external and internal surfaces of the foot must cally. Radiography is also necessary to make sure that the axial hinges
be located at the level of the center of the head of the talus [9]. One have been properly installed (According to Oganesyan et al. [103], the
swivel hinge is installed on the posterior aspect of the foot and one on imaginary biomechanical axis of the ankle joint (rotational axis) passes
the anterior aspect. A diastasis of 3–4 mm is created between the joint under the medial malleolus, through the center of the trochlea of the
surfaces. It is important to note that due to flexure of the transosseous talus, and emerges under the top of the lateral malleolus. Therefore,
elements the value of the distraction force on the hinges will not corre- axial hinges should be installed)
d
Fig. 23.63 Elimination of

forefoot equinus; external
fixation of a tibial non-union.
(a, b) Before treatment
b
c e
Fig. 23.63 (continued) (c, d) after applying the software-based Ortho-SUV Frame; (e, f) the deformity is eliminated, the struts are exchanged
for hinges
Fig. 23.63 (continued) (g, h) result of healing

Infectious Complications of Long-Bone
Fractures 24
Maurizio A. Catagni and Leonid Nikolaevich Solomin
This chapter structurally consists of two parts. In the first mendations for the use of external fixation in infectious com-
(Sect. 24.1) general data on the modern principles that underlie plications on the basis of the techniques developed at the
the treatment of infectious complications of long-bone frac- Russian Ilizarov Research Center [230, 474].
tures are presented. The second part (Sects. 24.2, 24.3, 24.4, The duration of fracture fixation in the presence of infec-
and 24.5) is devoted to questions regarding the practical use of tious complications is quite often long. Therefore, preoperative
external fixation in the pathology considered. Section 24.2 also preparation, transosseous element insertion, frame assembly,
provides information on the treatment of non-unions and and postoperative management should be given due attention.
defects, which discussed in detail in Chap. 19. Transosseous elements should not be inserted if the bone
or soft tissue is inflamed. This rule does not exclude wire
insertion for bone transport in the replacement of bone loss
24.1 General Data by Ilizarov’s method, or transosseous element insertion in
the presence of an anaerobic infection in which there is gas
Leonid Nikolaevich Solomin formation.
Infectious complications may result in changes to the
If infectious complications occur, external fixation results in topography of the main vessels and nerves due to a deformity,
the best outcome and is the only method that should be extensive scarring, and/or repeated operations. To reduce the
implemented: internal fixation is inadmissible and conserva- risk of vessel and nerve damage during transosseous element
tive methods cannot be the main ones. Only external fixation insertion, additional preoperative imaging, including com-
is able to provide the optimum conditions for the treatment puted tomography (CT), magnetic resonance imaging (MRI),
of infected bone and soft-tissue injuries and for the restora- and selective vasography, should be carried out.
tion of the anatomy and function of the extremities. The In the presence of infected tissue or extensive scarring,
“purifying” effect of external fixation on purulent defects of which are undesirable conditions for the insertion of tran-
bones and joints is known. Thus, Ilizarov’s statement that “in sosseous elements, the use of only reference positions is not
the fire of the distraction regenerate burns the infection” has always possible. At the same time, a patient may have an
practical embodiment. increased risk of joint stiffness or may already be experienc-
The variety of pathologies that can be considered (etiol- ing a restriction of mobility in adjacent joints. Thus, the
ogy, types, localization, process stages, etc.) are beyond the necessity to use safe positions conflicts with the requirement
scope of this book. Instead, we discuss the general recom- to fulfill all the conditions for the restoration of joint move-
ment. External fixation allows the setting of priorities in this
regard. Maintenance of the correct reduction of bone frag-
ments and their rigid fixation are priorities in external fixation.
M.A. Catagni (*)
Department of Orthopedics, Lecco General Hospital, Later, if the local dynamics are positive, the transosseous ele-
Lecco – 42, Via C., Lecco 23900, Italy ments should be replaced using reference positions.
e-mail: maurizio@catagni.it As a rule, a chronic infectious process accompanies osteo-
L.N. Solomin, M.D., Ph.D. porosis, which creates additional complexities for the
External Fixation Department, achievement of fixation, especially the maintenance of the
optimum rigidity of the fixed bone fragments. The decision-
St. Petersburg 195427, Russia making process concerning these problems is discussed in
e-mail: solomin.leonid@gmail.com Chap. 25.
1158 M.A. Catagni and L.N. Solomin
The bone canal is drained only after the transosseous elements (for bone transport) is then done. When contraindica-
ments have been inserted, unless precautions are taken; the tions, such as the gross hemodynamic instability of the
exception is fixing a drainage tube by wires. Half-pins with a patient or adverse local conditions, are present, bone trans-
channel and a lateral aperture can be used for bone canal port is carried out during the second stage of treatment.
drainage and the introduction of drugs [475]. With extensive tibial defects, “tibialization” (fibular trans-
The use of extracortical clamp devices instead of wires port) can be used, which involves moving a fibular fragment
and half-pins allows drainages and spacers to be entered into toward the tibial defect. A detailed discussion of the possible
the medullary cavity while avoiding contact with fixing ele- techniques is presented in Chap. 19.
ments (Figs. 12.24–12.32). With a hyperplastic type of osteogenesis and a chronic
Adjacent joint immobilization is often necessary in the pres- infectious process, external fixation can be used as the first
ence of infectious complications of bone fractures. The joints stage in deformity removal and in the union of pseudoar-
should be stabilized, to some extent, in their physiological posi- throses. The second stage is disinfection at the focus of the
tion. The forearm should be fixed in a position between supina- osteomyelitis. Either the damaged bone is replaced with a
tion and pronation. If for any reason the physiological position bone and muscle flap [476] or the osteomyelitis focus is
is not possible, external fixation modules fixing bone fragments replaced with a graft of transported bone [477].
are connected by two axial hinges and a swivel hinge. After the In the presence of an osteomyelitis cavity, the tactics for
physiological position of a joint has been achieved, the frame external fixation mainly depend on its size and location [478].
can be used for passive/active development of joint movement. If the cavity is located centrally and its size does not exceed
Detailed information can be found in Chap. 23. one-third of the bone’s diameter, oblique osteotomy through
The decision to use external fixation in the presence of the cavity is carried out. The osteotomy begins 15–20 mm
infected fractures is subordinate to decisions concerning the proximally and ends 15–20 mm distally. Sequestrations, path-
problems of bone fragment reduction, rigid fixation of the ological granulations, and purulent contents are then removed.
fragments, and adequate wound drainage. The basic princi- The wound is drained and sutured with one or two rows of
ples for choosing the approach to the specified tasks are out- sutures. Distraction at a rate of 0.25 mm four times a day is
lined in the chapters on external fixation of open fractures begun in 8–10 days. This procedure results in filling of the
(Chap. 14) and malunited fractures (Chap. 15). During deb- osteomyelitis cavity with new bone callus, deformity removal,
ridement, only small bone fragments with no blood supply and restoration of the segment length by up to 50–70 mm.
are removed. External fixation combined with modern anti- In a localized osteomyelitis cavity in which the defect
bacterial therapy and physiotherapy avoids the necessity to occupies one-third of the bone diameter, the cavity can be
remove large bone defects. At the same time, high-energy filled by bone transport, either above or below the defect.
trauma (for example, gunshot-related fractures) demands This requires a sequestrectomy with removal of the cavity
more radical surgery [94]. wall to the limits of the healthy tissue. In the presence of an
With acute purulent inflammation and extensive soft-tissue extensive osteomyelitis cavity occupying one-half or more of
infection, it is impossible to place transosseous elements near the bone diameter, the bone should be resected to the limits
a bone wound. In such cases, the stability of the basic supports of the healthy tissue. The defect is replaced by bone transport
should be increased. This is done by inserting additional wires of one or both bone fragments (Chap. 16).
and half-pins at some distance from the basic support followed The epimetaphysis is resected to the limits of the healthy
by their fixation by means of posts. After the soft-tissue tissue if the articulating ends of a bone are involved in a
inflammation has resolved, and taking into account the remain- chronic inflammatory process. If the cortical plate with the
ing issues to be addressed, additional supports and transosseous articulating cartilage can be preserved, the role of external
elements can be placed near the fracture area. fixation is to remove the loading of the joint and to provide
External fixation in the treatment of chronic traumatic passive and active development of joint movement. If the
osteomyelitis during remission follows the principles out- articulating end of a bone is removed, compression arthrod-
lined in Chaps. 16 and 19. esis is carried out. When the defect is at the distal articulating
Non-viable bone can be radically removed at non-unions end of the radius, the excess length of the ulna should not
and pseudoarthroses. The stage of an infectious process in bone exceed 2 cm. Its distal articulating end is resected and used
and the borders of the non-viable soft tissue can be defined as osteoplasty filler material. If the defect at the distal end of
by radiography, including enhanced images, fistulography, the radius exceeds 2 cm, it should be replaced by a bone
osteophlebography, CT, and MRI. autograph or by lengthening the remaining part of the bone.
The apparatus is assembled so as to allow subsequent In pathologies of the humeral and cubital joints, neoarthrosis
replacement of a bone defect. After surgical wound process- formation is an alternative method. The timing of subsequent
ing, drainage, and suturing of the soft tissues, the operational arthroplasty is determined on an individual basis.
field is cleansed again, and surgical drapes, gowns, and When a soft-tissue defect occurs after fistulas and scars
gloves are changed. Corticotomy of one or both bone frag- have been removed, the following method can be used. The
24 Infectious Complications of Long-Bone Fractures 1159
location of the external support and the connecting rods con-

ferring proper positioning of the bone fragments are marked.
The fragments are then positioned so as to allow wound clo-
sure without tension in the soft tissue. The deformities may
be either angular or rotational or the fragments may be dis-
placed laterally or longitudinally. The potential development
of trophic disorders due to goffering or excessive flexion of
the main vessels and nerves should be kept in mind. Bone
fragments are stabilized in the newly achieved position.
After healing of the soft-tissue wound and removal of the
sutures, gradual restoration of the bone fragments’ position
can be started.
24.2 General Strategy of Pseudoarthrosis

Treatment
Maurizio A. Catagni
The successful treatment of pseudoarthrosis (including

infected) by the method of Ilizarov mandates an understand- Fig. 24.1 The basic types of pseudoarthrosis: lax and stiff non-unions;
ing of its strategies and tactics. The treatment strategy for the latter includes those with and without an angular deformity
each non-union requires subtle changes in the tactics used by
the surgeon.
Numerous classification systems of pseudoarthrosis Normal fracture healing is dependent on stability, vascu-
exist, based on the shape, biological activity, and location of larity, and normal function. The pathogenesis of a non-union
the non-union. Many years of experience with the Ilizarov can be attributed to a deficiency in one or more of these
method at Lecco Hospital have resulted in a revision of parameters. For the successful treatment of non-unions, it is
the classification of non-unions. Thus, rather than relying essential to identify the defective components and to correct
on their radiographic appearance, the new classification is them during the treatment period. The fracture that lacks
based on the clinical relationship of the bone ends (mechani- only stability may progress to the stiff type of non-union,
cal properties of the non-union site) and therefore aids in the whilst the fracture that lacks both stability and vascularity
choice of the operative strategy and the technique’s appli- (often an open fracture) has the tendency to develop into a
cation. In this classification system, pseudoarthroses are lax type of non-union.
divided into lax and stiff non-unions; the latter are further When a fracture is infected, there is necrosis of the bone
divided into those with and without an angular deformity ends that results in a loss of vascularity and stability; this
(Fig. 24.1). point is addressed in a subsequent section. In a stiff non-
Lax non-unions are those that demonstrate little inherent union, the application of a stable frame in compression is
mechanical stability. Radiographically, these usually appear sufficient to promote union. This construct restores the miss-
as avascular non-unions, with poor callous formation and ing parameter in fracture healing.
minimal surface area of contact; they may have actual bone The stiff non-union has the cellular potential to unite if
substance loss. Stiff non-unions usually correspond radio- stable compression is applied, without the need for bone graft
graphically to what was previously termed “hypertrophic or decortication. This mode of treatment is “monofocal,”
non-union,” with exuberant callous formation and a large because the action occurs at a single site within the bone.
area of bony contact. Once fracture stability has been restored by compression,
The reason non-union has been divided into these two “continuous compression” must be maintained throughout
groups is due to the differences in the intervening soft tis- the period of healing. Initial compression is lost by several
sues. The tissue at the site of stiff non-unions is mainly means: bone remodeling, wire stretching, or the resorption of
fibrocartilage, and is capable of bony metaplasia under appro- soft tissue. The maintenance of compression involves a
priate mechanical conditions. Ilizarov’s research demon- schedule in which compression is applied 0.25 mm/day for
strated that a compression distraction force is the appropriate 2–3 weeks followed by 0.25 mm one to two times/week.
mechanical environment for bony metaplasia. Lax non-union In lax non-union, both stability and vascularity are lost.
tissue is mainly amorphous fibrous tissue with little potential Thus, treatment of the problem requires not only stability but
for biologic repair. also a biologic stimulus, i.e., a stable frame construct and an
osteotomy, usually in the metaphyseal region. Bone can be

lengthened through the osteotomy, while new vascularity is
introduced into the segment. The distraction produces
increased vascularity in both the bone and the surrounding
soft tissue. This was demonstrated by Ilizarov and other
independent researchers. Osteotomy is always required in a
lax non-union in order to enhance vascularity and restore
length regardless of whether the bone loss was due to the
initial trauma, repeated operations, or the natural history of
the non-union. This type of treatment is referred to as “bifo-
cal” because action occurs at two levels: the site of the non-
union and at bone lengthening.
With regard to limb function, during treatment with the
Ilizarov method, motion and rehabilitation can begin imme-
diately at the adjacent joints. This reduces peri-articular
fibrosis and maintains the functional abilities of the sur-
rounding soft tissues. In the lower extremity, this mode of
treatment allows early restitution of weight-bearing and pro-
vides a further stimulus for fracture healing.
It is important to restore the anatomic axis of the limb for
normal function in the long term. Restoration of the anatomic Fig. 24.2 Bilocal external fixation in the treatment of a lax non-union
axis ensures that true compressive forces are transmitted without bone loss
across the non-union site. Perfect function requires a perfect
axis, thus avoiding any shear or bending force, either of which
act negatively on the healing site. Angular deviation is not a
major problem in lax non-union because an acute correction
is possible. By contrast, angular deformities in stiff non-
unions are often resistant to acute correction and the presence
of a fixed angular deformity must be addressed during treat-
ment. In addition to angular deformities, leg length discrep-
ancy (LLD) must be considered. Up to 2 cm of shortening is
acceptable, as this small difference can be easily accommo-
dated by a patient with a normal spine, pelvis, and hip.
24.2.1 Non-unions Without Bone Loss
As noted above, the treatment of lax non-union without bone

loss necessitates both a stable compression frame and an
osteotomy. The site of bone interruption may be located
proximally or distally, based on the size of the segments.
Fixation involves several levels, two of which are located
close to the non-union site and the others as far as possible
from the osteotomy site. This concept of maximal spacing is Fig. 24.3 Monolocal compression type of external fixation in the treat-
important for soft-tissue lengthening (Fig. 24.2). ment of a stiff non-union
In the stiff non-union, it is sufficient to have a stable frame
with rings close to the non-union site. Each segment must be important to obtain progressive compression without
stabilized with two rings (a ring block) and a minimum of impingement of the rings and to have enough room to allow
four wires (two wires per ring). In the configuration used adequate radiographic visualization of the non-union site.
since 1989 at the Lecco Hospital, we substitute some of the The rings located far from the non-union site must be in the
wires with half-pins (5–6 mm, conical) for a more stable epiphyseal region, both proximally and distally. This results
configuration and increased patient comfort. A distance of in a large lever arm of fixation and therefore improves frame
4–5 cm must bridge the rings at the non-union site. This is stability (Figs. 24.3, 24.4, and 24.5).
a b c d
Fig. 24.4 (a–c) Atrophic humeral non-union; (d, e) open resection and compression with a guide wire; (f, g) frame construct
Fig. 24.4 (continued) (h, i)

module transformation (frame
dynamization)
h
Fig. 24.4 (continued) (j)

consolidation; (k, m) final
function
i j
k
l m
a b c d e
Fig. 24.5 (a) Normotrophic humeral non-union; (b) simple compression using an intramedullary rod; (c) frame construction; (d, e) consolidation
A stiff non-union with deformity and no shortening

requires a monofocal treatment strategy. The frame must be
constructed to correct the deformity. There are several differ-
ent methods used for correction, but we currently employ
only the method of hinge correction: physical hinges with
the original Ilizarov device, virtual with hexapod application
(Chap. 17).
Hinged correction is used in the majority of cases involv-
ing the long bones. Firstly, two blocks with two rings per
block are constructed. Each block is placed exactly perpen-
dicular to each segment (not necessarily parallel to the joint
line). These two blocks are connected by hinges, the axis of
which must lie exactly perpendicular to the plane of the
deformity and thus at the apex of the deformity on the con-
vex side (Chap. 16). The deformity is corrected by slow pro-
gressive distraction (Fig. 24.6a).
When the deformity is corrected all of the rings will be
parallel, allowing the removal of the hinges and their replace-
ment by straight rods, which are a more stable construct.
a b The result is the transformation of an angular correction
frame to an axial compression frame (Figs. 24.6b, 24.7, and
Fig. 24.6 Hinged correction of varus deformation at non-union. Note 24.8).
the necessity of a fibular bone fragment resection; (a) deformity correc- To avoid sliding of the wires within the bone it is essen-
tion using Ilizarov hinges; (b) removal of the hinges and their replace- tial to use four olive wires. Two of these are placed close to
ment by straight rods
a b c d
Fig. 24.7 (a, b) Hypertrophic non-union with deformity; (c, d) correction by hinges
e f g
Fig. 24.7 (continued) (e) frame construct; (f, g) consolidation with alignment
h i
j k
Fig. 24.7 (continued) (h–k) clinical result

a b c
Fig. 24.8 (a–d) Hypertrophic non-union with deformity

g h i
Fig. 24.8 (continued) (e, f) frame construct with hinges at the level of the deformity; (g, h) end of the correction; (i–l) consolidation with align-
ment and clinical result
j k l

the non-union site on the convex side of the deformity. The
distal and proximal olive wires are located in the metaphy-
seal area on the concave side of the deformity (Fig. 24.9). In
each segment there are two olive wires. Those close to the
non-union site represent the fulcrum, and those far from the
non-union site the power or force. The non-union itself rep-
resents the source of resistance. In the advanced configuration
it is possible to avoid the use of olive wires because half-pins
offer a more stable fixation (Chap. 16). Note: The pressure
of the olive on the bone can lead to bone destruction, while
penetration of the olive inside the bone carries a high risk of
inflammation, pain, and infection.
To enhance the possibility of consolidation and to shorten
the treatment time, following the Lecco experience, bony
decortications and the application of bone chips from the
iliac crest or marrow concentrate cells are an option. The use
of BMP together with low-intensity ultrasound has also been
proposed. This approach may also be suitable in hypertro-
phic non-union.
24.2.2 Non-union with Bone Loss
Fracture healing with a bone gap greater than 2–3 cm is

Fig. 24.9 The arrangement of stoppers in the correction of an angular defined as non-union with bone loss. All cases of bone loss
deformity are considered to be lax non-unions. The etiology of the bone
b c
Fig. 24.10 (a) Bone gap without limb shortening (type A); (b) segment shortening with bone contact (subtype B1); (c) segment shortening with
a bone gap and the absence of contact of the bone ends (subtype B2)
loss may be the original trauma, surgery-related, or due to Type A: Bone gap without limb shortening (Fig. 24.10a)
the natural history of the non-union. Every case of non-union Type B: Bone loss with limb shortening
with bone loss will require some variant of bifocal treatment. Type B can be subdivided into:
The principles of this type of reconstruction are to establish Subtype B1: Segment shortening with bone contact
bone continuity and restore bone length. (Fig. 24.10b)
Non-unions with bone loss can be divided into two main Subtype B2: Segment shortening with a bone gap and the
groups: absence of contact of the bone ends (Fig. 24.10c)
(Fig. 24.11), which is then transported internally while at the

level of the osteotomy site, new bone—the same length as
the initial osseous gap—will eventually form. When the ends
of the non-union come into contact, progressive compression
is initiated. Following the original Ilizarov method, compres-
sion is continued at this rate until callous formation is seen at
the non-union site. To enhance the consolidation of the non-
union, a revision of the non-union site is always performed,
removing the soft tissues between the fragment and applying
bone chips from the iliac crest. With this procedure, union is
achieved quickly and in 100% of cases (Figs. 24.12 and
24.13).
A variant of this technique is “trifocal treatment,” in which
there are two osteotomy sites and one compression site. In
this case, two intermediate rings are required for the internal
transport of the two bone segments (Fig. 24.14). The distrac-
tion rate at each osteotomy site should be 0.75 mm/day, with
an overall rate of bone regeneration of 1.5 mm/day.
Trifocal treatment decreases the bone transport time by
half and accelerates new bone consolidation, thus saving
Fig. 24.11 The general scheme of frame assembly in the treatment of time in both the consolidation and transport phases
group A non-unions (Fig. 24.15).
Another transport variant is the technique of oblique-wire
The difference between the main groups (A and B) is that bone transport (Fig. 24.16), which can be visualized as the
for the treatment of group A the bone loss must be recon- reins of a horse directing the bone. The construction of the
structed without any lengthening of the limb whereas in frame is similar to the previous frame but there is no need for
group B both reconstruction of bone continuity and restora- an intermediate block. Two crossed wires are inserted in the
tion of limb length are required. longer segment; an osteotomy is then performed and the seg-
At this point we must define two concepts concerning ment is transported by pulling threaded rods. The pulling
bone lengthening. Internal lengthening is the regeneration of construct is fixed to the shorter segment block. The interme-
bone to fill a gap without a change in the overall length of the diate bone segment is transported by the pulling threaded
limb. It is distinguished from external lengthening, which is rods at a rate of 0.75 mm/day, until contact is made at the
the process of regeneration to restore the length of the limb non-union site. At this point the olive wires are replaced with
and soft tissues. Group A requires transport of the bone to fill transverse wires (half-pins) attached to a full ring, followed
the gap, but not soft-tissue lengthening. Group B requires by the addition of bone graft. This allows for increased
both transport of the bone to restore the length of the limb stability and for compression at the non-union site. The
segment and lengthening of the surrounding soft tissues. advantage of the crossed olive technique (oblique-wire trac-
tion) is that it avoids transverse cutting of the soft tissues
24.2.2.1 Group A: Bone Gap Without Shortening (skin, muscle, and fascia) in the transport phase of non-union
The standard frame is similar to that used in lax non-union. healing (Fig. 24.17).
One module (two rings) is fixed on the shorter segment, with
one ring at the metaphyseal level and the other 2 cm from the 24.2.2.2 Group B1: Shortening with Bone Contact
site of non-union. Another module (two rings) is applied to The frame in this group is similar to simple that used in bifo-
the other segment at the epiphyseal region. The two modules cal treatment of lax non-union (resection of bone ends and
are connected with long threaded rods. In the longer seg- bone graft). The same blocks are applied to the long and
ment, a metaphyseal osteotomy is performed and another short segments. An osteotomy is performed in the standard
fixation level (wire, half-pins and ring) is added. The long manner and lengthening proceeds at the bony interruption
threaded rods should include this intermediate block site at a rate of 0.75 mm/day until the length of the limb has
Fig. 24.12 (a, b) Tibial bone loss; (c) clinical appearance; (d, e) bifocal transport; (f, g) frame construct
a b c d
e f
h i j
Fig. 24.12 (continued) (h, i) end of transport, after docking revision; (j, k) treatment results

k l
a b c
d e
Fig. 24.13 (a–c) Infected non-union with bone loss; (d, e) resection of the infected bone and bifocal transport
f g h
i j
Fig. 24.13 (continued) (f) frame configuration; (g–j) treatment results

a b
Fig. 24.14 Trifocal treatment method of osteosynthesis in the treat-

ment of group A non-unions
c
Fig. 24.15 (a, b) Atrophic infected tibial non-union; (c) resection of

necrotic, infected bone
Fig. 24.15 (continued) (d) trifocal

d e f
converging transport; (e, f) consolidation
without infection; (g, h) clinical
appearance
g h
Fig. 24.16 (a–d) Oblique-wire bone transport

a b
c d
a b
Fig. 24.17 (a) Infected tibial non-union; (b) clinical aspect: bone and plate exposed to air despite coverage
been restored. The compression rate at the non-union site is ceed at a slow rate to avoid the introduction of complications
0.25 mm/day for 1–2 weeks followed by 0.25 mm two to (Figs. 24.18, 24.19, 24.20, and 24.21).
three times/week. For shortening with bone contact the trifo-
cal strategy can again be used to reduce the treatment period. 24.2.2.3 Group B2: Shortening with a Bone Gap
However, it is important to keep in mind that with external The bifocal technique of treatment can also be applied to this
lengthening involves stretching the soft tissues. These tissues group of cases. The first step is to eliminate the bone gap by
may have a large amount of scarring, contracture or fibrosis internal lengthening and compression at the non-union site
from the trauma of the non-union. The strategy of trifocal following the standard method. The second step is restoring
treatment may cause problems with the soft tissues due to the limb length by external lengthening. The primary goal is first
accelerated rate of external lengthening (1.5 mm/day). The to close the bone gap and then to achieve union. In this type
treatment may increase an existing contracture or cause the of non-union, the trifocal treatment variant can be applied.
development of contracture. When the trifocal strategy is The same precautions must be taken as described above
chosen, the surgeon must carefully select the patient and pro- (Fig. 24.22).

c d
(c) very extensive bone
resection and frame
application; (d) clinical
aspect
Fig. 24.17 (continued) (e) osteotomy of the posterolat-

e
eral fragment and wire transport; (f) during transport:
insertion of a second wire to centralize the fragment
f
Fig. 24.17 (continued) (g) consolidation;

g h
(h) clinical aspect: 2 cm LLD
Fig. 24.18 (a, b) Femoral atrophic non-union; (c) hardware removal, improves stability; (e–g) consolidation; (f) during transport: insertion
fixation, bone graft at the non-union site, and proximal lengthening of a second wire to centralize the fragment
(simple bifocal); (d) frame configuration; fixation at the tibial level
a b c
d e f
g h i
Fig. 24.18 (continued) (g) consolidation; (h, i) clinical appearance

a b
Fig. 24.19 (a, b) Femoral atrophic non-union; (c–g) hardware removal, fixation, bone graft at the non-union site, and proximal lengthening
(simple bifocal)
d e f
g h i j
Fig. 24.19 (continued) (h–j) consolidation

k l m
Fig. 24.19 (continued) (k, m) clinical appearance
a b
Fig. 24.20 (a) Atrophic non-union; (b) resection of necrotic bone and K-wire fixation;
Fig. 24.20 (continued) (c) bifocal treatment(d) frame configuration;

f h
Fig. 24.20 (continued) (e) at the end of lengthening; (f, g) consolidation: no LLD (h) clinical appearance
a b
c d
Fig. 24.21 (a) Atrophic non-union with shortening; (b) bone graft at the non-union site and trifocal converging transport; (c) consolidation with-
out LLD; (d) clinical result
a b c
Fig. 24.22 (a, b) Tibial bone loss; (c, d) clinical appearance

e f g h
Fig. 24.22 (continued) (e, f) revision and realignment with a guide wire; (g, h) trifocal tandem transport distally to proximally; (i) skin necrosis
with open wound
j k
m n
Fig. 24.22 (continued) (j, k) during transport; (l) skin closure without plastic surgery; (m, n) consolidation with alignment; (o) clinical result
24.3 Infected Non-union Another variant involves the use of longitudinal intramed-
ullary wires, as explained in Fig. 24.28, with a clinical exam-
As noted above, Ilizarov’s was convinced that “in the fire of ple in Fig. 24.29.
new bone formation burns infection.” This concept is impor- In open surgical treatment of infected non-unions, it is
tant in the treatment of infection. To eliminate an infection mandatory to leave the wound partially open. Wound care
focus it may be sufficient to add new vascularity to the area consists of irrigation with hydrogen peroxide and Betadine
as it will aid in the delivery of the body’s immunologic arma- solution and packing the wound with iodoform gauze. This
mentarium to eradicate the infection. method prevents the formation of localized pockets of infec-
At the Lecco Hospital, this principle of treatment was tion and allows the wound to granulate from deep to
exploited in the original method, based on the mobility of the superficial.
non-union site. In stiff non-unions, a compression construct was The skin defect may invaginate and become interposed
applied, and in lax non-unions bifocal treatment was the method like a pocket between the two non-union segments, obstruct-
of choice. For stiff non-unions, the treatment results were highly ing bony contact. Should this occur, the skin must be resected.
satisfactory, with a consolidation rate of 100% and a 95% rate Additional bone resection may be necessary to increase the
of infection healing. However, for lax non-unions the results surface area of bony apposition, via a bone graft or marrow
were not as good. While consolidation was obtained in all cases cells (Figs. 24.30 and 24.31). The other option in this situa-
by the end of treatment, refracture through the non-union tion was discussed in Chaps. 14 and 19.
occurred in 11% of the cases and the infection persisted in 35%. It is often the case that non-unions become infected in
Consequently, the treatment strategy has been changed. patients whose fractures have been treated by internal
For true stiff hypertrophic non-unions with localized fixation. In such cases, the internal hardware must be
infection at the bone ends, the method of continuous mono- removed immediately, the necrotic bone resected, and bifo-
focal compression is applied. This is similar to the approach cal treatment instituted (monofocal only for resections
used to treat non-infected stiff non-unions; of course if a <1–2 cm). A transport variant consists of two-level transport
deformity is present, it will need correction (Fig. 24.23). in a converging/tandem system. In converging transport,
The lax non-union with a generalized bone infection is two osteotomies are performed: one in the proximal and the
treated by open resection of the infected segment followed other in the distal segment. When one segment is longer
by bifocal treatment for internal transport (as in a non-union than the other, the two osteotomies can be performed in the
with bone loss) (Fig. 24.24). same segment, referred to as tandem transport. The rate of
In the open surgical treatment of infected non-unions, lengthening will be 0.25 mm three time a day at each level
several variants can be easily applied: the simplest involves and compression of 0.5 mm three time/day. Accordingly,
the insertion of an intramedullary guide wire (1.8 mm), the speed of transport will be double that of bifocal treat-
which helps to maintain the axis of the bone segment during ment. This system decreases the transport time and the time
transport (Fig. 24.25). This wire may pass through the osteot- needed for new bone consolidation: in fact, the latter will be
omy site without disturbing new bone formation. It is fixed inversely proportional to the length of the bone regenerate
during the transport phase and removed when the bone ends (Fig. 24.32).
are in contact, after the bone graft and the start of the consoli-
dation phase (Figs. 24.26 and 24.27).
a b
Fig. 24.23 (a, b) A deformity will require correction

a b
Fig. 24.24 (a–c) Open comminuted tibial fracture


(d–f) fixation with a Hoffman
fixator
d e
f
i j
Fig. 24.24 (continued) (g) skin necrosis and infection; (h) necrotic infected bone resection; (i, j) trifocal tandem transport; antibiotic beads in the
area of bone loss; (k) frame construct: the wound is still open
l m n o
Fig. 24.24 (continued) (l, m) end of transport, after docking revision; (n, o) consolidation with realignment
p q
Fig. 24.24 (continued) (p, q) clinical aspect: the wound closed spontaneously
Fig. 24.25 The insertion of an intramedullary guide wire

(1.8 mm) helps to maintain the axis of the bone segment
during transport
Fig. 24.26 (a) Lax infected non-union; (b, c) clinical appearance with mobility
Fig. 24.26 (continued) (d) resection and trifocal

converging transport; (e) at the end of transport, after the
docking procedure; (f, g) consolidation without LLD;
infection eradicated
d e
f g
Fig. 24.27 (a, b) Infected

non-union with intramedullary
nail; (c) necrotic bone exposed;
(d) resection of the necrotic,
infected bone (the bone is
burned by reaming); (e)
realignment with a guide wire
a b c
e
f g h
i j k
Fig. 24.27 (continued) (f, g) trifocal converging transport; (h) after the docking procedure; (i, j) consolidation; (k–n) clinical
result
l m n
a b c
Fig. 24.28 Longitudinal intramedullary wires are placed in the intermediate segment and are used as transport guides (a, b). When the fragments come
into contact, the intramedullary wires are removed and replaced with transverse wires on a ring, to increase stability and maintain compression (c)
a b
c d
Fig. 24.29 (a) Humeral bone loss; (b) clinical appearance; (c) stabilization and transport with a hook wire; (d) clinical frame construct
e f
Fig. 24.29 (continued) (e) end of transport; increasing the fixation; (f) bone graft at the docking site; (g, h) a more stable frame
Fig. 24.29 (continued) (i) consolidation

j k
Fig. 24.29 (continued) (j, k) clinical result

a b
a b
Fig. 24.30 (a, b) Elimination of a soft-tissue invagination

a b c
Fig. 24.31 (a) Infected tibia, with bone loss; (b) treatment with static external fixation; (c) after frame removal; (d) resection of the necrotic
bone
e f
Fig. 24.31 (continued) (e, f) double lengthening and double transport (tetrafocal transport); (g, h) the open wound at the beginning of treatment
h i
Fig. 24.31 (continued) (i) skin invagination; (j, k) plastic surgery: removal of the extra skin

(l) end of transport after bone l n o
grafting; (m) skin closed;
(n, o) new bone consolidation
m
Fig. 24.31 (continued) (p, q) after

frame removal: complete consolida-
p q r
tion, no infection or LLD;
(r–t) clinical result
s t
a b
Fig. 24.32 Converging (a) and tandem (b) methods of bone transport
24.4 Skin Problems in Infected Non-unions is usually closed and the infection has disappeared. Of
course, it is mandatory to refresh the site of contact through
In a patient presenting with bone and skin loss, resection and the application of bone chips if there is not any drainage and
transport can be used to fill the bony gap and, simultane- as long as there is good skin coverage. If the wound has not
ously, the skin loss. The method is basically the standard completely closed but is sterile, another resection is recom-
one, leaving the wound open and changing the dressing every mended, delaying the docking procedure to another surgery
second day, with antiseptic and iodoform gauze. procedure (Figs. 24.33, 24.34, 24.35, 24.36, 24.37, and
The wound, after necrotic bone resection, granulates 24.38).
quickly from the bottom. By the time of docking, the wound
a b
Fig. 24.33 (a, b) Atrophic non-union with bone loss; (c) clinical appearance: skin loss
d f
Fig. 24.33 (continued) (d) resection of the infected bone; (e, f) wound open during trifocal transport
g h i
j k l
Fig. 24.33 (continued) (g, h) by the end of transport, the wound has closed; (i, j) consolidation: infection eradicated, no LLD; (k, l) final
clinical result
Fig. 24.34 (a, b) Infected non-union with skin loss

d e
Fig. 24.34 (continued) (c) resection of the infected bone; (d, e) trifocal transport
f g h
i j
Fig. 24.34 (continued) (f) wound open; (g, h) consolidation; infection eradicated, no LLD; (i, j) clinical appearance; skin closed
b c
Fig. 24.35 (a–c) Infected non-union

Fig. 24.35 (continued) (d) resection of the necrotic bone; (e) insertion of a guide wire; (f) bifocal transport; (g) wound open
Fig. 24.35 (continued) (h, i)

skin closed but non-union
remains; (j) second bone
resection
h i
j

(k) trifocal transport; (l) after
docking revision; (m, n)
-consolidation, infection
eradicated, no LLD; (o, p)
clinical result
k l m
n o p
Fig. 24.36 (a–c) Infected non-union;

(d, e) bone necrosis and skin loss
b c
e
Fig. 24.36 (continued) (f) resection of the infected necrotic bone; (g, h) fixation with wound open; (i, j) tandem trifocal transport
Fig. 24.36 (continued) (k) frame construct:

simultaneous foot deformity correction; (l) wound
progressively closing; (m) bone grafting at the
docking site
m
o p q
Fig. 24.36 (continued) (n) skin closed without a plastic procedure; (o, p, q) consolidation: infection eradicated, no LLD
r s t
Fig. 24.36 (continued) (r–t) clinical appearance

a b c
d e f
Fig. 24.37 (a ,b) Infected atrophic non-union; (c) skin loss; (d) bone resection; (e) wound open; (f, g) bifocal transport

(h) wound progressively
closing; (i, j) end of
transport and after
docking revision
g h
i j
k l m
n o
Fig. 24.37 (continued) (k) wound closed; (l, m) consolidation, infection eradicated, no LLD; (n, o) clinical appearance
Fig. 24.38 (a) Infected non-union treated with a plate and circular frame in a monofocal procedure; (b) necrotic bone and skin loss
c d
e f g
Fig. 24.38 (continued) (c, d) bone resection and trifocal transport without plastic surgery; (e) consolidation with alignment, infection eradicated,
and skin closed; (f, g) clinical appearance
24.5 Massive Segmental Tibial Bone Loss the Ilizarov principles. The pre-assembled Ilizarov frame for
ipsilateral fibular transport consists of one or two distal and
Massive segmental tibial bone loss of any cause (trauma, one or two proximal rings. Proximal and distal fibular osteot-
tumor, or infection) is limb-threatening for patients and a omies are performed to allow medial translation of the cen-
challenge to surgeons, especially if it associated with exten- tral portion of the fibula. The osteotomy site are chosen
sive skin and soft-tissue damage. The decision whether to depending upon the length of the segment required. Olive
amputate or reconstruct a severely injured leg is controver- wires, with the olives placed on the lateral aspect of the ipsi-
sial. Amputation is often considered the simplest surgical lateral fibula, are then applied.
solution, but it is not always acceptable to the patients and According to the severity and extent of the tibial bone
relatives. While several studies concluded that the initial loss, two different techniques of medial fibular transport can
hospitalization costs are considerably less for amputation be applied.
than for limb salvage, Williams reported that the long-term 1. Transport of almost all of the fibula to replace the entire
cost of amputation, with a need for repeated prostheses, is tibial defect. This is the method of choice in cases of mas-
considerably higher than for a successful Ilizarov reconstruc- sive bone loss involving almost the entire tibia. Olive
tion. Since severe disability accompanies above-the-ankle wires with the olives placed on the lateral aspect of the
lower-extremity amputation after trauma, then regardless of ipsilateral fibula are used to achieve complete replace-
the level of amputation it seems reasonable to explore alter- ment of the tibial defect by the fibula (Figs. 24.39 and
native limb-salvage operations. We propose new indications 24.40).
for use of the Ilizarov frame in fibular transport and therefore 2. Transport of a fibular segment to augment the remaining
that limb salvage in cases of massive tibial bone loss is pref- tibia. This is preferred in cases of bone loss of the lateral
erable to amputation. tibial cortex, partial tibial bone loss, or scarce tibial bone
Following the Lecco experience, we perform fibular trans- regenerate obtained during tibial lengthening. Olive wires
port when the extent of the bony loss and/or the poor condi- with the olives placed on the lateral aspect of the middle
tion of the residual bone make it unlikely that sufficient segment of the ipsilateral fibula are used to transport the
regenerate bone could be obtained with the Ilizarov tech- fibula to fill a partial-thickness defect of the tibia or to
nique for bone lengthening so as to replace the loss of almost support the mechanical strength of the lengthened tibia
the entire tibia. Another indication is to support the mechani- (Fig. 24.41). This method is used in conjunction with
cal strength of the lengthened tibia. Medial fibular transport bone transport if any tibial bone is deemed suitable to
is preferred over tibial transport with the Ilizarov method decrease treatment duration and increase overall bone
when there is considerable loss of the tibial segment and the strength (Fig. 24.42).
time required for transport would be excessive, increasing Gradual ipsilateral fibular transfer using the Ilizarov appa-
the risks of failure and complications. Medial fibular trans- ratus avoids donor site morbidity distant from the injured
port is also chosen when the residual tibia is not suitable for limb and, most importantly, it avoids any threat to the unaf-
lengthening because of poor local tissue conditions, or due to fected contralateral limb. As opposed to an allograft, gradual
infection, or when tibial lengthening alone, because of the ipsilateral fibular transfer using the Ilizarov apparatus has
scarcity of the bone regenerate, is not enough to replace the neither the problems of immunogenicity nor the risks of
bone loss. At our institution, medial fibular transport is also infections. Furthermore, it avoids the technical difficulties of
performed in patients with infected pseudarthrosis or microvascular transfer and the dependence on a sometimes
osteomyelitis. tenuous vascular pedicle. At the end of transport, the bone
The concept underlying gradual, medial ipsilateral fibular graft and compression are performed as in any transport, to
transport is to first construct a stable external fixator based on reduce the time of treatment.
a b c
Fig. 24.39 (a–c) Transport of almost all of the fibula to replace the entire tibial defect
a b
Fig. 24.40 (a) Open comminuted fracture; (b) fixation with circular frame; (c) massive skin and bone necrosis
d e f
g h
Fig. 24.40 (continued) (d, e) massive bone resection; (f) fibular transport; (g) tibial fragment transport; (h) consolidation

i
(i, j) -clinical appearance; (k) at
10 years follow-up
j k
a b c
Fig. 24.41 (a–c) Transport of a fibular segment to augment the remaining tibia (reconstructive tibialization of the fibula)
Fig. 24.42 (a) Comminuted tibial fracture; (b) immediate bone transport; (c) end of transport: cyst of the new bone formation
a b
c
e f g
Fig. 24.42 (continued) (d) re-application of the frame after cyst evacuation; (e) stable fixation, bone graft at the cyst site and partial fibular trans-
port; (f) frame configuration; (g) bone consolidation
Fig. 24.42 (continued) (h) clinical appearance
24.6 Frame Removal Post-fixation casting may be indicated in certain cases. If

the fixation must be removed prematurely due to intolerance
The decision when to remove the device is dependent upon or wire problems, or if plastic deformation occurs, a cast is
both clinical and radiographic findings. Clinical testing of the indicated. The casts may be worn for 1–2 months.
regenerate bone can be performed when radiographs reveal Alternatively, partial weight-bearing may be initiated and
complete bony bridging and remodeling of the defect over progressed based upon radiographic and clinical findings.
the entire cross-section. The cortex should be present Physical therapy to regain motion and muscle strength is a
over the entire circumference and be of normal thickness. necessity.
If weight-bearing is tolerated even after removal of the pro-
tective effect of the fixator against distractional and compres- Note After the title of this chapter, all Authors, who have contributed
sive forces, either by loosening the connecting rods or wire to the chapter, are listed. The specific authorship of the individual
paragraphs is given after each section title.
fixation bolts, then the fixation bolts may be removed. Clinical
evaluation of the non-union site itself can be difficult.
Features of External Fixation in Children,
the Elderly, and the Senile 25
Jury Evgen’evich Garkavenko, Elena Andreevna Shchepkina,
25.1 Indications and Features of External operative period. It is necessary to consider that children, after
Fixation in Children adaptation to the external fixation device and in the absence of
pain, move actively. This is of particular concern in patients of
There is a broad range of applications for transosseous osteo- school age. During active walking and during play, there is a
synthesis in pediatric orthopedic surgery, specifically, in con- high risk of traumatizing the soft tissues at the sites of the tran-
genital and acquired pathological conditions that are sosseous elements. Children at play are also vulnerable to falls,
accompanied by limb shortenings and deformities. which can lead to breakage of the transosseous elements or
While following the main principles of external fixation, bone fracture at the level of wire or half-pin insertion [479]. It
these procedures also require the consideration of two impor- is therefore necessary that parents carefully control their chil-
tant age-related features: the presence of growth zones and so- dren’s behavior during the external fixation period.
called periods of accelerated growth. During wire and half-pin In a child undergoing an external fixation procedure, use
insertion, extreme care must be taken to avoid the growth zones of a frame with a multi-colored external support can have a
because their damage can lead to the development of secondary positive psychotherapeutic effect. The younger the child, the
deformities. Accordingly, frame construction (Chap. 7) in the more desirable is “minimization” of the device. For this pur-
treatment of pediatric patients differs from that used in adult pose, external supports that are thinner (3 mm) and made of
patients. In children who must undergo surgery during periods lighter materials (alloys of aluminum, titanium; special grades
of accelerated growth, parents should be informed that limb of plastic) are used. Instead of half-pins, console wire are
length discrepancy (LLD) can remain and even increase, despite inserted and the frame is assembled with the minimum num-
limb lengthening according to the initially planned due value. ber of supports. To reduce the size (dimension) and weight of
Use of external fixation is possible in children as young as the device, it could be assemblied using basic supports only
12–18 months, but it demands especially meticulous pin-site (Fig. 25.1). These kind of frame configurations are mainly
care. Children have a lower threshold of pain sensitivity and used at small lengths of segment in younger children or at
must be carefully monitored for possible pin-induced joint severe segment shortening. Reductionally fixing transosseous
stiffness, which can be largely avoided by inserting the tran- elements are fixed, as well as basic wires and pins, to basic
sosseous elements in “reference positions” (Chap. 5) but also supports [9]. At the same time, it is necessary to consider that
later resolved by functional treatment of the patient in the post- fewer external supports and transosseous elements decrease
the device’s reduction and fixation possibilities.
External fixation is applied when it has evident advan-
J.E. Garkavenko, M.D., Ph.D. (*)
tages over conservative treatment. In the treatment of frac-
Department of Orthopedics, Turner Research Children’s Orthopedic
Institute, Parkovaja Str., 64-68, St. Petersburg, Pushkin 196603, Russia tures and congenital disorders, transosseous elements are
e-mail: yurijgarkavenko@mail.ru indicated if there is upper limb shortening of at least 6 cm
E.A. Shchepkina, M.D., Ph.D. (Fig. 25.1), shortening of the lower limb by at least 4 cm
Department of Orthopedics, R.R. Vreden Russian Research (Fig. 25.2), and in the presence of non-unions (Fig. 25.3),
Institute of Traumatology and Orthopedics, 8 Baykova Str., defects of the long bones (Fig. 25.4) and deformities
accompanied by shortening of more than 3 cm (Fig. 25.5).
e-mail: repozition@yandex.ru
It should be noted that these are general indications which
are therefore subject to correction depending on the patient and
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia the pathology (Sect. 1.3). Thus, in both congenital varus defor-
e-mail: solomin.leonid@gmail.com mations of the femoral neck accompanied by evident congenital
DOI 10.1007/978-88-470-2619-3_25, Springer-Verlag Italia 2008, 2012
1250 J.E. Garkavenko et al.
Fig. 25.1 Pediatric case;

13-year-old boy. Transosseous
osteosynthesis for shortening of
the right upper arm by 9 cm as
result of hematogenic
osteomyelitis of the proximal
meta-epiphysis of the right
humerus. (a, b) Before operation;
(c–e) during treatment
b c
25 Features of External Fixation in Children, the Elderly, and the Senile 1251
e
Fig. 25.1 (continued) (f, g) result

3 months after segment length
restoration
g

15-year-old boy. Lengthening of
the femur and lower leg
following hematogenic
osteomyelitis of the proximal
meta-epiphysis of the right
femur. (a, b) Before deformity
correction; (c, d) during the
correction
c d
Fig. 25.2 (continued) (e, f) result at 2 years

shortening and as a consequence of hematogenic osteomyeli- Preoperative preparation should include not only plan-
tis, the restoration of lower limb length is indicated only after ning of external fixation procedure, but also an all-round
stabilization of the hip joint and elimination of hip- and knee- examination of the patient including finding and treatment
joint contractures (Fig. 25.6). In these prolonged cases, the of the centers of a “dozing” infection. Psychological prepa-
child will need to use special orthopedic products to correct the ration should be carried out in the hospital ward, where the
LLD. same kind of patients have successful treatment. In addi-
The use of external fixation is inexpedient in mentally tion, exercise therapy is recommended to improve the func-
unstable children, or in those with a serious somatic pathol- tional condition of the child’s muscles and to eliminate or
ogy or trophic and neurologic changes in the extremities and reduce joint contractures. Measures should also be taken to
inflammatory processes involving the soft tissues. positively stabilize the emotional condition of the child.
a c
d e f
Fig. 25.3 Pediatric case; 14-year-old boy. External fixation of a non-union of the left radius and radial club hand. (a–c) Before treatment; (d–f)
during treatment
g h
Fig. 25.3 (continued) (g–i) result at 1 year

a b
c d e
Fig. 25.4 Pediatric case; 14-year-old boy. External fixation in the replacement of a humeral bone defect with a vascularized bone graft from the
external edge of the scapula. (a, b) Before surgery; (c–e) during formation of the diastasis

f
(f–h) treatment result after
1.5 years
g h
Parents should actively participate in physiotherapy exer- correction and lengthening assumes the need for physiother-
cises and the child’s gait-correction training. After the child apeutic procedures and medication aimed at improving blood
is discharged from the hospital, parents must be able to circulation and the regeneration of bone tissue.
carry out and supervise the orthopedist’s recommenda-
tions. Clarification of the immune status and the prescrip-
tion of preoperative immunomodulating therapy are 25.1.1 External Fixation in Children
necessary for children being treated for consequences of with Acquired Limb Deformities
hematogenous osteomyelitis.
Children undergoing this type of surgery should receive The consequences of hematogenous osteomyelitis and post-
general anesthesia. The postoperative period does not, as a traumatic deformities of the long bones comprise the main
whole, differ from that in adults and during deformity group of pediatric patients with acquired deformities.
a b
c d e
Fig. 25.5 Pediatric case; 3.5-year-old boy. External fixation neces- Note the need for fixation of the knee joint because of the threat of
sitated by hematogenous osteomyelitis of the distal meta-epiphysis subluxation of the lower leg
of the right femur. (a, b) Before treatment; (c, d) during treatment.
for lengthening in the middle third of the humerus

(Fig. 25.7).
Distraction epiphysiolysis to achieve bone lengthening is
not widely used because of its negative influence on further
function of the growth zones [484, 485].
Defects at any level of the humerus are, as a rule, accom-
panied by degenerate changes in the humeral head. Therefore,
to improve the bone’s blood supply it is first necessary to
restore its integrity, even at shortening. One of the possible
treatment variants is vascularized autografts, for example,
from the lateral edge of the scapula. Thus, installation of a
two-support distraction device (Fig. 25.4) is followed by
replacement of the defect by an autograft. After union of the
graft with the bone fragments, graft structural change, and
improvement of the structure of the humeral head, the sec-
ond stage (if necessary), i.e., lengthening of the humerus, is
carried out (Fig. 25.8).
The consequences of hematogenous osteomyelitis of the
forearm more often include non-unions or defects of the
radius and/or ulna, with the development of club hand
(Fig. 25.9).
If there is instability of the hip joint, operations aimed at
deformity correction, replacement of the defect, removal of
f LLD, etc. should be carried out in the second stage.
Procedures during the first stage are directed at stabilization
Fig. 25.5 (continued) (e, f) result at 1 year of the hip joint (open reduction, arthroplasty, various kinds
of femoral and pelvic-bone osteotomy).
In deformities of the proximal meta-epiphysis of the
Acute hematogenous osteomyelitis accounts for 6–12.2% femur accompanied by segment shortening, the LLD should
of purulent diseases occurring in children. Orthopedic conse- be eliminated mostly by upper leg lengthening [486]. If the
quences are seen in 22–71.2% and lead to early physical shortening is >5 cm, the knee joint should be fixed using an
inability in 16.2–53.7% of children [480–483]. additional transosseous module throughout the distraction
The most evident orthopedic changes are observed in period. The same method should be used in smaller shorten-
children who had acute hematogenic osteomyelitis soon after ings and in case of an initial instability of the knee joint and
birth. These changes include infringements on the anatomic the tendency to dislocation. In teenagers with a deformity of
condition of the joints (subluxations, dislocations) as well as the lower limb bones characterized by a torsion component,
disturbed function of growth zones, ranging from hypofunc- an additional osteotomy of the tibia and fibula is carried out
tion to destruction and from partial to full growth arrest with (Fig. 25.2d).
deformity development and shortening of the long bones. In Restoration of the length of the lower limb and knee joint
very young children and those in early adolescence, hematog- deformity correction are accomplished using bilocal distrac-
enous osteomyelitis leads to pathological fractures, non- tion or compression-distraction osteosynthesis (Fig. 25.6). It
unions, and bone defects while in teenagers ankylosis is is necessary to consider that in children with consequences
often in the wrong position. of hematogenous osteomyelitis, valgus deformation of the
Minimized frame configurations are preferable in the distal femur may be combined with a severe cicatrix on the
external fixation of the upper limbs. Restoration of a length external surface of the thigh, due to the inflammatory process
discrepancy in the upper arm of up to 6 cm is more expedient and to previous operative interventions. Therefore, simulta-
if monolocal distraction osteosynthesis is carried out using a neously with the correcting osteotomy, transection of the
monolateral, sectorial, or semicircular device (Fig. 25.1). cicatricial tissues, iliotibial tract, and external intermuscular
At varus deformity of the proximal humerus, upper arm septum are recommended. The femoral deformity correction
lengthening should be done with the help of bilocal osteo- should consist of shortening (in an acute correction) or the
synthesis using a pin-based or hybrid frame. “Abduction” formation of a wedge-shaped (trapezoidal) regenerate with
osteotomy is carried out directly under the head of the obligatory hypercorrection by 10–15°. Multi-level and multi-
humerus, without damaging the growth zone, and osteotomy planar deformity correction, including LLD elimination, is

10-year-old boy. External
fixation of the left femur
following hematogenous
osteomyelitis of the proximal and
distal meta-epiphyses and after
stabilization of the left hip joint.
(a–d) Prior to the elimination of
a length discrepancy in the lower
limbs
b


(e, f) during deformity correction,
including lengthening
f

(g, h) result at 2.5 years
h
a b
Fig. 25.7 (a, b) Pediatric case; 14-year-old girl. External fixation of humerus. (a) Frame assembly; (b) during lengthening. The red arrow
the right upper arm necessitated by hematogenous osteomyelitis, which specifies the level of the proximal “abduction” osteotomy
resulted in segment shortening and varus deformation of the proximal
preferably done in one stage, through the use of polylocal disturbance. In addition at consequence of hematogenic
polysegmentary distraction osteosynthesis. Limited exten- osteomyelitis there are bone rarification and depression of
sion of the confines of the external fixation device does not osteogenesis. To restore the integrity of the bone tissue and
cause significant inconvenience but will shorten the rehabili- decrease the rehabilitation period, vascularized bone
tation period. autografts should be primarily used. During the first stage of
Attention should be paid to important zones, such as the treatment, the goal of distraction osteosynthesis is to achieve
greater trochanter of the femur and the tibial tuberosity. a diastasis of the necessary extent (Fig. 25.10). In the second
Wires and half-pins should not be inserted through either of stage, external fixation is used for the stable fixation of the
these as this is likely to damage the growth zones, leading to vascularized fibular autograft (Fig. 25.11).
secondary deformities of the upper and lower legs. External fixation with the use of non-free bone-muscular
Certain difficulties could arise in the treatment of children autografts is the method of choice in the treatment of chil-
with non-unions and bone defects subsequent to hematoge- dren with stiff non-unions with a metadiaphyseal localiza-
nous osteomyelitis. It should be noted that post-traumatic tion. Open compression osteosynthesis with the use of
non-unions and deformities of the long bones, except con- cortical allografts is appropriate in the treatment of chil-
sequence of severe injury, are not, as a rule, accompanied dren with lax non-unions (Fig. 25.12). In addition, LLD
by significant disorders of the blood circulation. But non- removal and the elimination of secondary accompanying
unions and defects of femoral and lower leg bones, as result deformities allow simultaneous organotypic restructuring
of hematogenic osteomyelitis, have severe blood supply of the autograft.

10-year-old girl. External fixation
of the right upper arm as a
consequence of hematogenous
osteomyelitis, which resulted in a
defect-pseudoarthrosis with
segment shortening. (a–c) Before
treatment
b
Fig. 25.8 (continued) (d) plasties of the defect using a vascularized autograft from the lateral edge of the scapula; (e–g) 4 years after grafting
h j
i k
Fig. 25.8 (continued) (h, i) during lengthening of the upper arm; osteotomy was executed through the structurally changed autograft; (j, k)
1 year after lengthening by 14 cm
b c
Fig. 25.9 Pediatric case; 12-year-old boy. External fixation of the left forearm as a consequence of hematogenous osteomyelitis involving the
radial distal meta-epiphysis and resulting in radial clubhand. (a, b) Before treatment; (c, d) during treatment
Fig. 25.9 (continued) (e, f) result at 16 years

b c
Fig. 25.10 Pediatric case; 11-year-old girl. Replacement of a subtotal defect of the diaphyseal part of the left femur using a vascularized fibular
autograft. (a, b) Before treatment; (c, d) during diastasis formation
e f
Fig. 25.10 (continued) (e, f) result 6 years after replacement of the defect
a b
Fig. 25.11 Pediatric case; 14-year-old boy. Transosseous osteosynthesis for the fixation of a vascularized fibular autograft. (a–c) Before
treatment

(d–f) during treatment
c d
e
Fig. 25.11 (continued) (g–i) result after 1.5 years

i
a b
Fig. 25.12 Pediatric case; 9-year-old girl. External fixation of a non-union of the tibia and fibula using open side-to-side compression osteosyn-
thesis. (a, b) Before treatment
c d e
Fig. 25.12 (continued) (c, d) during treatment; note the additional wire stopper made from cortical allogenic bone; (e) consolidation of the
fragments
25.2 Features of External Fixation 1. Pairs of olive wires should be inserted in opposite direc-
in the Elderly and the Senile tions (Fig. 25.19a), for example: I,8-2; I,4-10. In case of
severe osteoporosis, standard olive stoppers (to avoid cut
Elena Andreevna Shchepkina in the stopper into the bone) are supplemented by linings
and Leonid Nikolaevich Solomin washer wider diameter, for example made from the of
allobone [479, 487].
There are no limitations regarding the use of external fixation 2. Insertion of additional transosseous elements off the plane
devices in the elderly or the senile. In such patients, external of supports and their fixation with the help of posts can be
fixation is preferable if they have accompanying disorders used, for example: I,8-2; I,4-10; II,3-9 (Fig. 25.19b); or
that prevent treatment using plunge osteosynthesis, for I,11-5; I,1-7; II,9,70 [9, 161].
instance in open injuries, as these operations are overly trau- 3. Wires are inserted at an angle to the bone axis from one
matic (Fig. 25.13). In case of improper bone restoration level to another. The support should be oriented perpen-
(Fig. 25.14), non-unions (Figs. 25.15, 25.16, and 25.17), or dicular to the longitudinal axis of the bone. The ends of
the necessity of reconstructive operations (Fig. 25.18), the the wires are fixed by posts (Fig. 25.19c), for example:
indications for external fixation are the same as those pre- V,8-VI,2; V,3-VI,9.
sented in Sect. 1.3. 4. Smaller-diameter drills can be used to form a channel for
In the planning of reconstructive-regenerative operations a half-pin. In osteoporosis, half-pins are inserted in the
it must be kept in mind that among the contraindications to diaphyseal part of the bone at a sharp angle to the longitu-
external fixation are conditions in which the patient is unable dinal axis. Radial fixation increases if wires with a special
to adequately perceive and carry out the treating physician’s thread are used [488].
instructions. In determining medical and rehabilitation 5. Tension is applied to each module fixing bone fragments
actions, it is necessary to consider the sex, age, and wishes of by applying moderate strength between the two relevant
the patient and/or his or her relatives. In addition, both the supports (Fig. 25.19d).
tactics and the expected outcome should be made clear to the 6. The ends of the wires in the plane of support are separated
patient and/or the family, including the features of the device [324] (Fig. 25.19e).
and device maintenance (Chap. 34). It is essential to exclude 7. Principle of a wheel spoke is used [489, 490] (Fig. 25.19f).
non-authorized intervention by the patient in the configuration To minimize the configuration of the external fixation
of the device. The postoperative period must be discussed as device, external supports made of lighter materials, the
well, especially the need to prevent infectious complications. fixation of reductionally fixing transosseous elements to the
Relatives of elderly and senile patients must be informed basic supports by means of posts, and a reduction in the
about the recommended range-of-movement training meth- number of supports should be considered.
ods and walking rehabilitation. At the same time, it is necessary to take into account that
During transosseous element insertion, the reference posi- reduction of the number of external supports and transosseous
tions (Chap. 5), where soft-tissue displacement is minimal, elements decreases the reductional and fixing characteristics
must be used and the tension of the wires carefully moni- of the device. “Minimization” of the device should not lessen
tored. Moving elderly and/or senile patients may incur dam- the quality of the external fixation! Mastery of external fixation
age to the soft tissues near the wires because of a decrease in methods includes knowledge of those applied in situations in
the elasticity of these tissues. This fact also demands the which the device is used only for fixing bone fragments, in the
regular control of the insertion sites. insignificant correction of the spatial orientation of the frag-
A number of methods to increase and maintain the ments, and in cases in which the size of a segment or bone
required level of stiffness of the fixation can be employed in fragment prevents the use of the full configuration. If, due a
case of osteoporosis (Fig. 25.19a–f). For example, external short segment, the distance between the base and reductionally
fixation elements cannot be inserted through the epimeta- fixing rings is slightly more than the length of a 4-hole post,
physeal parts of bone. Also, the use of half-pins in patients posts should be used instead. If simplifying the configuration
with evident osteoporosis is not allowed. During fixation, of the device leads to a significant decrease in the rigidity of
proper axial weight-bearing on the operated leg will result in the osteosynthesis and does not correspond to the set surgical
positive changes in the density of the bone tissue in the dam- tasks, full configurations of the device should be used. In gen-
aged segment. However, in the case of injury restricting eral, the full configuration increases the likelihood that the
weight-bearing osteoporosis will be more evident than in goals of treatment will be met. Moreover, when the necessary
other parts of skeleton [486]. spatial orientation of the bone fragments has been reached and
External fixation procedures in the elderly and/or senile the conditions for reparative osteogenesis are favorable, it is
include the following methods, used alone or combined, to possible to minimize the configuration at that stage, with par-
increase the rigidity of the osteosynthesis (Fig. 25.19): tial reassembly of the device (Figs. 25.13 and 25.15).
a
b
c d
Fig. 25.13 Combined external fixation in a 78-year-old patient with vessels, atherosclerotic cardiosclerosis, cerebrovascular deficiency
an open fracture of the lower leg. Accompanying diseases: stage II stage II. (a, b) View of the lower leg and the admission roentgenogram;
hypertension; extensive atherosclerosis of the brain and coronary (c, d) after osteosynthesis
Fig. 25.13 (continued) (e, f) module

transformation at 3 months
f
Fig. 25.13 (continued) (g, h) treatment result after 6 months

Fig. 25.14 Combined external fixation in a

73-year-old patient with malunion of the forearm
a
bones. Accompanying diseases: stage II
hypertension; extensive arteriosclerosis of the
brain and coronary vessels, arteriosclerotic
cardiosclerosis, stage II cerebrovascular
deficiency. (a, b) View of the forearm and the
admission roentgenogram
b
Fig. 25.14 (continued) (c, d) after osteosynthesis; (e, f) module transformation after 1 month
Fig. 25.14 (continued) (g, h) treatment result after 3 months


fixation in a 75-year-old patient with
an infected non-union of the right
femur, in the superior third of the
diaphysis. Accompanying diseases:
stage III hypertension,
arteriosclerotic cardiosclerosis. (a)
Prior to the operation; (b–d) 1 month
after the operation
a b
c d

e f
g
Fig. 25.15 (continued) (e–g) module transformation at 3 months

h i
g
Fig. 25.15 (continued) (h–j) treatment result after 8 months

a b
Fig. 25.16 Combined external fixation of the humerus after removal roentgenogram; (b, c) transosseous osteosynthesis after the removal of
of a broken plate and resection of an infected non-union joint in a the broken plate, with humeral shortening by 4 cm; (d) limb function
65-year-old woman. Accompanying diseases: stage III hypertension, 2 months after the operation
ischemic heart disease, atherosclerotic cardiosclerosis. (a) Preoperative
Device instability is one of the main reasons for compli- complicating walking, even by means of crutches with lim-
cations. In patients with adiposity, larger external supports ited weight-bearing on the operated limb, “minimization” is
must be used, although these negatively affect the rigidity of not advised; instead, the full configuration of the external
the external fixation. Therefore in the treatment of these fixation device should be installed and full weight-bearing
patients “minimized” configurations with a reduced number targeted in the early outpatient period.
of external supports are not recommended (Fig. 25.20). In The minimized configuration is appropriate in patients in
addition, in obese patients additional transosseous elements whom, due to an accompanying pathology, forceful activity
should be inserted, hybrid and rod configurations are pre- is reduced or walking is impossible in general. It is also per-
ferred, and the external supports should be connected by missible in patients with good control over a weight-bearing
means of 4–5 rods. In elderly and senile patients with limitation at walking and in the treatment of hypertrophic
restricted coordination owing to an accompanying pathology non-unions in the elderly and/or the senile (Fig. 25.17). Rod
a b
c d
Fig. 25.17 Combined external fixation of the right and left femur in cardiosclerosis after heart attack. (a, b) Preoperative roentgenograms of
a 63-year-old woman with a stiff non-union of the upper third of the right and left femurs; (c–g)-roentgenograms and function 1 month
the right tibia and atrophic non-union of the upper third of the left after the operation
tibia. Accompanying diseases: stage III hypertension, arteriosclerotic
1292 e f J.E. Garkavenko et al.

i j
Fig. 25.17 (continued) (h–j) result after 3 years

Fig. 25.18 Combined external fixation in a 66-year-old woman who posity, ischemic heart disease, arteriosclerotic cardiosclerosis. (a, b)
underwent correction of a post-traumatic deformity of the proximal Before the operation
meta-epiphysis of the right tibia. Accompanying diseases: grade III adi-
Fig. 25.18 (continued) (c, d) 1 month after the operation; completion of the deformity correction

e
(e, f) module transformation
3 months after the operation
f

g
(g, h) – result of treatment after
6 months
h
a b
c d
Fig. 25.19 (a–f) Methods to increase osteosynthesis rigidity. (a) olive bone fragments by applying moderate strength between the two rele-
wires should be inserted in opposite directions; (b) Insertion of addi- vant Supports. Compression (approaching supports) and distraction
tional transosseous elements off the plane of supports and their fixation (distancing of support from each other) (red arrows)
with the help of posts; (c) Wires are inserted at an angle to the bone axis
from one level to another; (d) Tension is applied to each module fixing
Fig. 25.19 (continued) e f

(e) The ends of the
wires in the plane of
support are separatelly
moved apart; (f)
principle of a wheel
spoke is used
I,8-2; I,4-10; II,3-9 ↔ III,12,120; IV,3-9 →← V,8-2; VI,4-10

↔ VIII,2-VII,8; VIII,10-VII,4 (d)
and hybrid devices provide a more stable fixation of the bone in a vertical position by flexing the knee joint. If necessary,
fragments than achieved with wire-based devices. This is skin and fascia are cut, a transosseous element is moved in
especially important in elderly, weakened patients, when the formed soft-tissue channel, and the skin is sutured. For
using crutches is difficult and gradual weight bearing cannot example, to avoid pressure of a wire on the soft tissues it may
be guaranteed. Designs of these types are easier because they be necessary to make an incision over 30 mm long and, if
allow patients to comfortably sit down after external fixation possible, reinsert the transosseous element instead of dissect-
of the hip and do not require a special bed with a niche for ing the soft tissues. This situation most frequently arises
the device. when wires are inserted at the first three levels of the upper
Diabetes is not a contraindication to the use of external arm or in the hip. Note that precise estimation of transosseous
fixation, except in severe decompensated forms, in which element pressure on soft tissues is possible only after the
case preliminary treatment of the disease is necessary [491, operation, i.e., when the patient starts “using” the limb.
492]. Therefore “freeing” soft tissues is typically carried out later,
Special attention should be paid to measures aimed at pre- 2–3 days after surgery.
venting transfixion contractures, including the use of the The patient’s age should be taken into account in those
“recommended positions” described in Chap. 5. Both a requiring an exact reduction of the fragments in case of frac-
decrease in the elasticity of the soft tissues and adiposity ture. The reduced regenerative abilities of the elderly require
warrant the insertion in the elderly of transosseous elements the maintenance of all conditions for successful healing of a
in positions with minimal displacement of the soft tissues bone wound, among which exact reduction is primary. In
and at sites where their thickness is less. This is especially children, the fusion of fragments in the wrong position can
important in external fixation of the humerus (Fig. 25.21) later lead to gross disorders of limb function. However in the
and femur. If the skin and muscles are flabby, then, whenever elderly and/or senile age there are comparatively few indica-
possible, the insertion of wires and half-pins in the projection tions for full restoration of the segment length, as shortening
of positions 5, 6, 7 at all levels should be avoided. Prior to of an upper arm (Fig. 25.16) or gradual shortening of the
element insertion, sagging of the soft tissues should be forearm up to 50 mm minimally influences limb function and
addressed. still allows the patient to be self-sufficient.
At the end of the operation, it is important to be convinced At the end of the operation the free ends of wires should
of the absence of pressure exerted by wires and half-pins on be carefully bent, embedded in the support of the device,
skin owing to their displacement when the limb position is and/or covered with caps or two or three wrappings of a
changed. Therefore. before the patient with external fixation sticky plaster.
of the upper arm leaves the operating room, it is important Finally, elderly and/or senile patients will require the con-
that he or she, even briefly, sits at the operating table, allow- secutive transition from external to internal fixation
ing examination of the arm during movement. In an osteo- (Fig. 25.22). The positive and negative features of this tech-
synthesis of the lower leg, the operated limb should be placed nique are discussed in Chap. 26.

fixation of a closed fragmental
fracture of the inferior third of
the right femoral diaphysis in a
69-year-old patient.
Accompanying diseases: stage II
hypertension, atherosclerotic
cardiosclerosis, severe reduction
in brain blood circulation, stage
III adiposity. (a) Preoperative
roentgenograms; (b–d)
roentgenograms and function
2 months after the operation
b
c d
e f
Fig. 25.20 (continued) (e, f) treatment results after 6 months

Fig. 25.21 Combined external fixation of a closed fracture of the sur- Limb function with a full wire-half-pin device configuration and
gical neck of the left humerus in a 63-year-old patient. Accompanying postoperative roentgenogram
diseases: atherosclerotic cardiosclerosis, ischemic heart disease. (a–c)

(d–f) limb function and
roentgenogram after module
transformation 1 month after the
operation
d

(g–i) treatment after 2.5 months
g
i
Fig. 25.22 Combined external fixation of the right femur in an (a) Preoperative roentgenograms; (b, c) external fixation after removal
85-year-old patient with an infected non-union of the femur. of a broken plate
Accompanying diseases: stage III hypertension, ischemic heart disease,
atherosclerotic cardiosclerosis, sclerosis after a heart attack.
Fig. 25.22 (continued) (d) at 3 months: transition

to internal fixation by nail with proximal and distal
locking according to the dynamic scheme
Combined and Consecutive
Use of External and Internal Fixation 26
Mehmet Kocaoğlu, Leonid Nikolaevich Solomin,
Erkal F. Bilen, Alexandr Nikolaevich Chelnokov,
John E. Herzenberg, and Florian Maria Kovar
This chapter presents the techniques of lengthening of a long 26.1 Lengthening Over a Nail (LON)
bone over a nail (Sect. 26.1), bone transport over a nail
(Sect. 26.2), and consecutive external fixation and blocked Mehmet Kocaoğlu, Leonid Nikolaevich Solomin,
nailing at lengthening and long-bone deformity correction and Erkal F. Bilen
(Sect. 26.3). Section 26.4 is devoted to the technique used in
the one-stage correction of deformities and the fixation of 26.1.1 Introduction
fragments by means of external fixation with immediate
transition to internal fixation, i.e., external-fixator-assisted Lengthening over an intramedullary nail is a superior to
nailing and plating. lengthening by conventional external fixator techniques. Bost
Information concerning training courses in the combined and Larsen [493] reported a technique for LON in which they
and consecutive use of external and internal fixation can used Rush pins for nailing. The current LON technique was
be obtained here: http://rniito.org/solomin, http://www. first described by Raschke [494] and optimized further by
rniito.org/download/exfix-nail-course-9-engl.pdf, http://www. Paley et al. [177]. The external fixation time is decreased
rniito.org/download/exfix-nail-course-4-engl.pdf, http://ortho- significantly, which subsequently increases patient comfort,
suv.org. compliance, and function while reducing risks related to the
prolonged use of external fixators, such as pin-tract infection
and reduced range-of-motion at the adjacent joints. In addi-
tion, the periosteal blood supply is significantly increased
with the LON technique [178, 495, 496].
M. Kocaoğlu, M.D. (*)
Department of Orthopedics and Traumatology, Istanbul Medical Another technique for lengthening, internal lengthening,
Faculty, Istanbul University, 34690 Capa, Istanbul, Turkey is even better since it does not require external fixation [149,
e-mail: drmehmetkocaoglu@gmail.com, kocaoglum@superonline.com 173, 312, 313], but it also has several drawbacks: it enables
L.N. Solomin, M.D., Ph.D. limited lengthening (only up to 6 cm via Fitbone, 8 cm via
R.R. Vreden Russian Research Institute ISKD, and 10 cm via Albizzia nails), the cost is three times
of Traumatology and Orthopedics,
higher than that of the LON procedure, and there is no chance
8 Baykova Str., St. Petersburg 195427, Russia
e-mail: solomin.leonid@gmail.com for re-shortening in case the bone is overlengthened. Thus,
LON is still a favorable technique for lengthening.
E.F. Bilen, M.D., FEBOT
Department of Orthopedics, Other, alternative techniques have also been described:
Istanbul Memorial Hospital, Lengthening and then nailing (LATN) [497] and plating after
Piyalepasa Bulvari, Okmeydani, 34385 Istanbul, Turkey lengthening (PAL) [498]. Detailed information concerning
A.N. Chelnokov, M.D., Ph.D. the sequential use of external and internal fixation is pre-
Department of Orthopedics Traumatology, sented in Sects. 26.3 and 26.4.
Ural Scientific Research Institute of Traumatology and Orthopedics,
The advantages of LON are related to the fact that the
7 Bankovsky Str., Ekaterinburg 620014, Russia
external fixation device fixes a limb segment during the dis-
J.E. Herzenberg, M.D., FRCSC
traction period only. Earlier removal of the apparatus than is
Department of Orthopedics, Sinai Hospital of Baltimore,
2401 West Belvedere Avenue, Baltimore, MD, USA possible with the Ilizarov method provides for: (a) increased
treatment comfort for the patient; (b) simplification of medi-
F.M. Kovar, M.D.
Department of Traumatology, AKH-Vienna, Medical University Vienna, cal monitoring; and (c) a lower risk of pin-tract infections
Währinger Gürtel 18-20, A-1180 Vienna, Austria and transfixation pin-induced joint stiffness.
1310 M. Kocaoğlu et al.
There are, however, also several disadvantages of LON. a

First, as the femur can be lengthened only along its ana-
tomic axis, the procedure can lead to lateral deviation of the
mechanical axis (Figs. 16.34 and 16.35). Second, there is
an increase in the amount of damage incurred by the opera-
tive intervention that becomes clinically significant in the
simultaneous lengthening of two segments. Third, the risk
of a deep pin-tract infection is higher and an expanded b
medullary infection may occur. Finally, there is the neces-
sity of an additional operation: distal blocking of the nail
and removal of the nail after reorganization of the distrac-
tion regenerate. The latter is optional while the former is
carried out simultaneously with frame removal.
26.1.2 Indications and Contraindications
Indications:
• Limb length discrepancy in adults
• Constitutional short stature
• Dwarfism
c
• Post-traumatic epiphyseal injury sequelae
• Concomitant lengthening and deformity correction
Contraindications:
• Active infection
• Immune-compromised patients [499, 500]
• Open physeal plate
• Intramedullary canal diameter <8 mm
• At femoral lengthening: initial lateral deviation of the
mechanical axis of the lower limb, if it is impossible to
obtain an adequate correction at LON
Fig. 26.1 Positions of the patient on the operating table. (a) Scissors posi-
tion, (b) using pelvic and lower leg supports, (c) at use of retrograde nail
26.1.3 Special Features of the Equipment
In patients weighing >80 kg and requiring increased postop- C-arm image intensifier, from the hip to the knee, preferable
erative mobility, and when two segments are lengthened by the attending surgeon prior to surgery. Sterile preparation
simultaneously, non-cannulated titanium nails and locking should include the hip up to the iliac crest. A K-wire is
screws of 5–6 mm diameter should be used. inserted through the piriformis fossa percutaneously while
Guide wires that allow not only the formation of the the surgical assistant places the extremity across the unin-
blocking nails but also the correct insertion of half-pins for volved limb (scissors position) (Fig. 26.1a).
the distraction frame should be used. A lateral shift of the entry point on the frontal plane will
For distraction, monolateral (Figs. 26.6 and 26.9d), circu- produce varization of the proximal fragment, whereas a
lar (Figs. 26.13 and 26.14) or hybrid (Figs. 26.8, 26.9a, b, medial shift will produce its valgization. Thus, the position
and 26.11) devices are options. Circular and hybrid devices of the K-wire must be checked with the C-arm on both
may be needed for lower leg LON and cross-lengthening planes, AP and lateral. A 5-mm cannulated drill is used over
procedures. this K-wire to open the entry point. Multiple drill holes are
created at the previously planned osteotomy level through a
0.5–1 cm incision by slow turns, in order to prevent heat
26.1.4 Femoral LON: Surgical Technique necrosis of the bone. This also produces venting of the canal
as well as internal grafting (Fig. 26.2). The medullary canal
The patient is placed supine on the radiolucent table. A radi- is reamed by 0.5-mm increments to 1.5–2 mm more than the
olucent support underneath the buttock is used to elevate the diameter of the planned intramedullary (IM) nail. At this
ipsilateral hip. The femur is checked for visualization with a point the osteotomy is completed by an osteotome, while the
26 Combined and Consecutive Use of External and Internal Fixation 1311
Fig. 26.2 (a, b) Multiple drill-hole a b

technique for osteotomy
guide wire remains in the medullary canal. The completeness

of the osteotomy is checked with the C-arm by translation of
the fragments (Fig. 26.3). The IM nail (for example, Ortopro
4 G IM, Istanbul, Turkey) is inserted over the guide wire,
which is then removed. Proximal locking of the nail may be
done either in the cephalomedullary (recon) or the intertro-
chanteric (standard) direction, with no advantages of one
over the other.
26.1.4.1 Half-Pin Insertion

Paley et al. [177] described three alternative configurations for
half-pin placement (Fig. 26.4). In the first, the half-pins are
inserted posterior to the nail both proximally and distally; in
the second, they are inserted anterior to the nail both proxi-
mally and distally; and in the third they are inserted anterior to
the nail proximally, and posterior to the nail distally. We prefer
the posterior insertion of the half-pins proximally and distally
as this configuration places the external fixator parallel to the
nail on the sagittal plane, which subsequently makes sliding
over the nail smoother and decreases sticking of the nail.
The proximal half-pins are inserted at the level of the
minor trochanter and posterior to the IM nail, without touch-
ing the latter (Fig. 26.5). This is achieved by initially insert-
ing a guide wire with the aid of an image intensifier: there
must be enough space between the wire and the IM nail on
the sagittal plane, and the wire must be perpendicular to the
IM nail on the frontal plane. Upon establishment of the
desired position of the guide wire, both cortices are drilled
Fig. 26.3 Translation of the fragments, evidencing the completeness via a 3.5-mm canulated drill bit, and a tapered 6-mm hydroxy-
of the osteotomy
apatite coated half-pin is inserted. At this point, the half-pin
is checked with the image intensifier to ensure that it is per-

pendicular to the IM nail on the frontal plane (Fig. 26.6) and
not in contact with the IM nail on the sagittal plane
(Fig. 26.7).
The clamp of the external fixator (Orthofix LRS or EBI
Monorail) is used as a guide for insertion of the second half-
pin. The distal half-pins are inserted at the supracondylar
level. The femoral condyles are imaged such that they are
superimposed on the sagittal view with the C-arm to obtain
a true lateral view. Two half-pins are inserted distally in the
same manner as explained above; perpendicular to the IM
nail on the frontal plane, without contact with the IM nail
on the sagittal plane. Holding the proximal and distal screws
as joysticks, the attending surgeon checks the distal frag-
ment manually for free rotation as a predictor of sliding
over the nail.
26.1.4.2 Application of the External Fixator

The claws and the rail of the external fixator are connected to
the half-pins. To ensure smooth sliding, the rail is checked
with the C-arm to confirm that it is parallel to the IM nail in
the frontal and sagittal planes. The claw at one side of the
osteotomy is fixed, while the other side is left loose for slid-
Fig. 26.4 Three different configurations for half-pin insertion ing. Before the session is concluded, the acute distraction
test by 0.5 cm must be performed as this will establish
whether or not the mechanism is working. If the distraction
test is positive, then the wound dressing is applied, and the
session may be concluded.
Note: If there is concern regarding the stability of the
half-pins, especially in osteoporotic bones, extra half-pins
and wires are inserted on different planes and connected to
the external fixator with use of a large Ilizarov arch
(Fig. 26.8a). Figure 26.8b–l shows the stages of LON with
the use of a combined (hybrid) frame.
When antegrade insertion of the nail is impossible (due
to a deformity in the proximal femur or the presence of a
foreign body), a nail is inserted using the retrograde method.
In this case, upon completion of lengthening, the nail is
locked proximally (Fig. 26.9).
26.1.5 Tibial LON: Surgical Technique
The patient is placed supine on the radiolucent table. Prior to

surgery, the tibia is checked with the image intensifier on AP
and lateral views, preferably by the attending surgeon. The
lower limb is prepared in sterile fashion to the level of the
iliac crest. A 2-cm transverse incision is made at the lower
pole of the patella (Fig. 26.10). A conventional longitudinal
Fig. 26.5 Placement of the proximal half-pins posterior to the IM nail section also can be used.
without contact Following the subcutaneous dissection, the paratenon and
patellar ligament are split longitudinally. The entry point is
prepared using a 5-mm cannulated drill, as in the standard
tibial nailing technique. The guide wire is inserted. Multiple
Fig. 26.6 (a–c) In the frontal

plane, half-pins must be
perpendicular to the IM nail:
I,10,90; II,10,90 ←→
←→ VI,9,90; VII,10,90
a b c
drill holes are created at the previously planned osteotomy

level through a 1-cm incision by slow turns, in order to pre-
vent heat necrosis of the bone. This also will produce venting
of the canal as well as internal grafting. The medullary canal
is reamed by 0.5-mm increments 1.5 mm wider than the
diameter of the planned IM nail. At this point, the osteotomy
is completed by an osteotome, while the guide wire remains
in the medullary canal. A 1-cm incision is made at the mid-
diaphyseal level of the fibula and the fibula is osteotomized
via the multiple drill-hole technique. The alternative proce-
dure of fibular osteotomy can be used (Fig. 15.1). The com-
pleteness of both osteotomies is checked with the C-arm by
translation of the fragments. The tibial IM nail (for example,
Orthopro 4 G IM) is inserted over the guide wire, which is
then removed. Proximal locking of the IM nail is done in the
usual manner.
26.1.5.1 Application of the External Fixator

We prefer circular type external fixators for tibial LON due
to the otherwise high risk of valgization of the fragments
during distraction, caused by the stiffness of the interosseous
Fig. 26.7 Placement of the distal half-pins posterior to the IM nail
without contact membrane. Herzenberg et al. [501] reported similar results
a b
c d
Fig. 26.8 Lengthening with use of the combined (hybrid) frame. (a) (b) Mounting the distal support: VII,8,90; VIII,3-9; VIII,8,90. (c)
For additional stabilization of the proximal fragment in the Orthofix Opening the medullary canal and guide insertion. (d) Multiple drill hole
device, an arch support should be used. (b–l) Stages of LON. at the osteotomy level
Fig. 26.8 (continued) (e) Drilling-out the medullary canal and osteotomy. (f) Nail insertion and proximal interlocking. (g) Mounting the proxi-
mal support: I,8,90; I,11,90; II,8,90
i j
Fig. 26.8 (continued) (h) Connection of the distal and intermediate VII,8,90; VIII,3-9; VIII,8,90. (j) Frame assembly using extracortical
supports: ____ ― VII,8,90; VIII,3-9; VIII,8,90. (i) Connection of prox- clamp devices (ECD) (Chap. 12.5)
imal and distal modules: I,8,90; I,11,90; II,8,90 ― _______ ←→
k l
Fig. 26.8 (continued) (k) Distal interlocking (using the standard assembly and the assembly based on ECD). (l) Frame removal
a b
c d e
Fig. 26.9 Lengthening over a retrograde nail. (a–l) Stages of the pro- (c) Opening the medullary canal and guide insertion. (d) Drilling-out of
cedure; (k–o) clinical examples. (a) Assembling the proximal support: the medullary canal. (e) Osteotomy
I,9,90; I,11,90; II,9,90. (b) Multiple drill holes at the osteotomy level.
f g
Fig. 26.9 (continued) (f) Nail insertion and distal interlocking. (g) Mounting of the distal and intermediate supports: _____ ― VII,8,90; VIII,3-9;
VIII,8,90. (h) Connection of the proximal and distal modules: I,9,90; I,11,90; II,9,90 ― ______ ←→ VII,8,90; VIII,3-9; VIII,8,90
Fig. 26.9 (continued) (i) Proximal interlocking.

i
(j) Frame assembly with ECD (Chap. 12.5)
j
k l
m n
Fig. 26.9 (continued) (k) Proximal interlocking (similar to (i)). (l) Frame removal. (m–q) Clinical examples

o
p q
when they used unilateral external fixators for tibial LON. When frame assembly can be based on the wires only, to pre-
A frame is prepared consisting of three rings: one for the vent a valgus position of the fragments during distraction, basic
proximal fragment, one for the distal fragment, and one wires should be inserted in “hypercorrection” (Fig. 26.12).
“dummy” ring in between, which is not used for fixation but Figure 26.13 shows an example of bilateral tibial LON of the
for frame stability (Fig. 26.11). anticnemion, and Fig. 26.14 LON of the upper arm and forearm.
A wire parallel to the proximal tibial joint surface is
inserted posteriorly and fixed to the proximal ring of the
frame. At the supramalleolar level, another K-wire, parallel 26.1.6 Distraction Period
to the distal tibial joint line on the frontal plane, is inserted
posteriorly without touching the IM nail and fixed to the Distraction starts on day 7 at a rate 0.25 mm four times day.
distal ring of the frame. Two half-pins (preferably hydroxy- On day 5, control roentgenogram should be done to specify
apatite coated) are inserted proximally without touching the conformity of the distraction size and regenerate lengths.
the IM nail, one of which will also fix the fibular head in Usually, both should be 1–2 mm less due to a deflection of
order to prevent distal migration during lengthening. This the transosseous elements.
half-pin is placed in the anteromedial tibia by the cannu-
lated drill bit technique. Both half-pins are fixed to the
proximal ring (Fig. 16.11). 26.1.7 Removal of the External Fixator
Distally, an olive wire is inserted at the lateral malleolar
level parallel to the joint line to establish tibiofibular fixation: The external fixator should be removed immediately after the
VIII(8-2)8-2. At this point, the distraction test is performed desired amount of lengthening is achieved. The extremity is
and the procedure is concluded. sterilely prepared, including the frame, in the supine position.
a b
Fig. 26.11 (a, b) The middle “dummy” ring is not used for fixation but
b to increase the stability of the frame: I,9-3; I,1,90; II,3-9 ←→ _____
― VII,I,90; VIII(8–2)8-2; VIII,4-10
Fig. 26.10 Position of the patient on the operating table (a) and variant
of the incision over the ligamentum patella for nail insertion (b)
26.1.8 Complications
The whole frame is draped except for the area used for distal There are significant complications associated with LON:
interlocking. The distal locking holes are prepared using can- • Mechanical sticking of the distraction system (wrong
nulated drills over the K-wire via the free-hand technique, technical application).
and the interlocking screws are inserted. If the insertion is at • Pin-tract infection.
the metaphyseal level, interference screws may be used on • Delayed union/inadequate regenerate production or pre-
each side of the IM nail to increase stability [502]. mature consolidation; distraction rates should be individ-
After the frame has been removed the patient is mobilized ually regulated on the basis of patient monitoring.
with two crutches and is allowed to bear 10% of his or her • Development of stiffness of adjacent joints. Therapeutic
body weight (depending on the nail type). The patient returns exercises should be instituted during distraction and fixation
for follow-up every month until the regenerate consolidates. periods. The threat of development of a severe contracture
During this period, stretching and range-of-motion exercises is an indication to stop the lengthening (Chap. 23).
are encouraged. To decrease the risk of nail breakage, full • Breakage of a half-pin or interlocking screw usually arises
weight-bearing is allowed only when three of four cortices from inadequate loading on the leg.
are consolidated, as seen on AP and lateral views during Detailed information on the complications arising from
follow-up. external fixation are presented in Chap. 33.
For locking screws with a diameter >5 mm and nails with A total lengthening of 6 cm, a lengthening rate of 21.5%,
a diameter of ³12 mm, the fatigue resistance of the locking and a Paley difficulty score of 8.5 are the critical cut-off
nail is usually sufficient not to limit weight-bearing begin- points above which complications are more likely to occur
ning at the first days after nailing [502]. [176, 177].
a b
c
Fig. 26.12 (a–n) Stages of lower leg LON. (a) Determination of the prevent a valgus deformity during distraction. (c) Multiple drill-holes at
level of distal assembly. (b) Mounting the distal support VIII(8-2)8-2; the osteotomy level. (d) Opening the medullary canal and guide insertion.
VIII,4-10. The support should be located with slight “hypercorrection” to (e) Drilling-out the medullary canal
f g h
Fig. 26.12 (continued) (f) Fibular osteotomy. (g) Tibial osteotomy. (h) Nail insertion and proximal interlocking. (i) Mounting the proximal support
I,9-3; II,3-9. The support should be located with slight “hypercorrection” to prevent valgus deformation during distraction. (j) Frame mounting
k l
n
m
Fig. 26.12 (continued) (k) Insertion of stabilizing half-pins II,1,80 and VII,1,90. (l) Final frame assembly: I,9-3; II,1,80; II,3-9 ←→ _____ ― VII,1,90;
VIII(8-2)8-2; VIII,4-10. (m) Distal interlocking. (n) Frame removal
a b c d
Fig. 26.13 (a–f) Clinical view of a patient with bilateral tibial LON
Fig. 26.14 (a, b) Upper arm and forearm LON
a b
26.2 Bone Transport Over Nail (BTON) and shortening through the distracted callus [153]. Older frames
often required repeated adjustment to prevent misalignment of
26.2.1 Introduction the docking site. The use of an IM nail together with an external
fixator avoids misalignment of the docking site, leading to
Mehmet Kocaoğlu, Erkal F. Bilen, significant decreases in the EFT, and better maintenance of the
and Leonid Nikolaevich Solomin anatomic length and the alignment [494].
The BTON technique prevents the common complica-
Numerous procedures for the treatment of bone defects have tions of bone transport, such as delayed consolidation, axial
been devised (Chap. 19), including acute shortening and then deviation, translation, and deformity recurrence or occur-
lengthening (most suitable for segmental defects up to 5 cm rence. This is attributed to the improved construct stability
long), bone transport (the best option for defects 5–12 cm in provided by the IM nail.
length), and vascularized free fibular grafting in combination Alternatively, minimally invasive plate osteosynthesis
with transport and lengthening or ipsilateral fibular transport (MIPO) may be used to obtain similar advantages [506, 507].
(for segmental bone defects >12 cm). Titanium mesh cages Bone transport may also be accomplished through the use of
filled with autograft, demineralized bone matrix, and fully implantable IM lengthening devices, such as an internal
allografts have also been used to reconstruct large segmental lengthening nail (ISKD). Cole [508] reported a technique
bone defects [503, 504]. through which healing of the non-union was targeted first,
In patients with limited life expectancy, the use of a seg- followed by lengthening with an ISKD to resolve a limb
mental prosthesis may be indicated, without having to wait length discrepancy.
for healing [505]. Oedekoven et al. [710] reported on the results obtained
Bone transport with the use of an external fixator is known to with the monorail system for bone transport over unreamed
be a reliable solution that leads to successful outcomes. The interlocking nails, used in 20 patients. Defect distances var-
time spent in an external fixator (the external fixation time, EFT) ied between 5 and 18.5 cm, and average transport time was
depends on the length of the required distraction, with longer 19.42 days/cm for the tibia, and 15.93 days/cm for the femur.
EFTs carrying a higher a risk of complications. The distraction Kocaoglu et al. [509] reported a mean external fixation index
phase is followed by the consolidation phase (which often lasts (EFI) of 13.5 days per cm in 13 patients (7 tibiae, 6 femurs)
more than twice as long), which is difficult for the patient to by means of the BTON technique.
tolerate. Removal of the external fixator before satisfactory con- By contrast, bone transport achieved with the Ilizarov
solidation has occurred is associated with fracture, deformity, device alone was associated with an extended EFT (average
16.7 months) and high EFI (average 2 months/cm) compared Relative contraindications:
to the BTON technique. There was also a significant differ- • Bone defect >12 cm
ence in the EFI between smokers and non-smokers (on aver- • Tobacco abuse
age, 2.60 vs. 1.45 months/cm, respectively) [510].
Although most surgeons are cautious about using IM nails
in open fractures, the BTON technique was shown to be suc- 26.2.3 Special Features of the Equipment
cessful in the treatment of Gustilo 3b open tibial fractures
[511, 512]. The transport process not only treats the bony Preoperative planning is of paramount importance for bone
defect, it also helps with soft-tissue coverage. transport procedures. AP standing orthoroentgenograms and
Management of the docking site requires specific proce- lateral plain X-rays are obtained and studied together with
dures. Acute shortening of the defect can reduce the trans- IM nail templates to determine the placement of additional
port time to achieve docking. The tibia and the humerus can holes to achieve locking of the transport segment.
be safely shortened by up to 3–4 cm, and the femur by up to For femoral defect reconstructions, unilateral external
5–7 cm. Once docking is established, straightforward length- fixators are used (Orthofix LRS, Italy; EBI Monorail, Biomet,
ening may be performed. USA), and for tibial defect reconstructions circular external
To further reduce the EFT, bifocal or trifocal strategies fixators (Ilizarov and Ortho-SUV Frames, Vreden Russian
may be used. Each osteotomy helps to shorten the overall Research Institute; Taylor Spatial Frame, Smith and Nephew,
treatment time by 0.5–1 mm/day. USA).
Upon completion of bone transport and lengthening, the
IM nail is locked statically and the external fixator is then
removed prior to consolidation of the new bone. However, 26.2.4 General Principles of the BTON
the bone transport over a nail technique has a steep learning Surgical Technique
curve and requires meticulous preoperative planning in addi-
tion to perfect patient compliance. Surgery can be executed either “closed” or “open.” In the
The cost of treatment is another issue that surgeons must closed method, a nail is inserted without exposing the ends
take into account. BTON significantly reduces the rate of of the bone fragments. If the closed method is difficult or
complications, overall number of operative sessions and impossible (due to expressed sclerosis, deformities of the
duration, and total hospital inpatient length of stay, thus bone ends, or foreign bodies) the operation is performed
reducing the cost of treatment. Amputation, as it is followed using the open variant. This variant is indicated when the
by prosthetic care for the remainder of the patient’s life, bone ends are thin, incongruent, or have a reduced blood
incurs greater overall costs [513]. supply, as this may result in atrophic non-union of the dock-
We note that BTON undermines two of Ilizarov’s princi- ing site.
ples for optimizing osteogenesis: preservation of the blood The open method starts with processing of the bone ends,
supply and of the medullary osteogenic tissue. Histological in which the medullary canals of the fragments are re-cana-
analysis of the regenerated segment has revealed asymme- lized. It is important to ensure adequate blood supply to the
tries in terms of enchondral bone formation, trabecular struc- bone ends, confirmed with the “Paprika sign” recommended
ture, metabolic activation, and cell viability [514]. However, by Mader [499]. If needed, an additional resection should be
it has been shown that LON does not compromise the viabil- performed to ensure viable bone ends. At the end of the bone
ity of the regenerating segment [177, 515]. One should be transport process, the bone ends must be congruous
cautious about the endosteal circulation, which might be (Fig. 26.15).
negatively affected. The next stage requires reaming the bone fragments. The
medullary canal should be reamed 1.5–2 mm wider than the
diameter of the IM nail to allow sliding of the nail. As a rule,
26.2.2 Indications and Contraindications the longer bone fragment is used for lengthening, whether
proximal or distal.
Indications: The next stage involves inserting the nail up to the osteot-
• Bone defects of 5–12 cm omy level, followed by the osteotomy and further forward
Contraindications: insertion of the nail. The osteotomy is performed using
• Vascular disease the multiple drill-hole technique (Fig. 26.2). If the nail is
• Diabetes mellitus inserted into a bone fragment that will be elongated, a diasta-
• Active infection sis at the osteotomy level is possible. This can be prevented
• Open physeal plate by temporarily fixing the fragment using a surgical hook,
• Intramedullary canal diameter <8 mm wire, or extracortical clamp device as it is carried through
segmental defect is very large (>10 cm), trifocal transport

over the nail may be helpful to reduce the EFT and the related
problems [516, 517].
Once docking is accomplished, the patient returns to sur-
gery for debridement (to guarantee viable ends with maxi-
mum contact) and grafting (to reduce the risk of non-union
or refracture at the docking site and to shorten treatment
duration) [518]. An iliac crest bone graft along with demin-
eralized bone matrix (DBM) or bone morphogenetic protein
(BMP-2) may be used for grafting. The docking site may be
compressed acutely if the external fixator is to be removed in
the same session. Alternatively, compression may be contin-
ued at a rate of 0.25 mm every other day until consolidation
of the docking site, if lengthening will be continued. We pre-
fer autogenous posterior iliac crest bone grafting and addi-
tionally use DBM to improve the healing potential in all
cases.
For intermediate bone fragment fixation, an additional
locking screw is inserted. The other option is a conventional
plate or monocortical locking plate (Fig. 26.17).
26.2.5 Femoral BTON Surgical Technique

Fig. 26.15 Congruence of the ends of the bone fragments
Diagrams of BTON using orthograde and retrograde nails
are provided in Figs. 26.18, 26.19, and 26.20.
The patient is placed supine on a radiolucent table with
an intermediate bone fragment (Chap. 12.5). However the the limbs in a scissors position (Fig. 26.1), and with a cush-
presence of a diastasis is not a problem because once the IM ion placed below the pelvis on the ipsilateral side. A standard
nail is inserted and locked, the fragment to be transported approach (through the piriformis fossa for antegrade nailing
is fixed either by wires or half-pins; thus any distraction or and through a parapatellar 1-cm transverse incision for retro-
diastasis through the osteotomy level can be corrected via the grade nailing) is used for reaming the medullary canal. After
external fixation. the reconstruction, there should be sufficient nail length on
The nail should be locked statically (proximally and dis- both sides of the regenerated bone to guarantee adequate sta-
tally) if additional lengthening is not required following bone bility. Thus, if lengthening is planned in conjunction with
transport (Fig. 26.19). Then the external fixator is applied; bone transport, the IM nail must be longer than the length of
wires and half-pins should be inserted tangentially, with no the femur (Fig. 26.20).
nail contact. In such cases, retrograde nailing is preferred because it
Wires (Figs. 26.16a, 26.20 and 26.21), half-pins allows the excess nail length to protrude into the buttock until
(Figs. 26.18, 26.19 and 26.22), and cables (Fig. 26.16b) can distraction has been completed, by which time the nail will
be used for the transport of intermediate bone fragments. have glided gradually to its correct position. Since the proxi-
Brunner et al. [515] found that the overall transport forces mal part of the nail features a larger diameter, the proximal
for large defects were slightly greater than those for small femur should be over-reamed in antegrade, and the distal
defects. In the former, transport forces leveled off during femur over-reamed in retrograde applications. An appropri-
bone transport before rising again, ultimately reaching ately placed corticotomy is then performed percutaneously
350 N. using the multiple drill-hole technique (Fig. 26.2) before the
In patients with large defects, bifocal distraction is recom- IM nail is inserted. The osteotomy level is chosen at least
mended to shorten net treatment times. Vidyadhara et al. 5–6 cm away from the bone defect. Finally, an IM nail (e.g.,
[516] reported an interesting observation regarding bifocal Ortopro 4 G) of appropriate size is inserted and locked proxi-
distractions, namely, that despite the same rate of distraction, mally, distally, or on both sides, according to the planned
shorter fragments move faster than longer fragments. This distraction.
can be attributed to the attachment of the soft tissue to the Two to three half-pins are inserted both proximally and
longer fragment, thereby hindering distraction. If the distally to the osteotomy level, taking care that they do not
Fig. 26.16 (a, b) Different

methods of intermediate bone
fragment transport
come into contact with the IM nail. There should be at 26.2.6 Tibial BTON Surgical Technique
least 1 mm of free space between the half-pins and the IM
nail to prevent medullary infection triggered by a pin-site The standard ligament split approach is followed and the
infection [176]. To insert half-pins without nail contact, medullary canal is over-reamed 1.5 mm wider than the
the cannulated drill-bit technique described by Paley et al. planned diameter of the nail. The nail is then inserted and a
[177] is recommended. A wire is inserted on the lateral three-ring circular external fixator is used (Fig. 26.21). It is
femoral cortex, perpendicular to the IM nail, at the level of very important that the longitudinal axis of the external
the half-pin. The location of the wire is confirmed with the fixator is parallel to the IM nail. Proximal and distal rings
C-arm. A hole is reamed over the wire with the cannulated are fixed with one wire and a half-pin. The fibula should be
drill bit. The half-pin can then be inserted, and clearance fixed to the tibia on each end. None of the external fixation
between the pin and the nail confirmed with the C-arm. pins or wires should come into contact with the nail. Before
In Figs. 26.17d, 26.18l and 26.19j, an alternative femoral the IM nail is inserted, a corticotomy is performed at the
BTON technique is presented. In the case of rigid fixation of appropriate level using ei ther the multiple drill hole
a nail in a proximal bone fragment, additional fixation of the (Fig. 26.2) or the Gigli saw technique. If there is shortening
fragment by external fixation support is not required. Half- in conjunction with the segmental bone defect, then an IM
pins and wires can be used for bone transport (Fig. 26.16). nail of the eventual desired tibial length is inserted and left
Fig. 26.17 (a–d) Different types of

intermediate bone fragment fixation. (a, b)
Using a locking screw; (c, d) using a plate
a b c
d
Fig. 26.18 (a–m) Bone transport

a
using an orthograde nail. (a)
Opening the medullary canal and b
guide insertion. (b) Drilling-out the
medullary canal. (c) Osteotomy. (d)
Nail insertion, proximal and distal
interlocking c
d
Fig. 26.18 (continued) (e) Half-pin insertion in the proximal bone transosseous elements for bone transport: III,8,90 и IV,9,90. (h)
fragment. Mounting of proximal support I,8,90; I,11,90; II,8,90. (f) Mounting the intermediate support
Mounting the distal support VI,8,90; VII,3-9; VIII,4,90. (g) Insertion of
i j
Fig. 26.18 (continued) (i) Connection of the proximal and distal modules: I,8,90; I,11,90; II,8,90 →← III,8,90; IV,9,90 ←→ VI,8,90; VII,3-9;
VIII,4,90. (j) Bone transport. (k) Frame assembly using ECD
Fig. 26.18 (continued) (l) Option of frame assembly (when rigid fixation of the proximal fragment by nail is possible). (m) Docking site care,
floating bone fragment fixation, and frame removal
d e
f g
h i
Fig. 26.19 (continued) (f) Mounting distal support VII,8,90; VIII,3- VIII,3-9; VIII,8,90. (h) Frame assembly using ECD (Chap. 12.5). (i)
9; VIII,8,90. (g) Mounting the intermediate support and support con- Bilocal osteosynthesis
nection: I,8,90; I,11,90; II,9,90 ←→ V,9,90; VI,9,90 →← VII,8,90;
Fig. 26.19 (a–k) Bone transport using a retrograde nail. (a) Assembling proximal support I,8,90; I,11,90; II,9,90. (b) Opening the medullary
canal and guide insertion. (c) Drilling-out the medullary canal. (d) Osteotomy. (e) Nail insertion, distal and proximal interlocking
j k
Fig. 26.19 (continued) (j) Option of frame assembly (when rigid fixation of the proximal fragment by nail is possible). (k) Docking site care
and floating bone fragment fixation; frame removal
proximally proud so that it can slide distally during 26.2.8 Complications

distraction.
Figure 26.22 shows the use of the monolateral device in There are significant complications in BTON:
BTON. • Pin-tract infection (most common problem with all types
of external fixation). Vigilant preventive maintenance is
necessary to avoid the development of a deep infection
26.2.7 Postoperative Care with expansion of the IM canal.
• Non-union of the docking site (most common problem
Distraction is started on postoperative day 7 at a rate of 1 mm/ except frame-related complications). The reason is over-val-
day, divided into four equal increments. Range-of-motion uation of the blood supply of the ends of the bone fragments.
exercises for both hip and knee are initiated immediately, Treatment: bone autografting, compression osteosynthesis;
excluding those patients with a long tibial IM nail (in whom less often, a resection of the fragment ends.
knee exercises should be postponed until the proud part of the • Poor regenerate formation is related to an improper rate of
nail enters the tibia during lengthening). Full weight-bearing bone transport.
with two crutches is started as soon as possible. • Premature consolidation occurs when the latency period
Once distraction and lengthening are completed, the nail before lengthening is too long or the rate of lengthening is
is statically locked and the external fixator is removed. In too slow.
patients with proximal femoral osteotomy, a non-vascularized • Pin cut-out during transport. This complication is more
fibular graft can be inserted into the posteromedial distrac- likely to occur in osteoporotic patients with large bone
tion site to provide additional support and to decrease the defects [519].
force transmitted through the nail until total consolidation Detailed information about the complications caused by
occurs. external fixation can be found in Chap. 29.
a b
c d e
Fig. 26.20 (a–e) The femoral retrograde BTON technique with additional lengthening
a b c d
f g
Fig. 26.21 (a–j) The tibial BTON technique. (a) Determining the (f) Mounting the frame: I,9-3; II,1,80; II,3-9 ― _____ ― VII,1,90;
level of distal support assembly. (b) Opening the medullary canal and VIII(8-2)8-2; VIII,4-10. (g) Insertion of transosseous elements for bone
guide insertion. (c) Drilling-out the medullary canal. (d) Tibial osteot- transport: IV,2,90; V,3-9
omy. (e) Nail insertion, and proximal and distal interlocking.
h i j
Fig. 26.21 (continued) (h) Bone transport: I,9-3; II,1,80; II,3-9 →← possible). (j) Docking site care, floating bone fragment fixation, and
IV,2,90; V,3-9 ←→ VII,1,90; VIII(8-2)8-2; VIII,4-10. (i) Option of frame removing
frame assembly (when rigid fixation of the distal fragment by nail is
a b c d
Fig. 26.22 (a–d) Patient X-rays showing the tibial BTON technique and the results. Note the fixation of the distal tibiofibular syndesmosis by the
screw
26.3 Sequential External Fixation • Defect of the long bones

and Nailing (SEFaN) Contraindications:
• Acute infection
Alexandr Nikolaevich Chelnokov • Open physeal plate
and Leonid Nikolaevich Solomin Besides, it is not always technically possible to perform
nailing if there are residual deformities of the segment, non-
26.3.1 Introduction removed implants, or a short epimetaphyseal fragment that is
insufficient for the fixation of at least two locking screws.
Acute deformity correction techniques using external fixation
methods followed by immediate internal fixation are covered
in Sect. 26.4. However, these techniques are not always 26.3.3 Special Features of the Equipment
applicable due to the limited indications for acute deformity
correction (Chap. 16 and Sect. 26.3). Under these conditions, Formation of a nail canal requires special reamers and drills
we use a two-stage sequential external fixation and nailing especially in case of pathological alterations of the medul-
(SEFaN) procedure. SEFaN is the alternative to LON lary cavity, such as closing of the bone ends formed due to
(Sect. 26.1) and BTON (Sect. 26.2) methods. non-unions and eburnation of the bone ends in fibrous dys-
The advantages of SEFaN are that the extremity segment is plasia. Using stiff straight drills is fraught with the formation
fixed with an external fixator only for the period of the defor- of false canals, associated with bone plate perforation. With
mity correction. The technique provides several advantages. flexible guides and reamers, it is often impossible to perfo-
First, it minimizes both technical problems and traumatic injury rate the sclerosed bone in the needed direction. To solve this
related to nailing due to the prior alignment of the axis and the problem, we suggest special elastic reamers of increasing
length of the segment. Second, treatment is more comfortable diameter [520]. These reamers consist of titanium rectangu-
for the patient and facilitates medical monitoring. Third, there lar cross-section nails with fixed cutting elements in the form
is a lower risk of infectious complications and pin-induced of a two-facet trapezoidal, conical, or diamond-shaped cutter
joint stiffness. Fourth, plastic transformation is unnecessary having butt and side cutting edges. The reamer set also con-
and fracture of the regenerate after fixator removal does not tains a T-shaped handle (Fig. 26.23).
occur. Finally, it obviates decision-making as to whether the To decrease the risk of inflammatory complications, solid
regenerate is mature enough to allow fixator removal. titanium nails must be used [239]. In patients weighing
The disadvantages of the technique are the more exten- >80 kg who require increased postoperative mobility, non-
sive traumatic injury of the surgical procedure; the necessity cannulated titanium nails and locking screws >5 mm in
of additional surgical interventions, i.e., nailing followed by diameter should be used.
removal of the construction in some cases; and the risk of Indications to use nails coated with antibiotic-containing
infection spread in the medullary canal. cement are: in the treatment of severe open fracture conse-
quences; pyoinflammatory complications in the fixator cor-
rection period; and chronic osteomyelitis in remission or
26.3.2 Indications and Contraindications following surgical sanation of the focus.
To cover a nail with cement it must be placed in a form
Indications: filled with liquid bone cement and removed from the form
• Congenital or acquired deformities of the long bones after polymerization of the cement [501, 521–523]. The
• Non-unions, associated with persistent deformity of the antibacterial coating is prepared ex tempore using either a
segment reusable mold or a silicon tube, e.g., a chest tube [522] The
Fig. 26.23 Set of elastic

titanium reamers with a handle
for their insertion
a silicon tube is more practical since the nail obtained does not
require further treatment except reconstruction of the holes,
while with the reusable mold it is necessary to remove the
ridge formed along the form’s junction [522].
A nail 8–10 mm in diameter is placed in a silicone tube
12–14 mm in diameter. A syringe is then used to inject
cement containing an antibiotic into the nail. Vancomycin
is the most popular antibiotic for this purpose since it suc-
cessfully combines high antimicrobial properties, a wide
range of action, and thermal stability. To one portion of the
b
cement (20 g) 2 g of vancomycin are added. To prevent the
cement from being too dense, about 75% of the dose should
be used or an additional amount of liquid monomer should
be added.
If cement already containing another antibiotic is used, a
dose of vancomycin should be added. After the cement
becomes hard, the tube is cut off (Fig. 26.24). The cement
covering to some extent decreases the rigidity of the osteo-
synthesis since a tube of smaller diameter is used with lock-
ing screws of a smaller diameter, which is to be taken into
consideration during preoperative planning.
To perform SEFaN of the femur, extracortical fixators are
c
needed (Table 1.2, item 23, Chap. 12.5, and Fig. 26.26).
Moreover, an Ilizarov distraction external fixator module
may also be needed for surgery (Figs. 26.27 and 26.29).
26.3.4 General Principles of the SEFaN

Surgical Technique
In the first stage, using external fixation, all bone deformity

components are eliminated, such as angulation, peripheral
dislocation, and shortening (Chaps. 16 and 17). Angular dis-
d
location and shortening are preferably eliminated with slight
hypercorrection.
In the assembly of the external fixator, the forthcoming
second stage of the surgery should be taken into account.
The intraosseous elements must be inserted so that they will
not interfere with the following insertion of the IM nail.
Thus, in the metaphyseal part, from the side of a nail inser-
tion at least one transosseous element must be placed eccen-
trically, i.e., beyond the projection of the nail canal. For
example, in the proximal part of the tibia one wire or half-pin
can be inserted in the frontal plane in the posterior semicircle
of the bone. It enables the removal of only those intraosseous
elements that will interfere with nail insertion; while the rest
(at least one in the proximal and distal parts) will provide
Fig. 26.24 Making a nail with an antibacterial covering: (a) pumping

cement into a silicone tube; (b) inserting the nail into the tube with the
liquid cement; (c) removing the tube after the cement has hardened;
(d) removing the cement from the holes in the nail
a b
Fig. 26.25 (a, b) Formation of the nail canal using titanium reamers
fixation of the achieved position of the bone fragments before fixator, healing the wounds made by the intraosseous
the insertion and locking of the intraosseous nail. elements, and then nailing) increases the risk of infectious
If this requirement has not been followed for whatever complications development [239].
reason, the external fixator is appropriately reassembled The patient is supine on the operating table, as a rule. In
before the nailing. For example, prior to IM fixation of case of external fixation of the femur, lying on the healthy
the femur the wire in the proximal part should be inserted side can be more comfortable. Considering the presence
just before the rods are removed from the upper third of of the fixator maintaining the achieved length and axis for
the femur. the period of nail insertion and locking, the use of a traction
Intramedullary fixation is best performed immediately table is not recommended. A plain non-opaque table is pref-
after external fixator correction is completed. It is not neces- erable. The patient’s position must allow for the use of mobile
sary to wait for the regenerate to be seen on the X-rays. Keep fluoroscopy equipment to visualize the whole bone. The
in mind that as the duration of the external fixation increases, assembled external fixator is not removed; rather, only
so does the risk of infection of the transosseous element the intraosseous elements that will interfere with nail inser-
canals. Accordingly, delayed tactics (removal of the external tion are removed. In order not to lose the position of the bone
fragments at the level of the proximal and distal metaphyses, proximal fragment in the femur or upper arm bones in the
as achieved by the external fixator, 1–2 intraosseous elements antegrade direction, and in the distal fragment in the retro-
are left, i.e., those located in the bone beyond the trajectory grade direction) or, as a last resort, the fragments edges are
of the nail insertion. Next, the fixator is carefully treated with exposed, the reamer is introduced into the wound, and the
antiseptics. medullary cavity is opened under visual control.
If in the basic (monolateral, arch) supports tangential After the nail’s insertion into the canal, it is locked. To
intraosseous elements cannot be fixed, then the supports maintain the distraction forces, the nail must be locked stati-
should be lengthened with radial plates to make them cir- cally. In case of over-distension, the options are either acute
cular or semicircular. After fixation of the proximal and compression of the bone fragments until the necessary
distal wires and the creation of a longitudinally stable con- length is achieved followed by static or dynamic locking of
struction, the intermediate intraosseous elements are the nail considering gradual shortening of the bone frag-
removed. To preserve the ability to control the bone fragments over the nail under the effect of dosed axial loading.
ments’ positions, the half-pins are removed from the distal The external construction is disassembled, as a rule, following
cortical plate and medullary canal but left fixed in the near nail locking.
cortical plate. If the first stage consisted of bone defect replacement by
Another option is when one more external fixators are to bilocal compression distraction external fixation, then during
be mounted over the present external fixator, which is a dis- nailing the intermediate fragment must be stabilized by an
traction fixation module. In this case, two external supports additional locking screw. This will require the preoperative
are used that must be one to three times larger than the sup- planning of an additional hole for a locking screw. To
ports of the main external fixator. At the level of the proximal decrease the risk of a fatigue fracture of the nail at this level,
and distal metaphyses of the bone, 1–2 intraosseous elements the diameters of the hole and the locking screw must be
are inserted. These are to be located tangentially in the bone, smaller than the diameters of the standard locking holes in
i.e., not intersecting the medullary cavity (Fig. 26.27). These the nail.
transosseous elements are fixed in the supports of the distrac- To fix the intermediate fragment, it is also possible to
tion fixation module. The module supports must be located use a locking plate with monocortical fixation of screws
so that they will not interfere with nail insertion and locking. (Chap. 26.2).
After assembly of the distraction fixation module, the main
external fixator is removed.
The crucial stage of the surgery is to form the canal for the 26.3.5 Femoral SEFaN Surgical Technique
nail in the pathologically altered medullary cavity. For this
purpose, a set of elastic titanium reamers is used (Fig. 26.23). Figure 26.26 shows an option for an external fixator assem-
In an axial deformity at the junction of the bone fragments, bly in which external supports are connected with the bone
they can be modeled (bent), which enables the formation of by extracortical fixators. These devices provide stable osteo-
a bent canal. The technical properties of the reamers provide synthesis and facilitate the insertion of a locking nail.
rigidity and flexibility at the same time and fully transmit If traditional intraosseous elements are used, then tangen-
both rotational and hammer forces on the cutting edge, even tially inserted wires in the anterior-posterior direction for the
if it is located significantly far from the point of insertion and whole period of external fixation are extremely uncomfort-
is bent in the medullary cavity. The cutting element, in the able for the patient. Instead, it is advisable to insert these
form of a facet with butt and side cutting edges, enables both wires in the transition to IM fixation, with this option included
drilling-out the canal by the side edges and canal formation in the distraction fixation module (Fig. 26.27).
by the butt edges. It also enables the use of a hammer to pass The SEFaN surgical technique as applied to the femur
an imperforated segment of the canal by hitting and rotating implies both antegrade and retrograde insertion of the
forces (Fig. 26.25). After the canal has been made, if the seg- locking nail.
ment axis is normal then further insertion and locking of the
IM nail is performed according to the standard method and
presents no difficulties. 26.3.6 Tibial SEFaN Surgical Technique
In some cases, due to sclerosis and curving of the bone
fragments’ ends as well as in case of residual widthwise, The wires are inserted at levels 0, I, and III in the frontal
lengthwise and angular dislocations, it may be virtually plane along the wall of the posterior cortical plate of the tibia
impossible to insert the reamer or drill in to the next bone so that the wires will not prevent nail insertion. The distal
segment. In these situations, a canal in the adjacent bone basic wires are inserted 3–5 mm distally from the level of the
fragment is made from the opposite side (for example, in the planned position of the nail end. In case of a low position of
Fig. 26.26 (a–d) Using the

Ortho-SUV Frame based on
extracortical fixators for
deformity correction a Before
correction: II,10,90; IV,9,90
―SUV―V,9,90; VII,8,90. (b)
After correction
b
Fig. 26.26 (continued) (c) Extracortical fixators do not interfere with nail insertion and locking. (d) After nailing
Fig. 26.27 SEFaN procedure for the femur: (a–i) stages of the operation; (j–o) clinical example a Frame mounting (for example, the Ortho-SUV
Frame): II,10,120; III,9,90; IV,8,100 ―SUV― V,8,120; VI,9,90; VII,8,70. (b) Deformity correction. Note the slight hypercorrection and diastasis
Fig. 26.27 (continued) (c) Traction device. The orientation of the proximal support will not interfere with locking of the nail. (d) The traction module
is applied on the basis of wires I,6-12 and IX,3-9. In a stiff deformity, additional wires should be used
e f
Fig. 26.27 (continued) (e) Frame removal. (f) Opening the medullary canal and guide insertion. (g) Formation of the canal for a nail using a titanium
reamer
h i
j k
Fig. 26.27 (continued) (h) Nail insertion, and distal and proximal locking. (i) After locking. (j) Subtrochanteric non-union of the femur with shorten-
ing by 5 cm after intramedullary fixation. (k) After length alignment by distraction at three levels (non-unions and corticotomy at two levels)
m o
Fig. 26.27 (continued) (l) Fixator view after the completion of distraction. (m) Mounting a distraction fixation module over the basic fixator. (n)
Removal of the rods and disassembly of the basic fixator as the intramedullary nail is inserted. (o) After nailing
the bone wound at levels VI and VII, then in addition to the monolateral or arch fixator, a distraction fixation module is
distal basic wires inserted at level IX additional stabilizing mounted over it just before the nailing procedure.
wires are inserted through the talus or calcaneus. At the level
of the diaphysis, the wires are inserted beyond the canal
through the crest of the tibia. 26.3.7 Upper Arm and Forearm SEFaN
If an Ilizarov external fixator has been traditionally assem- Surgical Technique
bled, the wires not interfering with the nail insertion are
inserted and fixed to the supports just before nailing As a rule, the SEFaN surgical technique for the upper arm
(Fig. 26.28). If deformity correction requires the use of a and forearm implies assembling a distraction fixation module
Fig. 26.28 SEFaN of the lower leg:

(a–j) stages of the procedure; (k–n) clinical
example. (a) Frame mounting (for example,
the Ortho-SUV Frame): II,1,90; III,4-10;
IV,2,120 ―SUV― V,2,120; VI,8-2; VII,1,90.
(b) Deformity correction. Note the slight
hypercorrection and diastasis
b
d e
Fig. 26.28 (continued) (c) Insertion of tangential wires. (d) Removal of the transosseous elements that prevent nail insertion. (e) Opening the
medullary canal
f g
Fig. 26.28 (continued) (f) Formation of the canal for a nail using a titanium reamer. (g) Drilling-out the medullary canal. (h) Shift of the frame
(if needed)
Fig. 26.28 (continued) (i) Nail insertion, and distal and proximal locking. (j) Frame removal. (k) Before deformity correction
Fig. 26.28 (continued) (l) After deformity correction. (m) Nail insertion. (n) Final X-ray after nailing
a c
Fig. 26.29 (a–d) Upper arm SEFaN surgical technique. (a) Fixation mounted over the basic fixator. (c) The basic fixator is removed.
of an open fracture of the upper arm using a monolateral half-pin based (d) One month after elastic stable intramedullary fixation
frame for 2 months. (b) The distraction module I,12-6 ←→ VIII,3-9 is
after deformity correction and removal of the basic fixator On the forearm, the proximal basic wire I, 3-9 is inserted
(Figs. 26.29 and 26.30). On the upper arm, the distal basic through the ulnar bone eccentrically anterior, closer to the
wire VIII, 3-9 or VII, 3-9 is used, both in the basic fixator base of the coronoid process. Wire I, 3-9 is also inserted
and in the module. The proximal basic wire of the module is through the radial bone. If the fixator assembly of a distrac-
inserted at the level I or II in the sagittal plane maximally tion fixation module is intended for the insertion of a wire
close to the medial cortical plate. into both bones, then this wire is inserted tangentially
a b
c d
Fig. 26.30 (a–e) Forearm SEFaN surgical procedure. (a) Before ana- Distraction device I,4-10 ←→ VIII,6-12(6-12) is mounted and the
tomic reduction in the fixator. (b) After anatomic reduction. (c) fixator is removed. (d) Insertion of nails in the radius and ulna
sis, loading on the extremity must be limited until the

X-ray shows signs of union (the regenerate’s organotypic
remodeling).
As a rule there is no need for dynamization of the nail
(removing the static screw or screws, enabling approxi-
mation of the bone fragments along the nail) after the
regenerate is formed; its maturation and organotypic
remodeling occur according to the length set by the nail.
Rarely, dynamization may be required in the case of slow
organotypic remodeling or asymmetric formation of the
regenerate, particularly, when during walking with full
loading there is a risk of fatigue fracture by the fixator
or locking screws. These terms vary by 1–2 months when
nails with a diameter <12 mm and locking screws with
a diameter <4–5 mm are used in the lower extremities,
and by 6–8 months and longer when fixators with a larger
diameter have been applied. Early term dynamization
appears to result in shortening of the bone fragments
over the nail with loss of the achieved segment length.
It should be emphasized that if nails of small diameter
(8–10 mm) and locking screws with a diameter £5 mm
were used, then postoperative loading on the operated
segment should be limited until clinical and X-ray signs
of the distraction regenerate’s organotypic remodeling
proves to be sufficient.
e The locking nail is removed according to the clinical and
X-ray findings of a non-union or union and to the degree of orga-
Fig. 26.30 (continued) (e) After osteosynthesis notypic remodeling of the distraction regenerate. There are no
absolute contraindications for asymptomatic intraosseous fixator
removal.
beyond the canal through the ulna into the radius: I,5-11
(I,5-11). If radial nailing is planned, the distal basic wire of
the distraction fixation module should be inserted through 26.3.9 Complications
the distal epimetaphysis of the ulna (metacarpal bones)
closer to the palm side. For the ulna, this wire is VIII, Possible complications when using external fixation are cov-
5-11. ered in Chap. 33.
If there is infection of the medullary canal, it is advisable
to remove the IM nail and insert a spacer that includes cement
26.3.8 Postoperative Period and antibiotics for 4–6 weeks. If sanation of the medullary
canal is successful, nailing and its locking must be repeated.
The techniques of deformity correction and bone defect replace- However, if the suppurative process is not controlled the
ment in the long bones are covered in Chaps. 16 and 19. spacer must be removed, the medullary cavity treated with a
After the second stage of surgery (conversion from reamer, and the canal thoroughly rinsed, followed by repeated
external to internal fixation), removal of the intraosseous insertion of the spacer.
elements provides maximally early patient mobilization An IM spacer or nail with an active antibacterial covering
and restoration of the adjacent joints’ function. There is no should be used in medullary or localized osteomyelitis types
need to restrict loading on the extremity when intraosseous I and III according to the classification of Cierny-Mader
fixators with a diameter ³12 mm and locking screws [524]. An extracanal spacer made of beads is advisable in
>5 mm are used. If locking screws with a diameter of case of superficial osteomyelitis type II. A combination of
4–5 mm are used and if there is no butt-end contact of the intra- and extracanal spacers is advised in diffuse osteomy-
main bone fragments or, especially, in a distraction diasta- elitis type IV.
26.4 External Fixation Assisted Nailing to enable normal alignment and a painless range of move-
(EFAN) and External Fixation Assisted ment and protect the cartilage surface of the involved bones
Plating (EFAP) for Deformity Correction [532–537]. To achieve this goal, accuracy in preoperative
planning and surgical execution is an absolute must [538,
John E. Herzenberg and Florian Maria Kovar 539]. Many possible solutions have been offered both in the
current literature and in the form of commercially available
26.4.1 Introduction medical devices [526, 527, 538, 540–542].
One has to differentiate between internal and external
Deformities of the lower limb may be corrected by two main fixation. The two methods have in common an osteotomy of
methods: osteotomy and internal fixation or osteotomy and the bone near the CORA [174, 531, 543, 544]. The most fre-
external fixation [525, 526]. External fixation has the possibility quently used techniques are the drill-hole osteotomy
of gradual correction during the postoperative phase, which (Sect. 26.1), focal dome osteotomy [545], derotation osteot-
means that less than accurate initial results can be corrected omy [546], and the open [547] or closed wedge osteotomy
postoperatively to achieve normal alignment [525–528]. With [548] (Chap. 16).
the ORIF (open reduction and internal fixation) approach, a After the osteotomy has been performed, it must be
precise correction of the deformity must be achieved at the stabilized. Four primary questions should be consid-
time of the initial surgery, with no option for changes in the ered: (1) Which method is the most accurate? (2) Which
postoperative phase. This requires considerable technical skill method is the most adjustable? (3) Which procedure has
and expertise [529]. External fixation is uncomfortable for the the lowest complication rate, including surgery and fol-
patient, as it has to be maintained for months at a time. Internal low-up? (4) Which method is the most comfortable for
fixation is more comfortable and avoids the problems associ- the patient? Possible answers to these questions are pro-
ated with chronic external fixation, such as tethering of the vided below.
muscles and recurrent pin-tract infections.
To obtain the accuracy and adjustability of external fixation 26.4.2.1 Which Method Is the Most Accurate?
and the patient comfort of internal fixation, we advocate the use In recent years, a preference for the use of a plate instead of
of fixator-assisted locked nailing (FAN) and fixator-assisted an IM nail for internal fixation has developed in response to
locked plating (FAP). These two related methods combine the the introduction of low-contact locking plates. These have
advantage of external fixation (accuracy, adjustability) with the gained broad acceptance for indications previously domi-
benefits of internal fixation (patient comfort). Osteotomy and nated by IM nailing [517, 542–551].
correction are performed with the help and stabilization of a Marangoz et al. [525] reported about 20 patients,
temporarily applied external fixator, which is used to adjust and including children and young adults, with frontal and
fine-tune the correction until the desired accuracy is achieved, sagittal plane deformities (valgus, varus and procurva-
as measured by radiographic tools. Once the final adjustment is tum) that were corrected using a Taylor Spatial Frame.
made, the fixator is tightened to lock it in place, and then the Successful correction of severe deformities was achieved
osteotomy is permanently fixated by a locked IM nail or a lock- gradually with this frame, resulting in a postoperative
ing plate [177, 526, 530–532]. Once the permanent internal correction of within 2.1° in the mechanical lateral distal
fixation is finished, with all the screws inserted, the fixator is femoral angle (mLDFA) (range: 1–7) in the valgus group
removed before the patient wakes up from surgery. The FAN/ and 1.5° (0–3) in the varus group. The postoperative pos-
FAP techniques have three main advantages: the ability to terior distal femoral angle (PDFA) was within 0.8° of
achieve precise correction, the ease of applying internal fixation normal (0–1).
while the osteotomy is comfortably and securely held with the In a series of eight polytrauma patients with open Gustilo
external fixator, and the permanent fixation with a nail or plate III femoral fractures, normal anatomic alignment, as deter-
without a loss in correction. The disadvantages primarily relate mined based on the mLDFA, PDFA, and mechanical axis
to the technical steps involved in applying the temporary exter- deviation (MAD) was achieved in all patients using the
nal fixation apparatus and pins in such as way as to not interfere Taylor Spatial Frame [552].
with the IM rod or the locked plate. Shafi [666] compared FAP vs. monolateral frames in a
series of 36 extremities for deformity correction. The aver-
age MAD in the frame group with varus and valgus defor-
26.4.2 Goals of Deformity Correction mity was 52 mm medial (18–100) and 34 mm lateral (8–83).
In the FAP group with valgus deformity, MAD was 27 mm
The main goal in deformity correction (Chap. 16) is to estab- lateral (3–55). An average correction of 48 mm in the varus
lish joint orientation angles within the anatomic range so as and 37 mm in the valgus group was achieved using a rail
frame. In the plating group, for valgus deformity an average not depend on plate–bone contact. Plates are available in
correction of 28 mm was reached. many different shapes, sizes, and angles. IM nails provide
Bilen et al. [554] presented a series of 18 patients treated excellent fixation but have even less room for adjustability
with FAN for lower limb deformities caused by metabolic than plates. Regardless of the type of internal fixation used
bone diseases. The mean change in MAD was 47.5 mm. (plates or IM nails), there is a need for the surgeon (or the
Bar-On et al. [526] published a series of 18 limb segments assistant) to hold the bone ends securely and accurately,
in 11 pediatric patients with corrective lower limb osteoto- and without movement, until definitive fixation has been
mies in whom the FAP subcutaneous plating technique was applied and locked. Given these limitations, it would seem
used. The deformities of all patients were corrected to within that the combination of temporary external fixation to
2° of the planned correction. secure the correction while the permanent internal fixation
Kocaoglu et al. [529] published a series of 25 patients is implanted would be the most adjustable internal fixation
treated with the FAN and LON (Sect. 26.1) techniques for method for complex deformity correction.
lengthening and deformity correction. The mean MAD
improved from 33.9 mm before treatment to 11.3 mm 26.4.2.3 Which Procedure Has the Lowest
(0–30 mm) after treatment. Complication Rate, Including
Gugenheim et al. [555] reported using the FAN technique Surgery and Follow up?
in distal varus and valgus deformity correction in 14 femora. Reviewing the current literature, pin-site infection and osteo-
Final average mLDFA in the valgus group was 89° (88–90) myelitis are the two main complications associated with
and 89° (86–93) in the varus group. Average MAD deviation external fixation devices [556–559]. In contrast to this surgi-
was 5 mm medial (14–0) in the valgus group and 3 mm cal challenge, the infection of plates and nails in elective,
(25 mm medial and 48 mm lateral) in the varus group. previously non-infected cases of deformity correction is a
In our opinion, plating has an advantage over nailing rare occurrence [526, 555].
under certain situations. Once the osteotomy has been per- Hardware failure in external vs. internal fixation methods
formed and then stabilized by the external fixator, changes in can be estimated as comparable and tolerably low. External
the limb’s position on the table should be minimized until fixation devices that are chronically installed carry an ongo-
internal fixation has been secured. However, with the retro- ing risk of infection, whereas in internal fixation the risk for
grade FAN technique, it is necessary to bend the knee for infection is primarily only in the first 2 weeks, until the sur-
retrograde access to the femur. This risks correction loss, gical incision is healed.
especially if the external fixator has been applied with only Fat embolism is a serious but rare complication associ-
one pin proximally and one pin distally. ated with IM reaming and nailing. This risk can be reduced
but not totally eradicated by the use of reaming irrigation
26.4.2.2 Which Method Is the Most Adjustable? devices [501, 560, 561] or by venting the canal prior to
For malformation correction in the lower limb, external reaming. With the FAN technique, the osteotomy is always
fixation allows postoperative correction, at least theoreti- done prior to reaming, thereby creating a large vent
cally. A publication compared the original Ilizarov to the for any increased IM pressure caused by subsequent
Taylor Spatial Frame and found that, for increasingly com- IM reaming.
plex deformities, the latter was better at achieving the
desired correction [527]. The combination of a rigid hexa- 26.4.2.4 Which Method Is the Most Comfortable
pod fixation system with the support of a web-based soft- for the Patient?
ware program offers the possibility of simultaneous External fixation devices (circular, monolateral or hybrid)
corrections of multidirectional deformities [527, 540]. have a great disadvantage when it comes to patient comfort.
Recently, new products have emerged with capabilities They are cumbersome, making clothing choices difficult,
similar to those of the Taylor Spatial Frame, including the and can lead to social isolation, as the patient may feel
Ilizarov hexapod system from Germany, and the Ortho- embarrassed and inhibited to have an external fixator attached
SUV Frame from Russia (Chap. 17). By contrast, the ORIF to his or her limb. Moreover, consider a patient going through
approach is highly operator dependent with respect to the airport security screening with an external fixator, creating
quality of the correction that can be achieved, as no adjust- consternation and suspicion [562, 563]. On the other hand,
ments are possible once the patient leaves the operating internal fixation allows a relatively brief treatment period
room. Internal fixation with a plate or a nail is a procedure with the possibility of early rehabilitation. A second surgical
in which final deformity correction has to be achieved per- intervention for hardware removal is mentioned as a risk fac-
fectly during surgery. Plates tend to be more forgiving, tor by some authors. This can be necessary if an internal
especially the newer generation of locking plates, which do fixation device causes pain or is under the skin in locations in
which close contact or pressure is unavoidable, such as the distal part of the femur, and two half-pins are inserted in
malleoli in the ankle region. the proximal femur, below the lesser trochanter, proximal to
the planned location beyond the projected proximal tip of the
IM nail. The distance between the two pins proximally and
26.4.3 Special Features of the Equipment distally is dependent on the type of monolateral fixator used.
The pins are connected with a monolateral external fixator.
Clinical and detailed radiographic preoperative planning are Distally, the external fixation pins are anterior to the planned
a prerequisite. In addition, a detailed explanation of the nail path; proximally, they are beyond the tip. The proximal
planned procedures and the aftercare with a suggested time- pins may therefore be inserted across the medullary canal. The
frame during face to face meeting with the patient is manda- interlocking screws will be applied from the medial side, so
tory in maintaining realistic expectations. Long-standing that the (medial) distal interlocking jig does not come into
radiographs of both sides in two planes (AP, lateral; see contact with the lateral external fixator (Fig. 26.31).
Chap. 6.1) are considered necessary and allow the surgeon to Instead of conventional half-pins screws, extracortical
see where the malalignment and malorientation originate. clamp devices are an option (see Table 1.2, item 23, Chap.
We use the CORA method to determine the apex, level, and 12.5, and Fig. 26.32).
magnitude of the deformity, so that an osteotomy can be In preoperative planning, the level of osteotomy has to be
planned. After surgery, the same radiographic analysis tech- proximal enough to enable the placement of at least two
niques allow the surgeon to determine whether the correction interlocking screws. A 2–3 cm vertical parapatellar tendon or
was successful (Chap. 4) [174, 238, 283]. transpatellar tendon incision is made to gain access to the
In femoral deformity reconstruction, unilateral knee for retrograde nailing. This is facilitated by flexing the
(Figs. 26.31, 26.33, and 26.34) and circular (Figs. 26.32, knee to 90° and bringing the C-arm into a cross-table lateral
26.35, and 26.36) external fixators can be used, depending view. Next, the osteotomy is performed in the supracondylar
on the surgeon’s preference. However, for FAN and FAP, region through a 1-cm lateral incision. The periosteum is
monolateral fixators are preferred over circular ones due to elevated, multiple drill holes 4.8 mm in diameter (Fig. 26.2)
their better accessibility. are made. The osteotomy is then completed with an osteot-
In cases of femoral EFAN, the use of extracortical clamp ome. The ideal osteotomy is straight, not comminuted, so
devices instead of conventional half-pins is reasonable that it can translate in the frontal plane first and then angu-
(Fig. 26.32; for additional information, see Table 1.2, item late. The external fixation pins may be used for leverage in
23, and Chap. 12.5). shifting and angulating the bone fragments to mimic the pre-
operative planning correction. Typically, the osteotomy is
proximal to the CORA, so some fragment translation is
26.4.4 Indications and Contraindications needed to achieve ideal alignment (Chap. 4).
In the next step, this preliminary deformity correction is
EFAN and EFAP are applicable for any long-bone deformity stabilized by reapplying the external fixator. The fixator con-
but are primarily used for osteotomies of the femur distal to nections are tightened, and the frontal plane alignment are
the lesser trochanter and for the tibia at all levels. In adults, checked by using a cautery cord stretched from the hip to the
either FAN or FAP is appropriate. In children, FAP is pre- ankle, visualized by C-arm AP images centered on the hip,
ferred, in order to avoid crossing the physes with IM rods. knee, and ankle (Figs. 16.140 and 16.141). If the cautery
cord is medial or lateral to the desired center of the knee, the
external fixator is adjusted and the alignment rechecked.
26.4.5 External Fixator Assisted Retrograde These steps are repeated as needed until a satisfactory result
Nailing for Acute Distal Femur Valgus is obtained. The sagittal plane alignment is then evaluated by
Deformity Correction: Surgical Technique fully extending the knee to ensure that there is no flexion or
hyperextension deformity, and the osteotomy is visualized
The patient is placed in supine position on a radiolucent table with the C-arm in the cross-table lateral position. Once the
with a cushion under the ipsilateral hemi-sacrum. A C-arm is alignment is confirmed to be perfect, the knee is flexed to 90°
positioned from the opposite side, with the ability to take AP and a retrograde IM nail inserted. The starting point is care-
and cross-table lateral views from hip to knee. The procedure fully checked on the AP and lateral C-arm images. Over a
starts by applying a monolateral four-pin external fixator to the beaded guide wire, a reamer is used to create a canal at least
femur, mimicking the valgus deformity. Two 6-mm half-pins 1–1.5 mm wider than the diameter of the selected nail. The
are inserted from the lateral aspect of the femur, in the frontal reamings will partially exit the osteotomy site, and function
plane parallel to the knee joint, in the anterior one-fourth of the as pre-positioned bone graft. The nail is inserted, with the
7°
Magnitude
12°=
of deformity
Actual
mLDFA
= 75°
Normal
mLDFA mLDFA
= 87° = 87° Angulation
12°
CORA Osteotomy
for opening Translation
wedge
correction
a b c
d e f g
Fig. 26.31 (a–k) External fixator assisted retrograde nailing for acute osteotomy is performed just proximal to the distal pins. (c) Angulation
distal femur valgus deformity correction. (a) AP view: mechanical axis and translation to correct the alignment; the fixator is reapplied.
planning demonstrates a 12° valgus deformity with the CORA in the (d) Starting point to access the intramedullary canal, posterior to the exter-
distal metaphysis. (b) Four external fixation pins have been inserted; the nal fixator pins. (e) Insertion of an intramedullary beaded guide wire. (f)
distal pins are placed anterior in the bone to avoid interference with the Lateral view: retrograde reaming over a guide wire. (g) After nail insertion
nail during insertion: I,9,90; II,9,90 –o– VIII,10,90; IX,10,90. Transverse and locking with screws
Normal
mLDFA = 87°
h i j k
Fig. 26.31 (continued) (h) Close-up view of the distal locking screw delta configuration. (i) Final AP view after the removal of the external fixator:
result of correction with mLDFA of 87°. (j) Preoperative erect-legs film showing left genu valgum and lateral MAD. (k) Postoperative view showing
corrected alignment after retrograde FAN
b
Fig. 26.32 (a–c) An example of two-level deformity correction of the was used for acute deformity correction: I,10,90; II,9,90 – IV,9,90 –o–
femur (L.N. Solomin’s case). (a) Before correction. (b) A hexapod IX,8-2; IX,4-10. After correction
assembled on the base of the extracortical clamp devices (Chap. 12.5)
locking jig (from the medial side) used to insert the three The frontal plane alignment should be checked using a
distal locking screws. The ideal IM nail for this application cautery cord stretched from the hip to the ankle, with multiple
has three distal screws in a delta configuration for maximal C-arm images focused on the hip, knee, and ankle (Figs.
stability. Additional Pollard screws may be inserted but are 16.140 and 16.141). Reduction in the sagittal plane is checked
rarely necessary. Next the proximal two interlocking screws with the C-arm in the cross-table lateral position. If needed,
are inserted and the external fixator removed [555]. the external fixator is loosened, the bone repositioned, and
the set-up controlled again as needed until the alignment is
satisfactory. This step is followed by locking plate insertion
26.4.6 External Fixator Assisted Plating (EFAP) in the submuscular-extraperiostal plane. Two to three lock-
for Distal Femur Valgus Deformity ing screws should be placed on both sides of the osteotomy
Correction: Surgical Technique either through the incision itself or through an additional
percutaneous incision. A minimum of three to four screws in
Preoperative planning and hardware selection are completed each segment is required. Empty holes in the plate may be
as described above. Positioning is also the same. The leg is filled with “dummy” screws to increase the strength of the
exsanguinated with an Esmarch bandage and a sterile tourni- plate. Finally, the external fixator is removed, the tourniquet
quet is inflated. A longitudinal lateral incision is made about is deflated, hemostasis obtained, and all incisions are closed,
5 cm in length, starting at the distal femoral condyle and over a drain if needed [526, 550].
extending proximally. The fascia lata is split and the vastus The procedure is shown in Figs. 26.33, 26.34, and 26.35.
lateralis is elevated from the intermuscular septum and lateral
femur. A subperiosteal dissection is made only at the level of
the intended osteotomy. The remainder of the periosteum 26.4.7 Postoperative Care. Additional Concepts
should be preserved. For distal femoral plating, the external
fixator is mounted in the frontal plane, medially. Typically it is Partial weight-bearing is encouraged as soon as possible
stable enough such that a single pin can be used above and (e.g., on the first post-operative day). Full weight-bearing
below the osteotomy, as the knee will not be flexed during this without crutches may be permitted when osseous healing
procedure (unlike FAN). The distal 6-mm external fixation pin (two of four intact cortices) is seen on follow-up radiographs,
is placed parallel to the knee joint, just distal to where the taken every 4 weeks. Modifications of the operative tech-
locking plate will be applied. The proximal 6 mm pin is placed nique may be made as needed and desired. For example, for
1–2 cm above the intended osteotomy level. More proximal combined frontal and sagittal plane (oblique plane) deformi-
placement in the inner thigh would risk injuring the superficial ties, it is necessary to apply a second two-pin external fixator
femoral artery and should be avoided. Once the external fixator anteriorly, in the sagittal plane, to control flexion and exten-
has been applied, it is removed for the osteotomy. Multiple sion at the osteotomy site. Fixators may be placed either
drill holes are made with a 4.8-mm drill bit, and the osteotomy medially or laterally, depending on the hardware configuration
is completed with an osteotome (Fig. 26.2). Since the defor- planned. As locking screws are being inserted, they may
mity apex is typically distal to the level of the osteotomy, it is impinge on certain external fixation pins. In such cases, the
necessary to first translate and then angulate through the other pins should be inserted first; then, once provisional
osteotomy. With the preliminary reduction, the medial exter- fixation is secured, the external fixator pins are removed and
nal fixator is reattached and tightened. the remaining locking screws inserted.
External
fixator
applied
Opening wedge Distal femur

osteotomy site Distal
translated
laterally Clamps femur
loosened angled
10°
a b c
Clamps
tightened
d e f
Fig. 26.33 (a–i) External fixator assisted plating (EFAP) for distal ally. (c) Angulation of the osteotomy and tightening of the external
femur valgus deformity correction. (a) Short medial fixator applied: fixator to lock in the reduction. (d) Locking plate applied. (e) Close-up
VI,3,90 –o– IX,3,90. Note the planning lines with CORA in the distal lateral view showing the locking plate. (f) Final AP view with the exter-
metaphysis, and the osteotomy level proximal to the CORA. (b) nal fixator removed
External fixator loosened to allow the osteotomy to be translated later-
g h i
Fig. 26.33 (continued) (g) Preoperative erect-legs film showing bilat- tion jig for locking the distal femur plate, and the separate stab incisions
eral genu valgum. (h) Intraoperative photograph during an FAP of the for the most proximal locking screw. (i) Postoperative view showing the
distal femur, showing the medial two-pin external fixator and the inser- corrected alignment
a b c
Fig. 26.34 (a–c) Alternative variants of the external fixation device a view showing the anterior external fixator in profile. c Variation with
Variation with two external fixators applied, perpendicular to each four-pin medial fixator for increased stability: VI,3,90; VII,3,90 –o–
other, for additional stability, particularly if there is a sagittal plane VIII,3,90; IX,9,90
deformity: VI,12,90 –o– VIII,12,90 and VII,3,90 –o– IX,3,90. b Lateral
a b
Fig. 26.35 (a–e) An example of acute femur deformity correction (L.N. clamp device (Chap. 12.5) V,10,90. The distal fragment was fixed using
Solomin’s case). (a) Before treatment. (b) The Taylor Spatial Frame is half-pins IX,4,90 and VIII,3,90. (c) Dome osteotomy. (d) Acute defor-
applied. The proximal fragment is fixed using wire V,12-6 and extracortical mity correction and plate “fitting”
Fig. 26.35 (continued) (e) Plating and frame removal
Fig. 26.36 (a–c) An example of an acute proximal tibia deformity correction (L.N. Solomin’s case). (a) Before treatment
Fig. 26.36 (continued) (b) Acute deformity correction using the hexapod (Chap. 17): 0,3,90; I,3,90 ―0― VI,9-3; VII,1,70. (c) Plating
Fig. 26.36 (continued) (d) Postoperative view showing the corrected

alignment
graphs is given after each section title
Applications of External Fixation
in Long Bone Tumor 27
Hiroyuki Tsuchiya and Katsuhiro Hayashi
27.1 Introduction bone graft
There has been a dramatic improvement in the survival

rate of patients with sarcomas and in the successful sal- Tumor transport
vage of limbs as a result of progress in chemotherapy,
radiological evaluation, surgical technique, and the tech-
nology of materials and implants. Complications, however, osteotomy
such as deep infection, fracture, bone resorption, and regenerated bone

breakages of prostheses still occur. The challenge to pro-
vide long-lasting survival and function of the limb after
reconstruction is now being met with biological solutions
using living bone. The ideal reconstruction should have
biological affinity, resistance to infection, sufficient bio- Fig. 27.1 The bone defect can be reconstructed by distraction osteo-
mechanical strength, and durability. Vascularized bone genesis combined with bone grafting
transfer has limitations in terms of length and strength.
Since 1990, distraction osteogenesis, which can regenerate
bone of sufficient strength for reconstruction, has been 27.2 Indications
adopted for tumor surgery.
In this chapter, we describe the Ilizarov method to recon- Distraction osteogenesis can be applied for any kind of
struct bone defects after tumor excision and the classification tumor, whether benign or malignant. Some cases of benign
of the technique [565–570]. The bone defect can be recon- or low-grade malignant lesions, including giant cell tumor,
structed by distraction osteogenesis combined with bone fibrous dysplasia, osteofibrous dysplasia, chondrosarcoma,
grafting (Fig. 27.1). A type 2 (Fig. 27.2) reconstruction is the and adamantinoma, are suitable for this reconstruction
typical procedure for bone tumor surgery because of the fre- method when the bone defect is too large to reconstruct with
quently involved location. When the remaining epiphysis is bone grafting or other material. It is more specifically indi-
too thin to insert wires, a type 4 reconstruction is warranted. In cated when the epiphysis is preserved. If the lesion is a high-
this type, the epiphysis should contain some length of meta- grade malignancy, such as osteosarcoma, Ewing’s sarcoma,
physeal lateral wall in order to stabilize the bone fragment. and malignant fibrous histiocytoma, and preoperative che-
motherapy is effective, this method is indicated. If preopera-
tive chemotherapy is not effective and the soft tissue
surrounding the tumor must be widely excised, this tech-
nique is not appropriate because of poor blood supply and
insufficient osteogenesis. In a patient with a distant metasta-
sis, we do not recommend distraction osteogenesis because it
takes much longer than prosthetic replacement, in consider-
H. Tsuchiya, M.D., Ph.D. (*) • K. Hayashi, M.D., Ph.D. ation of the patient’s expected life span.
Department of Orthopedic Surgery, Graduate School of Medical
We have studied the safety of external fixation during post-
Science, Kanazawa University, 13-1 Takara-machi, Kanazawa-shi,
Isikawa-ken 920-8641, Japan operative chemotherapy in patients who underwent distraction
e-mail: tsuchi-h@tg7.so-net.ne.jp; tsuchi@med.kanazawa-u.ac.jp osteogenesis after tumor resection. Postoperative chemother-
1380 H. Tsuchiya and K. Hayashi
Fig. 27.2 Type 1 reconstruction
Tumor
Tumor
apy for malignant bone tumors was found to have only a mini- Type 3 includes defects of the metaphysis and unilateral
mal effect on distraction osteogenesis. When infection defects of the epiphysis. Type 3 metaphyseal defects are
occurred, it was controllable in most patients by local antisep- reconstructed by shortening the diaphysis or by using a bone
tic care and the intravenous administration of antibiotics. cylinder from the diaphysis. A unilateral defect of the epi-
physis is repaired with the articular surface of the ipsilateral
patella and a strut graft from the iliac crest. The diaphyseal
27.3 Classification of Reconstruction defect is then filled in by bone transport. When the defect has
with Distraction Osteogenesis been shortened, a standard lengthening procedure is per-
formed at the diaphysis (Fig. 27.4).
Reconstruction with distraction osteogenesis can be classified The type 4 procedure is used in the reconstruction of sub-
into five types based on the location of the defect after tumor articular defects. Articular cartilage with or without some
resection: subchondral bone is left in situ after tumor excision, and
Type 1: Diaphyseal reconstruction Ilizarov wires cannot be applied through the epiphysis. A
Type 2: Metaphyseal reconstruction bone cylinder is taken from the diaphysis and fixed by wires
Type 3: Epiphyseal reconstruction to the remaining lateral or medial wall. The newly created
Type 4: Subarticular reconstruction diaphyseal defect is then filled by bone transport (Fig. 27.5).
Type 5: Arthrodesis In type 5 procedures, arthrodesis is used to reconstruct
In type 1, the diaphyseal defect is reconstructed by bone defects after joint resection and to correct a subsequent leg
transport or shortening-distraction (Fig. 27.2). To reconstruct length discrepancy (Fig. 27.6).
the metaphyseal defect in type 2, Ilizarov wires or half-pins A unilateral external fixator is convenient for a type 1
for fixation may be used through the remaining epiphysis. In reconstruction and for diaphyseal lengthening in a type 5
addition to bone transport or shortening-distraction, the arthrodesis. An Ilizarov apparatus is useful for the fixation of
metaphyseal defect may be reconstructed with a bone epiphyseal or metaphyseal structures and for simultaneous
cylinder from the diaphysis, filling the defect by bone trans- bone lengthening in the management of reconstructions car-
port (Fig. 27.3). ried out in types 2, 3, and 4.
27 Applications of External Fixation in Long Bone Tumor 1381
Tumor
Tumor
a b
0,8-2; 0,4-10; 0,3-9 VII(8-2)8-2; VII,4-10; VI,1,90 (a)

0,8-2; 0,4-10; 0,3-9; I,1,90; II,1,90 III,1,90; IV,1,90 VII(8-2)8-2; VII,4-10; VI,1,90 (b)
Fig. 27.4 An example of a type 2 reconstruction. A tumor in the proximal tibia is excised, followed by bone transport
patella
patella
Tumor
Tumor
Tumor

27.4 Type 1: Diaphyseal Reconstruction wires. Cylindrical bone is obtained from the remaining dia-
physial bone and grafted onto the proximal epiphysis with
Type 1 is the simplest procedure for the reconstruction of fixation using half-pin II,1,90. Autologous bone grafting can
the diaphyseal defect utilizing bone transport or shortening- be plated besides the cylindrical bone to create a metaphysis.
distraction. The combination of an intramedullary nail and The detached patellar tendon is reattached on the cylindrical
distraction osteogenesis may reduce the period of treatment bone with a spike washer. The middle ring is attached for
and thereby the incidence of wire or pin-tract infections as bone transport and osteotomy is performed.
well. The external fixation index can be reduced as the mat-
uration index approaches zero. We therefore apply intramed-
ullary nailing for distraction osteogenesis whenever feasible. 27.6 Type 3: Epiphyseal Reconstruction
A thin, stress-resistant intramedullary nail is appropriate for
combined use to preserve the intramedullary blood supply A type 3 reconstruction is used to for defects of the metaphy-
and to allow space for the insertion of wires or half-pins. sis and the unilateral epiphysis (Fig. 27.5). Metaphyseal
If shortening-distraction is employed, a bone graft at the defects are reconstructed by shortening of the diaphysis or
docking site is not necessary. Femoral shortening of about with a bone cylinder from the diaphysis, while the articular
10–15 cm can be achieved if wound closure is feasible. Careful surface of the ipsilateral patella and a strut iliac crest graft are
attention should be paid to the shortening of the tibia because used to reconstruct unilateral epiphyseal defects. The newly
of potential circulatory disturbance, but tibial defects can be created diaphyseal defect is then filled in by bone transport.
satisfactorily treated by bone transport for extensive bone loss. When the defect is shortened, a standard lengthening
procedure at the diaphysis is performed. The patellar liga-
ment or collateral ligaments can be reattached to the bone
27.5 Type 2: Metaphyseal Reconstruction cylinder or to the shortened diaphysis. Intramedullary nailing
can be applied after completion of both the distraction and
Type 2 is used to reconstruct a metaphyseal defect. Llizarov the union of the peri-articular structure.
wires or half-pins for fixation can be used through the remain-
ing epiphysis. In addition to bone transport or shortening-dis-
traction, the metaphyseal defect can be reconstructed with a 27.7 Type 4: Subarticular Reconstruction
bone cylinder from the diaphysis, and the newly created dia-
physeal defect is filled by bone transport. It is necessary to reat- Type 4 is used for the reconstruction of subarticular defects
tach the patellar ligament to the bone cylinder grafted for (Fig. 27.6). Articular cartilage with or without subchondral
reconstruction of the metaphyseal defect of the proximal tibia. bone is left after tumor excision. In contrast to type 2
Careful attention should be paid during tibial shortening reconstruction, Ilizarov wires cannot be applied through
because of the potential for circulatory disturbances. lntramed- the epiphysis (Fig. 27.7). The primary periarticular recon-
ullary nailing can be used for the femur before and after distrac- struction should be performed to stabilize the knee joint
tion but for the tibia only after distraction in selected cases. and to avoid collapse of the articular surface. The bone cyl-
Before the tumor is excised, the external fixator frame inder from the diaphysis and the remaining lateral or medial
should be applied on the affected bone, otherwise the align- wall should be fixed by wires. The newly created diaphy-
ment shifts after tumor excision and it requires much more seal defect is filled in by means of bone transport. This
effort to correct it. Figure 27.4 shows, as an example, the type of reconstruction would be applied for the proximal
stages of external fixation in case of a bone tumor in the and distal ends of the tibia. The patellar ligament or col-
proximal tibial metaphysis. Two rings are applied as the first lateral ligaments can be reattached to the periarticular
step, after which the tumor is excised with an adequate mar- structure. Since intramedullary nailing is not indicated for
gin. Usually, the proximal bone segment is very thin and this reconstruction, the healing time of a type 4 reconstruc-
metaphysical reconstruction is performed in advance. If the tion is longer time than required for other types of
preserved epiphysis is >1 cm thick, it can be fixed with three reconstruction.
27.8 Type 5: Arthrodesis
Type 5 is used to reconstruct defects after joint resection by

arthrodesis and to correct subsequent leg length discrepancy.
In hip arthrodesis, shortening of the defect and lengthening
of the femur and/or tibia combined with intramedullary nail-
ing are advised in order to reduce the treatment period. For
long defects after tumor resection, bone transport is con-
ducted because the wound cannot be primarily closed.
Shortening of the defect, if feasible, will lead to a reduction
of the treatment period.
27.9 Postoperative Care
Distraction is initiated at 0.5 mm twice daily or 0.25 mm four

times daily approximately 7–14 days after the operation. It is
then either reduced to zero or increased to 1.5 mm per day,
according to the degree of bone formation. The external
fixator is removed as soon as sufficient consolidation is
obtained and replaced by casting or an orthosis for approxi-
mately 4 weeks. In cases with very poor callus formation,
either distraction is delayed or compression and distraction
of a moving segment (accordion maneuver) are applied.
Antibiotics (penicillins or second-generation cepha-
losporins) are administered as a single intravenous dose
before the operation and then orally for 3–5 days after.
Careful attention is paid to the maintenance of aseptic condi-
tions during wire insertion, followed by care of the wires and
Fig. 27.7 An example of a type 4 reconstruction. In contrast to a half-pins, using 0.05% chlorhexidine gluconate or simply
type 2 reconstruction, Ilizarov wires cannot be applied through the
epiphysis
rinsing, beginning immediately after the operation,. All
Tumor
Tumor

c d
Fig. 27.9 Osteosarcoma of the proximal tibia: type 1 reconstruction. (c) Excision of the tumor and bone transport from the distal part. (d)
(a) Initial X-ray examination. (b) MRI findings before (left) and after Most recent X-ray image (4 years after surgery). The patient can run
chemotherapy (right). The tumor has shrunk and pain has disappeared. and play soccer
Fig. 27.10 Osteosarcoma

of the proximal tibia: type 2
reconstruction, shortening
distraction method. (a) Initial
X-ray examination. (b) Excision
of the tumor and proximal tibial
reconstruction by the shortening
method. The patellar tendon is
reattached with a spike washer.
(c) Distraction osteogenesis is
completed. (d) Final follow-up
a b
c d
a b
c d
Fig. 27.11 Osteosarcoma of the distal femur: type 3 reconstruction. the patella. (c) Distraction osteogenesis. (d) The most recent X-ray
(a) Involvement of the lateral condyle by tumor and resection including image, showing the reconstructed distal femur
the epiphysis. (b) Reconstruction of the resected lateral condyle using
patients (or their parents) are instructed to perform pin-site prophylactic intravenous antibiotics (second-generation
care twice weekly at home after discharge from the cephalosporins) for 3–5 days during chemotherapy.
hospital. Clinical examples of the Ilizarov method for long-bones
Patients administered postoperative chemotherapy after tumors are shown in Figs. 27.7, 27.8, 27.9, 27.10, 27.11 and
tumor resection and application of the external fixator receive 27.12).
Fig. 27.12 Osteosarcoma

a
of the proximal tibia: Type 4
reconstruction. (a) X-ray and
MRI show tumor in the tibial
epiphysis. Only the joint surface
can be preserved after tumor
excision. (b) Reconstruction of
the proximal tibia with
cylindrical bone obtained from
the diaphysis.
b
c d
Fig. 27.12 (continued) (c) Bone transport started (left) and finished (right). (d) Final X-ray shows the excellent reconstruction. Limb function
was normal
Application of Transosseous
Osteosynthesis in Vertebrology 28
Alexander Nikolaevich Djachkov,
Alexander Timofeevich Khudiaev,
Oksana Germanovna Prudnikova,
and Oleg Sergeevich Rossik
28.1 Introduction for adequate deformity correction and stable fixation of the
spine as well as early activity in the postoperative period.
The main goals of reconstructive spinal surgery are: decom- The laboratories of Clinical Vertebrology and Neuro-
pression of spinal canal structures, restoration of the ana- surgery of the Russian Scientific Center “Restorative
tomic and biomechanic interrelations of the spine, and the Traumatology and Orthopedics” have developed and clini-
reliable stability of the achieved result [571–576]. Experience cally applied new and original techniques for the surgical
with the various techniques and devices in spinal surgery treatment of diseases and injuries of the spinal column and
indicates that these goals have not been entirely met and spinal cord. These techniques allow for the correction of
improvements are needed. The known surgical techniques of kyphoscoliotic deformity, the correction and stabilization of
acute correction of various anatomic and functional disor- the spine in case of spondylolisthesis, and injuries of the
ders of the spinal column with internal fixation systems are spine and spinal cord [593–595].
invasive and dangerous for the spinal cord [577–581]. The External transpedicular fixation enables the gradual con-
frequency of neurological and vascular conflicts in such trolled correction of spinal deformities, taking into account
cases amounts to 10.2%, based on the findings of several their multi-planar character. It avoids the development of
reports [582–589]. Besides, the corrective and repositioning neurological and vascular disorders associated with traction
possibilities of these devices are limited. on the spine and the contents of the spinal canal and addresses
New perspectives in reconstructive and restorative spinal all of the factors affecting deformity correction. The efficacy
surgery have appeared with the introduction of transosseous of external transpedicular fixation depends on the establish-
compression and distraction osteosynthesis methods into ment of favorable mechanical and biological conditions with
medical practice [590–592]. The benefits of transosseous directed influence on the pathologically changed spine.
osteosynthesis are the safe and stable fixation of the injured However, the achieved correction requires reliable stabiliza-
segment, the gradual effect on the spinal column tissues, the tion, which in turn necessitate fixating fusion. The choice of
creation of conditions for reparative regeneration and directed fusion technique depends on the character of the disease, the
vertebral modeling, and the improved tendency to obtain type of surgery, and the technical possibilities.
complete anatomic and functional restoration of the nervous
and vascular structures of the spinal canal. The method allows
28.2 Equipment Properties
The Ilizarov transosseous osteosynthesis apparatus is used. It

is produced at the pilot plant of the RISC “RTO” (registra-
A.N. Djachkov, M.D., Ph.D. (*) tion ID FSR 2007/00756, September 28, 2007, potential risk
Department of Orthopedics, Russian Ilizarov Scientific Center class 1, OKP 94 3810, regulatory document КRD no. 25321,
“Restorative Traumatology and Orthopedics”, M. Uljanova Str., 6, August 6, 2007, authorized by the order of Federal Service
640014 Kurgan, Russia on Surveillance in Healthcare and Social Development of the
e-mail: naucaalex@mail.ru; oksiniyap@yandex.ru
Russian Federation of September 28, 2007, no. 2887, PR/07).
A.T. Khudiaev, M.D., Ph.D. • O.G. Prudnikova, M.D., Ph.D. The half-pins are made of a titanium alloy, VT-6 (National
O.S. Rossik, M.D., Ph.D.
Department of Neurosurgery, Russian Ilizarov Scientific Center Standard 19807-74), and the plates and other elements of
“Restorative Traumatology and Orthopedics”, M. Uljanova Str., 6, external fixation of stainless steel type 12X18H10T (National
640014 Kurgan, Russia Standard 5632-72) (Fig. 28.1).
1392 A.N. Djachkov et al.
a b c
Fig. 28.2 Half-pin: 1 stopper; a length of the screw part; b length

of the smooth part; c length of the threaded part; d diameter of the
half-pin
Table 28.1 Characteristics of standard size half-pins

a, mm b, mm c, mm d, mm
For thoracic Th1 35–37 30–35 60 3.0
vertebrae Th2 35–37 30–35 60 3.0
Th3 35–37 30–35 60 3.0
Th4 35–37 30–35 60 3.0
Th5 36–38 30–35 60 3.2
Fig. 28.1 Parts making up the external transpedicular fixation Th6 36–38 35–40 60 3.2
apparatus Th7 36–38 35–40 60 3.4
Th8 38–40 35–40 60 3.6
Th9 38–40 35–40 60 3.6
The main parts of the apparatus are half-pins, support
Th10 38–40 35–40 60 3.8
plates, L-shape clamps, threaded rods, nuts, washers, a spe-
Th11 38–40 35–40 60 3.8
cial wrench for half-pin insertion, and a standard wrench.
Th12 38–40 40–45 60 4.0
For lumbar L1 40–42 40–45 60 4.0
vertebrae L2 40–42 40–45 60 4.5
28.3 Special Principles in the Application L3 40–42 40–45 60 4.5
of Transosseous Osteosynthesis L4 40–42 40–45 60 5.0
in Vertebrology L5 40–42 40–45 60 5.0
Transpedicular fixation includes the insertion of half-pins

through the roots of the arches into the vertebral bodies fol- The half-pins are inserted through skin micro-incisions
lowed by strengthening them externally. transpedicular from both sides through the vertebral body at
Preoperative CT scans are used to choose the lengths of the an angle of 45–47° depending on the properties of the
threaded and screw parts and the diameters of the half-pin patient’s spinal structure (Fig. 28.3).
(depending on the width of the pedicle of the arch) for each L-shaped clamps are used to attach the half-pins to the
vertebra, as well as the direction of half-pin insertion through support plates, which are interconnected into support blocks
the pedicle of the arch for each of the vertebrae. The optimal by threaded rods. The support blocks are interconnected by
half-pin construction is chosen considering the anatomic struc- hinges allowing manipulation of the construction elements
ture of the thoracic and lumbar vertebrae (Fig. 28.2). Table 28.1 in various planes.
lists the characteristics of the standard size half-pins. The choice of the osteosynthesis scheme and the number
The insertion site of the half-pin is chosen considering of support blocks depends on the type of disease and the goal
data from the preoperative CT transverse sections of the of treatment.
examined vertebrae and spinal X-ray images and from the Half-pins are inserted and repositioning manipulations
image intensifier with the patient on the operating table. are done under image intensifier control.
28 Application of Transosseous Osteosynthesis in Vertebrology 1393
Fig. 28.3 Insertion of the a b

half-pins and attaching them to
the support plate: (a) Horizontal 2
view. (b) Lateral view. 1 half-pin,
2 support plate, 3 vertebral body.
View A: side view
1
2
28.4 Transosseous Osteosynthesis Initial deformity correction is done on the operating table.
in the Management of Patients For the purpose of kyphosis correction, compression forces
with “Uncomplicated” Fractures are applied between the blocks of the apparatus by adjusting
of the Thoracic and Lumbar Spine the nuts of the hinges (Fig. 28.5).
To correct scoliosis, distraction is done between the
After complex examination, including radiography of the spine fixator blocks on the concave side, and compression on the
in two views, CT and MRI (in the absence of spinal cord com- convex side.
pression, spinal canal deformity, or the need for urgent surgical After surgery, further gradual correction of all the compo-
intervention) are done followed by closed transosseous osteo- nents of the deformity is carried out under radiographic con-
synthesis of the spine using external transpedicular fixation. trol (Figs. 28.6 and 28.7).
Indications for this type of surgery are compression frac- Further treatment tactics depend on the goal of treatment,
tures of the thoracic and lumbar spine with an evident spinal e.g., formation of a block in the operated segment. For this
deformity. purpose, fixating fusion (anterior or posterior) is performed
Absolute contraindications for the surgery are pyoin- or the device is switched to fixation mode until the formation
flammatory conditions in the area of the surgical interven- of bone or a bone-fibrous block. The device is removed after
tion, septic conditions, psychic diseases, alcoholism, drug radiographic or CT-densitometric verification of fracture
addiction. Relative contraindications are traumatic shock healing. The patient should wear a semi-rigid brace for the
and age under 12 years. following 6 months, until the next radiographic
Figure 28.4 shows the fixation of two vertebrae above and examination.
below the fracture level.
Fig. 28.4 View of the external transpedicular fixator on a dry anatomic

preparation of the spine
Fig. 28.5 (a, b) Osteosynthesis

of the spine for uncomplicated
a b
spinal fractures
Fig. 28.6 (a, b) CT images and

a
spondylograms of the lumbar
spine of patient K. before and
after treatment for a compression
fracture of vertebra L1
b
a b c
Fig. 28.7 Spondylograms after treatment (a, b) and late follow-up (c, d): the axis of the spine is correct, the deformity has been corrected
28.5 Transosseous Osteosynthesis

in the Management of Patients
with Complicated Fractures
of the Thoracic and Lumbar Spine
Indications for surgical treatment of these patients are severe

spinal deformity with spinal canal deformity and compres-
sion of the spinal cord.
In patients with compression of the spinal cord or cauda
equina roots, surgical treatment must include spinal cord
decompression and stabilization of the injured segment by
external transpedicular fixation. Decompression of the spinal
cord is done through a posterior approach and includes the
following stages: a
1. Extensive laminectomy is performed at the level of com-
pression. If the compressing substrate is sufficiently
extensive in the longitudinal direction then for the pur-
pose of expanding the surgical approach a laminectomy
of one vertebra is supplemented by partial resection of
the adjacent arches, which provides a complete view of
the spinal canal posteriorly on the right and left strictly
along its side walls. This approach allows for good mobi-
lization of the dural sac along the entire length of the
surgical wound. Anterior, lateral, and posterior decom- b
pression of the spinal cord and cauda equina roots is
done through the posterior approach without any Fig. 28.8 (a, b) Spinal cord decompression
difficulties or dangers of additional trauma to the spinal
cord. Free-lying bone fragments and lost fragments of
the disc are removed. Curettage of the disrupted disc and
anterior fusion are done in patients with third-degree anterior-lateral approach. This approach and material for
compression (Fig. 28.8). the fusion depend on the level and character of the damage.
If the compressing factor consists of many unconnected The osteosynthesis procedure is similar to the technique
small fragments located under an intact posterior longitudi- used for uncomplicated spinal lesions and consists of the
nal ligament, this compressing substrate is pressed with a insertion of two pairs of half-pins below and two pairs
curved rasp, positioning it behind the dural sac anteriorly and above the fracture line. The compressed vertebra remains
tapping it using a mallet to strike the rasp. This results in intact.
straightening of the anterior wall of the spinal canal and A kyphotic deformity >25° is addressed by a device with
eliminates compression of the spinal cord and cauda equina two modules, consisting of three pairs of half-pins, which
roots. allows for increased construction stability and improved
The next step is revision of the spinal cord through a lin- deformity correction (Fig. 28.9).
ear longitudinal incision of the dural sac, made using a nar- The initial correction of traumatic kyphosis or scolio-
row spreader. The spinal fluid cyst is emptied, if one is sis is done on the operating table by compression between
present, the subdural or intramedullary hematoma is evacu- the blocks of the device, which is either equal on the two
ated, and spinal cord detritus is washed away. The dura mater sides (kyphosis), or different in size depending on the
is then stitched. direction of the curvature (scoliosis). The support blocks
In case of vertebral dislocation or subluxation, open are interconnected using hinges in case of a scoliotic
correction is done using a rasp or one-tooth hook. component of the correction. Residual deformity is
Manipulation of the operating table panels facilitates patient addressed by additional correction in the early postopera-
positioning. tive period.
Osteosynthesis of the spine by external transpedicular Epidural electrodes are placed above and below the
fixation is used in patients requiring a gradual correction of injury level in order to improve the spinal cord’s conduc-
their deformity. Anterior fusion is the main stage of the tive function. Electrical stimulation sessions are applied
intervention and is accomplished using a posterior or twice a day for 20–30 days. Complex restorative treatment
is prescribed at the same time, including vascular medica-

tions, nootropics, neuroprotectors, vitamins, physical
exercise therapy, massage, and hyperbaric oxygen
therapy.
After surgery and radiographic control and correction of
all spinal deformity components, the device is set into fixation
mode.
Radiographic examination and computer tomography
(CT) are necessary to verify the formation of a bone,
bone-and-fibrous, or bone-and-metal block in the oper-
ated segment of the spine. Upon verification of fracture
consolidation, the fixator is removed. The average con-
solidation time is 30–35 days (Figs. 28.10, 28.11, 28.12,
and 28.13).
After fixator removal it is recommended that the patient
Fig. 28.9 Spinal osteosynthesis with a device consisting of two mod- wear a semi-rigid brace for 6 months, until the next radio-
ules, each of which includes three supports graphic control.
b c d e
Fig. 28.10 Patient photo (a), spondylograms (b, c) and myelograms (d, e) of 32-year-old patient B., admitted to the hospital for an L2 compres-
sion fracture with kyphotic and scoliotic spinal deformity and deformity of the dural sac covering two-thirds of the AP diameter
a b c d
Fig. 28.11 Patient photos (a, b) and spondylograms (c, d) after decompression of the cauda equina roots and fixator application. The spinal axis
is correct, the deformity has been corrected
a b c d
Fig. 28.12 Patient photos (a, b) and myelograms (c, d) of patient B. after fixator removal. The spinal axis is correct; there is no spinal dural sac
deformity
Fig. 28.13 (a, b)

Spondylograms of patient B.,
2 years after discharge from the
hospital. The spinal axis is
correct; there is no spinal canal
deformity
a b
28.6 Transosseous Osteosynthesis by the method of transosseous osteosynthesis are: the pres-
in the Management of Patients ence of spinal cord compression that has not been corrected
with Neglected Lesions in a timely manner, severe spinal deformity, and orthopedic
of the Thoracic and Lumbar Spine failure of the injured part of the spine.
Surgical intervention consists of the following:
The management of patients with intermediate- and late- 1. Extensive laminectomy at the level of spinal cord com-
term spinal cord traumatic disease is not clearly defined. The pression. Two adjacent arches are resected to increase the
obstacles to complete acute correction of a spinal column surgical approach. If there is a connective tissue scar, it is
deformity in all patients with neglected complicated spinal resected. The mobilized dural sac is pulled aside, fol-
trauma is a persistent evident pain syndrome after surgery, lowed by anterior decompression of the spinal cord.
the danger of spasm in vessels participating in the blood sup- 2. Spinal fluid circulation is restored during the subsequent
ply of the spinal cord, and a deterioration of neurological meningo-myelolysis.
symptoms. Also, both the presence of bone or bone-and 3. Based on the indications, inter-body fusion and osteosyn-
fibrous consolidation at the level of deformity and scar thesis with an external transpedicular fixator are per-
changes in the spinal canal create significant difficulties in formed (Fig. 28.14).
case of acute correction, first of all due to a worsening condi- The osteosynthesis technique for the spine and the stages of
tion of the injured spinal cord. By contrast, a gradual restora- deformity correction do not greatly differ from the corre-
tion of the spinal axis does not cause either blood supply sponding procedures used to treat acute spinal and spinal
disorders or tension on the spinal cord and its roots. cord trauma. After all the manipulations are completed and
Indications for surgical treatment of patients with inter- radiographs have been taken, the device is set to fixation
mediate- and late-stage traumatic disease of the spinal cord mode (Figs. 28.15, 28.16, 28.17, and 28.18).
Fig. 28.14 (a, b)

Decompression,
osteosynthesis,
and fusion of the spine
a b
Fig. 28.15 (a, b)

Patient P., 35 years
old, with
consequences of a b
neglected L2 fracture,
including contusion
and prolonged
compression of the
spinal cord, lower
paraplegia, and
functional disorders of
the pelvic organs
Fig. 28.16 Spinal X-ray images of patient

P. (a, b) Myelography before surgery shows a b
compression of the dural sac at L2. (c, d)
Spondylograms after surgery show the
gradual correction of the spine and spinal
canal deformities
c d
Fig. 28.17 (a–e) Patient P. after

a b c
surgery. The patient walks
unaided using a support
d e
Fig. 28.18 Photo (a–c) and

a b c
spinal X-ray images (d, e) of
patient P. after fixator removal.
He walks unassisted and without
additional support. There is no
deformity of the spine and spinal
canal
d e
28.7 Transosseous Osteosynthesis of the above-lying vertebrae and two pairs of half-pins in the
in the Management of Patients iliac wings.
with Spondylolisthesis The fixator is assembled on the operating table. The dis-
placed vertebra and three-four of the above-lying vertebrae
Transosseous osteosynthesis in the gradual reduction of a are pulled posteriorly in a staircase order (more L5, less L4,
displaced vertebra is especially relevant for the management a bit less L3, etc.) with the help of a microchannel bracket.
of patients with spondylolisthesis [597, 598]. In case of acute Translation of the displaced vertebra should not exceed 1.0–
reduction of the displaced vertebra, there may be sharp pain 1.5 cm (Fig. 28.19).
in the area of the surgery, pain in the lower limbs, and neuro- After surgery, gradual reduction is done under spondylo-
logical disorders. gram control in lateral views (Fig. 28.20).
Indications for surgery are: progressing vertebral dis- The displaced vertebra are maximally reduced to allow
placement secondary to dysplasia or spondylolysis, recovery of the anatomic and biomechanical inter-relation-
traumatic spondylolisthesis, unstable grade III–IV spon- ships in the injured segment, with the possibility of fusion. In
dylolisthesis, and spondylolisthesis with stenosis of the spi- case of a pain syndrome and transient neurological disorders,
nal canal. the reduction is stopped.
The first stage of the procedure consists of osteosynthesis The next stage of surgical treatment is fusion at the level
with the external transpedicular fixator. In patients with com- of the displacement using an anterior approach (lower-medial
pression of the spinal canal’s structures by the arch of the laparotomy for L5–S1, extraperitoneal for above-lying
displaced vertebra, then simultaneously with spinal osteo- segments).
synthesis laminectomy and discotomy are done at the level In a lower-medial laparotomy, after a linear skin incision
of the affected site. on the mid-line of the abdomen from the level of the omphalus
The osteosynthesis is carried out by the insertion of half- to that of the pubis and dissecting the abdominal membrane,
pins in the displaced vertebra, specifically into two or three intestinal loops are moved aside to facilitate access to the
Fig. 28.19 Assembly of the

external transpedicular fixator. 1
Microchannel bracket, 2 plate, 3
threaded rod interconnecting the
plates, 4 plate at the level of the
displaced vertebra, 5 L-shaped
clamp, 6 half-pin
Fig. 28.20 The stages

of osteosynthesis using external
fixation: (a) after laminectomy,
discotomy, and osteosynthesis
with the external fixator; (b) after
reduction of the displaced
vertebra
a b
posterior wall of the abdominal cavity at the level of L5–S1. A

castellated burr is used to make a slot in the bodies of the adja-
cent vertebrae. Autograft or porous nickelide titanium implant
is tightly packed into the slot (Figs. 28.21 and 28.22).
The extraperitoneal approach is done at the lower edge
of the 12th rib, on the right, with the patient lying on his or
her side. By blunt and sharp dissection, the iliopsoas mus-
cle and the bodies of the involved vertebrae are exposed.
The fusion level is specified under radiographic control
with the help of a reference wire. The soft tissues are sepa-
rated from the bodies of these vertebrae. A set of chisels is
used to perform a discotomy at the indicated level followed
by curettage of the disc cavity using a set of scoops. The
implants are tightly inserted under the edge of the annulus
fibrosus into the disc cavity with the aid of an impactor
(Figs. 28.23 and 28.24).
The external transpedicular fixator is removed after
verification of the bone-fibrous or bone-metal block accord-
ing to the CT data, on average after 20 days. During the fol-
lowing 6 months, patients should limit loading of the lumbar
spine and wear a fixating brace.
Recently, internal transpedicular systems have been
employed in combination with anterior fusion with nickelide
titanium through a posterior approach, in order to stabilize Fig. 28.21 Lower-medial laparotomy: approach to L5, S1 (1, 3),
the achieved reduction, as shown in the above figures. fusion with an autograft (2)
a b
Fig. 28.22 (a) CT of 14-year-ol patient M., admitted with grade IV spondylolysis antelisthesis of L5; (b) during treatment, (c) after treatment.
Anterior fusion with an autograft from the iliac wing
a b c
Fig. 28.23 Osteosynthesis using an external transpedicular fixator and anterior fusion with a porous nickelide titanium implant: (a) before treat-
ment, (b) after reduction, (c) fusion with the implant through an extraperitoneal approach
a b c
Fig. 28.24 Spinal X-ray images of 39-year-old patient K. diagnosed fusion with a porous nickelide titanium implant (extraperitoneal
with grade II spondylolysis antelisthesis of L4 before (a) and after (b) approach after Chaklin); after external fixator removal (c)
closed osteosynthesis using external transpedicular fixation and anterior
28.8 Transosseous Osteosynthesis in the visualize the spinous processes, the cuffs of the spinal cord
Management of Patients with Scoliosis roots, and the nerve trunks (Fig. 28.25).
The scheme employed in the osteosynthesis depends on
The goal of surgical treatment for patients with scoliosis is the the type and degree of the deformity as well as whether there
maximally rational correction of the spinal deformity and its is evidence of a rotational component. Osteosynthesis in
stabilization in the achieved position of correction. This goal C-shape spinal deformities and non-evident rotation of the
is fulfilled through multi-stage surgical treatment. Indications vertebral bodies has the following specific features
for treatment are scoliotic spinal deformities of grades III–IV. (Fig. 28.26):
The first stage of the surgical intervention is resection of • The first module of the fixator, consisting of three sup-
the costal curvature to improve the cosmetic appearance and ports, is positioned at the base of the curvature arch in the
to increase spinal mobility during deformity correction. The upper-thoracic spine.
second stage is closed osteosynthesis of the spine with exter- • The second module of the fixator, consisting of two sup-
nal transpedicular fixation. ports, is positioned at the apex of the deformity.
The surgical intervention is planned with the aid of CT • The united support module is assembled, consisting of
imaging to reveal maldevelopments, determine the degree of two supports at the base of the curvature in the lumbar
vertebral body rotation and the spatial positioning of the spine and one or two supports positioned on the basis of
pedicles of the arches and the spinal cord position, and to half-pins inserted into the iliac wings.
a b
Fig. 28.25 Planning half-pin

insertion: (a) scheme of
transpedicular insertion; CT data
of (b) a normal vertebra and (c)
scoliosis
Fig. 28.26 Osteosynthesis for C-shaped spinal deformities with non-

evident rotation of the vertebral bodies
Fig. 28.27 Osteosynthesis for C-shaped spinal deformities with evi-
dent rotation of the vertebral bodies
The specific features of osteosynthesis for C-shaped spinal
deformities and evident rotation of the vertebral bodies are
(Fig. 28.27): After the external transpedicular fixator is assembled, the
• The module consisting of three support plates is posi- scoliotic deformity is partially corrected (30–50°) acutely on
tioned at the base of the curvature in the upper-thoracic the operating table by half-pins inserted into nuts on the dis-
spine. traction hinge units between fixator blocks, distracting on the
• The module consisting of one or two supports is assem- concave side and compressing on the convex side (Fig. 28.29).
bled at the base of the curvature in the lumbar spine. The rate and efficacy of scoliosis correction is controlled
• The module consisting of two supports is assembled on radiographically as often as once every 10–14 days.
the iliac wings. Correction takes on average 28–32 days (Figs. 28.30 and
There are also several specific features in the osteosynthesis 28.31).
used to treat S-shape spinal deformities (Fig. 28.27): The next stage of surgical treatment is stabilization of the
• The module consisting of three supports is positioned at achieved correction. The type and level of fusion are chosen
the base of the curvature in the upper-thoracic spine. depending on the degree of deformity, the patient’s age (at
• The module consisting of three support plates is assem- the end of osteogenesis), and the type of equipment.
bled in the intermediate area at the base of the curvature Directly after fixator removal, the spine is immobilized
in the lower thoracic and lumbar spine. with a rigid thoracic and lumbar brace. The patient should
• The united support module is assembled on the basis of wear a rigid brace for 6 months and follow an orthopedic
one support in the lower thoracic spine and two supports regime consisting of physical exercise therapy, massage, spa
assembled on the basis of half-pins inserted through the therapy, etc. Blows and axial stress to the spine should be
iliac wings (Fig. 28.28). avoided.
Fig. 28.28 The fixator for S-shaped scoliosis: 1 half-pin, 2 plate, 3

hinge unit, 4 distraction rods
Fig. 28.29 Insertion of half-pins

(a), fixator assembly (b)
a b c
Fig. 28.30 Spinal X-ray images of patient G. with an S-shaped scoliosis (a) before surgical treatment and (b, c) on days 2 and 20 after surgery
Fig. 28.31 Spinal X-ray images

before treatment (a) and after
correction (b) of a C-shaped
scoliosis deformity of the spine;
view of the patient (c)
a b c
28.9 Complications the degree of vertebral rotation, the insertion angle, and the
length of the half-pin threads.
28.9.1 Complications During Surgery If X-ray images reveal malpositioning of a half-pin or if
neurological disorders appear then a CT exam is urgently
Bleeding from the surrounding tissues can arise during half-pin required immediately after surgery, which allows for deci-
insertion and can be stopped by pressure dressing or temporary sion-making regarding the removal and reinsertion of the
packing with cotton swabs soaked in hydrogen peroxide. fixation element. In such cases, the compressing factor is
In case of liquorrhea from the half-pin site, the half-pin urgently removed and complex restorative treatment is
should be removed, the pin-tract sealed using an interrupted applied, including vascular medications, nootropics, spas-
suture, and the half-pin reinserted elsewhere. molytics, massage, electrical stimulation, and physical exer-
cise therapy.
Liquorrhea indicates positioning of a half-pin in the spi-
28.9.2 Postoperative Complications nal canal, necessitating removal of the half-pin, sealing of
the pin-tract by interrupted sutures under local anesthesia,
Non-compliance with the technique of half-pin insertion can and medications to decrease liquor production.
cause neurological complications associated with penetra- In the postoperative period, there can be inflammatory
tion of a half-pin into the spinal canal (liquorrhea), complications associated with non-compliance with the
inflammatory complications, and breakage of parts of the hygienic rules and the non-opportune change of dressings.
construction. Medical staff and the patient’s caregivers must comply with
Planning of the surgical intervention should consider all the rules regarding aseptic and antiseptic use. In case of soft-
of the anatomic properties of the deformed spine in order to tissue inflammation around a half-pin, conservative treat-
prevent neurological disorders. CT of the vertebral bodies at ment is necessary using antiseptic solutions and a course of
the apex of the deformity is therefore necessary to determine antibiotic therapy.
When breakage of a fixation element is diagnosed it must plete correction of the spinal column deformity in 90%. None
be removed and the question of spinal fixation again is of the patients, according to CT and MRI data, had a verte-
addressed. bral-medullary conflict at discharge from the hospital.
In our experience, there have been 54 (13.86%) complica- Among patients with neglected spinal injuries at the time
tions of general character. Another 52 (13.33%) involved of discharge from the hospital, in 86% of cases a stable bone
suppuration of the soft tissue around the half-pins, osteomy- block had formed in the operated segment. Signs of pro-
elitis of vertebral bodies L4 and L5 in one patient and T10– longed compression of the spinal cord and its structures were
T11 in another. Osteomyelitis was arrested in both cases after not seen in a single case. Kyphotic spinal deformity was cor-
conservative treatment. A strong bone block formed at the rected entirely in 60% of patients, and severe vertebral dis-
area of inflammation was confirmed at the time of discharge placement in 28%. Positive shifts in neurological status were
from the hospital. Follow-up examinations did not show evi- established in 48% and included active motions (12%) in the
dence of osteomyelitis recurrence. Pin-tract soft-tissue lower limbs and a decrease of the degree of paresis (36%).
inflammation was arrested with conservative measures. Partial regression of pelvic disorders was documented in
Among the local complications, there were 21 (5.38%) 18% of patients. Treatment results were evaluated as positive
breakages of half-pins; the half-pin fragments were later in 80% of the patients with a syndrome of complete spinal
removed. cord conductivity impairment, and in 93% with a partial con-
ductivity impairment.
Surgical treatment results for patients with complicated
28.10 Efficacy of Transosseous Osteosynthesis spondylolisthesis were evaluated using the classification of
Application in Vertebrology Zaretskov. A positive result after surgery was confirmed in
96% of the patients with spondylolisthesis, and a poor (per-
The short-term results of surgical treatment of patients with sistent neurological deficit) in 4%.
uncomplicated spinal trauma were evaluated as good in Spondylolisthesis was eliminated by the time of discharge
94.82% of patients and satisfactory in 5.17% of cases. There in 46% of the patients, with residual displacement within
were no poor results. grade I in 34%, grade II in 12%, and grade IV in 8% of
The degree of correction of traumatic kyphotic spinal patients. Not a single patient had a grade III vertebral dis-
deformity using external transpedicular fixation amounted to placement at discharge, which can be explained by the verte-
72.74%. bral reduction procedure.
An EMG study after fixator removal was compared with Thus, the use of an external transpedicular fixation for the
the preoperative findings. Changes in the indices consistent management of patients with complicated spondylolisthesis
with functional recovery of the nervous structures were of the lumbar spine allows for positive outcomes after sur-
determined. In that study, all patients with acute spinal and gery in 96% of cases, and positive long-term results in
spinal cord trauma after decompression of the spinal cord 95.45%.
and cauda equina roots underwent external transpedicular Results of treatment for patient with scoliosis were evalu-
fixation to correct the deformity and provide fixation of the ated immediately at their discharge from the hospital and
spinal column. Patients with evident neurological deficit later at an interval of 6 months to 6 years. Data regarding
were treated with epidural electrodes for subsequent electri- orthopedic status and based on spinal X-ray images and neu-
cal stimulation in the early postoperative period. rological examinations were used in the evaluation of the
Severe traumatic spinal deformities >20° prevailed in results. Of particular relevance is that neurological complica-
more than half of the patients (51.47%). A kyphotic defor- tions associated with traction of the spine and the contents of
mity <20° was determined in 48.52%. spinal canal did not appear in a single case.
Anterior compression of the spinal cord and cauda equina In a group of patient with grade III scoliosis, treatment
roots by bone structures and traumatic disc herniations was results were better in patients age 12–15 years (60–85% cor-
diagnosed in 73.52%. rection) than in other age groups. A shorter time for defor-
Spinal shock was diagnosed in 4.9% but did not have an mity correction was also noted in this group, on average
evident clinical picture. These patients had neurological dis- 20 ± 5 days. Loss of correction after 1 year did not exceed
orders (motor, sensory, disorders of pelvic organ functions) 4–6%, and over the longer term (1–2 years) it did not exceed
and most (80%) had severe disorders of spinal cord on average 10%.
function. In older patients with grade IV scoliosis, treatment results
As a result of treatment, the number of patients without were satisfactory, defined as a 20–60% correction of the
motor disorders significantly increased compared to the num- deformity. The duration of scoliosis correction in these
ber at admission (3.92% and 96.07% respectively). Recovery patients was 30 ± 6 days. Loss of correction after 1 year was
of pelvic organ function was determined in 30%, and com- 13% and over the longer term (1–2 years) 16%.
Conclusion good mobilization of the dural sac and the staged removal
The surgical management of patients with lesions and dis- of compressing factor are essential components.
eases of the spine and spinal cord is one of the most Multi-year experimental studies at the RISC “RTO”
important issues of modern medicine. have provided scientific confirmation of the efficacy of
It is very important to restore the correct axis of the transosseous osteosynthesis in the treatment of spinal
injured spinal segment, not only decompression of the pathology, including safe and stable fixation and the grad-
spinal cord and cauda equina roots but also controlled ual impact on the tissues of the spinal column. This method
fixation of the injured part of the spinal column. establishes the conditions for reparative regeneration and
A thorough picture of the nature and extent of injury of well-aimed vertebral modeling while improving the likeli-
the spinal cord and its formations in patients with “uncom- hood of complete anatomic and functional recovery of the
plicated” spinal fractures requires complex methods of nervous and vascular structures of the spinal canal.
examination (clinical, radiographic, electrophysiologi- For patients with spondylolisthesis in the lumbar spine,
cal). This information provides the basis for performing opportune decompression of the cauda equina roots and
external transpedicular fixation and, in general, the sys- stable and controlled transpedicular fixation of the spinal
tem of management for patients with fractures of the tho- cord at the pathology level allow for early patient activa-
racic and lumbar spine. tion, better treatment results, and a lower rate of
Results of clinical investigations have shown that surgi- disability.
cal intervention in the acute, intermediate, and late periods For patients with grade III–IV scoliosis, effective
of traumatic spinal cord disease is indicated only in the deformity correction without neurological consequences
presence of compression of the spinal cord or cauda equina and recovery of the anatomic and biomechanical interre-
roots, regardless of the character of the external compress- lations can be expediently achieved with osteosynthesis
ing substrate. Anterior decompression of the spinal cord is of the spine using external transpedicular fixation and
possible through a posterior approach. Wide laminectomy, subsequent gradual correction of the scoliosis.
Correction of the Sizes and Forms
of the Jaws 29
Metin Orhan
29.1 Introduction Accordingly, DO can be used in children who require

treatment while still in the early stage of growth and in those
For the correction of skeletal malocclusions, conventional with moderate and severe maxillary deficiency who need only
orthognatic surgical methods can be utilized in adults; how- a large forward or a forward and downward lengthening of
ever, these surgical procedures have limitations due to the the maxilla [609]. The correction of a maxillary deficiency by
acute advancement of bones [599–601]. Due to the resistance DO in growing patients improves not only the psychological
of the soft tissues to acute stretching and the difficulty of status of the patient but also that of his or her parents [609].
adaptation, sufficient bone advancement can not be achieved, A review study of 285 reports on DO analyzed 828 patients
thus resulting in relapse [602–605]. who were treated by this procedure. Of these, 579 patients
Distraction osteogenesis (DO), in which bone is moved underwent mandibular DO, 129 maxillary DO, 24 both man-
forward gradually, is an alternative treatment method that dibular and maxillary distraction, and 96 in whom the proce-
was developed to overcome the limitations of conventional dure involved the midface and cranial region [611].
orthognathic surgery. Previously, DO was used for the cor- In a meta-analysis of the maxllary DO reports published
rection of craniofacial deformities, but nowadays it is applied between 1996 and 2003, 95% of the patients used an extraoral
to the early or late treatment of orthodontic skeletal discrep- distractor (69% the RED appliance, in 26% a reverse head-
ancies [606, 607]. gear), and 2% an intraoral distractor (Cheung and Chua
Some of the advantages of DO compared to orthognatic 2006).
surgery are:
1. No need for bone graft
2. More stable results 29.2 Indications and Contraindications
3. Treatment of younger patients
4. Correcting of deformities at earlier ages, thereby increas- The indications for craniofacial distraction are:
ing patient wellness and self-confidence 1. Unilateral or bilateral mandibular hypoplasia [612]
Distraction can be achieved without a bone graft [608, 2. Mandibular transversal deficiency [613, 614]
609]. The results are more stable and the amount of relapse 3. Maxillary and mid-face deficiency (craniofacial microso-
is less due to the progressive movement of bone [608, 610], mia) [607, 610]
Moreover, in orthognatic surgery, it is necessary to wait until 4. Maxillary transversal deficiency [615]
the end of growth whereas DO can be performed at every 5. Segmental advancement of the maxilla in maxillary
growth stage [608]. deficiency [606, 616]
6. Vertical augmentation of the alveolar crest before implant
surgery [617]
7. Distractive eruption of ankylosed teeth [618]
M. Orhan 8. Maxillary and mandibular micrognathia [619]
Faculty of Dentistry, Department of Orthodontics, The contraindications are a health condition incompatible
Gazi University, Biskek caddesi, 82 Sokak, No 4, Emek,
Cankaya, 06510 Ankara, Turkey with a DO procedure and an insufficient bone vasculariza-
e-mail: mmetinorhan@gmail.com, metinorhan@hotmail.com tion and repair capacity.
1418 M. Orhan
Fig. 29.1 Hoffman mini Lengthener (Stryker Leibinger, Kalamazoo,

MI, USA)
Fig. 29.2 ACE/Normed bi-directional distractor (KLS-Martin, L.P

Jacksonville, FL, USA)
29.3 Special Features of the Equipment

29.3.2 Intraoral Distractors
Generally, craniofacial distraction appliances can be
classified as either extraoral or intraoral. Intraoral distractors can be used for lengthening and widen-
ing of the mandible [622], widening of the maxilla [615],
and lengthening of the maxilla [616].
29.3.1 Extraoral Distractors There are three types of devices, distinguished according
to their anchorage sites:
The first report of the use of an extraoral distractor was that of 1. Bone-borne: anchorage provided only from bone
McCarthy et al. in 1992 and involved four patients. Mandibular 2. Tooth-borne: anchorage provided only from the teeth
sagittal distraction was achieved with the “Hoffman Mini 3. Hybrid: anchorage from both teeth and bone
Lengthener” (Stryker Leibinger) (Fig. 29.1), a uni-directional Bone-borne intraoral distractors consist of a cylindirical
distractor used in hand reconstruction [612]. distractor rod (screw ) mounted on two miniplates. It can be
In 1996, Klein and Howaldt reported both sagittal and used in both the maxilla and the mandible with the same pro-
vertical advancement using bidirectional (bilateral) mandib- cedure and rules of application [623, 624]. In patients with
ular distraction in 18 patients [620] (Fig. 29.2). oligodonthia, the main advantage of bone-borne distractors
In 1997, Polley and Figueroa developed their Rigid is that there is no need for tooth support [625].
External Distraction system for maxillary advancement In tooth-borne intraoral distractors, a hyrax-type screw is
(RED; KLS-Martin LP) (Fig. 29.3). With the RED, a 15-mm soldered onto orthodontic bands or steel crowns placed on
maxillary advancement was achieved in a 10-year-old patient the teeth in a previous laboratory process. The first use of
with bilateral cleft-lip/palate. Stable results at 1 year follow- tooth-borne distractors was in mandibular sagittal DO and in
up were reported [621]. mandibular symphyseal DO [613, 617, 626]. In recent years,
The RED appliance consists of a halo frame that resembles these distractors are mostly preferred for segmental maxil-
an Ilizarov ring fixator fixed to the cranium. Maxillary traction lary DO [606, 616].
is achieved by an intraoral tooth-borne splint or/and bone-borne The anchorage of hybrid intraoral distractors is provided
fixation as anchorage. As a result of modifications to the device from two areas: (1) the supporting bone adjacent to the dis-
that have been made since its introduction, it has been widely traction area and (2) the teeth, which are banded or crowned
accepted as a treatment method for mid-face deficiencies. [614] (Fig. 29.4).
29 Correction of the Sizes and Forms of the Jaws 1419
a b
Fig. 29.3 (a) RED I (Rigid External Distractor; KLS-Martin, L.P Jacksonville, FL, USA). (b) RED II (Rigid External Distractor; KLS-Martin,
L.P Jacksonville, FL, USA)
Fig. 29.4 Intraoral distractors

1420 M. Orhan
29.4 General Principles of the Surgical osteotome. During this procedure, to prevent laceration of the
Techniques in Maxillary palatal flap and the inadvertent use of excess (uncontrolled)
and Mandibular Distraction force, the palatal region should be supported by the index finger.
The vertical and horizontal osteotomies are joined in such a
Although some researchers recommend that local anesthesia way that the mobility of the segment can be ascertained.
and conscious sedation can be used for patients undergoing During osteotomy, damage to the dental roots adjacent to
DO surgical procedures, the use of general anesthesia is often the osteotomy line should be avoided. The total mobility of
preferred, both for the patient’s and the surgeon’s benefit. the segments should be checked. After the intraoral place-
The distraction rate takes into account the total amount of ment of the distractors (bone-borne, tooth-borne, or hybrid),
bone segment movement performed per day, while the dis- the mucosal flap is closed and sutured. With the patient still
traction rhythm is the number of increments per day into under anesthesia, the tooth-borne distractor is cemented to the
which the distraction rate is [617]. teeth with a light cure resin (Transbond XT, 3 M Unitek).
After a 7-day latent period, the distraction period begins,
typically with a distraction rhythm of 2 × 0.5 mm/day and a dis-
29.4.1 RED Surgical Procedure traction rate of 1 mm/day. The patient is seen once a week. When
sufficient distraction is accomplished, the distraction period is
The first step is maxillary osteotomy, which can be of the Le terminated and the consolidation period is started. The distrac-
FORT I, II, or III type. Following the osteotomy, the halo frame tors are removed at the end of the 8–12-week consolidation
of the RED appliance is adjusted to the patient’s skull and fixed period, once accurate and adequate stabilization is confirmed.
rigidly with two or three screws. After a latent period of
3–5 days, the vertical bar of the RED is placed along the mid-
sagittal plane and then, with steel wires, rigidly engaged with 29.5 Postoperative Protocol
the external extensions of the intraoral part. In the distraction
period, the distraction rhythm is 2 × 0.5 mm/day, and the dis- 29.5.1 RED
traction rate 1 mm/day. The patient is seen once a week. When
a sufficient amount of distraction is obtained, the distraction One of the most important issues in the use of the RED is the
process is stopped and the distractor is unscrewed to release care of the pins, as in Ilizarov ring fixators. The pins should
the stress on the internal part. If distraction is stopped but the be frequently checked and the pin sites should be protected
device is not unscrewed, the maxilla continues to move for- against infection.
ward due to the residual forces stored in the extensions [627]. The appliance is kept in place during the 3-week con-
solidation period. The pins can be removed without seda-
tion or local anesthesia and the extraoral traction hooks are
29.4.2 Segmental DO Surgical Procedure cut. After 3 weeks, traction is continued with the reverse
headgear (protraction face mask) and one or two 6-oz elas-
Today, this technique is primarily used in the maxilla. tics (minimum 8 h/day) This period is referred to as the
Osteotomies are performed along the interdental regions. retention period and it lasts 6–8 weeks [627].
The maxilla can be moved forward so that an increase in arch
length is achieved.
At either end of the horizontal mucosal cut, vertical cuts 29.5.2 Intraoral Distractor
to extend the bone level of the alveolar crest are made
between the premolars. The mucoperiosteal flap is then After segmental DO, the latent period is 7 days. The patient
elevated to provide better visualization and to protect the is controlled clinically; if any mobility is seen, the appliance
adjacent dental roots during vertical osteotomy. The amount is removed and recemented.
of dissection should be kept to a minimum in order to pro- Considering the thread configuration of the screw and the
tect the gingiva in the alveolar crest. stretching limitations of the surrounding soft tissues, the
Horizontal osteotomy is performed 3–5 mm above the distraction rate should be 0.5–1.0 mm/day. The amount of
dental root tips using a motorized saw. The anterior nasal screw activation depends on the needs of the patient and it is
spine is separated by a nasal osteotome. checked with a digital Boley gauge. It is important to confirm
Vertical osteotomy lines are pencil-marked between the that the patient has performed the activation process.
bicuspids along a line extending from the attached gingiva to Complete mineralization of the distraction regenerate dur-
the piriform aperture. ing the consolidation period may take as long as 3 months.
Preferably cortical bone is first cut vertically by a bone sep- A case of maxillary sagittal and vertical deficiency treated
arator and then gently separated with a very thin interdental by distraction osteogenesis is shown in Fig. 29.5.
a b
Fig. 29.5 (a–f) Use of an intraoral bone-borne distractor in the max- was 11 mm in the sagittal and 7 mm in the vertical direction. (a)
illa of a 27-year-old female. A segmental maxillary osteotomy was Maxillary occlusal view before distraction, after distraction (after
performed between the first molar and second premolar followed by consolidation). (b) Overjet before distraction, after distraction, after
sagittal and vertical distraction. Skeletal movement of the maxilla consolidation
1422 M. Orhan
c d
e f
Fig. 29.5 (continued) (c) Before distraction. (d) After distraction. (e) After consolidation. (f) Superimposed before distraction and after consoli-
dation cephalograms
Table 29.1 Complications associated with the use of the RED Table 29.2 Complications of intraoral distractors
Pain Oral mucosal infections due to the long-term placement of the
Loosening and/or migrations of the pins distractor in the mouth [608]
Scars around pinhole Gingival recessions due to insufficient adaptation of the approximal
Penetration and/or migration of pins to the skull gingival mucosa to the distraction rate
Intracranial hemorrhage, cerebrospinal fluid leak, intradural/ During either the distraction or the consolidation period, the fracture
extradural abscesses, cysts and osteomyelitis of the skull of distractor plates made of flexible or non-rigid materials [636]
Pin-tract infection, soft-tissue infection Fracture of any part of the distractor as a result of overloading due to
miscalculation of the left and right distraction vectors
Broken pins, distractor parts
Displacement of the frame
Traumatic disasters
29.6 Complications (PLA/PGA) plates with a diameter of 0.8 cm were designed.

Each plate has a 1.5-mm hole in the center, through which the
The complications encountered with the RED device are pri- tip of the pin passes. These PLA/PGA plates, or stoppers, are
marily associated with the halo fixation pins and are listed in placed over the bone surfaces of the cranium where the tip of
Table 29.1. the pins press, thus acting as a second barrier. In addition,
In a retrospective study, there were 42 complications in they spread the pressure of the screws to larger surfaces, thus
21 patients treated with the RED, 92.9% of which were securing better stabilization. The penetration of wider por-
related to the pins. The most frequent problems was loosen- tions of the screw into the scalp is reduced, minimizing scalp
ing of the pins (42.9%) and frame displacement (28.6%), damage caused by the screws. Thus, these biodegradable and
with 25% of the latter cases due to trauma [628]. biocompatible PLA/PGA stoppers avoid the intracranial
Several studies have reported the penetration of fixation migration of the fixation pins, especially in children [633].
pins into the intracranial region during RED application In one patient treated with the RED, cerebrospinal fluid
[627, 629–632]. Five patients with midface hypoplasia leaked and a fracture sound was heard during removal of the
underwent Le Fort III osteotomies, and a rigid external dis- halo frame. On computed tomography examination, a local
traction device (RED II System, Martin L.P Tuttlingen, fracture and large arachnoid cyst were diagnosed. The men-
Germany) was applied. Despite precautions to avoid pin pen- ingitis was treated with broad-spectrum antibiotics for
etration, this complication occurred in two patients in whom 3 weeks. By the end of treatment, the patient had recovered
stoppers had not been used [631]. and there were no remaining symptoms [634].
A simple preventive method to avoid some of the serious A skull fracture was reported in a 7-year-old child wear-
problems associated with the RED was developed by Mavili ing an RED after he felt down [635],
et al. in 2004 [633]. To prevent pin penetration in rigid The complications associated with intraoral distractors
external distraction, circular polylactic acid/polyglycolic acid are listed in Table 29.2.
Application of External Fixation
in Skull Surgery 30
Alexander Nikolaevich Djachkov,
Alexander Timofeevich Khudiaev,
and Oksana Germanovna Prudnikova
30.1 Introduction consequences of stroke are very severe. According to some

authors, 20–50% of patients who suffer from cerebral insult
In brain ischemia, arterial blood flow to the brain is remain disabled, and only 10–15% are subsequently able to
insufficient or blocked. Ischemic injury to the brain can return to their jobs. In addition, 70–80% of patients with
develop in response to brain injuries or to non-traumatic con- brain insult become disabled, and 20–30% of them need
ditions (insults, infarctions, emboli) and may be of acute or regular family support [643, 645].
delayed onset [637]. The treatment of cerebral ischemia is directed at improv-
The rehabilitation of patients with brain ischemic lesions ing blood flow at the ischemic site and stimulating collat-
has become the focus of increasing interest due to the grow- eral recanalization. A combination of medical and physical
ing number of these cases and to the absence of effective therapy produces only short-term gains and has little effect
treatments aimed at improving blood supply to the brain. on reparative processes [646–651].
Moreover, there have been few efforts aimed at helping In recent years, surgical treatment has been employed to
patients adapt to the altered quality of life that often follows restore blood flow in the involved brain. These surgical proce-
ischemic injury. dures include endarterectomy [652, 653], palliative surgeries
The pathogenetic mechanisms underlying the disturbed of the sympathetic nervous system [653–655], and the cre-
microcirculation are related to those involved in neuronal ation of extra-/intracranial anastomoses [645, 656–658], all of
death and other structural and functional changes. This is also which were are most effective in patients with mild residual
the case regarding the clinical manifestations of cerebral post- ischemic effects. In patients with evident neurological symp-
ischemia, in which motor, sensory, and cognitive disturbances toms, however, good clinical results cannot be expected.
are inter-related and are characteristic for cerebral ischemia The high incidence of disability and the absence of reli-
of both traumatic and non-traumatic origin [638–640]. able methods to restore disturbed functions of the body
The scope and severity of a traumatic brain injury often have stimulated the search for new trends and solutions,
have social and economic consequences. Indeed, more than including with respect to the brain. Experimental studies of
60% of patients who suffer traumatic brain injury develop brain substance mechanical tunneling [659], omentum free
stable organofunctional disorders of the nervous system that vascularized graft [660, 661] and fetal nerve tissue grafting
result in social and occupational maladjustments. These inju- [662] have yet to be clinically adopted and their clinical
ries account for around 12% of the neurological deficits that relevance is not yet fully understood. According to the
result in disability [641–644]. respective authors, however, these techniques may be more
Strokes and infarctions are the most common causes of appropriate in treating acute disorders of the cerebral
brain ischemia among non-traumatic conditions. The social circulation.
A.N. Djachkov, M.D., Ph.D. (*)

Scientific Medical Department on Organization and Methodical Work, 30.2 Theoretical Basis Underlying the Use
Russian Ilizarov Scientific Center “Restorative Traumatology of Transosseous Osteosynthesis
and Orthopedics”, M.Uljanova Str., 6, 640014 Kurgan, Russia
e-mail: naucaalex@mail.ru, oksiniyap@yandex.ru
in Craniosurgery
A.T. Khudiaev, M.D., Ph.D. • O.G. Prudnikova, M.D., Ph.D.
Beginning in the later 1970s, researchers at the RISC
Department of Neurosurgery, Russian Ilizarov Scientific Center
“Restorative Traumatology and Orthopedics”, M.Uljanova Str., 6, “RTO” conducted a series of experiments addressing brain
640014 Kurgan, Russia injuries, cranial flat bone abnormalities, and brain
pathologies. In the initial experiments, a long-bone-defect

model was used to investigate the Ilizarov treatment
approach in the repair of post-traumatic and postoperative
cranial defects. The findings [663] suggested the feasible
repair of a cranial defect by transporting an autologous
graft. The first experiments involving cranial defect repair
were also performed using the same model and included an
osteotomy of one of the bone fragments followed by grad-
ual transport of the fragment together with surrounding tis-
sues. The defect appeared to be filled by the transported
bone and the newly forming regenerate bone, with the
resulting structure matching the one observed with limb
lengthening [230].
The starting conditions in each experiment (blood
supply, distraction rate, etc.) were different in each of the
series. Distraction provided tension stress in the tissues
forming in the gap between the rims of the fragment
being transported and the calvarial defect that contrib-
uted to distractional regenerate bone formation
(Fig. 30.1).
Bone tissue was shown to form in the gap during transport
of the bone fragment harvested at the defect border. Bone
trabeculae oriented along the transportation seemed to origi-
nate from the transported fragment, and the defect border
after a 7-day distraction became evident after a 5–7-day
latency period. Radiological and morphological findings dur-
ing the distraction period showed distractional regenerate
bone characterized by a zoned build-up of two bone sections
extending from (a) the defect border and the fragment and (b)
the connective-tissue layer. This “growth zone” consisted of
longitudinally oriented collagenous fiber bundles, fibroblasts, Fig. 30.1 Radiograph of an experimental model of cranial defect
less differentiated cells, and capillaries (Figs. 30.2 and repair
30.3).
Areas of active osteogenesis were noted at the bound-
ary of the growth zone and sites of osseous regeneration
throughout the entire observation period, with structural tissues indirectly impacted by the distraction. The pro-
rearrangements occurring in the new bone tissue at the cesses of angiogenesis and restructuring of the circulatory
defect border and the transported fragment. Active demin- bed are closely related to the level of bone formation
eralization was found to occur in the fragments trans- activity [642, 665].
ported during the first 3 weeks of distraction, as detected Operative intervention, bone distraction, and distrac-
using photon absorptiometry. Reparative processes were tional regenerate bone formation are accompanied by mor-
shown to be enhanced in the fragment after a 4-week dis- phofunctional changes in the blood circulatory system.
traction. Bone union between the fragment and the defect Blood filling shows at least a two-fold increase and remains
border developed 6–7 months later, with the transported high for approximately 1 year. The pattern of vascular pool
bone fragment completely restructured and filled with restructuring is based on wider lumens in all chains of the
newly formed bone tissue (Fig. 30.4) [664, 665]. circulatory bed, accelerated blood flow, and the availabil-
Regeneration of the vascular network develops from ity of circulatory reserves. With an increased vascular pool
blood vessels of the bone bed, revascularized regeneration and accelerated blood flow, a hypervascularized area
vessels, and vessels of the dura mater. Distractional osteo- extends over the distractional regenerate bone, the adja-
synthesis induces the build-up, growth, and development cent bone ends, and the bordering layers of muscles, fas-
of blood vessels at both the lengthening site and in the cia, and skin. Vascular morphogenesis is maintained by
30 Application of External Fixation in Skull Surgery 1427
Fig. 30.2 Histotopogram

of canine cranial bones after a
21-day distraction. H&E
staining; magnification (loupe)
Fig. 30.3 Regenerate “growth zone” with bone

trabeculae running across the zone. Same
observation as Fig. 30.2. Van Gieson’s staining
with picrofuchsin
Fig. 30.4 Histotopogram of

cranial bones after a 2-month
follow-up. H&E staining;
magnification (loupe)
the graduated distraction of tissues and by the impact of regenerate under the stimulating influence of distraction on
hemodynamic factors (increased volume of the circula- angiogenesis. A dense arteriovenular and capillary network
tion, pressure on the vascular wall, etc.). The latter are rich in anastomoses and an integrated microcirculatory sys-
important for the ingrowth of new blood vessels into tis- tem of blood outflow develop in the regenerate bone, thereby
sues that do not undergo distraction. A continuous increase ensuring enhanced arterial blood supply and a high level of
in blood filling provides functional loading for the venous metabolism (Fig. 30.5).
portion of the vascular network. Changes in the dilation of This results in both repair of cranial bone defects and
the great veins, their anastomoses, and microvessels, the stimulation of the blood supply in the involved portion of the
opening up of a circulatory reserve, and the introduction of brain in patients with post-ischemic cerebral disorders of
additional outflow pathways from the sites of regenerate traumatic and non-traumatic genesis. An advantage of the
bone all contribute to prevent venous insufficiency [666]. method is its potential application in the treatment of patients
Morphological findings show a spatially organized struc- with delayed disease in whom all other options have been
ture of blood inflow and outflow formed in the distractional exhausted.
Fig. 30.5 Microphotograph showing the

morphofunctional changes in the circulatory
system. Regenerated capillaries are oriented
along the transportation at day 21 of distraction.
Vessels filled with Gough solution. H & E
staining
30.3 Etiology and Pathogenesis of Brain from it. The fate of these cells differs and depends on the
Ischemia response to therapies aimed at restoring activity. Nevertheless,
cells injured directly may die, although the resulting impaired
Impaired cerebral circulation following a traumatic brain function may be recovered by the disinhibition of cells that
injury is characterized by a combination of organic and func- were previously inactive or hypoactive. Recovery of impaired
tional changes in the brain vessels. The initial pathogenetic function is also determined by the recruitment of previously
mechanism includes an injury to the vascular wall and artery functionally-inactive systems. The health of these supple-
and arteriolar spasm. Arterial spasm, impaired vascular reac- mentary systems (condition of the vessels, integrity of the
tivity, reduced local cerebral blood flow, and low cerebral contralateral parencephalon) determines the extent of their
perfusion pressure all contribute to ischemic cerebral lesions, involvement in compensating for the impaired functions
which are observed in 2–34% of patients and in 95% of those [668, 673, 674].
with severe traumatic brain injury. In addition, brain isch-
emia following a traumatic brain injury can develop due to
post-traumatic stroke, caused by a thrombus that develops as 30.4 Clinical Manifestations and the
a consequence of traumatic changes in the vascular wall, vas- Diagnosis of Cerebral Ischemic Lesions
cular spasm, or secondary hemorrhage at foci of ischemic
necrosis or ischemic brain tissue [667, 668]. The classification of the sequelae of complete cerebral isch-
With the high incidence of severe traumatic brain injuries, emia (CCI) is based on the following principles: (a) patho-
the number of patients with cranial defects has considerably genesis, (b) morphological substrate, and (c) clinical
increased. Primary cranioplasty in patients undergoing sur- manifestations [643]. A delayed period before the onset of
gery for diseases and traumatic injuries of the brain, the CCI is clinically characterized by the eventual recovery of
meninges, and skull bones is performed in slightly more than most of the impaired functions. However, the consequences
half of the cases (56.5%) [641, 669]. The defect that devel- of progressive CCI are dementia, epileptic seizures, syn-
ops over the long-term following a traumatic injury is a con- dromes of borderline neuropsychic disorders, asthenia, para-
nective tissue scar that is fused with the borders of the bone noid behavior, and psychopathic syndromes. Focal symptoms
defect, the meninges, periosteum, and skin, thus causing lead to stable residual performance but with a combination
hemodynamic, CSF-circulatory, functional, and organic dis- of dropout, anger, and disintegration.
orders that in turn result in the aggravation of brain ischemia Traumatic cerebral disease identified as a residual conse-
[670–672]. However, the problem of choosing the optimal quence of craniocerebral injury tends to show a dynamic
material for cranioplasty has not been solved. In some cases, progression and a progressive course. As noted above,
autologous bone can be used to repair a cranial defect. patients with cranial defects develop a connective tissue scar
The pathological nidus resulting from an acute stroke var- that is fused with the borders of the bone defect, the menin-
ies, reflecting the scope and severity of injury to the nerve ges, periosteum, and skin. Over the long-term period, these
elements. Nerve cells and fibers are degraded in the core, patients with traumatic disease are at risk of skull trephine
with many nerve cells showing less or a complete inhibition defects, inner and external hydrocephalus, ventricular scars,
of activity either in the proximity of the nidus or at a distance infection, and post-traumatic epilepsy.
The clinical manifestations of the consequences of 30.5 Transosseous Osteosynthesis

stroke depend on the extent and localization of the infarc- for the Treatment of Patients
tion. Maximal recovery of impaired motor function is with Cranial Vault Defects
observed in the first 6 months, everyday activities and abil-
ity to work within 1 year, and speech 2–3 years from the Transosseous osteosynthesis is performed during the recov-
time of acute stroke. Rehabilitation success likewise relies ery period (not earlier than 6 months in an acute condition).
on the extent and localization of the focus as well as the The indications include post-traumatic and postoperative
severity of the neurologic deficit and the disease duration defects of the frontal, parietal, and temporal lobes. Absolute
[643, 675–678]. contraindications are severe psychic disorders and arterial
Correct diagnosis of the disturbed circulation and of the hypertension poorly controlled with medications. Chronic
pathological changes in the brain is important in determin- diseases in the active phase are relative contraindications.
ing the appropriate treatment and rehabilitation of these The external fixation device is manufactured by FGUP
patients. Transcranial Doppler sonography and carotid (Pilot plant RISC RTO, Roszdrav, ul. M. Ulianovoy, 6,
angiography are used to assess cerebral blood flow and Kurgan, 640014). A titanium alloy, VT-6 (GOST 19807–74),
the collateral circulation. Craniography is informative for is used for the half-pins; stainless steel 17X18H9T (GOST
cranial bone defects and allows assessment of the site and 5632–72) for the wires with stoppers of silver containing
the dimensions of the defect. Computed tomography has blaze, and stainless steel 20×13 (GOST 5632–72) or carbon
facilitated the diagnosis of many injuries and diseases of fiber for the arches (Fig. 30.6).
the brain by evaluating the mechanisms of cerebral impair- Preparation of the patient for the surgical procedure is
ment, the scope and extent of the swelling and brain disloca- similar to that in any other surgical intervention. Endotracheal
tion, and the dynamics of these changes. New possibilities intubation is carried out with the patient in supine position.
with magnetic resonance imaging (MRI) allow both the The major external landmarks of the brain are the frontal and
visualization of brain substance and the assessment of the parietal tubercles and the sagittal suture. The procedure is
great cerebral vessels, without the use of contrast material. carried out as follows:
MR-angiography differs from conventional angiography, 1. Following a longitudinal dissection of the skin and perios-
offering a completely different approach that considers teum (up to 2 cm), a bilateral window to the inner cortex
blood flow velocity and direction. It allows imaging of the of the frontal and parietal tubercles is established to allow
arteries and the veins and is currently the gold standard for half-pins to be placed later on.
neurovisualization of the brain. Electroencephalography 2. Meningolysis, with the rims of the burr hole either
and electroneuromyography are used to assess the func- refreshed or extended.
tional condition of the nervous and nervous-muscular 3. A bone flap obtained from the removed bone fragment.
systems. and measuring one-fourth to one-third of the original size
Fig. 30.6 Parts of a cranial

external fixation device
a b
Fig. 30.7 Diagram of the frame assembly (a) and appearance of the patient (b)
a b
Fig. 30.8 Craniograms showing the repair of a parietotemporal defect during bone flap traction (a) and the termination of traction (b)
is formed. Two canals are drilled in the flap; these will be wires and threaded rods attached to the half rings
threaded with the wires with stoppers for further bone (Fig. 30.7).
traction. Finally, another set of canals is drilled in the Bone flap transport (traction) starts after a 4–6-day latency
skull, with the wires placed epicutaneously. period. The rate has been worked out using experimental
4. The bone flap is placed along one of the borders of the models and determined to be 0.5–1.0 mm/day, performed at
trephine opening. The ends of the wires are then drawn least twice.
outside through the soft-tissue punctures. Finally, the skin A radiological checkup (craniograms, lateral view) of
is stitched and drainage is placed under the skin flap. the bone transportation is performed every 7–10 days.
5. Half-pins are placed in the windows and two Ilizarov half- Radiologically, traction of the bone flap is seen as an increas-
rings are attached with L-like threaded rods. The half ing gap between the rim of the cranial defect and the bone
rings are connected by two longitudinal rods with hinges. flap border, the size of which depends on the distraction rate
A traction unit is assembled consisting of a plate with and length (Fig. 30.8).
Traction is terminated after the flap reaches the opposing

rim of the trephine opening. The frame is transferred to the
bone flap fixation mode. The mean fixation time is 10–14 days.
Note that a shorter fixation period results in the flap being
shifted from the trephine opening border in retrograde man-
ner after the frame is removed. Removal of the frame takes
place under pre-anesthesia conditions.
30.6 Transosseous Osteosynthesis

for the Treatment of Patients
with Disturbed Cerebral Circulation
Indications for surgical treatment with transosseous osteosyn-

thesis during the recovery period following acute conditions
(minimum: 6 months post-event) involving frontal, parietal
and temporal lobe defects include: (a) consequences of acute
cerebral circulation disorders (ACCD), such as those resulting
from ischemia or hemorrhage and (b) cerebral ischemia due
to occlusion and stenosis of the major cerebral vessels. Severe Fig. 30.10 Craniogram after frame removal
psychic disorders and arterial hypertension poorly controlled
with medications are absolute contraindications. Chronic dis- frame assembly depends on the size and location of the tre-
eases in the active phase are relative contraindications. phine opening (Fig. 30.9).
The operation is performed according to the stages After the flap has been transported to the opposing rim of
described above. A specific feature of the second phase is an the trephine hole, traction is terminated and a radiological
osteoplasty rectangular craniotomy projected on the patho- checkup is performed. The frame is set for bone flap fixation,
logical cerebral focus. A four-hole osteoplastic craniotomy which lasts 10–14 days on average. The checkup craniogra-
is performed in the conventional manner, using a burr and a phy is performed with the frame off (Fig. 30.10).
Gigli saw. The size of the trephine opening depends on the
cerebral involvement, measuring on average 3 × 6 cm. The
30.7 Efficacy of Transosseous Osteosynthesis
in Craniosurgery
The results of 112 patients with ischemic cerebral lesions of

varied genesis who underwent transosseous osteosynthesis at
the Neurosurgery Department, RISC “RTO,” were reviewed.
The patients were divided into two groups according to
disease etiology. Patients in group I had negative conse-
quences of traumatic cerebral injury (n = 15) while those in
group II had negative consequences of non-traumatic cere-
bral disorders (n = 97). The disease occurred between
6 months and more than 4 years prior to surgery. Patients in
group I were not older than 40 years. Patients in group II
varied widely in age, with the majority being 41–50 years
old. Most of the patients in both groups were males.
According to their medical records, 11 patients in group I
had sustained a closed severe traumatic brain injury and
brain contusion; the remaining 4 (men) had suffered an open
traumatic brain injury. Prior to admission, 11 patients had
undergone operative treatment for acute cerebral compres-
sion due to intracrerebral hematoma. Cranial defects were
localized to the parietal and temporal bone (n = 9) and fron-
tal, parietal, and temporal bones (n = 6).
Fig. 30.9 Craniogram (lateral view) following osteosynthesis prior to Patients of group II had negative consequences of ACCD.
bone flap traction Ischemic type ACCD were diagnosed in 82 patients, while
a b c
Fig. 30.11 Appearance of the patient before (a), during (b), and after (c) treatment
the remaining 15 had the hemorrhagic type. Five patients in aphasia (n = 1), mild motor aphasia (n = 2), dysarthria (n = 1).
the group had undergone surgical treatment for cerebral The remaining seven patients did not have speech disorders.
compression due to subdural or intracerebral hematoma. Among the 97 patients in group II, 55 patients had speech
In the two groups, locomotor disorders including hemipare- disorders. Severe motor aphasia was detected in 15; 22 had
sis of various degrees had been determined in 100 patients. moderate aphasia, and 12 mild motor aphasia. Dysarthria
Nine patients of group I had developed severe hemiparesis, was observed in six patients.
five moderate hemiparesis, and a female patient had moderate All patients showed neurological regression of varying
tetraparesis. Among the patients of group II, severe hemipare- extent during treatment. Motor regression was manifested by
sis was noted in 61, moderate in 25, and 1 patient had mild greater muscle strength, greater volume of active motion,
tetraparesis; another patient had developed severe tetraparesis. and less muscle spasticity in the paralytic limb.
Motor disorders in all patients were assessed by spasticity Severe hemiparesis in group I regressed to moderate in
type with enhanced tendon and periosteal reflexes, the pres- nine of the affected patients; moderate regressed to mild in
ence of pathological foot signs, and muscle spasticity. All five patients. Mild tetraparesis regressed almost completely
patients with hemiparesis had Wernicke-Mann’s posture, in one patient. A patient with severe tetraparesis showed
with gait assessed as paretic. Fourteen patients with trau- positive motor dynamics to a moderate degree.
matic and 86 patients with non-traumatic cerebral disorders All patients reported less muscle spasticity (Fig. 30.11).
used additional means of support (a cane) for walking; one Positive sensory dynamics were manifested by low pain
female patient could not walk without assistance. sensitivity and greater thermal threshold and tactile sensitivity
Disturbed superficial sensitivity manifested as skin hyp- in 12 patients with traumatic and 80 patients with non-traumatic
esthesia on the side opposite to the involved nidus in 12 cerebral disorders among 12 and 84 patients, respectively.
patients of group I and in 84 patients of group II. Four patients with severe motor aphasia in group I were
Speech disorders were detected in eight patients in group able to pronounce several words after treatment. Moderate
I in the form of severe motor aphasia (n = 4), moderate motor aphasia was shown to regress to dysarthria; in one
a b
Fig. 30.12 Patient K. Recurrent repair of a post-traumatic right-side parietotemporal defect of 6 × 8 cm. Primary cranioplasty with protakril failed
due to inflammatory changes. (a) during repair of the defect, (b) after treatment: distraction regenerate in the defect area
a b
Fig. 30.13 CT findings: distractional regenerate bone at the site of osteoplasty craniotomy at a short-term follow-up (a) and in a 3D reconstruc-
tion at long-term follow-up (b)
patient, mild motor aphasia patients regressed to dysarthria; Patients with agraphia and alexia could write in response to
and in one, dysarthria regressed completely. dictation and read simple words at the postoperative period.
Patients with severe motor aphasia in group II (n = 15) Craniography showed distractional regenerate bone at the
were able to pronounce several words. Speech disorders site of the osteoplasty craniotomy at short-term follow-up
completely regressed in 14 patients (8 with aphasia and 6 (Figs. 30.12 and 30.13).
with dysarthria). Moderate motor aphasia regressed to mild Computed tomography (CT) findings at short-term
motor aphasia in 10 patients and to dysarthria in 12. Mild follow-up were determined with respect to the initial
motor aphasia regressed to dysarthria in four patients. pathological cerebral changes. A patient in the first group
a b
c d
Fig. 30.14 (a, c) before treatment (b, d) after treatment
was diagnosed with a nidus of pathologically altered cere- Further increases in vocabulary occurred in four
bral tissue that was at a formative stage preoperatively. The patients in group I who had severe motor aphasia preop-
remaining patients in both groups showed a tendency towards eratively. In two patients of this group the speech disor-
a decrease in the size of the involved nidus and of the sur- ders regressed.
rounding swollen area. In addition, further formation of dis- Vocabulary increased in 10 group II patients with severe
tractional regenerate bone and osteofibrous consolidation with motor aphasia. Positive speech dynamics persisted in the
the rims of trephine opening were seen on CT in all patients. remaining patients. Regular exercises somewhat improved
On MRI, the findings included an amplified vascular pat- writing and reading skills in several patients with an extended
tern in projection of the bone flap due to the presence of a vocabulary.
network of small convoluted collateral vessels (Fig. 30.14). Radiological and CT findings indicated further formation
Twelve patients in group I and 56 in group II showed posi- of distractional regenerate bone and osteofibrous consolida-
tive dynamics at one-year follow-up, with decreased muscle tion with the rims of the trephine opening in all patients. An
spasticity of the hemiparesis side and an increased range of increase of the involved cerebral nidus was not seen in any of
active motion that resulted in a more confident gait. the patients.
Fig. 30.15 Dynamics in arbitrary after treatment

muscle EMG activity on the m.rect.fem
hemiparesis side before and after
treatment m.flexor c.rad. before treatment
m.tibialis ant.
m.biceps fem.
mm.Hypothenar
m.flexor c.uln.
0 0,1 0,2 0,3 0,4 0,5 0,6
Table 30.1 Positive dynamics in thermal and pain sensitivity at the involved side
Limb Thermal sensitivity threshold (degree) Pain sensitivity threshold (degree)
Pre-op After treatment Difference Pre-op After treatment Difference
Arm 36.4 ±0.4 (range 35–40) (10) 34.3 ±0.3a (range 32–37) (5) 3.3±1.0 47.0 ± 0.8 (range 44–50) 43.6 ±0.6a (range 42–46) 3.4 ± 0.5
Leg 40.6 ±1.9 (range 38–45) (9) 35.4 ± 1.2a (range 32–39) (4) 5.0 ± 1.7 46.8 ± 0.7 (range 44–50) 43.8 ± 0.6a (range 41–46) 3.4 ± 0.6
a
Significance of differences in values from preoperative measures (P £ 0.05). Italicized figures denote the number of patients with absent thermal
sensitivity.
Forty-nine patients (7 in group I and 42 in group II) were remounted to stabilize the construct. The complication had
followed from 1 to 3 years. Neurological status regression no affect on treatment outcome.
was determined in all of them. Therefore, the technique proposed to treat patients with
Clinical outcome was reconfirmed by EMG (Fig. 30.15) negative consequences of cerebral ischemic lesions of trau-
and esthesiometry findings (Table 30.1) matic and non-traumatic genesis was shown to facilitate reli-
Positive motor dynamics were steady. Sensory disorders able fixation of the cranial vault using an external fixation
tended to regress in six patients in group I and in 36 patients device. The resulting bone flap, its transport in the trephine
in group II. Normalized pain as well as tactile and thermal hole, and filling of the gap with newly forming regenerate
sensitivity thresholds were determined in a patient in group bone were demonstrated.
II at the time of observation.
Speech disorders diagnosed at the time of hospital dis- Conclusion
charge persisted. Speech was shown to subjectively improve The incidence of craniocerebral injuries and cerebrovas-
due to the smooth-flowing pronunciation of words and sen- cular diseases, the severity of their consequences, and the
tences, with an extension of vocabulary, while regained writ- resulting socioeconomic status of these patients have
ing and reading skills were maintained. stimulated interest in the treatment of traumatic cerebral
Radiographs and CT scans demonstrated regenerate bone injury and cerebral ischemic disease [637, 640] with the
at the osteoplastic cranial trephine site in all patients. goal of establishing new forms of treatment.
An array of conservative treatment techniques and
rehabilitation options is primarily effective in the first
30.8 Complications months of disease onset [641]. By contrast, for patients
with negative consequences of traumatic cerebral injury
Local errors and complications were detected with the use of at long-term follow-up and residual manifestations of
transosseous distractional osteosynthesis. stroke and infarction, surgical treatment remains
Local complications were identified in two patients (1.8%) underdeveloped.
in the form of pin-tract infection, which was arrested with Transosseous osteosynthesis for the treatment of dis-
antibacterial and antiseptic treatment. eases and injuries of the tubular bones can provide the
Technical errors during surgery occurred in four patients: basis of craniosurgery for cranial bone defect repair. The
fibrous healing of the bone flap and trephine opening rims in findings [663] reported thus far suggest that repair of a
three patients (2.7%) were due to a low traction rate of the cranial bone defect is possible by transporting an autolo-
bone flap. Another operative intervention was needed to gous graft. The observed changes in the microcircula-
mobilize the flap. Traction of the bone flap then proceeded at tion of the bone and surrounding soft tissues have
a higher rate. encouraged the use of this method to stimulate cerebral
Stability of the frame was not ensured in one patient dur- blood flow in patients with cerebral ischemia of various
ing fixation. Bone fixation continued with the frame origins [664, 665].
A review of treatment results obtained in patients with Speech disorders completely regressed in 21.7% of the
cerebral ischemic lesions of traumatic and non-traumatic patients.
genesis who underwent transosseous distractional osteo- Therefore, transosseous osteosynthesis can be used to
synthesis has allowed the indications and contraindica- stimulate the cerebral circulation and leads to a regression
tions to the technique to be defined. of neurological deficits, with improvements in motor and
Complete regression of motor disorders was detected sensory disorders and in disturbed higher cerebral func-
in 2.1% of the patients during treatment, with positive tions. The regression of neurological disorders was found
dynamics observed in 97.9% of the patients, as mani- to proceed more slowly at long-term follow-up than during
fested in greater muscle strength, decrease muscle spas- the short-term postoperative period. This is likely due to
ticity, and a greater range of active motion. greater changes in the circulation of the involved cerebral
Positive sensory dynamics were detected in 85.7% of areas occurring at an early postoperative period, during
the patients. In 14.2%, positive dynamics were not bone flap traction and distractional regenerate bone forma-
obtained due to the involvement of subcortical nuclei tion. Improvements in the neurological status of the
and the thalamus. patients persisted throughout the period of observation,
Disturbed higher cerebral functions, identified in 49.4% with further regression of pathological changes observed
of the patients, were shown to regress in all cases, with at long-term follow-up in several patients.
the extent of regression dependent on the preoperative The persistent regression of neurological symptoms
performance. Patients with severe disorders (43.4%) were achieved during treatment and later reconfirmed supports
subsequently able to pronounce several words. Patients with transosseous osteosynthesis as an effective treatment for
less evident disorders extended their vocabulary, with patients with cerebral ischemia of traumatic and non-
improved speech flow and a smoother speech pattern. traumatic origins.
External Fixation in the Treatment
of Chronic Limb Ischemia 31
Vladimir Dmitrievich Shatokhin
31.1 Introduction number of other disciplines, including plastic surgery and

angiosurgery [145, 685, 686].
In a study published in 1961, Lerish was able to demonstrate In 1972, Ilizarov and Ledjajev proposed a method for
the effects of an injury on the circulation in the involved bone thickening in which a splintered cortical fragment was
extremity: a short period of spasm is followed by active formed and subsequently transversely transported (R.F. pat-
vasodilation combined with local hyperemia [678]. Later, ent no. 691148). In 1976, Ilizarov extended this work to lat-
vasoactive amines were shown to play a substantial role in eral lower leg remodeling, a procedure involving the
the pathogenesis of injury and inflammation. As a number of controlled reorientation of the axis of the fibula, thereby
authors have since confirmed, an impairment of tissue integ- changing the bone’s shape (R.F. patent no. 564359). The
rity, regardless of the etiology, sets off an inflammatory pro- ability to manipulate bone fragments combined with the high
cess [106, 679–681]. This reactive process comprises a restorative and plastic potential of bone tissue resolved
sequence of complex alterations in the microcirculation—as numerous problems associated with increasing the size of
well as in the blood circulation as a whole and in conjunctive the bone and restoring its proper shape in the affected lower
tissues—that is aimed at localizing and eventually eradicat- leg (Figs. 31.1 and 31.2).
ing the harmful agent and at restoring (or replacing) the dam- In patients with sequelae of poliomyelitis, it was shown
aged tissue [680, 682]. that when the initial volume rate of blood flow is substan-
In the regeneration zone created during bone surgery, tially decreased, implementation of the tibial thickening
active capillary formation takes place. Indeed, the stimulat- procedure results in a marked increase in the volume rate
ing effect of surgery on the operated extremity’s blood sup- of blood flow. Proceeding from this observation, in 1982
ply can be attributed to functional sympatholysis, in which Ilizarov proposed a clinical experiment: to utilize distraction
the increased metabolic demands of the tissues result in regenerate formation resulting from the transverse transport
dilated vessels insensitive to the constrictive cues from the of a bone splinter to increase the blood circulation of the
sympathetic nervous system [145, 681, 683, 684]. distal limbs in patients suffering obliterating diseases of the
Research conducted under the direction of G.A. Ilizarov peripheral arteries (Fig. 31.3).
led to the discovery of a number of biological responses that This positive results of the experiment confirmed the con-
allow for controlled tissue growth. Of these, distraction, nection between bone trauma and consequent improvement
when applied to living tissue, was shown to create distraction in the blood circulation of the affected limb as a whole in
tension, which initiates and then maintains the regeneration response to bone damage. They also provided insight into the
and growth of tissue structures. This discovery made it pos- mechanisms underlying this reaction. These findings were
sible to control tissue genesis and it became the foundation substantiated and proposed for clinical practice in angiosur-
of a new technique, developed by Ilizarov and his disciples, gery as circulation-boosting procedures, based on the con-
to treat patients with fractures and orthopedic diseases. These trolled mechanical effect exerted by these maneuvers upon
researchers also realized the applications of distraction to a bone and bone marrow [680, 687, 688].
Microcirculation disturbances are known to play a major
role in the genesis of ischemic disorders. Therefore,
according to some authors, one of the reasons for unsatis-
V.D. Shatokhin, M.D., Ph.D.
factory results in treatment obliterating diseases of the
Department of Orthopedics, Kalinin Regional Clinical Hospital,
Tashkentskaja Str., 159, Samara 443095, Russia peripheral arteries, in particular the poor results of recon-
e-mail: apple080@rambler.ru structive surgeries, might be the disseminated destruction
1438 V.D. Shatokhin
Fig. 31.1 Lower leg shape

remodeling
a b
Fig. 31.2 (a–c) Modeling of lower leg shape: results

31 External Fixation in the Treatment of Chronic Limb Ischemia 1439
Fig. 31.3 Scintigram after lower leg thickening: circulation in the

affected limb
c endocrine, and secondly with its hydrostructures. The latter

determine the degree of functional activity of the microcircula-
Fig. 31.2 (continued) tory subsystems at various levels [679, 691].
The similarity in pain patterns (character, intensity) asso-
of the tissue vasculature [689, 690]. Thus, before a treat- ciated with hematogenous osteomyelitis and chronic limb
ment strategy is offered to a patient, functional screening ischemia suggested that intra-osseous pressure underlies the
of his or her blood supply and microcirculation systems is pathogenesis of both conditions. Our studies provided evi-
essential. dence for this hypothesis in that an increase in intra-osseous
The peripheral arterial system in humans is not linear, pressure was measured in both sets of patients, before and
but rather linearly closed. According to basic hemodynam- after surgery. Similarities were determined not only in the
ics, any vessel curve is an impediment to smooth fluid flow, absolute values but also in affected-to-intact limb differ-
resulting in energy losses. These are especially high in the ences [692]. Figure 31.4 shows intra-osteous pressure mea-
arterial arches, where flow enters from opposite directions. surements in affected and intact extremities before surgery.
The loss of energy has been calculated to be proportional to As seen in the figure, there is a distinct relationship between
the drop in blood pressure. About two-thirds of the energy the degree of ischemia and intra-osseous hypertension. One of
of a heartbeat is converted, on its way from the main arteries the reasons might be that the patient feels compelled, due to
to the arterioles, into heat energy, which is utilized to lower the reduced arterial flow, to rest the affected limb. This leads to
blood viscosity and to warm the surrounding tissues [688]. venous stasis and impairments in the microcirculation accom-
The microcirculation’s course is functionally connected firstly panied by tissue edema, with effects on the bone marrow.
with the body’s main regulatory systems, both neurohumoral and Intra-osseous hypertension results in a persistent pain
1440 V.D. Shatokhin
Fig. 31.4 Relation between 400 Pressure in

intra-osseous pressure and “damaged
ischemia before surgery extremity”
Pressure, mm of water
300
200 Pressure in
contralateral
extremity
100
Gradient of the
0 ischemia pressure
I II III IV
stage stage stage stage
Fig. 31.5 Changes of 200

intra-osseous pressure after Pressure in
surgery “damaged
150 extremity”
Pressure in
100
contralateral
extremity
50
Gradient of the
ischemia pressure
0
syndrome while impaired microcirculation and metabolic dis- 31.3 Preoperative Protocol
turbances cause trophic disorders, which, in turn, increase
pain. Preoperatively, it is necessary to assess the overall condition of
Figure 31.5 shows the intramedullary pressure dynam- the patient as well as the circulation in both the affected and
ics after surgery. According to our research, decompres- intact limb. Proceeding from the data received, the therapeutic
sion of the medullary cavity helps to normalize intra-osseous strategy and tactics are developed. Failure to consider even
pressure as well as to reduce pain and improve the circula- minor nuances may prevent the achievement of good results
tion [145]. Therapeutic methods that exploit the reaction of and can even lead to complications nullifying the effort, includ-
the body to trauma result in substantially improved results ing conditions that either preclude the possibility of limb sal-
in patients with chronic obliterating arterial diseases. vage or are life-threatening. A comprehensive examination of
the heart, lungs, and brain vessels will minimize
complications.
31.2 Indications and Contraindications
Distal limb ischemia caused by obliterating arterial diseases 31.4 Stimulation of the Blood Supply
such as thromboangiitis obliterans, arteriosclerosis obliter- and Microcirculation by Forming
ans, Raynaud’s disease, and Raynaud’s syndrome is an indi- a Bone Splinter Followed by Its
cation for microcirculatory stimulation. Consequent Transversal Transport
While there are no absolute contraindications to the appli-
cation of the techniques described below, the relative con- This technique is used in the treatment of the initial stages of
traindications include: ischemia, specifically, in the first or second stage according
1. Compromised circulation in the lower leg to the Fontain-Pokrovsky classification.
2. Marked trophic changes in the region of intended surgery The length of the “splinter” and its level depend upon the
3. Severe concomitant diseases, including psychosis location of the occlusion or arterial stenosis, the stage of
ischemia, and the patient’s condition. The upper part of the

splinter has to overlap with the occlusion or ischemia zone
while its lower part must be positioned at the distal metaphysis
of the involved segment. Fragments with lengths varying
between 10% and 20% of a segment’s length are considered
short, while those with lengths exceeding 20% of the segment
length are long. In terms of thickness, fragments are divided
into massive and cortical ones. A massive fragment’s thick-
ness constitutes at least one-third of the bone diameter [691,
693].
If it is necessary to boost the blood supply and microcir-
culation in both the proximal and the distal portions of the
limb, there must be two bone splinters formed at two levels
of one or both lower or upper extremities. The shorter the
splinter, the weaker the expressed therapeutic effect.
However, in the presence of severe ischemia it is inexpedient
to create long massive splinters, as they might provoke the
development of “steal” syndrome. Instead, the creation of
two shorter splinters at two levels will produce the same
therapeutic effect as one long splinter. The method of improv-
ing blood supply by forming a tibial splinter is diagrammed
in Fig. 31.6.
Surgery starts with anesthesia and the application of a
two-ring external fixator 1–1.5 cm proximally from the
tibial crest, around the top and bottom areas of the intended
splinter location. Two 0.5–1.0 cm longitudinal incisions of
the skin and subcutaneous tissue are made. Through these
cuts, a narrow osteotome is used to carry out partial trans-
verse osteotomies on the medial surface of the tibia in
order to mark the desired length of the fragment. Two
osteotomes, directed toward each other, are used in the
closed mobilization of a portion of the bone intended for
splintering. Fig. 31.6 Circulation boosting by the formation of a tibial splinter and
The next step is to dissect—while taking care to mini- its consequent measured transport
mize damage to the bone marrow and to avoid intraosseous
circulation disturbances—the anterior wall of medullary
cavity, which is done using an osteotome. Two osteotomes
are then inserted into the upper and lower incisions. By translated with the olive wires for 25–30 days, followed by
making a 180° turn with each of the osteotomes around their a consolidation phase lasting 30–40 days. Figure 31.7 shows
axes, the desired fragment of the tibia, i.e., the “splinter,” is the results.
mobilized while the marrow and periosteum are left as intact A drawback of this technique is the risk of “splinter”
as possible. The bone splinter is held, by an osteotome or perforation through the skin. This is especially relevant
elevator, in its “turned aside” position and olive wires are with inadequate trophism and a lowered restoration poten-
then conducted through it, extending to the posterointernal tial of the skin, in which even minor injury may lead to
surface of the tibia or externally to the femur. These wires persistently non-healing trophic ulcers. Thus, in patients
are fixed to traction clips which are in turn fastened to the with significant stage IIb ischemia, the use of a simplified
basic support ring using posts. The splintered bony frag- variant of the procedure is recommended. The detached
ment is then gradually moved by olive wires. Distraction “splinter” is moved inwardly and posteriorly for 2–3 mm
starts at day 10–12 and continues at a rate of 0.25 mm twice to achieve decompression of the medullary cavity. This
a day. The late onset and slow rate of distraction are essen- helps to eliminate the pain syndrome, while boosting the
tial to stabilizing the limb’s circulation, thus creating opti- restoration processes improves both the blood supply and
mal therapeutic conditions [691, 693]. The fragment is the microcirculation in the involved segment.
1442 V.D. Shatokhin
Fig. 31.7 (a–c) Lower leg

thickening used to stimulate the
circulation (angiograms of
patient Sh. before and 6 months
after treatment)
a b c
31.5 Stimulation of the Peripheral tibial segment, the frame is assembled on the calf and the
Circulation Using Wires Implanted into wires are implanted in the medullary canal of the tibia. The
the Medullary Cavity of a Long Bone external ends of the implanted wires are fixed to traction
clips which are in turn fastened to the basic support ring
This technique was proposed by Shevtcov et al. [479]. The using posts. Figure 31.8 provides a scheme of the surgery.
level and the extent of the external fixation device’s appli- Postoperatively, starting from day 8–10, the implanted
cation depend upon the location of the circulatory impair- wires are gradually moved with the traction clips four
ment. If blood flow is restricted in a femoral segment, the to six times a day at rate of 1 mm per day until complete
frame is assembled on the femur and wires are implanted extraction of the wires from the medullary cavity is
into the femoral medullary cavity. If occlusion involves a achieved.
a b
Fig. 31.8 Frame assembly and the implantation of wires at femoral (a) and tibial (b) sites
ment of patients suffering obliterating arterial diseases. In

31.6 Revascularizing Bone Trepanation (RBT) RBT, multiple drill-holes each with a diameter one-sixth
in the Stimulation of the Blood Supply of the diameter of the medullary cavity are created along
and Microcirculation the entire length of the affected limb. While this maneuver
has a positive impact in the majority of cases, weakening
In 1991, a study by Zusmanovich [694] included a method of the bone along its complete length may result in limb
of revascularizing bone trepanation (RBT) for the treat- fracture.
1444 V.D. Shatokhin
31.7 Stimulation of the Blood Supply

a
and Microcirculation by Creating
Tunnels in the Bone Metaphysis
Indications for this technique include ischemia of stage IIb–

III and the presence of limited trophic changes. The basis of
the procedure is diagrammed in Fig. 31.9.
Distally to the tibial tuberosity and 3–4 cm above the
ankle joint line, incisions are made through the skin and sub-
cutaneous tissue. Holes in the proximal and distal metaphy-
ses, almost reaching but not touching the opposite cortical
wall, are made using a 10-mm drill bit. The wound is sutured
without leaving a drain. Figure 31.10 shows the results.
Fig. 31.10 (a, b) Technique of tunnel drilling through the metaphyseal

part of the bone. Thermograms of patient K., diagnosed with arterio-
sclerosis obliterans, before and after treatment
Fig. 31.9 Stimulation

of the blood supply and
microcirculation by creating
tunnels in the bone metaphysis
Fig. 31.11 Boosting of the

a b
circulation through a “scooping
out” osteotomy
31.8 Stimulation of the Blood Supply

and Microcirculation Using
a “Scooping Out” Osteotomy Fig. 31.12 (a, b) “Scooping out” osteotomy. Radionuclide angiogra-
phy from patient B. before and 6 months after treatment
This technique has several advantages over the previously
described procedure. Stimulation of the circulation and
enhanced restoration processes in the cartilage are achieved using Volkmann’s curette to scoop out portions of the marrow
through decompression, denervation, fenestration, and a and bony trabeculae in the metaphyseal parts of the bones [695].
revascularizing osteotomy without bone transection [206]. This advanced approach has proved to be effective in the treat-
The “scooping out” osteotomy is indicated for patients diag- ment of ischemic disorders. Two 1.5-cm incisions of the skin and
nosed with vascular arterial diseases accompanied by severe subcutaneous tissues are made in the proximal and distal meta-
(stages IIb–III, Fontain-Pokrovsky) ischemia and good physeal regions. An osteotome is then used to remove a 2 × 2 cm
results have been achieved in such cases (Fig. 31.11). cortical plate from the anterior surface of the bone, followed by
Paskachev and Gorodnichenko, to achieve a lasting cure in evacuation of the marrow through these “windows” using
the treatment of deforming arthritis, further developed this tech- Volkmann’s curette. The incisions are closed over drains.
nique. Those authors expanded the “scooping out” osteotomy, Angiographic images are shown in Fig. 31.12.
1446 V.D. Shatokhin
31.9 Stimulation of the Blood Circulation 31.10 Postoperative Care

and Microcirculation by Fenestration
and Dosed Damage of the Bone Marrow Good postoperative care to a great extent determines the
outcome of surgery aimed at compensating chronic isch-
We developed a method for the prolonged stimulation of the emia in the lower leg tissues. Measures are taken to allevi-
blood supply and microcirculation in the lower leg that ate pain, reduce vascular spasm, and to regulate the
includes fenestration, decompression, and dosed marrow coagulant and anticoagulant systems. It is expedient to
damage [691]. The scheme of the surgery is shown in catheterize the superior epigastric artery for arterial infu-
Fig. 31.13. sions of rheological solutions and anticoagulants. Direct
The first step in this surgical procedure involves creating anticoagulants (heparin, Fraxiparine) are administered for
two holes, one in the proximal and the other in the distal 5–7 days after surgery accompanied by the control of coag-
metaphysis of the bone segment. As in the “scooping out” ulation factors, followed by indirect coagulant therapy
osteotomy, small portions of red bone marrow are retrieved (Pelentan, Syncumar, Finilin). In the following period,
through these holes. A Babcock probe is passed through the agents to support the microcirculation and the rheological
medullary cavity, which limits trauma to the bone marrow. properties of the blood (Trental, Tiklid, Rheomacrodex) are
Fatty marrow is evacuated using a surgical aspirator. The administered. A wound dressing is applied on the first day
wounds are sutured over drains. Figure 31.14 shows the after surgery, later according to necessity. Early mobiliza-
results. tion is important. Starting from postoperative day 2–3,
patients walk using walking aids. Partial weight-bearing is
encouraged on postoperative day 3–4, controlling for pain
during movements. Exercises for the ischemic muscle group
are recommended.
The circulation in the operated extremity is closely moni-
tored and precautions against inflammations and other com-
plications are to be taken.
In patients with a severe autoimmune process, extracor-
poreal detoxification is recommended as it substantially
improves results.
All patients are administered antibiotics for 10–14 days
after surgery, until the stitches are taken out. The reason-
able choice of operative technique with consideration of
the stage and progress of the disease and the characteristics
of the patient will lead to an optimal course of treatment
and improve the likelihood of success. Close observance
of surgical technique and careful adherence to pre- and
postoperative routines help to avoid many mistakes and
complications.
31.11 Complications
Common complications during the postoperative period

in patients with chronic lower leg ischemia are of the
inflammatory type. Should hyperemia or pus outflow around
Fig. 31.13 Stimulation
of the circulation by pin-tracts occur, the soft tissues adjacent to the wires must
fenestration, decompres- be injected for 2–3 days with antibiotic solutions, taking
sion and dosed marrow into account the susceptibility of the wound microflora. If
damage there is no effect, then the pins must be removed. If there
was forced bone transport or the operative trauma appears
Fig. 31.14 (a, b) Technique

involving fenestration,
decompression, and limited
marrow damage applied in the
treatment of patient T
a b
to have been inadequate considering the given stage of of the ischemia and the condition of the limb’s circulation.
ischemia, “steal” syndrome is possible, which could lead If the fragments to be splintered off are too massive, frac-
to worsening of the ischemia and even to limb gangrene. tures may occur in the region of detachment, necessitat-
To avoid this complication, it is necessary to properly ing the insertion of additional wires. Fragment translation
choose the technique, the pace of transport, and the type is then performed with consideration of a possible limb
of postoperative protocol in accordance with the severity deformity.
General Principles of Patient
Management in the Postoperative 32
Period
Postoperatively, it is necessary to check the peripheral pulse especially lengthening of the lower leg, the foot support
and the skin color (Fig. 32.1). After the patient’s recovery should not be removed, including (preferably) overnight, for
from anesthesia, nerve function is tested (Fig. 32.2). the entire period of distraction.
32.1 Position in Bed 32.2 Anesthesia
The bed for patients who have undergone external fixation Narcotic and non-narcotic analgesics are used for the first
should be equipped with a Balkan frame for subsequent 2–3 days after the operation. The need for their further
exercise therapy (Fig. 32.3). After external fixation of the administration and that of other drugs is determined indi-
humerus, a wedge-shaped pillow is placed between the side vidually. After external fixation for acute trauma, pain in the
of the body and the device so that the arm is abducted by fracture region should last no more than 3–4 days. Remaining,
35–45° (Fig. 32.2b). After external fixation of the forearm, stable pain generally indicates a technical problem with the
the arm is elevated by placing it on a roll or pillow. Two rods external fixation. First, it is necessary to remove pressure
are fixed to the distal support of the forearm between which from the transosseous elements on the soft tissue by releas-
a gauze sling is attached to support the hand in the mid- ing the skin and fascia, if necessary, and by moving the ele-
physiological position (Fig. 32.4). ment in the tunnel formed in the soft tissue. The skin is then
Patients who have undergone external fixation of the sutured (Fig. 7.35). Additional information regarding the
femur should stay in bed for 7–10 days with the knee flexed treatment and prophylaxis of pain can be found in Chap. 26.
at 90–100° (Fig. 32.5). A convenient method is to attach the Pain is a symptoms of most of the complications discussed.
distal support with an elastic fixator to the Balkan frame. It is Continued psychological lability of the patient despite a
also possible to use a stand made from the components of the reduction in the pain threshold suggests that a consultation
Ilizarov apparatus; one end of the stand is fixed to the distal with a psychotherapist would likely be beneficial to the
support and the other rests against the bed. The first night patient.
after the operation is particularly important. After the patient
has regained consciousness the knee joint is flexed. The time
spent in bed with the knee joint flexed can gradually be 32.3 Dressings
reduced.
Following external fixation of the bones of the lower leg, The first dressings are generally applied the day after the
the extremity is kept elevated for 2–4 days. A foot support operation. All gauze dressings are removed. The skin and
that limits plantar flexion (Fig. 32.6) is used. In fractures, device components are carefully cleaned of blood and wound
this support is maintained until the active range of motion in exudate using a hydrogen peroxide solution. The exit sites of
the ankle joint is not less than 30/0/5. In deformity corrections, the transosseous elements are treated with iodine solution,
the traces of which are removed using an alcohol solution to
prevent skin burn. The next step is to cover the exit sites of
the transosseous elements with gauze dressings impregnated
with 70% ethyl alcohol. The dressing should not be wrapped
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia on the wire because this leads to pressure on the skin. The
e-mail: solomin.leonid@gmail.com dressing is cut in the middle, placed over the wire, and
1450 L.N. Solomin
Fig. 32.1 (a, b) In the

immediate postoperative phase,
the surgeon should check the
patient’s peripheral pulse
pressed to the skin with a holder. For the first 2–3 days the exudate, which is a consequence of inflammation in the
dressings are changed every day, or as necessary, and there- region of the transosseous elements. Dried exudates should
after as they become soiled, but at least once every 7–10 days. be regularly removed as they complicate outflow of the
The cotton frame cover is changed together with the dressings wound effluent.
(Fig. 3.22). During each dressing change, the skin tension at the
Crusts that form around the transosseous elements are transosseous elements is estimated and changes in edema
an endogenous biological barrier and have a positive role, are determined by measuring the circumference of the
reducing the danger of pin-tract infection [696]. However, extremity at the level of the bone wound, as well as above
these “crust-covers” should not be confused with dried and below it.
32 General Principles of Patient Management in the Postoperative Period 1451
Fig. 32.2 (a, b) After the patient recovers from anesthesia, nerve function is tested
In contrast to the above-described, “Russian” method of 32.4 Exercise Therapy

pin-tract care, there is an alternative, “open” (“British,”
“Western”) method: The day after the procedure, the skin and The protocol for restoring weight-bearing and movement is
the device are washed with bactericidal soap and areas around established on an individual basis, with due regard to the pur-
the transosseous elements are moistened with an alcoholic poses of the external fixation, the type of pathology treated,
solution. Similar manipulations are carried out weekly. Gauze the segment, the patient’s age, the specifics of the patient’s
pads and frame covers are not used. The patient can shower somatic and local status, and the biomechanical characteris-
and even swim in pools containing sea or chlorinated water tics of the fixation device used.
(Fig. 32.7). Taking baths is forbidden! After showering, the Usually, on the first day after the external fixation, isomet-
skin and the frame are dried using a hairdryer. ric exercises and active–passive movements of the fingers or
Nonetheless, comparative studies have shown that toes and the wrist or ankle are recommended. In order to
application of the “Russian” method reduces the danger of prevent the development of pin-induced joint stiffness,
infectious complications [697]. In our opinion, use of the providing the rigidity of the bone fragment fixation allows,
“open” method can be justified in countries with a dry, exercise therapy is started as early as possible, generally
sunny climate and high-quality water, and by patients who 2–3 days postoperatively. However, if concomitant muscle
are able to carefully follow all of the doctor’s instructions. injury is present exercises with minimum loading are recom-
While we do not exclude the expediency of a combination mended, with emphasis placed on passive movements.
of elements from the “Russian” and “Western” methods of Exercise therapy is combined with breathing exercises and
pin-tract care, purposeful studies in this field have not been general health-improvement measures, both of which are
conducted yet. very important for elderly and senile patients.
1452 L.N. Solomin
Fig. 32.3 A special trolley and

bed (with a recess for the frame)
are required after Ilizarov
external fixation of the femur.
The niche is not necessary when
using hybrid devices
For the first 3–4 days, the exercises can be carried out on the itself restore the extremity’s function, and that such therapy is
ward, under the guidance of an exercise therapist. Each exer- not the end of the rehabilitation process. Rather, the exercises
cise session lasts 20–30 min with one or two sessions per day. mastered should form the basis for independent efforts aimed at
Exercises should include passive and active movements in restoring the lost potential for self-support and working skills.
adjacent joints. On the third or fourth day, the exercises are An exemplary complex of exercises is illustrated in Chap. 34.
performed in the gym and the duration is increased to 45–60 min. After external fixation of a leg, weight-bearing is recom-
As the acute postoperative events ameliorate, mechanotherapy mended soon after the operation. The procedure for selecting
is started using special equipment. Light massage is also the individual load is as follows: The patient is asked to bal-
beneficial. At the same time, the patient must understand that ance on the treated leg while standing on the floor, and the
exercise therapy under the supervision of a specialist cannot by load is gradually increased until discomfort is felt (pain,
Fig. 32.4 (a, b) Two rods are fixed to

the distal support of the forearm a
between which a gauze sling is
attached to support the hand in the
mid-physiological position
Fig. 32.5 After external fixation

of the femur the patient should
stay in bed for 7–10 days with the
knee flexed at 90–100°
1454 L.N. Solomin
32.5 Physio- and Pharmacotherapy
Participation of a physiotherapist and clinical pharmacologist

in working out the different components of the rehabilitation
protocol is essential. This protocol will be fairly complex
when the patient shows pronounced edema of the soft tissues
of the injured extremity (increase in circumference at any
level by >40–60 mm), tension in the soft tissues, a change in
skin color, asymmetry in the rheological indices of the two
extremities by >40%, and/or a shift in hemostasis values
towards hypercoagulation. Pharmacotherapy involves drugs
that improve the rheological properties of the blood and
microcirculation, tissue oxygenation, and vasoconstriction.
Types of treatment include laser, ultra-high-frequency, mag-
neto-, light, and reflex therapies. The protocol is used for
7–10 days, with dynamic monitoring of efficiency and insti-
tuting the required correction(s). Decisions as to whether
treatment should be stopped, continued, or modified are
based on dynamic clinical data (pain, edema, skin color,
function of the extremity), functional test indices, and bio-
chemical tests.
32.6 Biomechanical Device State
The main discussion of the different biomechanical devices

is presented in the sections on the treatment of fractures,
malunions, non-unions, deformities, and long-bones defects.
Fig. 32.6 After external fixation of the bones of the lower leg, a foot In this section, we expand on those discussions.
support that limits plantar flexion is used At least once every 3 weeks, tensioning of the wires
should be checked by using a wire tensioner or traction
sensation of tissue tension at the wires, etc.). That load is clips, or tightening the wire-fixing nuts (Figs. 7.29, 7.30,
taken as the initial load and is recorded in the patient’s medi- 7.31, and 7.32). In the latter case, bone fragments may
cal record. Thereafter, increments in weight-bearing are become displaced if the wire fixation point on the support
monitored weekly (Fig. 3.16). is displaced. Wires with a stop should be simultaneously
Restoration of correct gait is also an important consid- tensioned with two wire tensioners. Maintenance of wire
eration. To allow the patient to take a step with the treated tension in the Ilizarov apparatus is particularly impor-
leg and then bring the other leg against it is a gross meth- tant, and even more so than in combined wire–pin
odological error. Instead, the patient should be encour- assemblies.
aged to take steps of equal length—that is, when taking Of great significance is maintenance of the biomechan-
the next step, to set the heel at the level of the toe—begin- ical state (distraction, compression, and neutral forces)
ning in the first postoperative days. The step length will required at that particular moment of the postoperative
gradually increase to the length it was before the trauma stage—both between the supports of the device and
(Fig. 3.20). between the modules—for fixing the bone fragments.
An important element in the biomechanics of gait is During manipulations involving displacement of the
the phase of rolling over the ankle joint. Therefore, external supports, it is necessary to place control marks
avoidance of pes equinus and early restoration of rear on the connecting rods, e.g., narrow strips of adhesive
flexion of the foot, accomplished using a foot-support tape (Fig. 1.14). Similar marks are also placed on the trac-
(Fig. 32.6), are necessary. It is a mistake to use a rigid tion wire clips with arrows showing the direction of nut
sole-shaped foot-support because it impedes rolling over rotation. The Ortho-SUV Frame and Taylor Spatial Frame
of the foot. (Fig. 1.2p, q and Chap. 17) already have millimetric
a b
Fig. 32.7 (a, b) “Russian” and (c) “Western” (observation by W. Terrell) methods of pin-tract site care
1456 L.N. Solomin
a b c
Fig. 32.8 Axial approximation of the supports in an oblique fracture pression should be side-to-side rather than axial, for example, as
(a) will not result in “compression,” but will instead lead to the dis- achieved with the help of transosseous elements (c)
placement of one fragment relative to another (b). In this case, the com-
divisions on the struts such that no further labeling is compression at a rate of 0.5 mm a day for 4–7 days, and then
needed. The patient should also receive a diagram of the supporting compression of 1 mm/day over 7–10 days [317].
external device indicating the rods that are used to carry In neutral external fixation (e.g., fragmented fractures), it
out the distraction or compression, the necessary manipu- is advisable to apply tension in the modules fixing the bone
lations, and their magnitude (Chap. 34). fragments. For this purpose, the supports that fix one bone
It is a grave error to carry out longitudinal compression of fragment are approximated by 1 mm once every 3 weeks,
bone fragments with oblique or helical ends. In such cases, it and the external supports that fix the other bone fragment are
is more appropriate to bring the external supports together, moved apart by the same distance (Fig. 32.9).
leading to the bone fragments’ “sliding off” one another The rate and magnitude of distraction can vary not only
rather than to use compression. In such cases, contralateral with the different pathologies but also over time during
compression by means of transosseous elements (Figs. 2.10, treatment of the same patient. A magnitude of 1 mm a day in
2.11, and 2.12), or the mutual displacement of the modules four stages (0.25 mm four times a day) is accepted as the
fixing the bone fragments (Figs. 2.5 and 2.6) is required. The gold standard in external fixation. Rotation of an M6 nut by
average compression rate in fractures is 1 mm/day over 90° corresponds to a movement of 0.25 mm. Better condi-
10–14 days (Fig. 32.8). tions for the formation of distraction regenerate will be
In the external fixation of metaphyseal fractures or in obtained using automatic high-rate distracters [698, 27]
compression arthrodesis of the large joints, the fragment (Fig. 32.10).
ends are brought into close contact for 3–5 days. Primary The first 2–3 days are taken up with bending the tran-
vascular lacunae need to form at the site of contact. Thereafter, sosseous elements, especially in wire-based devices. Later,
compression is carried out at a rate of 0.25 mm two or three the increase in distance between the bone fragments should
times a day for 7–10 days. After a pause of 5–7 days, a radio- correspond to the rate of distraction, which is estimated from
graph is obtained. Arthrodesis is followed by continued the marks on the connection rods.
It should be noted that the magnitude of distraction (com-

pression) is the same as the change in the distance between
the bone fragments. Thus, in cases in which a triangular
regenerate is formed, monolateral distraction of the external
supports by 1 mm does not lead to lengthening of the regen-
erate base by the same value (Figs. 16.18 and 16.20).
Similarly, when traction-guiding wires inserted at an angle to
the displaced bone fragment (oblique-wire bone transport)
are used, displacement of the traction clip by 1 mm leads to
lengthening of the regenerate by a smaller amount. To ensure
a preset rate of distraction, skiagrams are used to carry out
the special calculations given in the sections discussing open
injuries and deformity correction, and in the specialist litera-
ture [9, 236, 317, 102].
In malunited fractures, distraction to reduce the bone
fragments is started after 3–5 days at a rate of 0.75–2 mm
a day depending on the fracture location (metaphysis,
diaphysis) and the time elapsed since the trauma.
Distraction of a tight non-union with the aim of forming
a distraction regenerate is carried out at a lower rate of
0.25 mm one to three times a day and is monitored by
biochemical testing [322].
To form a distraction regenerate, displacement of the bone
fragments after corticotomy is started 5–7 days postopera-
tively. Following open osteotomy, distraction is started after
10–14 days [699]. In children, the distraction rate can be
increased to 1.25–1.5 mm/day and in elderly patients
decreased to 0.5 mm/day. In the replacement of a bone defect
by lengthening both fragments (polylocal distraction- Fig. 32.9 Dynamic stabilization of the device in neutral osteosynthesis
Fig. 32.10 Automatic distractors

1458 L.N. Solomin
compression external fixation, or bilocal bone transport), the mities according to the Ilizarov method, the patient should
rate of distraction at the distal regenerate is, as a rule, remain hospitalized throughout the deformity correction
0.25–0.5 mm less than at the proximal bone fragment. After period or be prepared at any time to transfer to the outpatient
V- and Y-shaped foot osteotomy, distraction is started after department to change the reduction unit and to undergo
3 days at a rate of 0.25 mm four to eight times a day [361]. radiological control of the treated limb.
Both the absence of pain and neurotrophic disturbances After discharge, a nurse should examine the patient every
and the satisfactory functioning of adjacent joints are indica- 7–10 days and change the dressings. At least once a month,
tors of a favorable reparative course of osteogenesis, includ- the patient should consult the doctor charged with control-
ing tension and lengthening of the soft tissues. The amount ling the postoperative regimen. During outpatient treatment,
and rate of distraction are monitored using radiography, den- the involvement of the surgeon who performed the operation
sitometry, and ultrasonography, with biochemical testing is also essential.
carried out monthly [227, 322, 473, 700–702, 466]. At home, the patient follows, in accordance with the doc-
The period subsequent to formation of the distraction tor’s instructions, a course of rehabilitation to ensure self-
regenerate is termed the “fixation period.” To maintain the support, restore work ability, and carry out domestic tasks
rigidity of the osteosynthesis support, distraction of 1.5 mm (cooking, cleaning, ironing), and to enable re-engagement in
is performed in one stage over 7–10 days. It is recommended hobbies (playing musical instruments, etc.). Students can
that the distraction regenerate is increased in thickness by an return to their studies, and those in non-manual employment
amount equal to its “growth zone” (5–10 mm). The supports can return to work. Elderly patients after external fixation of
are then brought together in a single step by the amount of the arm, forearm, or lower leg, as a rule, can fully attend to
that additional lengthening. This method, developed at the themselves and do not require the continued support of care-
Russian Ilizarov Scientific Center “Restorative Traumatology givers. The rehabilitation regimen after external fixation of
and Orthopedics,” leads to a significant reduction of the time the femur is somewhat more limited.
needed for distraction regenerate reconstruction [466]. Later, in accordance with the clinical and radiographic
Distraction used to reduce old dislocations or to remove findings, loading of the extremity is increased so that by the
joint contractures is started after 3–5 days at a rate of end of the fixation period weight-bearing is 70–100% of the
1.5–2 mm a day in six to eight steps. The magnitude of dis- normal functional level (Figs. 25.2, 25.3, and 25.4) (Figs. 32.11,
traction should be reduced and the number of manipulations 32.12, and 32.13).
increased when pain or symptoms of tension in the vessels Partial reassembly of the frame is considered as a tech-
and nerves occur [396]. nological component in external fixation. For example,
Exercise therapy, physiotherapy, and monitoring of the when during bone transport soft tissues are cut by wires,
device’s biomechanical status are the most important compo- fixed in the support (“cross-wire bone transport”), they
nents of the restorative treatment in patients after external should be changed for traction-guiding wires (“oblique-
fixation. Generally, failure to monitor the biomechanical sta- wire bone transport”) (Figs. 18.5 and 18.6). After defor-
tus of the device and the dynamics of extremity function res- mity correction, reduction units (Ilizarov hinges or struts)
toration should be considered a treatment error. may be replaced by connection rods and additional tran-
sosseous elements may be inserted. Furthermore, non-sys-
tematic and disorganized manipulations, a lack of care in
32.7 Outpatient Treatment the initial planning, and arrangement of a device based on
the assumption that errors can be corrected later are unac-
After external fixation of closed fractures, the ambulant regi- ceptable practices. The order of all manipulations should
men can begin after 3–5 days (and sometimes earlier). In be planned in advance and documented in the medical
patients with prolonged correction of fragment position records. Exceptions to this planned approach are when a
(removal of deformity, replacement of a bone defect, seg- wire needs to be reinserted because of a pin-tract infection,
ment lengthening, etc.) and continuing presence of the or a defective component of a device needs to be replaced,
wound, the timing of the transfer to an outpatient treatment and similar situations requiring urgent attention. Most of
regimen is determined individually. Thus, in patients who the above-mentioned manipulations can be managed in the
have undergone segment lengthening or replacement of a out-patient department.
segment defect, a radiographic examination should be per- Another example of changing the arrangement of a
formed after 7–10 days of distraction. Correspondence device during the fixation period is modular transforma-
between the distraction rate and the regenerate length and tion, which is an integral component of combined exter-
coaxial separation of the fragments are important factors in nal fixation. As discussed in Chap. 3 (Fig. 3.5), modular
allowing a patient’s discharge from the hospital. When transformation of an external device is planned in accor-
correcting complex (multi-planar, multi-component) defor- dance with the weight-bearing capacity of the bone regen-
Fig. 32.11 Function of the arm after external fixation of a diaphyseal fracture (a, b) and non-union of the humerus (c, d) and after combined
strained fixation of a non-union of the humerus (e, f)
erate, with the potential to gradually reduce the number and with the minimal amount of change in the external sup-
of transosseous elements, connection rods, and supports port’s geometry following removal of a part of the support.
without the insertion of additional transosseous elements The aims of modular transformation are to optimize the
1460 L.N. Solomin
conditions for bone wound healing (according to Ilizarov’s above and below the level of the fracture. The range of
“training the regenerate” and “dynamization” of the frame), motion in the adjacent joints is progressively restored.
reduce the risk of pin-induced joint stiffness and pin-tract Radiographs obtained during this period show a fine
infection, and increase patient comfort by making the device periosteal regenerate over the surface of the fragment ends,
less bulky. with a density exceeding that of the soft tissues. There is
Usually at fracture fixation, weight bearing in 5–8 weeks pronounced endosteal regenerate rarefaction of the cortical
corresponds to 50–70% of body weight, i.e., the patient can plate (fibrosis of the cortical layer). The presence of these
walk with the aid of one crutch. There is generally no soft- clinical and radiographic signs indicates that the basic sup-
tissue edema but if there is then it does not exceed 1–2 cm ports of the device can be removed.
Fig. 32.12 Function of the arm

after combined external fixation
of a Monteggia fracture (a–d), a
non-union of the ulna (e–h), and a
deformity of both forearm bones
(i, j). (k–t) Function of the arm
after combined strained fixation of
an ulnar fracture (k–n), a
malunited fracture of both
forearm bones (o–r), and a defect
involving the soft tissue and the
ulna (s, t)
c d

1462 L.N. Solomin
g h

k l

1464 L.N. Solomin
m n

q r

1466 L.N. Solomin

s
At 9–11 weeks after surgery, weight-bearing has increased cal and radiological parameters, such as the criteria used for
to 70–100%, meaning that the patient can walk with the aid module transformation. Unfortunately, there is no accessible,
of a cane. Movements in the knee and ankle joints are not commercially released device that determines the degree of
limited. Clinical testing of the union shows the presence of a bone fragment mobility during the fixation period. The
tight bond. Radiography shows an increase in the density of benefits of this type of device would be that, in defining the
the periosteal regenerate, with structural conversion into degree of fragment mobility in a patient (in vivo) it would
bone. In the interfragmentary gap, single longitudinally ori- provide a higher degree of objectivism than the current indi-
ented shadows of the newly-built bone regenerate are seen, rect criteria. The criteria for module transformation are, as a
and there are initial signs of the formation of a common cor- whole, similar to those for dynamization of a locking nail.
tical plate. The presence of these signs indicates that sectors However, it is necessary to recognize that in external fixation
of the reductionally fixing supports can be removed. Similar dynamization is much more strictly controlled.
clinical and radiological data are used to decide upon module Table 32.1 summarizes the clinical and radiological crite-
transformation in patients with non-union or deformities of ria for module transformation.
the long bones. If necessary (for example, in the insertion of additional
It is necessary to emphasize that, at least for now, the transosseous elements or partial reassembly of the device), a
mobility of the bone fragments is determined based on clini- patient can be hospitalized again for a short time.
a b
Fig. 32.13 (a–f) Function of the lower extremity after combined lower extremity after combined external fixation of a tibial segment
external fixation of a femoral non-union (a–c) and a traumatic coxa fracture (g–l), and splintered fractures of the femur and lower leg bones
vara with the femur shortened by 11 cm (d–f). (g–m) Function of the (k–m)
1468 L.N. Solomin
f g h


i
j
1470 L.N. Solomin
k l

Table 32.1 Criteria for stages of module transformation (3–5 weeks before the intended day of device removal) is
Stage 1 Stage 2 also known. To “train” the regenerate so as to achieve this
Parameters 5–8 weeks 8–11 weeks goal, some of the transosseous elements are removed in
Painless loading 50–70% 70–100% stages, some of the external supports are removed, spring-
Soft-tissue edema +2–3 cm +1–2 cm loaded connection rods are used, etc. This type of procedure
ROM Not limited, painless Not limited, painless is the basis of module transformation.
Clinical test for – Tight amortization In conclusion, we can say that there are two approaches
fragment union
to determining device removal. First, the device is removed
X-ray examination Fine periosteal Increase density of the
regenerate over the periosteal regenerate
in the presence of a stabilized union. In such cases,
surfaces of the with conversion of its weight-bearing by the extremity is considerably (up to
fragments ends, with structure into bone. In 50%) reduced. Whether a plaster support or brace is used
density exceeding that the interfragmentary is decided on an individual basis. Second, the device is
of soft tissues; gap single longitudi-
pronounced endosteal nally oriented shadows
removed when a strong union is present. In such cases,
regenerate with signs of the newly-built the reduction in weight-bearing by the extremity is
of rarefication (fibrosis bone regenerate are insignificant (average up to 20%) after device removal. In
of the cortical layer) of observed; initial signs both cases, loading gradually increase up to full-weight
the cortical plates of the formation of a
common cortical plate
bearing within 4–6 weeks. The patient should be involved
in the decision as to which approach is adopted: to con-
tinue fixation with the device (accepting some continuing
inconvenience) or to remove the device earlier (with ini-
32.8 Device Removal tial limits to activity) [213].
It should be noted also that the period of fixation with an
There are three levels of strength of bone fragment unions: external device is established individually, on the basis of
stabilized, strong, and final [703]. In stabilized unions, the dynamic clinical and radiographic monitoring. Normal skin
strength of the bone callus ensures the absence of patho- color, absent or insignificant edema, painless movement of
logical mobility, but slight mobility (where the fragments the joints, positive clinical testing for union, and the absence
have become bonded) still occurs in the fracture zone. of negative dynamics after device “dynamization” are clini-
Establishment of this level of union, according to the rec- cal criteria for device removal. The presence of a radio-
ommendations of the Russian Ilizarov Scientific Center graphically visible fracture line and the absence of
“Restorative Traumatology and Orthopedics”, indicates pronounced periosteal regenerate in the presence of the
that the device can be removed. Such conditions are gener- listed signs of union are not contraindications for device
ally found in external fixation of the humerus or the fore- removal. Computed tomography can be used to resolve
arm bones. When a strong union has been achieved, uncertain cases.
1–2 months after device removal, the strength of the callus Methods to quantify the restoration of the bone’s mechan-
is such that the patient can return to work without limita- ical strength on the basis of biomechanical, laboratory, opti-
tions. By the time a final union has been achieved, cal, electrophysiological, radiological, and other kinds of
1.5–2 years after the trauma in diaphyseal fractures, the monitoring are currently the subject of intensive develop-
coarse bundle of bone callus with low strength has been ment. Unfortunately, for various reasons, none of the widely
replaced by lamellar bone. known approaches and methods is in clinical use, at the time
Clinical testing of the strength of the bone fragment union of publication of this book. Therefore, in uncertain cases we
is carried out 10–14 days before the intended day of device should, at least for now, be guided by the principle: “Better
removal. Prior to testing, the modules fixing the proximal one month late than one day early.”
and distal bone fragments are left unattached for some time. Table 32.2 lists the average periods of fixation and treat-
The degree of mobility of the bone fragments is then deter- ment used in the external fixation of fractures according to
mined by testing the patient’s ability to maintain the extrem- the data of the Russian Ilizarov Scientific Center “Restorative
ity in the horizontal position, and by manually applying Traumatology and Orthopedics” [704, 705].
lateral, axial and torsional loads (Fig. 32.14a). When no The period for fixation of a pseudoarthrosis mainly
pathological mobility is seen, the connection rods are reat- depends on the initial type of bone formation, the shape of
tached and the device is “dynamized” by slackening the nuts the bone fragment ends, and the degree of their devitaliza-
of the connection rods of the intermediate support(s) by tion; typically it is in the range of 3–4 to 6–8 months. Longer
1–2 mm (Fig. 32.14b). In combined strained fixation, dynam- periods for fragment consolidation should be expected if
ization is carried out by reducing the tension of the axial non-union occurs after bone osteosynthesis. Union of an
compression wire. Earlier dynamization of the frame arthrodesis takes place in 3–5 months.
1472 L.N. Solomin
a b
Fig. 32.14 Manipulations before frame removal: (a) clinical testing of the strength of the bone fragment union; (b) frame dynamization
During formation of the distraction regenerate, the fixation level of the skin. After removal of the transosseous
index (number of days for fixation of the formed regenerate elements, the wounds are treated with antiseptics and
divided by the length of the regenerate in centimeters) should covered with a sterile dressing. The patient can take a
not exceed 25–30. hygienic bath only after the skin wounds have healed but
Devices are generally removed in the out-patient depart- by no means earlier than 10–14 days after removal of the
ment. To remove wires with stops and half-pins, local anes- device.
thesia is sometimes required. In children and psychologically Once again, we emphasize that after device removal
unstable patients, a sedative is also needed, or perhaps the weight-bearing should be decreased and then gradually
induction of brief narcosis. increased up to the functional norm within 1–1.5 months (for
First the basic transosseous elements are disconnected an arm, within 3–5 weeks). Whether plaster bandages and
from the external supports. Then, the reductionally fixing braces are needed during this period is established on an
wires and half-pins are disconnected. To avoid causing individual basis. Patients with a device mounted on the ankle
pain by the sudden release of tension in a wire, the ten- or foot should be advised to use an orthopedic insole for
sion should be eliminated before the wire is cut off at the 6 months after removal of the device.
Table 32.2 Average periods of fixation and treatment (days) in Ilizarov external fixation
Location and type of fracture Fixation period Treatment period
Closed fractures of the proximal humerus (11-A, 11-B) 22–27 46–51
Closed/open diaphyseal fractures of the humerus (12-A, 12-B, 12-C1) 39–66/49–73 85–118/109–156
Closed fractures of the distal humerus (13-A, 13-B) 18–25 32–53
Closed fractures of the proximal forearm bones (21-A, 21-B) 25–47 39–89
Closed/open diaphyseal fractures of both forearm bones (22-A3, 22-B3) 49–67/88–117 100–115/124–152
Closed/open diaphyseal fractures of the ulna (22-A1, 22-B1) 50–67/65–82 77–94
Closed/open diaphyseal fractures of the radius (22-A2, 22-B2) 48–59/62–77 80–96
Closed fractures of the distal forearm bones (23-A, 23-B) 18–37 32–58
Closed fractures of the proximal femur (31-A, 31-B) 50–53 155–186
Closed/open diaphyseal fractures of the femur (32-A, 32-B) 62–92/77–92 109–154/189–229
Closed fractures of the distal femur (33-A, 33-B, 33-C1) and the proximal lower 46–52 78–88
leg (41-A, 41-B, 41-C)
Closed/open diaphyseal fractures of the lower leg (42-A, 42-B) 60–82/101–121 97–122/151–169
Closed fractures of the ankle (44-B, 44-C) 51–57 106–116
Complications and Solutions
33
External fixation devices are more complicated than internal drainage, antiseptic dressings, and treatment with antibiotics
fixation implants. Consequently, external fixation has more (with due regard for sensitivity), enzymatic drugs, or a solu-
nuances than other methods of osteosynthesis and the sur- tion of insulin and glucose. According to indications, dress-
geon must be aware of possible complications and how to ings with a water-soluble ointment are placed on the wound.
avoid or at least limit them. Optimum insulin therapy is supplemented with the use of
The enormous variation in the percentage of complications albumin drugs, anabolic hormones, angioprotectors and
reported in the literature for external fixation (1.5–100%) has immunostimulants [491]. Special attention should also be
given rise to endless debates. The complications can be divided paid to wires inserted near growth zones. Stabilizing the
into those occurring during the operation and those inherent to frame by the insertion of additional wires (or half-pins) may
the postoperative period, both during the fixation period and be necessary.
after disassembly of the device. In some cases, different com- Delayed removal of a septic wire can lead to pin-tract
plications can lead to the same unfavorable result (Figs. 33.1, osteomyelitis (Fig. 33.2), which is also caused by burning
33.2, 33.3, 33.4, 33.5, 33.6, 33.7, 33.8, and 33.9). the bone during insertion of a wire or pin, especially if a dull
According to the SOFCOT classification [706], patients drill bit was used. Usually, the course of pin-tract osteomy-
with complications can be divided into three categories: elitis is not malignant, and spontaneous remission is often
Category 1: No complications at all or mild complications the case. However, resistant osteomyelitis requires operative
not detected during the treatment period treatment, with excision of the ring sequestrum and debride-
Category 2: Complications requiring surgical interven- ment of the pin or wire hole.
tions not planned at the beginning of treatment but Inflammation of the soft tissues near transosseous ele-
which can be eliminated without consequences or with ments inserted near joints can result in septic arthritis. In
consequences not worsening the treatment result such cases, the injured joint is stabilized by mounting on an
Category 3: Serious complications with consequences at additional transosseous module followed by removal of the
the end of treatment and/or deterioration of the treat- wires or pins inserted through the intrasynovial portion of
ment result the joint. Septic arthritis is treated by the usual method with
Table 33.1 lists some of the complications, the causes of due regard to the specifics of the disease.
their development, the principles of prophylaxis, and the rec- When a nerve is damaged by a wire or pin or there is neu-
ommended treatment. ritis caused by the pressure exerted by an adjacent tran-
If conservative treatment of pin-tract infection (Fig. 33.1) sosseous element, the transosseous implant should be
for 3–4 days is ineffective, the transosseous element should removed. In most cases, conservative treatment is adequate
be removed. In the presence of concomitant diabetes, more to resolve this complication.
active tactics are needed: wide opening of the wire channel, There are also reports of biologically active reactions to
the wires, with symptoms, of dermatitis, edema, intermittent
fever, and pain, none of which could be eliminated by con-
L.N. Solomin, M.D., Ph.D. (*) servative treatment [80, 85, 103, 707]. Removal or replace-
ment of 1–2 wires may be necessary if local treatment fails
e-mail: solomin.leonid@gmail.com to control the problem. A reflex therapist should be con-
sulted, if needed.
S.A. Green, M.D.
Department of Orthopedic Surgery, University of California, Irvine, Soft-tissue cutting (Fig. 33.5) by the wires is common
3771 Katella Avenue Suite 310, Los Alamitos, CA 90720, USA during distraction and cross-wire bone transport. It is
b d
Fig. 33.1 Principal causes of infectious complications. (a) Failure to gauze pads. (b, c) Chronic trauma (in this case, tension) to the soft
observe the rules regarding asepsis and antiseptics: pay attention to tissues by the transosseous elements. (d) A device assembly was used
possible soiling of the device’s frame and of the disc clips holding the that did not provide adequate rigidity for osteosynthesis
33 Complications and Solutions 1477
a b
Fig. 33.2 (a, b) Pin-tract osteomyelitis

a b
Fig. 33.3 In this case, soft-tissue necrosis has arisen owing to excessive will require partial reassembly of the frame (b). Incorrect choice of ring
pressure upon the skin of a disc clip used to hold the gauze pad (a). diameter and absence of timely care, resulting in complications (obser-
Proximal ring press soft tissues and prevent flexion in knee joint; this vation of I.A. Voronkevich) (c)
a b c
Fig. 33.4 Contact allergic dermatitis (a, b) in the absence of adequate authors to autosensitization to the allergen, in this case wires inserted
treatment leads to eczema (c). The etiology and pathogenesis of trau- through acupunctural points
matic eczema, except for infectious process, has been ascribed by some
a b
c d e
Fig. 33.5 If pressure of a wire upon the soft tissues is relieved in due different levels (for example, III, 9 and V, 9) can lead to the occurrence
time, it does not lead to significant consequences (a). Removal of a of necrosis tracks connecting these elements. Therefore, the greater the
half-pin in this case will lead to wound healing within 2 weeks (b). distraction, the greater the distance should be between wires and half-
Soft-tissue cutting by transosseous elements results in infectious com- pins of different transosseous modules (“a stock of soft tissues”).
plications, with non-healing wounds (c, d). Distraction between tran- Except for rare cases, it is necessary to avoid introducing transosseous
sosseous elements entered into projections of the same position at elements in a longitudinal alignment (e)
a b
Fig. 33.6 Treatment of a patient with a non-union of the humerus and IV,9,90: (e) reassembly of the device; (f) modular transformation of the
pin-hole fracture. (a) Roentgenogram before treatment; (b, c) combined frame; (g) 5.5 months later. After a primary osteosynthesis, the device
external fixation and upper limb function on postoperative day 4. (d) A was dismantled; (h) upper limb function 3 days later
fall from a height of 2 m resulted in a crisis in the field of half-pin
d e


f
g

b d
Fig. 33.7 (a–d) A principal cause for the development of pin-induced joint stiffness is the failure to use reference positions (Chap. 5) in the
introduction of transosseous elements (a, b and d) as well as a “superfluous” amount of wires and pins (c)
a b c
Fig. 33.8 Secondary bone fragment displacement, as a rule, reflects fixation with respect to the applied loading (b), the breakage of tran-
the absence of coaxiality between the transosseous modules and the sosseous elements (c), or problems with details of the frame’s
axes of the bone fragments (a), an inadequate rigidity of bone fragment configuration
a b
Fig. 33.9 (a–d) The method of

external fixation is invalidated by
incorrect configurations of the
devices and the absence of bone
fragment reduction, in turn
leading to malunion and
non-union

Table 33.1 Complications of external fixation
1488
Complications Main causes Prophylaxis Treatment

Inflammation of the soft 1. Violation of asepsis and antiseptics rules 1. Strict observance of asepsis and antisepsis during the Administration of antibiotics with due regard for
tissues around tran- insertion of transosseous elements; use of dressings the sensitivity of the microflora
sosseous elements 2. Chronic trauma of soft tissues adjacent to 2. Use of positions with minimum soft-tissue displacement Releasing soft tissues to eliminate tension by
(pin-tract infection) transosseous elements during the insertion of transosseous elements, transosseous elements
thus eliminating tension on the soft tissues
3. Instability of the external device 3. Measures to maintain the construction stability Restoration of device stability
Soft-tissue necrosis 1. Use of external supports of inadequate size 1. Arrangement of the device supports with due regard for As an urgent measure, when there is a danger of
(caused by pressure of the the possibility of increasing the ring circumference by compression: placement of a flexible flat spacer
external supports and 4–6 cm; eccentric arrangement of the supports with between the ring and the skin; elevated position
other device elements) room for the soft tissues at potential sites of swelling of the extremity
2. Excessive pressure exerted by the wires 2. When there is a danger of pronounced swelling, Partial reinstallation of the device
decreased compression of the gauze pads Debridement (if necessary), local treatment of the
surrounding the wires pathological process
Injury of vessels and 1. Insertion of transosseous elements with 1. Use of “safe” and “reference” positions for the insertion Removal of the transosseous element and
nerves knowledge of vessel and nerve anatomy of wires and half-pins; use of preliminary contrast hemostasis by compression of the soft tissues
vascular studies in difficult cases; half-pin insertion or ligature of the vessel (if necessary)
with vessels and nerves beyond the opposite cortex
2. Winding of soft tissues on the wire 2. Use of wires with polished surfaces; use of a pin or wire In case of bleeding caused by decubitus, operative
drill sleeve treatment (ligature, vascular, plasty)
Dermatitis 1. Dressings with drugs causing allergic reactions 1. Allergen elimination Allergen elimination
2. Reaction to the presence of an infected wound, 2. Timely diagnosis and treatment of the inflammatory Stopping the inflammatory process
soft-tissue inflammation in the region of the process Consultation with a dermatologist
transosseous elements (microbial eczema)
Neurovascular disorders In most cases, exceeding the distraction or Controlled rate of distraction of the bone fragments Increase distraction multiplicity (e.g., from
compression rate 0.25 × 4 to 0.125 × 8)
Use of automated high-frequency, low-increment Decreased distraction rate or temporary interrup-
distractors tion or reversal of distraction
Pharmacotherapy, physiotherapy
L.N. Solomin and S.A. Green
33
Contractures and 1. Insertion of the transosseous elements at sites 1. Use of “reference positions” for wire and half-pin Intensive exercise therapy
pin-induced joint stiffness where soft-tissue displacement is large relative insertion
to the bone
2. Failure to account for soft-tissue displacement 2. Creation of redundant soft tissues by proper positioning Use of special components in the device to
during wire insertion when inserting transosseous elements through “flexion” increase of ROM
and “extension” surfaces of the limb; manual displace-
ment of soft tissues
3. Use of rings that are too close to the joints 3. Use of open external supports (half-rings, 2/3 rings) Replacement or removal of transosseous elements
near joints
4. Tension of the soft tissues because of 4. To prevent permanent contractures, avoidance of Reducing the rate of lengthening, or stopping
distraction segment lengthening in a single stage by more than a altogether
Complications and Solutions
certain critical magnitude

5. Disregarding additional measures 5. Use of special positions of the extremity after the
for contractures prophylaxis operation, as well as devices attached to the apparatus
Active-aggressive postoperative rehabilitation; mainte-
nance during the entire fixation period of the joint
movement amplitude present on the operating table
instead of trying to regain ROM after contracture
appearance
Subluxations and 1. Violation of lengthening principles (including 1. Strict observance of osteosynthesis methods Stopping the distraction
dislocations of the joints excessive magnitude of lengthening, too rapid
rate of distraction); errors in apparatus
arrangement
2. Disregarding the prophylaxis of this 2. Taking preventive measures (e.g. temporary fixation of Modification of the device (if necessary)
complication the joint with a transosseous hinge module) Mounting of additional components to allow
correction of the present complication
Arthrolysis, lengthening the tendons (according
to indications)
Secondary bone fragment 1. Failure to observe the biomechanical 1. Strict observance of biomechanical standards when As a rule, partial reinstallation of the external
displacement fundamentals of mounting, reduction, using external fixation device
and fixation of bone fragments
2. Failure of device components 2. Use of high-quality certified equipment
3. ROM, segment condition, and frame 3. Adequate patient monitoring
uncontrolled
Breakage of transosseous 1. Overloading of the “frame – extremity” system 1. Proper device mounting (including wire tension); Replacement of broken components; partial
elements, failure of ensuring that: (a) loads on the extremity correspond reinstallation of the device
device components to the bearing capability of the newly formed bone;
(b) the rigidity of bone fragment fixation by use of
an adequate device assembly
2. Defective metalwork or metal fatigue 2. Use of high-quality certified equipment
3. Lack of observance of the rules for storage, 3. Observance of the rules for storage, sterilization,
sterilization and disinfection of the device, and disinfection of the device
resulting incorrosion; deformity, loss of
mechanical properties due to temperature
changes, etc.
1489
(continued)
1490
Complications Main causes Prophylaxis Treatment

Cutting into the bone by 1. Insertion of transosseous elements near the 1. Insertion of the transosseous elements through two Replacement of transosseous elements when
the transosseous elements cortical edge cortices, except in special cases necessary to retain their initial number and the
2. Inadequate area of the wire’s bead (stop) in 2. Increased number of transosseous elements and use degree of bone fragment fixation rigidity
relation to the requirements of the fixation of a beaded wire of adequate area
and the magnitude of osteoporosis
3. Use of half-pins in patients with pronounced 3. Use only of beaded wires in case of pronounced
osteoporosis osteoporosis
Patient’s psychological Underestimation of the patient’s psychological Taking into consideration all contraindications for the use Consultation with a psychotherapist
inability to accept condition before treatment and of critical of external fixation Sedative therapy
external fixation circumstances in the patient’s life that make the Removal of the device only when absolute
further use external fixation devices impossible necessity and conversion to other methods
of fixation
Malunion, non-union and 1. Inaccurate reduction of bone fragments; 1. Ensuring accurate reduction (adaptation in reconstruc- Gradual bone fragment reduction
formation of a hypoplas- secondary displacements tive procedures); prophylaxis of secondary
tic distraction regenerate displacements
2. Inability of the frame to provide early 2. Use of an external fixation device that achieves rigid Ensuring adequate rigidity of fixation
restoration of ROM and weight-bearing fixation, adequate to weight-bearing capability of the Use of special methods for optimizing reparative
regenerate bone and early ROM osteogenesis on the basis of biological, mechani-
cal, physical and pharmacological factors
Post-fixator re-fracture, 1. Premature removal of the device, inadequate 1. Consideration of clinical, X-ray criteria for device Conservative treatment, re-osteosynthesis,
secondary deformity loading after dismantling the device (including dismantling reconstructive surgery(according to indications)
due to non-observance of recommendations by
the patient)
2. Bone union without restoration of the mechani- 2. Restoration of the mechanical axis
cal extremity axis
3. Union involving a limited cross-sectional area 3. Exact reduction of the fragments
4. Primary union (without periosteal callus) 4. Subsequent decrease in weight-bearing after device
removal
L.N. Solomin and S.A. Green
a b c d
Fig. 33.10 (a–d) Identification of knee joint subluxation in sagittal cortical lines of femur and tibia (at knee extension these lines coincide).
plane. (a) At knee joint extension the centers of joint lines should cor- In order to find the axis of rotation of a knee joint, it is necessary to
respond to each other. (b) Subluxation in the knee joint. (c) The axis of make the roentgenogram of contralateral (intact) joint. (d) Flexion con-
rotation of the knee in sagittal plane is located in crossing of posterior tracture and subluxation
generally cured in two stages. In a distraction of up to 4–6 cm the joint the transosseous elements are inserted or the closer
(depending on the segment), releasing the soft tissues is often to the joint the corticotomy is performed, the greater is the
sufficient. Later, reinsertion of the transosseous elements is risk of contracture development. In case of bilocal lengthen-
required. The use of oblique-wire bone transport or an axial ing of the lower leg, after the formation of a distal distraction
distraction wire will reduce the likelihood of this complica- regenerate of more than 20–30 mm there appears to be an
tion. In case of soft-tissue damage caused by joint move- increased risk of pes equinus, even when all precautionary
ment, the skin should be cut as necessary. measures are taken. This is an indication that the rate of dis-
The diameter of a half-pin must not exceed 20% of the traction should be reduced to 0.25 mm once or twice a day,
bone diameter at the level of its placement so as not to or even stopped. Residual shortening should be compensated
decrease the mechanical strength of the bone [708]. In case by the formation of the proximal distraction regenerate.
of pin-hole fracture (Fig. 33.6), reassembly of the device or, Knee joint flexion contracture at femur lengthening is
rarely, changing the fixation method may be necessary. quite often accompanied by posterior subluxation of tibia. In
To prevent the development of resistant joint contractures, Fig. 33.10 is shown how it is possible to find subluxation in
the segment should not be lengthened in one stage and should knee joint in sagittal plane.
not exceed a certain critical value, which is determined indi- The treatment of already-generated joint stiffness and/or
vidually with due regard to the segment being lengthened, subluxation is described in Chap. 23.
the type of pathology, and the method used. In particular, The main way to prevent complications of external
lengthening by >15% of the initial segment should not be fixation was enunciated by G.A. Ilizarov: “A surgeon should
attempted if before treatment there was moderate limitation know not only the device but also the method proposed with
in the range of motion of the adjacent joints. A decrease in it; therefore, its detailed mastering is a must.” Careful fol-
the range of motion by an average of 50–60% of the initial lowing of this advice will allow most complications to be
value is the limit. It should be kept in mind that the closer to avoided.
Part III
Supplementary Materials
External Fixation: a Brochure
Containing Useful Information 34
for Patients
Leonid Nikolaevich Solomin, Tatyana Nikolaevna

Vorontsova, and Victor Viktorovich Ershov
In this chapter the reader will find how to answer the ques- limb. Additionally, it allows manipulation of the limb seg-
tions that are frequently raised by patients during treatment ments to achieve restoration of the bone’s length and align-
using external fixation. The dialogue with the patient is an ment. Synonyms of “external fixation” are “transosseous
essential part of the therapeutic process: for this reason, osteosynthesis,” “external fixing,” and “external osteosyn-
addressing the patient with a simple language and listing the thesis” as opposed to “internal fixation”, i.e. to an osteo-
most important points is vital to carry out all of the pre- and synthesis with the use of internal fixators (plates, nails,
postoperative steps. In the following pages the reader can screws).
find how to practically advise the patient: general informa- Compared with methods of internal fixation, external
tion about the external fixation, the different types of crutches fixation has unique advantages: minimum traumatic inter-
and canes, recommendations about nutrition, weight, per- ventions, the possibility of wire and pin insertion beyond the
sonal hygiene, and physiotherapy exercises. damage zones of the bone and soft tissue, the possibility of
closed bone-fragment reduction, and the control of the rigid-
ity of fixation.
34.1 General Information Nowadays more than 1,000 devices for external fixation
are available. In 1952, in Russia, G.A. Ilizarov (Fig. 34.1)
34.1.1 What Is External Fixation? developed the first such apparatus. Following improvements
over the years, the Ilizarov apparatus is now one of the best
External fixation is a method of treating bone and joint external fixation devices.
injuries as well as correcting skeletal deformities by attach- Thanks to its possibilities, both the device and the Ilizarov
ing bones to an external device that stabilizes the injured method have won wide international acceptance in many
countries of the world (Australia, the USA, Japan, Italy,
L.N. Solomin, M.D., Ph.D. () Portugal, Brazil, India, etc.) There is even an international
R.R. Vreden Russian Research Institute of Traumatology and Association for the Study and Application of the Method of
Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia Ilizarov (ASAMI).
However, it is necessary to understand that the Ilizarov
T.N. Vorontsova, M.D., Ph.D. apparatus and other external fixation (ExFix) devices must
Department of the Public Health, R.R. Vreden Russian
be adapted to the particular fracture, non-union, deformity,
Research Institute of Traumatology and Orthopedics,
8 Baykova Str., St. Petersburg 195427, Russia bone defect, or combination thereof. Your orthopedic surgeon
will select the device and the method of its application that
V.V. Ershov
Department of Orthopedics, City Urgent Hospital, are optimum for your treatment. Figure 34.2 shows some of
Al. Nevskogo Str., 90, Kaliningrad 236008, Russia the variants of the Ilizarov frame.
Fig. 34.1 Prof. G.A. Ilizarov
Fig. 34.2 (a–d) External fixation devices

34 External Fixation: a Brochure Containing Useful Information for Patients 1497
c d
34.1.2 Design of External Fixation Devices bone deformities, the formation of new bone tissue can be
compared to building a house. First, the beams and supports
An ExFix apparatus consists of transosseous elements and a of the house are assembled, as is the ExFix frame. The walls
frame (Fig. 34.3). The latter is constructed from supports of of the house are built up brick by brick, while in the case of
different geometries (ring, half-ring, and arches) connected osteosynthesis new bone tissue develops. As the partitions
by threaded and telescopic rods. and communications between rooms of the house take form
Transosseous elements are 1.5–2 mm wires and 4–6 mm so does the growth of body’s blood vessels and muscle fibers
half-pins. They connect the bone fragments with the frame. at the injury site. Finally, completion of the building’s exte-
Wires and half-pins are inserted through a bone and its sur- rior can be compared to the growth of the skin.
rounding soft tissues. This imposes special requirements for
pin-site care. Transosseous elements are fixed to the frame According to the biological law revealed by the work of
by means of special clips and bolts. G.A. Ilizarov, if a bone is cut and the bone fragments are
strongly fixed by an external fixation device and subjected to
distraction, new bone tissue will form. Thus, in deformity
correction, lengthening, and bone defect replacement two
34.1.3 How Is New Bone Formed? stages can be defined: distraction (deformity correction) and
fixation.
An ExFix device provides optimum conditions for regener- Distraction is the period during which new bone grows and
ate (“bone callus”) formation between the bone fragments of the deformity is corrected. It starts after bone cutting (osteot-
a fracture or a non-union. In the shortenings and defects of omy) and frame assembly. On day 5–7 after the operation,
a b c
d e f
Fig. 34.3 The main parts of the Ilizarov apparatus: (a) ring, (b) half-rings, (c) arches, (d) connecting rods, (e) telescopic rods, (f) bolts, nuts,
washers
g h i difficulties that must be overcome. Your will-power, under-

standing of the treatment method, and active participation
in the recovery process are the keys to therapeutic success.
To achieve the goals of treatment, you will need the support
of relatives and friends. Their telephone numbers should be
readily available in case of emergency. Your support group
should be involved in the process of treatment. They will
help you to adjust to the external fixation device and partici-
pate in your care. You may also want to seek the advice and
counsel of a spiritual mentor prior to hospitalization.
During treatment you will be supported by professionals
who love their work and who are committed to your recovery.
In recommending treatment with the Ilizarov apparatus (or
other device), your orthopedic surgeon is convinced that it
offers you the best therapeutic strategy.
ExFix-based treatment, in contrast to other methods,
requires the participation of an external fixation specialist at
each stage, prior to the removal of the frame. He or she will
plan the specific treatment, perform the surgery, monitor
compliance with appointments, and answer your questions.
A therapist will also be involved in preparing you for sur-
gery. If you have any chronic illness, he or she will work together
with your physician to determine prophylactic treatment aimed
at preventing an acute episode of the disease. If you are under-
going an elective operation, any nidus of infection should be
appropriately managed. You should also see your dentist.
A nurse will assist your doctor at every stage of treatment,
carrying out the procedures assigned. She or he will answer
your questions or seek out the information or expertise that
you need. While in the hospital, it is recommended that you
pay attention to the manipulations of the nurse or other staff
when they are changing your wound dressings, since after
discharge from hospital you may need to do this yourself.
Fig. 34.3 (continued) (g) wires, (h) half-pins, (i) wire and half-pin
fixators
34.2 Treatment Planning
distraction is initiated at a rate of 1 mm a day. Thus, the dis-
traction period for a 4-cm bone lengthening is 45 days. As a rule, treatment consists of three stages: the preoperative
The fixation period is required for transformation of the period, the operation, and the postoperative period.
distraction regenerate (newly formed “young” bone tissue) In the preoperative period it is necessary for you to pre-
into normal bone that is capable of functional loading. On pare crutches, a cane, or a walker. The crutches must con-
average, it takes 1 month to transform 1 cm of distraction form to your height and weight. An orthopedic shop can
regenerate. Thus, the fixation period for a 4-cm lengthening provide assistance. Figure 34.4 shows traditional crutches.
is 4 months. To reduce the length of the fixation period, the Note: Crutches that are too high or too low will cause
ExFix device can at some point be replaced with an internal chronic pain in the shoulder joint(s) and along the spine, and
fixator, in the form of a plate or a nail. You can discuss with you will be unable to lean on them correctly.
your surgeon the positive and negative features of bone The back of a person standing with the help of crutches
fixator replacement. should be straight. The upper crossbar should be 4–5 cm
lower than the axilla (Fig. 34.5). The forearm should press
the crutch to the body. The hand crossbar should be located
34.1.4 Your Core Team at wrist level. With the hand on the crossbar, the elbow joint
should be flexed at an angle of approximately 160°.
You are the most important person in the process of treat- Note: Do not impose pressure on the axilla! Non-
ment and postoperatively you will be confronted with several observance of this rule can result in “crutch paralysis,” that
Fig. 34.6 “Canadian” crutches
Foam-rubber padding on the axillary crossbar
Foam-rubber padding on the hand crossbar
Rubber tip
Fig. 34.4 Traditional crutches
is, sensory and movement disturbances in the upper limbs. If

the crutches have a rigid upper crossbar, it should be cush-
ioned with foam-rubber padding.
Note: There are numerous kinds of crutch adaptations for
secure walking, such as rubber tips (nozzles), which prevent
sliding on the floor. The nozzles will wear out with extended
use and/or eventually crack. This can cause a fall, which can
lead to a postoperative crisis. If the tips require replacement,
both must be replaced at the same time. Also, it is recom-
mended that rugs in your house be removed, to protect against
a potential trauma caused by slipping or sliding on them.
As adaptations will be made for walking, proper footwear
is essential: a low persistent heel with a corrugated and
flexible sole. Shoes should be convenient and comfortable.
Installation of a hand-rail will facilitate use of the bath-
room and toilet after you return home.
In addition to the above measures, you will need to pre-
pare covers for the device, organize clothes that can accom-
modate the device, and, for operations on the lower leg,
obtain a foot supporter. Detailed information on these items
is provided in the Appendixes at the end of this chapter.
“Canadian” crutches (Fig. 34.6) are similar to a high cane
reaching the elbow and have a special flexible support. You
must adjust the height of the crutches so that your back is
Fig. 34.5 The distance between the axilla and upper crossbar of the straight and the flexible support meets the back surface of the
crutch should be 5 cm forearm, slightly lower than the elbow joint.
Fig. 34.7 Cane with support
Fig. 34.8 Walker
A typical cane is shown in Fig. 34.7. The support on a 34.3 The Postoperative Period
cane reduces leg loading by as much as 20% of body weight.
Adjust the cane according to your height, defining the appro- Analgesics are used for the first 2–3 days after the operation.
priate length while you are standing. The arm supporting the The need for further drugs is determined individually.
cane should be bent at the elbow at an angle of 20°. If the lower leg has been operated on, it is necessary to
Note: A short cane is of reduced efficacy, and an overly keep it in an elevated position for 2–4 days. Use of a
long one causes overloading of the arm muscles. The cane foot-hammock is obligatory (Fig. 34.9a). In deformity cor-
should be positioned on your “healthy” side! rection and lengthening, the foot-hammock cannot be
A walker (Fig. 34.8) is a support intended to aid those removed, even at night! More detailed information is pro-
who because of illness or trauma are weakened and unable to vided in the Appendixes at the end of the chapter.
use crutches or a cane. The size of the walker should be After femoral external fixation, when you are in bed the
adjusted according to your height. The arm resting on the knee joint should be flexed at 90° and more. For this purpose
walker should be bent at the elbow at a 15–20° angle. the distal frame support can be attached to the Balkan frame
Before the operation, you will be examined by the of the bed. A belt for attaching the support to the frame
anesthesiologist, who will select the optimum method of should be prepared in advance (Fig. 34.9b).
anesthesia. Your physician will again explain the opera- If the ExFix frame was applied to the forearm, the hand
tive procedure to you and will ask you to sign the neces- should be kept in a hand-hammock (Fig. 34.9c).
sary informed consent forms, including those specifying The hospital stay varies from 3–5 days for fractures to
that you have been informed of the possible complica- 1–2 months foe complex deformity correction. It is impor-
tions, their preventive maintenance, and the overall tant that, with the guidance of experts, you to learn to cor-
treatment. rectly walk using crutches (cane, walker) and that you master
If the operation is planned, you will take a hygienic bath the physiotherapy exercises. You should also keep an ortho-
on the morning of the procedure and the hair in the field of pedic status diary. Further information is available in the
operative intervention will be shaved off. You will then be Appendixes at the end of the chapter.
given special “preoperative” medications and transported to Special attention must also be given to the correct frame
the operating room. manipulations: compression, distraction, etc. You will need
a b
Fig. 34.9 (a–c) Necessary positions of the operated extremities: (a) foot-hammock, (b) patient in bed after external fixation of the femur,
(c) hand-hammock
to do these yourself, or with the help of relatives or friends, fixation, requires that you are monitored by the attending
after discharge from the hospital. Further information is physician throughout the fixation period.
available in the Appendixes at the end of the chapter. Note: During out-patient treatment, you may need to be
After discharge, a patient care institution will be recom- readmitted to the hospital for partial reassembly of the frame,
mended to you. Note that external fixation, unlike internal the reinsertion of transosseous elements, etc.
34.3.1 Nutrition 34.3.6 Physiotherapy Exercises
Proper nutrition will support the formation and growth of new Physiotherapy is obviously necessary. Not only oxygen but
bone tissue, and promote the healing of wounds, the function- all mineral substances are delivered to the damaged bone by
ing of soft tissues, and keep your body in good shape in arterial blood flow, which is increased by exercise. Venous
response to the increased physical and emotional burden posed blood removes the products of tissue disintegration and cell
by surgery. A balanced diet with sufficient amount of easily metabolism. Intensively working muscles strengthen blood
acquired proteins (the building blocks of bone), minerals, and flow by several fold, thereby considerably improving the
vitamins is therefore essential. Your diet should contain processes involved in damaged tissue restoration. Flaccid
sufficient amounts of vegetables and fruits. Consult a dietician muscles do not support the delivery of the necessary amounts
if necessary. When indicated, the attending physician will pre- of oxygen and minerals. In addition, they slow down the
scribe calcium preparations. During treatment, try to avoid the outflow of venous blood, which leads to edema and subse-
overuse of carbonated drinks containing phosphoric and car- quently to trophic disturbances. To avoid the negative conse-
bonic acids, as they prevent the assimilation of calcium. quences of compelled immobilization, in the first days after
an osteosynthesis isometric gymnastics and active-passive
movements of the joints are recommended.
34.3.2 Weight
In isometric gymnastics, the muscles contract but joint
movements are absent. The best known example is when a
Excess weight increases loading of the joints, ligaments,
man strains his stomach muscles by an effort of will such
muscles, and cardiovascular and respiratory systems, mak-
that the outlines of the muscles are visible in the absence of
ing it even more difficult for you walk during rehabilita-
movements. Therefore, before hospitalization, it is very
tion. If necessary, consult a dietician regarding ways of
important that you learn to strain the muscles of your upper
keeping fit.
and lower limbs. Let the muscles work as frequently as pos-
sible, for example, when you read a book or watch TV.
34.3.3 Personal Hygiene Besides active movements of the joints, passive ones are
also important. These do not consist of muscle tensioning
With the permission of your attending physician you can intended to cause movements of the joint but are made by a
take a warm shower, if there is a central water supply with healthy hand or the hands of the doctor or therapist and
chlorinated water, using antibacterial soap. After showering, involve special mechanical devices.
dry the frame and your skin using a hairdryer (warm air). After external fixation of the femur and lower leg, loading
Make sure a fresh bandage and a clean, ironed frame cover of the operated limb is recommended, as a rule, as early as
are afterwards available. the first few days after operation. To determine the appropri-
ate amount of loading, the patient steps with the operated
limb onto a floor scale. In this position, loading should be
34.3.4 Sex
gradually increased until discomfort appears: pain, an aware-
ness of soft-tissue tension in the area of the wires, etc. This
Both doctors and psychologists say that having sex is not only
value of loading is taken as the initial one and is documented
pleasant but also useful. Sex will reduce stress as well as
in your medical chart and in your orthopedic status diary.
sleeplessness and improve cardiovascular function. You can
Later, weight loading will be incrementally increased under
lead a normal sexual life after ExFix surgery. Be sure to cover
weekly supervision. Further details can be found in the
the frame with a dense fabric so as not to injure your spouse.
Appendixes at the end of the chapter.
Note: You must pay particular attention to the restoration
34.3.5 Quit Smoking! of correct gait. Improper gait is when, for example, the patient
takes a first step with the operated limb and then brings the
Tobacco is unique in that it is a legally sold product whose other leg to it. Pay attention to the uniformity of your steps. In
use does enormous harm. In Russia, about 500,000 people the first few days after the operation take small steps of equal
die each year of smoking-related diseases. Nicotine slows length. At each step, place the heel at the level of the toe of the
down the process of new bone formation, narrows the other foot. Later the length of each step should be gradually
blood vessels, interrupts the circulation, and weakens increase until it is the same as before the fracture.
immunity. It has been scientifically proven that the frac- Your physicians along with the exercise therapy specialist
tures of smokers unite more slowly, the quality of new will choose the necessary exercises from the list in the
bone formation is poorer, and the risk of complications Appendixes at the end of the chapter.
higher than in non-smokers. Passive smoking is just as The development and improvement of your physical con-
dangerous. dition are of great importance. Preservation as well as
Table 34.1 Complications

Complications Possible reasons
Pin-tract infection, evidenced by pain, edema, In most cases, this complication arises because of non-compliance with the hygienic
skin reddening, and suppuration guidelines regarding care of the ExFix device
Partial necrosis of soft tissues, evidenced by theirThis can be due to excessive pressure of the disc clips that hold the gauze dressings. Make
darkening color and decreasing sensitivity sure the disc clips do not press into soft tissues!
Dermatitis, accompanied by inflammation, edema, This is indicative of an allergic reaction. The dressing should include only those medica-
and skin desquamation tions recommended by the doctor! Prior to surgery, inform the doctor concerning all
previous allergic reactions
Neurovascular disorders: characterized by This complication is most likely due to excess distraction. The distraction rate recom-
reflected pain below the ExFix device, altered skin mended by the attending physician must be strictly observed!
sensitivity, a creeping sensation, change of skin
color, and the appearance of edema
Contractures and pin-induced joint stiffness, Be sure to use keep the operated extremity in the positions recommended by the doctor for
manifested as a restricted range of movement the postoperative period. Do not carry out unprescribed ROM, but maintain and increase
(ROM) in the joints the amplitude of the movements daily
Refracture (repeated fracture), secondary Prevention requires the avoidance of overloading after frame removal. The correct amount
deformation of weight-bearing should be discussed with your doctor
Malunion, non-union This is most often seen in compound fractures. The most frequent cases are associated
with tobacco and alcohol abuse
Deformation and damage of the parts of the The most common reason is inadequate loading exceeding the mechanical durability of the
device ExFix device. Follow your doctor’s recommendations
progress in your abilities are an important psychological fac- 34.4 Possible Complications
tor. As the force of the muscles returns and the range of
motion advances, you will find daily life much easier. The Like any other methods of surgical treatment, complications
body’s respiratory and cardiovascular systems are strength- may arise after external fixation. These are listed and briefly
ened by regular exercise, which accelerates the removal of explained in Table 34.1.
by-products and toxins. As you become more mobile you Note: If any of the signs of complications appear, your
will better endure stresses and will be better able to perform attending doctor should be informed immediately to prevent
physical activities. their further development.
A physical work-out program should be started before the
operation and continued afterwards at home. For a proper
training regime, it is not mandatory to visit expensive fitness A Appendixes
studios. Simple equipment, such as a ball, dumb-bells, an
elastic band, and an expander will allow you to reach the A.1 Appendix A: Dressings
desired result. However, you should honestly assess your
abilities, which will depend on your initial condition and Dressings are changed by a nurse. You should do this your-
improve only with regular training. self only after receiving permission and proper training. The
necessary materials are (Fig. 34.10):
1. Basin or a rubber sheet
34.3.7 Removal of the External Fixation Device 2. Pair of sterile gloves
3. Tweezers
Removal of the ExFix device is usually done according to 4. Sterile scissors
your doctor’s recommendations and on an out-patient basis. 5. 10-ml syringe
Prior to the removal, you will be administered a bone-union 6. 70% ethyl alcohol (prepared as shown in Fig. 34.11) or a
clinical test and be asked to walk with the destabilized chlorhexidine gluconate solution (available from a
(dynamized) device for 5–7 days. The attending physician pharmacy)
will explain what this entails and why it should be done. The 7. 3% solution of hydrogen peroxide
doctor will also decide whether, after removal of the frame, 8. 5 × 5 cm sterile napkins
you will benefit from a plaster bandage or brace. 9. Clean frame cover
After the transosseous elements are removed, the wounds Sequence of actions:
should heal in 1–2 weeks. According to recommendations, 1. Remove the cover from the external fixation device.
limited weight-bearing should be undertaken. 2. Place the basin or spread the rubber sheet under the frame.
3. Wash your hands with bactericidal soap or with antisep- 7–10 days. Simultaneously, replace the frame cover with a
tic gel; put on the sterile gloves. clean one. If the napkins get wet they must be changed—
4. Clean the frame with a sterile napkin moistened with 3% even every day—to avoid their contamination.
hydrogen peroxide. Then wipe the frame with a napkin
moistened with chlorhexidine.
5. Wipe your hands with chlorhexidine. A.2 Appendix B: Frame Manipulation
6. Move aside the disc clips and throw away the soiled nap-
kins (Fig. 34.12). To move the external supports of the frame, you will need two
7. Using 3% hydrogen peroxide, clean the skin near the 10-mm wrenches to rotate the nuts on the connecting rods
transosseous elements. and hinges for compression, distraction, etc. (Fig. 34.13).
8. Wipe the skin near the transosseous elements with 70% Your doctor will specify which nuts need to be adjusted in
ethanol or chlorhexidine. order to move the bone fragments in the right direction. To con-
9. Impregnate the napkins with 70% ethanol or chlorhexi- trol the screws, their connecting rods should have labels, which
dine and slightly press them onto the skin using the disc can be made for example, with 5-mm strips of tape. Every label
clips (Fig. 34.12). Do not wrap the napkins around wires must have the serial number of the connecting rod and an arrow
and half pins! showing the direction the nuts are to be turned (Fig. 34.14). Of
10. Place a clean, ironed cover over the frame. the two nuts, one moves a support, and the other (check-nut)
Consult your attending doctor about the frequency of maintains the rigidity of the support fixation.
dressings! Usually, if there is no suppuration and the napkins One full turn (360o) of the nut causes a 1-mm movement
remain dry, the dressing should be changed once every of the support along the rod. Turning the nut at 90o corre-
sponds to a support movement of 0.25 mm. The number of
0.25 mm-cycles can vary from 1 to 8 times a day, and it may
be different for each of the connecting rods. To control that
the nut has been turned, it could, for example, be marked.
To move a support 0.25 mm, follow this procedure: Using
a wrench, move the check-nut away from the support by
0.5–1 mm. Then the nut is turned 90o. This nut is located at the
site of the label. To measure a 90o turn, it is convenient to use
the right angle of a corner of a sheet of paper (Fig. 34.15). The
check-nut is then tightened to stabilize the support. The rest of
the connecting rods should be adjusted in the same way.
The number of nut turns for all connecting rods will be
determined by your doctor. If the recommended distraction rate
is 0.25 mm four times per day, these manipulations are best
performed at 8:00 AM, 12:00 PM, 04:00 PM and 08:00 PM.
Throughout the treatment period, the compression (dis-
traction) rate may vary. It is therefore necessary to document
all procedures in your orthopedic status diary, as shown in
Fig. 34.10 A dressing set Table 34.2.
Fig. 34.11 Preparing 70%

ethanol. Add 3 ml of sterile water
in a syringe to 7 ml of 98%
ethanol. Mix well 3 ml water for injections 7 ml 98% ethanol
a b
Fig. 34.12 Changing the dressing. (a) Put on sterile glovers before changing the dressing. (b) Cut a 5 × 5 cm sterile napkin in half. (c) Place the
napkin on the wire making use of the napkin slit. (d) Slightly press the napkin into place using the disc clips
Fig. 34.13 Wrenches
Lock-nut
Nut
Label
Fig. 34.14 Labels of the connecting rods, nuts, and check-nuts
Fig. 34.15 Turning the nut 90°; (a) initial position, (b) nut rotated
by 90°
Table 34.2 Diary of compression and distraction

Scheme of the Days of compression (distraction), the value, and rate
apparatus
Table 34.3 Dynamics of the orthopedic status
1508
Post- Post- Post- Post Posto- Post- Post- Post- Post- Post- Post- Post- Post-
Before the operative operative operative operative perative operative operative operative operative operative operative operative operative
operation day 1 day 7 day 14 day 21 day 28 day 35 day 42 day 49 day 56 day 63 day 70 day 77 day 84
Circumference At level
___
At level
___
At level
___
Movement in Proximal
the joints joint
Distal joint
Circumference At level
___
At level
___
At level
___
Movement in Proximal
the joint joint
Distal joint
Weight-bearing
L.N. Solomin et al.
Note: It is necessary once a week (for example, on

Monday) to check strength of fixing of all device nuts, except
for the nuts fixing wires.
A.3 Appendix C: Your Orthopedic Status Diary
Your measurements of weight-bearing, limb circumference,

and range of joint motion are critically important for your
doctor. These parameters enable him or her to evaluate the
functional recovery of the operated limb and to provide appro-
priate recommendations for your rehabilitation. Accordingly,
you must enter these data on a weekly basis in the form of a
special table as shown in Table 34.3.
To measure weight-bearing (Fig. 34.16), first measure
your own weight by stepping onto a scale with the healthy
leg. Then step on the scale using your operated leg and load
it until a feeling of discomfort (pain, tension on the soft tis-
sue, etc.) is noted. Take note of these feelings and do not
overload the leg when walking.
To measure the limb circumference, you will need a mea-
suring tape (Fig. 34.17a). Generally, measurements are taken
at three levels: at the level of the damage, and above and
below it. For comparisons, the circumferences at symmetri-
cal levels of the healthy limb are measured before treatment.
Your doctor will specify the exact levels of measurement. a
To control ROM, you need a protractor (Fig. 34.18). The
accuracy of your measurements will be checked by your
doctor.
A.4 Appendix D: Walking with the Aid

of Crutches or a Cane
A.4.1 Using Crutches

The proper use of crutches requires both good balance and
coordinated movements, as well as muscle strength. Before
you need to walk on crutches, learn how to use them properly
and safely. This takes only a small amount of practice.
A.4.2 Walking on Crutches with Complete

Unloading of the Operated Leg
Initial position: standing on the healthy leg. The crutches are
positioned 6 cm forward and 15 cm laterally to your feet
(Fig. 34.19).
Place the crutches 25–35 cm ahead of you. Lean on the
crutches. Transferring your body, lean on your healthy leg,
placed at a distance of 25–35 cm in front of the crutches. Use
your hands to firmly press the upper part of the crutches to
the chest without causing any pressure on the axilla. Use b
only your hands for support (Fig. 34.20).
Note: If the step of the healthy foot is shorter than the one Fig. 34.16 Measuring weight-bearing: (a) measuring body weight;
taken by the operated leg, the next step of the operated leg (b) measuring maximum possible limb loading
c d
Fig. 34.17 Measuring the circumference of the lower leg at three levels using a measuring tape (a). Measure the circumference above the dam-
aged area of bone (b), at the level of bone damage (c), and below the area of damaged bone (d)
Crutches
6 cm
15 cm
Fig. 34.18 Protractor Fig. 34.19 Initial position when walking with crutches
Fig. 34.20 Walking at partial Take a step using the right leg (loading 25 kg)
loading with the help of crutches.
White shoe print Healthy left leg,
yellow shoe print operated right
leg
Take a step using the left leg (full loading)
Take a step using the right leg (loading 25 kg)
Take a step using the left leg (full loading)
Take a step using the right leg (loading 25 kg)
should be shorter. The initial goal is to take small steps of be in need of assistance or require more space. A special
equal length. Pay particular attention to this! Try going winter cane is available for safe walking under icy street con-
upstairs with the healthy leg, and downstairs with the oper- ditions. By pressing a button on the handle, a pin appears at
ated one. the bottom of the cane to increase traction and prevent
slippage.
A.4.3 Using a Cane Hold the cane in the hand opposite to the damaged leg
Note: When placing the cane on the side of the operated leg, (Fig. 34.21). This will result in the transfer of part of your
the load on the joints will increase by means of the body swing. weight to the cane, increasing the area of body support and
The cane should be placed opposite to the damaged leg. thereby providing the body balance and confidence needed
The first step is taken using the damaged leg. At the same during walking. Lean on the cane at the same time that you
time, the cane is moved ahead. When leaning on the dam- take a step using the operated leg. This way of walking
aged leg you should support it/yourself with the cane. Then unloads the operated leg and prevents the pelvis from swing-
the healthy leg is placed between the cane and the operated ing. The use of two canes will make it easier to maintain
one. At first, the steps must be of short (shorter than the foot body weight on both sides.
length) but equal length. Then move on to walking by taking
steps of usual length.
You can use a cane to walk effectively if you are able to A.5 Appendix E: Clothing Adjustments
firmly hold its handle and have sufficient upper limb strength
such that you do not feel pain in the joints. Using the cane Correctly adjusted clothes will not only help you to
outside the house will make pedestrians aware that you may camouflage the frame but will also provide the operated leg
(Fig. 34.22b, c). During cold times of the year, use an addi-
tional cover made of warm material (Fig. 34.22d).
If the ExFix device is on the lower leg, use a foot-hammock
to ensure that the foot position is at a right angle to the axis of
the tibia, which will avoid the development of pes equinus (tip
foot). To make the foot-hammock, draw a rectangular tem-
plate corresponding to the size of the forefoot, as shown in
Fig. 34.22e. The foot-hammock can be made from a piece of
plywood 3–5 mm thick and containing drill holes in its corners
to attach elastic bands (rubber cords). These should be fixed to
the upper ring of the external fixation device (Fig. 34.22c).
You can wear polyurethane foam slippers, as they are
light, durable, flexible, and hygienic. Some models of
slippers simulate the arch of the foot. Place a rubber cord
under the front part of the shoe sole (Fig. 34.22f) and fix it
on the frame with tension.
Note: You should not use a hard foot-hammock in the
form of the sole, as it will hinder proper gait.
Some patients have made their own crutches, even deco-
rating them (Fig. 34.23).
A.6 Appendix F: Isometric Exercises
The basis of isometric exercise is muscle tension without

joint motion. This is achieved either by resting the foot
(hand) against an immobile support or by muscle straining,
as if to exhibit well-defined abdominal muscles.
Regularly carrying out isometric exercises will improve
your postoperative rehabilitation. The exercises should be
done several times a day for 10 min each time. You will soon
feel positive changes, including an increase in the tone and
strength of the muscles.
The basic guidelines of isometric exercises are:
• Exercise with maximum effort; strain and relax muscles
smoothly.
• Breathe rhythmically (inhale 6 s, exhale 6 s), straining the
muscles during exhalation.
Fig. 34.21 Cane positioning while walking • Do each exercise 6–10 times, then pause for 30–60 s
before repeating the exercise.
For the first 2 months, do 9–12 exercises, then exchange 3–6
with warmth and ventilation and protect the insertion sites of of the exercises for new ones, adding another three each month
the transosseous elements from dirt and infection. until you have a set of 20–24 exercises per training session.
You should wear loose-fitting clothes with a broadened Among the following exercises, your doctor will choose
sleeve or trouser leg. Pants can be split along the inner or the best ones for you. You should determine your load (num-
external seam, with a triangular fabric insert placed into ber of exercises) based on the advice of your physician or
the slit together with a zipper or strip of Velcro exercise therapist.
(Fig. 34.22a).
Prepare at least two frame covers made of breathable cot- A.6.1 Isometric Exercises
ton. The cover should not stretch like a stocking or trouser for Upper Limb Injuries
leg. Its length should not cover the fingers of the hand nor the 1. Hold out your arms and place your bent fingers against a
foot. At the upper and lower edges of the cover insert laces table. Breathe in; then, while breathing out, press your
so that you can fasten it above and below the frame. On the fingers on the table as if you want to push it through the
front of the cover, place a zipper, strip of Velcro, or buttons floor.
a b c
d e f
Fig. 34.22 Clothes, covers, and foot-hammocks. (a) Adjusted trousers; (b) the frame cover for the forearm; (c) frame cover and foot-hammock;
(d) heat-insulated cover; (e) the template for the foot-hammock; (f) a slipper-based foot-hammock
2. Bend your arms, make a fist, and press it against the

table with effort, as if you are trying to push it away.
3. Place your hands under a table-top and push up, trying to
lift it.
4. Set your arms behind the back of a chair and try to lean
forward, despite the resistance of your hands.
5. Hold the seat of your chair with your hands and try to lift
yourself.
6. Stand behind a chair, hold its back, and try to alternately
compress and stretch it, as if you are playing the
accordion.
7. Lean your elbows on a table, pressing your hands against
each other on your forehead. While trying to overcome
the resistance of your hands, tilt your head forward.
Relax the neck and shoulder girdle muscles and repeat
the exercise 1 min later.
8. Lean your elbows on a table and tilt your head back. Press
your chin on your palms, trying to lower your head.
g 9. Join your hands behind your neck, trying to push it for-
ward. At the same time resist using the full strength of
Fig. 34.22 (continued) (g) a toe-hammock your neck muscles.
10. Stretch out your arms. One hand should make a fist, the
other one should clasp the fist. Push your hand against
each other. Shift hands.
11. Sit on a chair, join your legs together, and put your hands
under your thighs close to your knees. Try to lift your
Fig. 34.23 (a, b) Creative crutch a b

designs
shoulders up; without bending your hands, press your 3. Sitting on a chair, clasp its legs using your feet. Straining
palms to the underside of your thighs. all your leg muscles, try to press the chair.
12. Stand with your face to a wall at a distance of about one 4. Sit on a chair. With raised and straightened legs, put your
step from it. Raise your hands high above your head hands on your thighs. Press your hands on your legs and
and place them against the wall, trying to move it try to lift both legs without bending your knees.
away. 5. Lying on a bed, place your feet on its back. Pushing against
13. Extend your hands forward, palms inward. Press your it, stretch your feet as if you are trying to stand on tiptoes.
palms against each other in full strength. Turn your 6. Strain the sural muscle of one leg. Repeat with the other leg.
palms outward and push again.
14. Extend your hands forward and join the fingers together.
Without releasing your fingers, try to stretch your hands A.7 Appendix G: Rehabilatory Gymnastics
apart.
Two sets of physiotherapy exercises are presented in
A.6.2 Isometric Exercises for Lower Tables 34.4 and 34.5 (Fig. 34.24).
Limb Injuries An electronic version of this brochure can be found at
1. Lying or sitting, strain the muscles in your buttocks. http://rniito.org/solomin/download/forpatient-engl.pdf and
2. In the supine position, strain the thigh muscles, trying to http://ortho-suv.org
move the kneecap upwards. Repeat with the other leg.
Table 34.4 Physiotherapy exercises set #1

1. Initial position (IP): lying on your, roll under your feet. Point and flex your
feet. At the same time flex and extend your fingers
2. IP: lying on your back, roll under your feet. Raise your hand up by turns, and
then lift both hands up together
3. IP: lying on your back, roll under your feet, legs apart. Rotate your legs
inwards and outwards
4. IP: lying on your back, roll under your feet. Unbend your knees by turns
5. IP: lying, one leg is bent at the knee. Bend and unbend the other leg, sliding
your heel along the bed. Alternate with the other leg
(continued)

6. IP: lying down, one leg bent at knee. Drop the other leg to the side, sliding it
along the heel. Alternate with each foot
7. IP: lying down, both legs are bent at the knee. In turn, raise your bent legs to
your stomach
8. IP: lying down, both legs bent at the knee. First move your knees apart in
turn, then both at the same time
9. IP: lying down, both legs are bent at the knee. While breathing out, raise in
turn each knee to the stomach
10. IP: lying on your back, roll under your legs. At the same time, extend your
arms, palms facing up, and straighten the legs at the knee joints
11. IP: standing in the doorway. The upper limb is bent at the elbow joint, the
hand and forearm are on the door stud. The required stretching of the
pectoralis major muscle is achieved by rotation of the torso outward and
inward
Table 34.5 Physiotherapy exercises set # 2

1. IP: lying down, legs straight. At the same time, point and flex the feet,
clenching your fingers intensively for 4–6 s
2. IP: lying down, legs straight. In turn, raise your arms up, lifting the shoulder
off the surface intensively for 4–6 s. The head can be slightly raised
3. IP: lying down, legs straight. Push the back of your head against the lying
surface for 4–6, relax the muscles for 7–8 s; repeat. Do the same for the
shoulder blades, buttocks, and heels
4. IP: lying down, legs bent. Lift your head while breathing out. At the same time,
strain your abdominal muscles for 4–6 s
5. IP: lying down, legs bent. Lift your pelvis while breathing out, leaning against
your shoulder blades and heels
6. IP: lying down, legs bent. One hand is raised while breathing in. Then this hand
is lowered as the head and shoulders are lifted. At the same time, lean
forewords toward the other knee while breathing out. Do this for both hands
alternately
7. IP: lying down, legs straight. Alternately bend the legs at the knee joint. When
straightening, slightly push the heel against the bed
8. IP: lying down, legs straight. Bend both legs at the knee joint
9. IP: lying, roll under the feet. Lift your pelvis and hold it in this position for
4–6 s
(continued)

10. IP: kneeling. Deflect your spine up (do not sag when returning to the IP!)
11. IP: kneeling. Sit on your heels, without lifting your hands off the bed. Remain
in this position for 4–6 s and then return to the IP (do not sag when returning
to the IP!)
12. IP: lying down, legs straight. At the same time, extend your hands over your
head and with your heels push away. Do this for 4–6 s with effort
Fig. 34.24 (a–d) Exercise for the development of movements in the shoulder joint: creeping with your fingers
Method for the Definition of
“Reference Positions” for the 35
Insertion of Transosseous Elements
Leonid Nikolaevich Solomin, Maxim Vasil’evich Andrianov,

Roman Nikolaevich Inyushin, Dmitry Alexandrovich
Mykalo, and Pavel Nikolaevich Kulesh
35.1 Introduction 35.2 Main Principles in the Determination

of Positions with Minimum Soft-Tissue
“Reference positions” for the insertion of transosseous ele- Displacement
ments must comply with two very important requirements:
minimum soft-tissue displacement during movements in the Skin, fascia, and muscle at the same level are displaced by dif-
joints adjacent to the segment, and no risk of damage to the ferent amounts, which have been determined from cadaver
great vessels and nerves. The use of positions with minimum experiments. The method involves assessing the magnitude of
soft-tissue displacement decreases the risk not only of pin- the displacement of each soft-tissue layer (skin, fascia, muscle,
induced joint stiffness, but also of pin-tract infection because tendons) using the device shown in Figs. 35.1 and 35.2. The
chronic traumatic soft-tissue injury by the transosseous ele- main features of this device are its rigid fixation to the bone,
ments is reduced. If soft-tissue displacement is not consid- the rigid fixation of the guide to the basic support, the precise
ered, the term “safe positions” is used. orientation of the guides relative to the long-bone axis, and the
Thus, to find the reference positions it is necessary to deter- possibility of controlling the orientation of the positions under
mine positions with minimum soft-tissue displacement and examination relative to the center of the bone diameter.
then from these positions eliminate those in which the insertion The device is used in the following way. As soft-tissue
of wires and half-pins could damage the great vessels and displacement decreases with increasing distance from the
nerves, i.e., “contraindicated positions.” Accordingly, reference joint where the movements are occurring, the basic support is
positions are positions with minimum soft-tissue displacement placed at the maximum distance from the joint. For example,
and which are not contraindicated (forbidden) positions. in the evaluation of soft-tissue displacement during move-
For the exact designation of “reference positions,” “safe posi- ments of the knee joint, half-pins are inserted at the level of
tions,” and “contraindicated positions,” a system of coordinates
is used according to the method for the unified designation of 4
2
external fixation (MUDEF), extensively discussed in Chap. 4.
1
L.N. Solomin, M.D., Ph.D. ()

M.V. Andrianov, M.D., Ph.D. 3
Department of Orthopedics, City Adult Outpatient
Department No 6, Elizarov Str., 32, Build. 2,
Fig. 35.1 Diagram of the device for determining soft-tissue displace-
R.N. Inyushin, M.D., Ph.D.
ment. The device consists of two or three half pins (1), to which a basic
Department of Orthopedics, City Polyclinic No 25,
support (2) is rigidly fixed. Guides (3) are rigidly fixed to the basic sup-
Solodarnosti Str., 1, St. Petersburg 1193312, Russia
port. There should be at least two guides in order to prevent rotational
D.A. Mykalo, M.D., Ph.D. • P.N. Kulesh, M.D., Ph.D. displacement of the control support. The control support (4) is based on
Department of Orthopedics, R.R. Vreden Russian Research a half, three-quarter, or full ring and it is able to move along the guides.
Institute of Traumatology and Orthopedics, 8 Baykova Str., Each guide is provided with a thread, nut and lock nut. The control sup-
St. Petersburg 195427, Russia port is shown in greater detail in Fig. 35.2
plastic film, etc.). In the following step, curve 1, with a des-

ignation of all 12 positions (according to the feeler number),
is transferred (copied) to clear plastic film.
Movement of the type under study is performed with
maximum possible amplitude and the joint is fixed in the
new position. Once more, dye, but this time of a different
color, is placed on the feelers. These are moved to the bone
up to the stop. Where the feelers contact the skin and under-
lying soft tissue, the marks remain. The feelers are removed
from the skin and fixed with bolts. These new marks are con-
nected to form curve 2. Once more, the segment at the level
of examination is wrapped with the same sheet of tracing
paper (or clear plastic film) oriented such that the feeler ends
of the control support exactly coincide with the feeler marks
of curve 1. Curve 2 is transferred to the tracing paper.
Displacement of curve 2 relative to curve 1 shows the dis-
placement of the skin relative to the “0” position with the
given movement of the joint.
To facilitate data processing, both curves are transferred
to graph paper. It is essential to retain the positional marks
Fig. 35.2 To the control support are rigidly fixed 12 tubes (1) located designated by the feelers because the bones of all the extrem-
diametrically opposite each other in pairs, each with a fixing bolt (2).
ities are eccentrically located relative to the soft tissues and
Into each guiding tube a feeler (3) is inserted. When all feelers have
been inserted, their guiding ends meet in the support’s center the distances between the control positions are different.
Therefore, it would be a mistake to divide the obtained “0”
line into 12 equal segments (parts).
the proximal metaphysis of the femur. To fully eliminate the The above procedure is carried out to determine soft-tis-
possibility of restricting soft-tissue displacement relative to sue displacement for all movements. A separate sheet of
the bone, radial full-depth incisions in the soft tissues as far graph paper should be used for each movement, for the con-
as the bone are made in the half-pin insertion region. venience of the subsequent analysis. Thus, by the end of the
The basic support with rigidly fixed guides is fixed to the first stage of the evaluation, the number sheets of graph paper
half-pins, while fulfilling two important conditions: (1) The with curves of soft-tissue displacement is equal to the num-
guides are oriented parallel to the anatomic bone axis. (2) ber of movements evaluated.
The shortest distance at the same level of each guide to the
center of the bone diameter should be equal among guides,
i.e., the center of the control support should correspond to 35.2.2 Fascia Displacement Evaluation
the center of the bone diameter at any point during move-
ment of the support over the guides. To fulfill these require- Skin and subcutaneous fatty tissue are removed from the seg-
ments, X-ray control, feelers, etc., are used. ment under examination. The entire procedure described
The control support is then placed on the guides and fixed above is repeated, with the exception of transferring curve 1
with nuts and a lock nuts at the level where the soft-tissue (“0” position, initial position of the soft tissues) first to the
displacement will be evaluated. The joint is placed in the “0” tracing paper and later to the graph paper. As a result, on
position. each sheet of graph paper there should be three lines: “0,”
skin displacement, and fascia displacement. The precision of
the process is ensured by aligning the extended feelers with
35.2.1 Skin Displacement Evaluation the available control point marks.
A dye, e.g., a solution of brilliant green, is put on the feelers.

All feelers in turn are moved to the bone until the stop. 35.2.3 Muscle Displacement Evaluation
Reference marks are left at the points where the feelers con-
tact the skin and appear as circles of dye. The feelers are In the next stage, the fascia is removed and a few experi-
removed from the skin and fixed with bolts. All the marks are ments on the muscles are performed. Separate curves can be
then connected. The segment at the level of examination obtained for different groups of muscles (superficial, deep,
is wrapped with transparent material (tracing paper, clear etc.) and muscle tendons. Therefore, on the sheets of graph
35 Method for the Definition of “Reference Positions” for the Insertion of Transosseous Elements 1521
paper the number of lines should be equivalent to the number Thus, positions III,8; III,9; III,10, and III,11 have the min-
of experiments. Figure 35.3 provides an example of the soft- imum soft-tissue displacement for given movements of the
tissue displacement relative to the femur, in case of flexion in shoulder joint at level II of the upper arm.
the knee joint with an amplitude of 90/0 at level VII. Finally, the positions with minimum soft-tissue displace-
The data obtained are then analyzed to determine the ment for all evaluated movements of the joints adjacent to the
positions with minimum displacement of skin, fascia, and segment are determined. The following should be borne in
muscles for a specific movement. mind. As already mentioned, soft-tissue displacement relative
In the next stage, the positions with minimum soft-tissue to the bone decreases with increasing distance from the joint
displacement for all movements in the given joint are deter- where the movement is occurring. Thus, at the level of the
mined. For example, at level II of the upper arm the mini- middle third of the segment, the maximum amount of dis-
mum displacement of soft tissues is as follows: placement is close to the minimum amount in the immediate
• For flexion of the shoulder joint in the projection of posi- vicinity of the joint. It may therefore be conditionally assumed
tions 2, 3, 4, 8, 9, 10, 11. that the soft tissues of the proximal third of the segment (from
• For abduction of the upper arm in the projection of posi- level 0 to level III) are “relatively stationary” during move-
tions 8, 9, 10, 11. ment of the joint, which is distal relative to the given segment.
a b
Fig. 35.3 Identifying reference positions at level VII of the femur. ments in the joint. Also, minimal soft-tissue movement takes place in
(a–c) Research of soft-tissue movement at level VII during flexion of the projections of positions 3 and 9, with slightly more in positions 8
the knee joint for the skin (a), fascia (b), and muscles (c). (d) Schedules and 4. In the projections of these positions, the main vessels and nerves
of soft-tissue movements of the femur during 90/0 flexion of the knee are absent. Therefore at level VII the reference positions are: VII,3;
joint at level VII. Due to the relative remoteness of level VII from the VII,4; VII,8 and VII,9
hip joint, it is possible to neglect soft-tissue displacement from move-

c
40
d
30
20
10 Skin
Fascia
0
5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 Muscles
−10
Similarly, the amount of soft-tissue displacement relative to Reference positions are similarly determined for all seg-
the bone during movements of the joint proximal to the given ments, as presented in the atlas of Chap. 5.
segment can be neglected from level VI to level IX. Levels IV The specific characteristics used to evaluate soft-tissue
and V are the “boundary” levels and the data obtained here displacement of the upper arm and forearm, and the upper
should be interpreted individually. and lower leg are discussed below.
VIII,8,90; VIII,4,90; VIII,12,90
Fig. 35.4 Device for investigating soft-tissue displacement as a result

of hip flexion and abduction
35.3 Determination of Positions with

Minimum Soft-Tissue Displacement
I,8,90; I,12,90; II,10,90
35.3.1 Femur
For investigating soft-tissue displacement due to movements of flexion of the lower leg
of the hip joint, the basic support is positioned at the level of
the distal femoral metaphysis (Fig. 35.4) and, due to move- the elbow joint, at the level of the proximal humeral metaphysis
ments of the knee joint, at the level of the proximal femoral (Fig. 35.7). Based on the particular anatomic characteristics, posi-
metaphysis (Fig. 35.5). Based on the particular anatomic tions 2, 3 and 4 at levels 0 and I are excluded from examination.
characteristics, positions 2, 3, and 4 at levels 0 and I are In the atlas (Chap. 5), reference positions are determined during
excluded from the examination. In the atlas (Chap. 5), refer- the investigation of soft-tissue displacement as a result of:
ence positions are determined during the investigation of • Flexion of the shoulder joint with an amplitude of 65/0
soft-tissue displacement as a result of: • Arm abduction with an amplitude of 90/0
• Flexion of the hip joint with an amplitude of 90/0 • Flexion of the forearm with an amplitude of 90/0
• Hip abduction with an amplitude of 45/0
• Flexion of the lower leg with an amplitude of 90/0
35.3.3 Lower Leg
35.3.2 Upper Arm
To investigate soft-tissue displacement due to movements of
To investigate soft-tissue displacement due to movements of the the knee joint, the basic support is positioned at the level of
shoulder joint, the basic support is positioned at the level of the the distal tibial metaphysis (Fig. 35.8), and due to move-
distal humeral metaphysis (Fig. 35.6), and due to movements in ments of the ankle joint, at the level of the proximal tibial
I,8,90; I,10,90; II,11,90

of flexion of the forearm
VIII,4,90; VIII,8,90; olecr.,6,90
Fig. 35.6 Device for investigating soft-tissue displacement as a result between pronation and supination. The control support is
of flexion and abduction of the arm centered in relation to the bone for which measurements are
to be made. In the atlas (Chap. 5) reference positions are
metaphysis (Fig. 35.9). Since the evaluation of soft-tissue determined during investigation of soft-tissue displacement
displacement relative to the fibula does not have any impor- as a result of:
tant clinical significance, in the atlas (Chap. 5) reference • Flexion in the elbow joint with an amplitude of
positions are determined during investigation of soft-tissue 140–150°
displacement relative to the lower leg as a result of: • Movements of the wrist joint (amplitude of flexion/exten-
• Flexion in the knee joint with an amplitude of 120/0 sion 110–130° and radial/ulnar abduction 50–70°)
• Movements in the ankle joint with an amplitude of • Rotational movements with an amplitude of 160° (80°
40/0/20 supination, 80° pronation)
When investigating soft-tissue displacement due to move-
ments of the elbow joint at levels 0, I, II, and III, the control
35.3.4 Forearm support on the ring base will not allow the forearm to be bent
at an angle of 140–150°. Therefore, at these levels a three-
Soft-tissue displacement relative to the ulna and to the radius quarter support is used. The basic support is fixed on three
are investigated separately. The forearm is positioned midway half-pins (Fig. 35.10).
I,3,90; I,12,90; II,8,90

of movement of the ankle joint
at the level of the proximal metaphysis of the forearm bones.

The half-pin olecr.,6,120 is inserted into the distal metaphy-
VII,5,90; VIII,9,90; VIII,12,90
sis of the humerus, blocking the elbow joint (Fig. 35.12).
Fig. 35.8 Device for investigating soft-tissue displacement as a result To investigate soft-tissue displacement relative to the radius
of flexion of the knee joint due to forearm rotation, the basic transosseous elements are
inserted at the level of the distal radial metaphysis. Movements
of the wrist joint are prevented by the additional insertion of a
In measurements of soft-tissue displacement due to move- half-pin into the second metacarpal (Fig. 35.13).
ments of the wrist joint, the basic transosseous elements are Further measurements are carried out in the same way as
inserted at the level of the proximal metaphysis of the fore- described for the ulna.
arm bones (Fig. 35.11). To determine skin displacement due to the movements of
To measure soft-tissue displacement due to forearm rota- joints in an individual patient, the device shown in Fig. 35.14
tion, the control support is replaced by a long connection is used. Its main feature is non-rigid fixation of the basic sup-
plate with a threaded end in which the guides for insertion of port onto the segment surface. Instead of a light source
the feelers are fixed at the standard levels of the forearm. (incandescent lamp) and a beam-focusing device (Fig. 35.14,
During the procedure, a cantilever is fixed in turn at each of 9), one may use a laser pointer or the feelers, as in a standard
12 standard positions. device (Figs. 35.1 and 35.2).
Investigations of soft-tissue displacement relative to the In Fig. 35.15, individual studies of skin movement during
ulna require that the basic transosseous elements are inserted upper arm abduction and forearm flexion are shown.
a b
VII,3,90; VIII,6,90(VIII,6,90); m.carpi II,12,90 (a)

(VII,3,90); VIII,6,90(VIII,6,90); m.carpi II,12,90 (b)
Fig. 35.10 Devices for investigating soft-tissue displacement as a result of movement of the elbow joint relative to the ulna (a) and radius (b)
a b
olecr.,6,120; I,5,90(I,5,90); I,9,90 (a)
olecr.,6,120; I,5,90(I,5,90); (II,9,90) (b)
Fig. 35.11 Devices for investigating soft-tissue displacement as a result of movement of the wrist joint relative to the ulna (a) and radius (b)
a
olecr.,6,120; I,5,90; I,8,90
Fig. 35.12 Device for investigating soft-tissue displacement as a result of forearm rotation relative to the ulna. The distance between lines AA and
BB at each level reflects the magnitude of soft-tissue displacement at that level, as shown, for example, in the projection of position 4
9
8
5
7
6
4
1
3 2
2
3 3
3
Fig. 35.14 Device for determining the magnitude of skin displacement

due to movement in a joint. Attached to a platform (1) are two fixing
belts (2) with textile fasteners (3). A riser (4) is rigidly fixed in the
center of the rectangle and perpendicularly to it. To the riser is attached
a pivoting telescopic rod (5) the opposite end of which is fixed, with
nuts, a support (6) (ring, half-ring, or three-quarter ring) with a slide (7).
A pivoted tube (8) is fixed onto one end of the slide. A light source
(incandescent lamp) and a beam-focusing device (9) are mounted at the
end of the tube
(VII,1,90); (VIII,10,90); m/carpi II,12,90

of forearm rotation relative to the radius
Fig. 35.15 Individual studies

a
of skin movement during upper
arm abduction (a) and forearm
flexion (b)
b
Method for Rigidity Testing
of External Fixation Assemblies 36
Leonid Nikolaevich Solomin, Petr Iosiphovich Begun,
and Vladimir Anatol’evich Nazarov
36.1 Introduction that are less than sufficient may result in increased surgical
trauma and an unnecessarily bulky device.
Rigidity is the ability of the elements of a construction to The material presented in this chapter enables deficiencies
resist displacement. Values for the rigidity of bone fragment in preoperational planning to be compensated and provides
fixation are the basic values characteristic of devices for the investigator and practicing physician with a method for
external or internal fixation. the analytical determination of the optimal external device
The testing instruments used in machine construction are assembly for a given clinical situation. In investigations of
limited in their application to osteosynthesis rigidity determi- the rigidity of bone fragment fixation, the method includes
nations. To determine the rigidity of models in 6° of freedom an algorithm of standard actions and calculations to deter-
requires many testing instruments, which few investigators mine the basic rigidity characteristics of the external fixation
can afford. Consequently, there is an abundance of non-stan- device. The ability to replicate the experiment and to verify
dard equipment of investigators’ own design. The situation is the research data is ensured by the use of the Method for the
further complicated by the fact that differences in experimen- Unified Designation of External Fixation (MUDEF) and by
tal methods regarding the choice of material for simulating applying standard displacing forces and standard processing
bone and its destruction, the method by which the model is to determine the rigidity index.
fixed to the laboratory bench, the number of displacement
indicators and the methods for their installation, the methods
for evaluation of the test results, etc., prevent comparisons 36.2 Indications and Contraindications
among the data from different research groups.
This lack of a standard method for rigidity testing of From the biomechanical point of view, injuries of the long
external fixation assemblies is an obstacle to determining the bones can be divided into two types:
optimal construction for a particular application. Clinically, • Type I: Fracture of a single bone segment or fracture of
this is often manifested in the use of external devices that do both bones in a two-bone segment. Fractures of one bone
not provide sufficient osteosynthesis rigidity for effective of a two-bone segment due to luxation of the proximal or
functional treatment, which in turn enhances the risk of com- distal interosseous articulations (radioulnar, intertibial)
plications and may influence the results of treatment. Also, are also classified as type I.
attempts to increase the rigidity of bone fragment fixation • Type II: Fracture of one bone of a two-bone segment
with retention of anatomic inter-relationships in the
proximal and distal interosseous joints. When a previous
L.N. Solomin, M.D., Ph.D. ()
R.R. Vreden Russian Research Institute luxation of a pair of bones was set and the possibility of
of Traumatology and Orthopedics, reluxation was eliminated (ligament suturing, diafixing
8 Baykova Str., St. Petersburg 195427, Russia wire inserted), then the injury could also be classified as
type II.
P.I. Begun The method is developed for the experimental determina-
Department of Mechanics, The State Electrotechnical University,
tion of fixation rigidity values in models of extrajoint diaphy-
5 Popova Str., St. Petersburg 195007, Russia
seal monolocal fractures of type I for any external fixation
V.A. Nazarov, M.D., Ph.D.
devices. The method is not intended for examining models of
Department of Orthopedics, R.R. Vreden Russian
Research Institute of Traumatology and Orthopedics, external fixation of intra-articular fractures or of type II
8 Baykova Str., St. Petersburg 195427, Russia injuries.
a a
Fig. 36.2 According to established biomechanical requirements, each

bone fragment fixed in an external device is fixed with one or two first-
order modules. A subsystem comprising two first-order modules (fixing
one bone fragment) is designated a second-order module (M2). (a) A
uniform second-order module (M2u) is a subsystem comprising two uni-
form first-order modules. (b) A combined second-order module (M2c) is
a subsystem comprising two combined first-order modules or a uniform
Fig. 36.1 First-order modules. (a) Modules with transosseous ele- second-order module together with a combined second-order module
ments of the same type (only wires or only half-pins) are uniform first-
order modules (M1u). (b) Modules with external supports and different
types of transosseous elements (e.g., a wire and a half-pin) are com- “Third-order modules” (M3) for one bone fragment can
bined first-order modules (M1c) be considered only in hypothetical terms. Therefore, a mod-
ule M3 is the complete arrangement of the external device.
When there are two bone fragments, there are three versions
36.3 General Theoretical Principles of module M3:
• M1 + M1
36.3.1 Transosseous Module Classification • M1 + M2 or M2 + M1
• M2 + M2
A functional unit in the construction of external devices con- Depending on the types of transosseous elements being
sists of the external support with one or several transosseous used (only wires, only half-pins, combination of wires and
elements fixed to it. This functional unit is designated as a half-pins), M3 modules are formally designated as M3u or
transosseous “first-order module” (M1) (Fig. 36.1). Two M3c. A general classification of external fixation modules is
first-order modules united into a general subsystem (fixing given in Table 36.1.
one bone fragment) are designated as a “second-order mod- The use of the “module” concept in this setting allows the
ule” (M2) (Fig. 36.2). use of the term in external fixation to be regulated. The given
Table 36.1 Classification of transosseous modules
36
First-order modules (M1)

Method for Rigidity Testing of External Fixation Assemblies
Uniform first-order modules (M1u) Combined first-order modules (M1c)

(continued)
1533
1534
Second-order modules (M2)
Uniform second-order modules (M2u) Combined second-order modules (M2c)

L.N. Solomin et al.
36
Third-order modules (M3)

Method for Rigidity Testing of External Fixation Assemblies
Uniform third-order modules (M3u) Combined third-order modules (M3c)

1535
classification of modules ensures a standardized approach to Transverse forces F2 cause angular displacements of the
investigating the biomechanics of transosseous osteosynthesis fragment in the frontal plane A during abduction and adduc-
rigidity: beginning with the most common uniform (wire) first- tion (Fig. 36.3).
order modules (M1u) to combined second-order modules The rigidity of osteosynthesis in abduction is the transverse
(M2c) to the complete external device assembly (module M3). rigidity of osteosynthesis during flexion of the fragment by a
force F2 in the frontal plane. The rigidity of osteosynthesis in
adduction is the transverse rigidity of osteosynthesis during
36.3.2 Method for the Unified Designation flexion of the fragment by a force F2 in the frontal plane.
of External Fixation Transverse forces F3 cause angular displacements of the
fragment in the sagittal plane C (Fig. 36.3). The flexion rigid-
To allow the replication and verification of experimental ity of osteosynthesis is the transverse rigidity of osteosynthe-
results by any investigator, all external device assemblies sis during flexion of the fragment by a force F3 in the sagittal
should be strictly designated. Changing the levels of tran- plane. The extension rigidity of osteosynthesis is the trans-
sosseous element insertion, the angle of element intersec- verse rigidity of osteosynthesis during flexion of the frag-
tion, the geometry and dimensions of the external supports, ment by a force F3 in the sagittal plane.
the distance between the supports and the biomechani- Rotational forces F4 cause angular displacements of the
cally preset conditions between them, along with other fragment in the transverse plane B (Fig. 36.3). The outward
values, will influence the experiment results. Therefore, rotation rigidity of osteosynthesis is the rigidity of osteosyn-
an obligatory condition for investigating the rigidity of thesis during rotation of the fragment by a force F4 in the
transosseous osteosynthesis is the exact designation of transverse plane. The inward rotation rigidity of osteosyn-
the assemblies of the examined devices, using the MUDEF thesis is the rigidity of osteosynthesis during rotation of the
system. Chapter 4 provides a full description of the fragment by a force F4 in the transverse plane.
method (http://rniito.org/solomin/download/mudef.zip and Linear rigidities of the module are characterized by the
http://ortho-suv.org). rigidity coefficients of distraction and compression K:
K = F1 /U,
36.3.3 Modeling the Displacing Forces
where U is the fragment displacement in the axial direction
Investigations of the rigidity of osteosynthesis include an due to distraction or compression. The unit for measuring the
examination of the transosseous modules’ response to linear rigidity coefficient is Newtons per millimeter (N/mm).
displacing loads in six standard degrees of freedom Transverse rigidities of osteosynthesis are also character-
(Fig. 36.3a). ized by rigidity coefficients K:
The rigidity of a transosseous module is represented by its
ability to resist the displacement of fragments caused by the K = F2 L/ϕ
influence of an external load. The rigidity of osteosynthesis
is characterized by: where L is the length of the arm on which the transverse
• The rigidity coefficient (K), which is determined from the forces create bending moments (distance from the point of
ratio of the external loads to the linear and angular application of the force to the site of rigid fixation of the
displacements module, Fig. 36.3), and j is the angle of fragment rotation
• Compliance, which is determined from the ratio of the under the influence of the transverse forces, during abduc-
linear and angular displacements to the isolated loads (of tion, adduction, flexion, or extension.
opposite magnitude as the rigidity coefficient) In module M1st, LM1st = 100 mm (Fig. 36.4); in module M2st,
This method uses the first of the above characteristics. LM2st = 250 mm (Fig. 36.5); in module M3st, LM3st = 275 mm
The greater the rigidity coefficient K, the greater the rigidity (Fig. 36.6). The unit for measuring transverse rigidity coefficients
of the bone fragment fixation. is also Newton millimeters per degree (N mm/°).
Axial forces F1, i.e., compression and distraction, are Rotational rigidities of osteosynthesis are characterized
applied in the direction of the longitudinal axis of the model by rigidity coefficients K of osteosynthesis during inward
bone. The rigidity of osteosynthesis in longitudinal distrac- and outward rotation:
tion is the rigidity of external fixation under the influence of
an extension force F1 in the longitudinal direction. The rigid- K = F4 h/ϕ
ity of osteosynthesis in longitudinal compression is the rigid-
ity of osteosynthesis under the influence of a compression where h is twice the distance from the point of application
force F1 in the longitudinal direction. of force F4 to the fragment axis (Fig. 36.3) and j is the angle
36 Method for Rigidity Testing of External Fixation Assemblies 1537
Fig. 36.3 Schematics of a

standard displacing loads. (a)
Possible displacements according
to degrees of freedom, (b)
Loading scheme: F1 longitudinal
distraction/compression force, F2
transverse abduction/adduction
force, F3 transverse flexion/
extension force, F4 rotational
inward/outward force, A frontal
plane, B transverse (horizontal)
plane, C sagittal plane
of fragment rotation under the action of rotational forces, modules) has reached 1 mm or 1°, further loading is not
inward or outward. advisable (it would serve no purpose).
For all modules (M1, M2, M3), h = 200 mm.
It should be noted that the purpose of the experiment is not
to determine the displacing force that will destroy or deform 36.3.4 Primary Standard for the Rigidity
the transosseous elements and the device frame, because such of Transosseous Modules
knowledge is of no great importance for clinical practice. The
experiment is carried out with the understanding that when To compare the rigidity of modules of different devices, it is
displacement of the loaded fragment (in investigations of necessary to use the primary standard. To compare the rigid-
first- and second-order modules) or displacement at the ity of modules of different devices, it is also necessary to use
junction of bone fragments (in investigations of third-order a primary standard.
250
L = 100 100
280
I,2-8; I,4-10 − IV,3-9

160 160
175
Fig. 36.5 The standard second-order module (M2st) is considered a
I,2-8; I,4-10 model based on two ring supports 150 mm apart and connected with
160 three rods. The bone model is 280 mm long. The wires of the proximal
support are inserted at a distance of 25 mm from the base of the bone
Fig. 36.4 The standard first-order module (M1st) is a model based on a model, which is assumed to be at level I. The distance between the
ring support with an inner diameter of 160 mm. The ring is from the com- levels is assumed to be 50 mm. The wire with a stop of the second sup-
plete set of the Ilizarov apparatus. The long axis of the bone model is port is inserted at level IV at a distance of 150 mm from level I. The
located in the center of the ring support. The diameter of the wires is 2 mm, tensioning force of the wires is 1,000N. The length of the loading arm
their angle of separation 60°, and their tensioning force 1,000N. The bone in the sagittal and frontal planes (L) is 250 mm
model is 175 mm long. The wires are inserted at a distance of 25 mm from
the base of the bone model, which is assumed to be at level I. The length of
the loading arm in the sagittal and frontal planes (L) is 100 mm
275
500
I,2-8; I,4-10 − IV,3-9 − V,9-3 − VIII,2-8; VIII,4-10

160 160 160 160
Fig. 36.6 The standard third-order module (M3st) is a complete exter- between the levels is assumed to be 50 mm. A diastasis of 2 mm is
nal device, consisting of two standard second-order modules connected made between the bone fragments in order to investigate the response
by three rods. The bone simulator is 500 mm long. The wires of the of the model to an axial compression load. The length of the loading
proximal support are inserted at a distance of 50 mm from the base of arm in the sagittal and frontal planes (L) is 275 mm
the bone simulator; which is assumed to be at level I. The distance
Table 36.2 Rigidity coefficients of standard modules

Rotational rigidity Transverse rigidity Longitudinal rigidity
КMst, КMst, Sagittal plane Frontal plane КMst КMst
N mm/° N mm/° КMst КMst КMst КMst (N/mm (N/mm
inward outward (N mm/°flexion) (N mm/°extension) (N mm/°adduction) (N mm/°abduction) distraction) compression)
КM1st 3 × 103 3 × 103 3 × 102 3 × 102 7 × 102 7 × 102 63 63
3 3 3
КM2st 3.2 × 10 3.2 × 10 2 × 10 2 × 103 3.51 × 103 3.51 × 103 54 54
КM3st 2.8 × 103 2.8 × 103 2.03 × 103 2.03 × 103 6.6 × 103 6.6 × 103 53 53
When comparing a module with the standard module, the 36.4.1 Investigating the Rigidity
relative rigidity (rigidity index, RI) is determined: of Transosseous Modules of the
First (M1) and Second (M2) Orders
Il = Кst / Кex,
An algorithm for investigating the rigidity of first- and
where Кst is the rigidity coefficient of the standard module second-order modules is presented, by way of example,
and Кex is the rigidity coefficient of the module under for investigating a standard first-order module (M1st;
examination. Fig. 36.4).
Thus, to determine RI it is necessary to know the values
of Кst for M1st, M2st, and M3st in the presence of compres- 36.4.1.1 Longitudinal Rigidity
sion, distraction, flexion, extension, adduction, abduction, A diagram of the experiment is shown in Fig. 36.7.
inward rotation, and outward rotation. The force that causes a displacement of 1 mm is consid-
Table 36.2 shows the rigidity coefficients of standard ered the control force. When loading most assemblies in the
modules. For example: range 5–200N, the load–displacement curve can be approxi-
• When RI = 1, the rigidity of the examined module equals mated with sufficient accuracy by straight-line segments
that of the standard module. with load increments of 5N. The relationship between dis-
• When RI = 0.5, the rigidity of the examined module is placement and force is assumed to be linear with these incre-
twice that of the standard module. ments. When investigating assemblies, to ensure adequate
• When RI = 2, the rigidity of the examined module is half rigidity values for the osteosynthesis, the load increment can
that of the standard module. be decreased.
The use of wood, metal, or plastic for simulating bone Investigation of standard first-order modules has shown
may be considered a problem in principle, but it is not a that a displacement of 1 mm occurs with a load of 63N ± 5N.
problem in practice because, in the process of modeling the Thus, the rigidity coefficient of the module under the
displacing forces, deformation of the bone is infinitesimal influence of a distraction force is:
compared with deformation of the transosseous elements.
The use of cadaver bones for bench tests has no obvious КM1st/distraction = 63 N/mm
advantages; but it does have limitations both legally and ethi-
cally. There is also the practical difficulty of obtaining The particular characteristics of N1st (insertion of two
cadaver bones with anthropometric properties suitable for wires without stops in one plane perpendicular to the long
the experiment. Therefore, wooden rods with a diameter of axis of the bone model) ensure the same value of the RI for
30 mm can be used as bone models. distraction and compression:
КM1st/compression = 63 N/mm
36.4 Experimental Procedures
36.4.1.2 Rotational Rigidity
The experiment is repeated three times in each case and the A diagram of the experiment is shown in Fig. 36.8.
results are analyzed statistically using a software program The load F4 is applied inwards or outwards in gradually
package, e.g. Statgraphics. increasing increments of 2N: 2N–4N–6N–8N, etc.
a Displacement values VA and VB at points A and B obtained

from displacement-sensing instruments after each load incre-
ment (VAi and VBBi, where i is the number of applied loads)
are used for further processing.
The rotational angle of the bone model is calculated from
the equation:
F1
i
tgϕ i = ( VAi + VBi )/L = n after calculation of tgϕ I
where L is the distance between points A and B.

The quantity that causes the displacement of the bone
simulator (depending on the direction of the rotation load)
outward or inward by 1° is considered to be the control
b quantity.
The force that causes the outward or inward displacement
of the bone model (depending on the direction of the rota-
tional load) by j1° is considered to be the control force.
Investigation of M1st has shown that a 1°displacement
occurs with an inward or outward load (F4) of 15N ± 1N.
F1
Thus, the rigidity coefficient of a standard first-order mod-
i ule under the influence of an inward or outward rotational
force is:
КM1st/invard = КM1st/outward = 15 × 200 = 3 × 103 N mm/degree
36.4.1.3 Transverse Rigidity in the Sagittal Plane

Fig. 36.7 Investigation of the longitudinal rigidity of a first-order When Modeling Flexion and Extension
module in compression (a) and distraction (b). The external support of A diagram of the experiment modeling flexion and extension
the module is rigidly fixed. An instrument to measure the linear dis- is shown in Fig. 36.9.
placement is attached to the base of the bone simulator. The studied Displacements of the bone model (V) at points A and B
load (e.g., distraction) is applied in gradually increasing increments of
5N (5N–10N–15N–20N, etc.). The displacements of the bone simulator following each load increment (VAi and VBi, where i is the
with each load increment are recorded. The experiment is stopped as number of applied loads) are measured using displacement-
soon as the displacement reaches 1 mm sensing instruments.
F4
B1 B
h
Fig. 36.8 Schematic modeling rotational loads. The L

external support of the module is rigidly fixed. On the
free end of the loaded bone simulator fragment a
metal bar (1) is mounted. To points A and B, which
are at the same distance from the center of the bone
simulator, two sensing instruments are attached at a
recommended distance (L) of 100 mm. The load is
applied at points A1 and B1 on a second metal bar,
A1 A F4
which is also mounted on the free end of the loaded
bone simulator fragment at a distance of 50 mm from 1
the support plane (for a second-order module at a
distance of 50 mm from the distal support). Points A1
and B1 are also equidistant from the center of the
bone simulator. The recommended distance between
points A1 and B1 (h) is 200 mm
100 100
B B
a a
O O A B
A B
F2
F3
Fig. 36.10 Investigation of the transverse rigidity of a first-order mod-

ule in the frontal plane (for the standard first-order module, with a wire
Fig. 36.9 Investigation of the transverse rigidity of the standard intersection sector of 60°). The experiment is similar to that for a mod-
first-order module in the sagittal plane under flexion. To apply the ule load in the sagittal plane (Fig. 36.9), with the difference that abduc-
flexion load in the sagittal plane (for the standard first-order module, tion and adduction are modeled
with a wire intersection sector of 120°), two linear displacement-sensing
instruments of the clock type are attached to the free end of the bone
simulator at a distance apart (a) of 40 mm. The distance from the plane
of the ring support (point O) to the first indicator (b) is 40 mm. In a
36.4.1.4 Transverse Rigidity in the Frontal
second-order module, point O is in the plane of the distal support. To Plane When Modeling Abduction
apply an extension load in the sagittal plane, the assembly is rotated by and Adduction
180° and fixed A diagram of the experiment is shown in Fig. 36.10.
The arrangement of sensing instruments in the plane of
application of the forces as well as the values of the forces
F2adduction, F2abduction and the calculations are similar to those
The rotational angle of the bone model following each discussed for investigations in the sagittal plane.
load increment is determined from the equation: For M1st, it has been established that a 1° displacement in
the frontal plane for abduction and adduction occurs with a
tgϕ i = VAi - VBi /a = n load (F2) of 7N ± 0.5N.
Thus, the rigidity coefficient of a standard first-order
where a is the distance between points A and B. module in the frontal plane is:
A load is applied in the sagittal plane (relative to the ori-
entation of M1 and M2) gradually increasing incrementally КM1st/abduction = КM1st/adduction = 7 × 100 = 7 × 102 N mm/degree
by 1N (1N–2N–3N–4N, etc.). The load is applied at a dis-
tance of 100 mm from the conventional point O. To investigate (when necessary) a module in any other
For flexion and extension resulting from the application intermediate transverse plane, the model is fixed to the fixing
of force F3, the load that leads to rotational displacement panel of the bench in a position that ensures loading in the
of the bone model by j = 1° is considered the control plane of interest.
force.
For M1st it has been established that a 1° displacement in
the sagittal plane due to flexion and extension occurs with a 36.4.2 Investigating the Rigidity
load of 3N ± 0.5N. Thus, the rigidity coefficient of a standard of Third-Order Modules (M3)
first-order module under flexion or extension is:
Diagrams of the experiment for investigating longitudinal
КM1st/flextion = КM1st/extention = 3 × 100 = 3 × 102 N mm/degree rigidity are shown in Fig. 36.11.
Fig. 36.11 Investigation of the

a
longitudinal rigidity of a
third-order module (a compres-
sion, b distraction). The free
proximal end of the fragment is
rigidly fixed. A linear displace- F1
ment-sensing instrument is i
attached to the base of the loaded
fragment. The load (e.g.,
distraction) is applied in
gradually increasing increments
of 5N (5N–10N–15N–20N, etc.).
The displacements of the bone
simulator with each load b
increment are recorded. The
experiment is stopped as soon as
a displacement of 1 mm has been
reached
F1
i
F4
B1 B
h
A1 A F4
1
Fig. 36.12 Investigation of the rotational rigidity of a third-order mod- distance apart (L) of 100 mm. The load is applied to points A1 and B1
ule. The free proximal end of the fragment (2) is rigidly fixed. A metal on a second metal bar that is also mounted at the loaded end of the bone
bar (1) is mounted on the loaded end of the bone simulator. Two sensing simulator at a distance of 50 mm from the plane of the distal support.
instruments are attached to points A and B, which are located at the Points A1 and B1 are also equidistant from the center of the bone simu-
same distance from the center of the bone simulator at a recommended lator and are separated by a recommended distance (h) of 200 mm
The load leading to displacement of the bone model by number of applied loads) are measured using displacement-
1 mm is considered the control load. For standard third-order sensing instruments.
modules it has been established that a 1 mm displacement The rotational angle of the bone model is calculated from
occurs with a load of 55 ± 5N. Thus, the rigidity coefficient the equation:
of a third-order module is:
tgϕ i = ( VAi + VBi )/L = n
КM3st/distraction = КM3st/compression = 55 N/mm
where L is the distance between points A and B.
For standard third-degree modules it has been established
36.4.2.1 Rotational Rigidity that a 1° displacement occurs with a load of 14N ± 1N. Thus,
A diagram of the experiment is shown in Fig. 36.12. the rigidity coefficients of a standard third-order module for
A load is applied gradually increasing in increments of inward or outward rotation are:
2N (2N–4N–6N–8N, etc.). Displacement (V) at points A and
B following each load increment (VAi and VBi, where i is the КM3st/invard = КM3st/outvard = 14 × 200 = 2.8 × 103 N mm/degree
Fig. 36.13 Investigation of the transverse 275

rigidity of a third-order standard module in
the sagittal plane during flexion and B
extension (for the standard third-order
module, with a wire intersection sector a
of 120° for the basic supports of the
third-order module). To apply the load in
the sagittal plane during flexion, two linear
displacement-sensing instruments are
attached to the distal end of the bone O
simulator at a distance apart (a) of 40 mm.
A B
The distance from the point O (at level
VIII) to the first sensing instrument (b) is
40 mm F3
Fig. 36.14 Investigation of the 275

transverse rigidity of a third-order
module in the frontal plane (for B
standard third-order module loading
should be applied in the sector of the a
basic supports wires intersection of
120°). The algorithm for performing
the experiment is similar to that for the
module loading in the sagittal plane
A B
(Fig. 36.13) O
F2
36.4.2.2 Transverse Rigidity in the Sagittal Plane 36.4.2.3 Transverse Rigidity in the Frontal
When Modeling Flexion and Extension Plane When Modeling Abduction
A diagram of the experiment modeling flexion and extension and Adduction
in the sagittal plane is shown in Fig. 36.13. A diagram of the experiment is shown in Fig. 36.14.
A load is applied gradually increasing in increments of The arrangement of the sensing instruments in the plane
1N. The load is applied at a distance of 100 mm from the of application of the forces, the applied loads F2, and the
conventional point O, located in the plane of level VIII. calculations are similar to those for investigating rigidity in
Displacement (V) at points A and B following each load the sagittal plane.
increment (VAi and VBi, where i is the number of applied For standard third-order modules it has been established
loads) are measured using displacement-sensing instruments. that a 1° displacement in the frontal plane due to abduction
To apply the load for extension, the assembly is fixed after or adduction occurs with a load of 24N ± 0.1N.
turning through 180°. Thus, the rigidity coefficients of a standard third-order
The rotational angle of the bone model is determined fol- module in the frontal plane during abduction or adduction
lowing each load increment from the equation: are:
tgϕ i = ( VAi + VBi )/L = n КM3st/abduction = КM3st/adduction = 24 × 275 = 6.6 × 103 N mm/degree
where L is the distance between points A and B. For investigation of a module in any other intermediate
The force that causes a 1° displacement of the bone model transverse plane, the model is fixed to the fixing panel of the
is considered the control force. For third-order modules it has bench in a position that ensures loading in the plane of
been established that a 1° displacement in the sagittal plane interest.
during flexion and extension occurs with a load of 11N ± 0.1N. Experimental rigidity coefficients for all standard mod-
Thus, the rigidity coefficients of a standard third-order ules are presented in Table 36.2. These data not only allow
module in the sagittal plane during flexion and extension are: the RI to be obtained but also serve as criteria for establish-
ing the correctness of manufacture of the biomechanical
КM3st/flexion = КM3st/extension = 11 × 275 = 3.02 × 103 N mm/degree bench and of the conduct of the investigation.
Appendixes
Appendix A: Method for the Unified Designation of External Fixation (MUDEF)
Levels
0
I
II
III
IV
VI
VII
VIII
IX
Positions
a 11 12 1
b 1 12 11
10 2 2 10
9 3 3 9
8 4 4 8
7 6 5 5 6 7
DOI 10.1007/978-88-470-2619-3, © Springer-Verlag Italia 2008, 2012
1546 Appendixes
12 Forearm positions 12
a 1 b 11 1
11
10 2 10 2
9 3 9 3
8 4 8 4
7 5 7 5
6 6
Designation of K-wires
11 12 1
I
II 10 2
III
IV 9 3
VI 8 4
VII
7 6 5
VIII
IV,9-3
12 Designation of K-wires in Forearm 12

11 1 1
11
10 2 2
10
9 3 9 3
8 4 8 4
7 5
6 7 5
6
I,5-11(I,5-11) VIII,6-12(VIII,6-12)
I,5-11(I,5-11) VIII,6-12(VIII,6-12)
Appendixes 1547
Designation of Half-Pins
60°
11 12 1
I
10 2
II
III
IV 9 3
VI 8 4
VII
7 6 5
VIII
II,8,60
Designation of the External Supports
I,9-3; II,1,60
3/4 150
(VII,11,120); VII,8,120; VIII,6-12(VIII,6-12)

120
1548 Appendixes
MUDEF of a humeral bone fracture Designation of the bone transport operation
— - neutral
→← - compression
←→ - distraction
o hinge
←o→ - distraction hinge
1 2 3 7 8
(I,8-2)I,8-2; I,4-10; II,1,60 ←→ IV,2-8; IV,4-10 →←
I,7-1; I,11-5 –– IV,3-9 →← V,9-3 –– VII,8-2; VII,10-4 150 150
¾ 140 130 130 ¾ 130 6 4 5
→← VII,1,120; (VIII,8-2)VIII,8-2; VIII,4-10
150
Designation of Ortho-SUV Frame application
2 1 3 5 4 6
II,2,120; III,3-9; IV,12,70 –SUV– V,12,120; VI,3-9; VI,2,70
150 150
Appendixes 1549
Appendix B: Tables for the Insertion of Transosseous Elements: Reference Positions
Upper arm
Positions
Levels Contraindicated positions Safe positions Reference positions
I 3, 4 1, 5, 6, 7, 8, 9, 10, 11, 12 8, 9, 10, 11
II 1, 2, 3, 4 5, 6, 7, 8, 9, 10, 12 8, 9, 10, 11
III 1, 3, 4, 5 2, 6, 7, 8, 9, 10, 11, 12 9, 10, 11
IV 1, 3, 5, 6, 7 2, 4, 8, 9, 10, 11, 12 8, 9, 10, 11
V 1, 2, 3, 7, 8, 9 4, 5, 6, 10, 11, 12 4, 5, 6, 10
VI 2, 3, 9, 10, 12 1, 4, 5 , 6, 7, 8, 11 4, 7, 8
VII 2, 4, 10, 11, 12 1, 3, 5, 6, 7, 8, 9 3, 8, 9
VIII 1, 2, 11, 12 3, 4, 5 , 6, 7, 8, 9, 10 3, 4, 8, 9
NB! By convention, position 3 is always (for the right and left extremities) located on the medial surface of the segment, and position 12
anteriorly
1550 Appendixes
Ulna, mid-position
Positions
Contraindicated Reference positions that
Levels positions Safe positions Reference positions allow rotation
I 1, 3, 12 2, 4, 5, 6, 7, 8, 9, 10, 11 4, 5, 6, 7, 8, 9, 10 4, 5, 6, 7, 8, 9, 10
II 1, 2, 3, 12 4, 5, 6, 7, 8, 9, 10, 11 4, 5, 6, 7, 8, 9, 10 4, 5, 6, 7, 8, 9, 10
III 1, 2 3, 4, 5, 6, 7, 8, 9, 10, 11, 3, 4, 5, 6, 7, 8, 9, 10, 11, 4, 5, 6, 7, 8
12 12
IV 1, 2, 3 4, 5, 6, 7, 8, 9, 10, 11, 12 4, 5, 6, 7, 8, 9, 10 5, 6, 7
V 1, 3 2, 4, 5, 6, 7, 8, 9, 10, 11, 5, 6, 7, 8, 9, 10, 11, 12 5, 6, 7
12
VI 1, 3 2, 4, 5, 6, 7, 8, 9, 10, 11, 5, 6, 7, 8, 9, 10, 11, 12 5, 6, 7
12
VII 1, 3 2, 4, 5, 6, 7, 8, 9, 10, 11, 5, 6, 7, 8, 9, 10, 11, 12 6, 7
12
VIII 1, 2, 3, 4 5, 6, 7, 8, 9, 10, 11, 12 6, 7, 8, 11, 12 6
anteriorly
Appendixes 1551
Radius, mid-position
Positions
Contraindicated Reference positions that
Levels positions Safe positions Reference positions allow partial rotation
I 1, 2, 3, 4 5, 6, 7, 8, 9, 10, 11, 12 5, 6, 7, 8 8
II 1, 2, 3, 4, 11, 12 5, 6, 7, 8, 9, 10 5, 6, 7, 8 8
III 2, 3, 4 1, 5, 6, 7, 8, 9, 10, 11, 1, 5, 6, 7, 8, 9, 10, 11, 1, 8, 9, 10, 11, 12
12 12
IV 2, 3, 4, 5 1, 6, 7, 8, 9, 10, 11, 12 1, 6, 7, 8, 9, 10, 11, 12 1, 8, 9, 10, 11, 12
V 1, 2, 3, 4, 5 6, 7, 8, 9, 10, 11, 12 6, 7, 8, 9, 10, 11, 12 8, 9, 10, 11, 12
VI 2, 3, 4, 5 1, 6, 7, 8, 9, 10, 11, 12 1, 6, 7, 8, 9, 10, 11, 12 1, 8, 9, 10, 11, 12
VII 2, 3, 5 1, 4, 6, 7, 8, 9, 10, 11, 1, 6, 7, 10, 11, 12 1, 10, 11, 12
12
VIII 2, 3, 4, 5 1, 6, 7, 8, 9, 10, 11, 12 1, 6, 7, 10, 11, 12 1, 10, 11, 12
NB! By convention, position 3 is always (for the right and left extremities) located on the medial surface of the segment, and position
12 anteriorly
1552 Appendixes
Femur
Positions
I 1, 4 5, 6, 7, 8, 9, 10, 11, 12 8, 9, 10, 11
II 1 5, 6, 7, 8, 9, 10, 11, 12 8, 9, 10, 11
III 1, 2, 3, 4 6, 7, 8, 9, 10, 11, 12 8, 9, 10
IV 2, 3, 4, 5 1, 6, 7, 8, 9, 10, 11, 12 8, 9, 10
V 3, 4, 5 1, 2, 6, 7, 8, 9, 10, 11, 12 8, 9
VI 4, 5 1, 2, 3, 6, 7, 8, 9, 10, 11, 12 3, 7, 8, 9
VII 5, 6 1, 2, 3, 7, 8, 9, 10, 11, 12 3, 4, 8, 9
VIII 5, 6, 7 1, 2, 3, 4, 8, 9, 10, 11, 12 3, 4, 8, 9
anteriorly
Appendixes 1553
Tibia
Positions
I 6, 7, 8 1, 2, 3, 4, 5, 9, 10, 11, 12 1, 2, 3, 9, 10, 11, 12
II 6, 7, 8 1, 2, 3, 4, 5, 9, 10, 11, 12 1, 2, 3, 9, 10, 11, 12
III 6, 7, 8 1, 2, 3, 4, 5, 9, 10, 11, 12 1, 2, 3, 9, 10, 11, 12
IV 6, 7, 8 1, 2, 3, 4, 5, 9, 10, 11, 12 1, 2, 3, 9, 10, 11, 12
V 5, 6, 7, 8 1, 2, 3, 4, 9, 10, 11, 12 1, 2, 3, 9, 10, 11, 12
VI 5, 6, 9 1, 2, 3, 4, 9, 10, 11, 12 1, 2, 3, 10, 11, 12
VII 5, 6, 11 1, 2, 3, 4, 7, 8, 9, 10, 12 1, 2, 3, 8, 9, 10, 12
VIII 5, 6, 11 1, 2, 3, 4, 8, 9, 10, 11, 12 1, 2, 3, 4, 8, 9, 10, 12
anteriorly
1554 Appendixes
Appendix C1: Reference Lines and Angles of the Upper Limb
Mechanical axes of the upper limb Anatomic axes of the upper limb
130°
150–155°
Finding the anatomic axis of a proximal Finding the anatomic axis of a proximal
bone fragment in the frontal plane bone fragment in the sagittal plane
84°
81°
9–10°
Methods of finding the anatomic axis of a distal bone fragment in the frontal plane
Appendixes 1555
60–70°
30°
Finding the anatomic axis of a distal
Retroversion of the distal humerus
bone fragment in the sagittal plane
1/2 1/2
1 /2
1/2
85°
113°
20°
2°
14°
3°
1/2
5°
1°
3°
2°
1/2
Reference angles for the preservation of Reference angles for the preservation of the physiological
the physiological curvature of the curvature of ulna in the sagittal plane
ulna in the frontal plane
1556 Appendixes
1/2 1/2
88°
13°
1/2
5°
13°
1/2
8°
m
2–3 m
63°
1/2
1/2
Reference angles for the preservation of the physiological curvature of the radius in the frontal plane
Appendixes 1557
86°
5°
4°
1/2
4°
1/2
84°
2–3 mm
Reference angles for the preservation of the physiological curvature of the radius in the sagittal plane
1 mm (0) (−)
(+)
12 mm
Locations of variants of joints levels of the radius and elbow bones
1558 Appendixes
Appendix C2: Reference Lines and Angles of the Lower Limb
130° 170°
(124–136°) (165–175°)
84°
(80–89°)
81° 83°
(79–83°) (79–87°)
87°
(85–90°) 81°
(77–84°)
89° 80°
(86–92°) (78–82°)
Anatomic angles in the frontal plane Anatomic angles in the sagittal plane
Appendixes 1559
53°
90° (50–65°)
(85–95°)
78°
88° (73–84°)
(85–90°)
87° 83°
(85–90°) (79–87°)
89° 82°
(86–92°) (78–85°)
Mechanical angles in the frontal plane Mechanical angles in the sagittal plane
MAD
4.1±4 mm
Mechanical axis of deviation

1560 Appendixes
44°
44°
7°
130°
Methods of finding the mechanical axis of a proximal

7° bone fragment in the frontal plane
84°
130°
Reference angles in the Methods of finding the anatomic axis of a proximal

frontal plane bone fragment in the frontal plane
81°
88°
20–25°
Finding the anatomic axis of a Finding the mechanical axis of a Anteversion of the proximal femur
distal bone fragment in the distal bone fragment in the
frontal plane frontal plane
Appendixes 1561
87°
89°
30–35°
Finding the mechanical axis of a Finding the mechanical axis of a Torsion of the distal tibia
proximal bone fragment in the distal bone fragment in the
frontal plane frontal plane
83°
2/3 1/3
80°
4/5 1/5
81°
1/2 1/2
Finding the anatomic axis of a Finding the anatomic axis of a Finding the anatomic axis of a
distal femoral bone fragment proximal tibial bone fragment distal tibial bone fragment
in the sagittal plane in the sagittal plane in sagittal plane
1562 Appendixes
10°
(5–15°)
16°
(12–25°)
7°
(4–13°)
Reference angles for the preservation of the physiological curvature

of the femur in the sagittal plane
Appendixes 1563
Appendix C3: Reference Lines and Angles of the Foot
14.5° 14.5°
12° 12°
3°
3°
3° 3°
3° 21°
7° 21°
7° 14° 3°
7.5° 14°
87° 87° 7.5°
2°
2°
98° 98°
90.5°
37°
90.5° 104° 104°
37° 22°
14°
22°
14°
Basic reference lines and the angle of the foot: frontal plane
1564 Appendixes
21° (14–28°)
20°
Angle between two axes of the Angle between the axis of the talar body and the line
talus and calcaneus along the lateral surface of the calcaneus
5–8°
142° (136–148°)
Metatarsal parabolic angle Angle between the first and

the second metatarsals
Appendixes 1565
8–10°
15° (10–20°)
1/2
1/2 1/2
Angle between the axes of the Axis of the tarsal bones

first and the fifth metatarsals
5–6°
96° (92–100°)
1° (0–2°)
Joint line convergence angle of the first First interphalangeal valgus angle
proximal interphalangeal angle. Anatomic
proximal medial angle of the first phalanx
1566 Appendixes
3–5°
88° (84–92°)
96° (92–100°)
Anatomic proximal medial angle of Angle between the anatomic axis of the first proximal
the first phalanx. Anatomical distal lateral angle phalanx and the line perpendicular to the first
metatarsophalangeal articular surface
8–16°
3° (1–5°)
First metatarsophalangeal valgus angle Joint line convergence angle of the

first metatarsophalangeal joint
91° (87–95°)
92° (88–96°)
3–6°
Anatomic proximal medial angle of the first metatarsal Angle between the anatomic axis of the
metatarsal and the line perpendicular to the
first metatarsophalangeal articular surface
Appendixes 1567
10 mm
0–6°
Anatomic axis of the calcaneus Valgus angle between the two
axes of the tibia and calcaneus
24.5°
24.5°
22°
22°
28°
28°
130° 130°
Angle between the longitudinal axis of the calcaneus and the forefoot; angle between the horizontal plane and the
metatarsal/forefoot axis; the hindfoot angle between the horizontal plane and the axis of the heel; angle between
the talar axis and the horizontal plane
24.5°
25–28°
Calcaneal-bearing angle Angle between the talar axis and the horizontal plane
1568 Appendixes
20–40°
50°
Talocalcaneal angle Böhler angle (tuber angle)

Instead of the Conclusion
A book written by one of my teachers, Professor Anatoly

Petrovich Barabash, concludes as follows: “Traditionally, a
book requires a conclusion, but I believe that the orthopedic
surgeon will draw his[her] own conclusions, in the silence of
his[her] office, either after the operation or at the end of the
working day, having practiced the techniques offered …” I
am sure that all authors of this volume would readily agree
with these words. Let them serve as the “Conclusion”!
Over the course of time, we increasingly appreciate how
wise are the words of those who have guided us into this
country called “Orthopedics” (but, alas, we did not always
duly consider them), helping us to take the first correct steps
while imparting their love of research and practical work.
A deep bow is offered to our Teachers!
On behalf of the authors of this book

1569
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Index
A elbow, 1051–1059
Accordion method, 847, 1384 hip, 1062–1121
Aesthetic humeral joint (glenohumeral), 67, 68, 71, 920, 1047
correction, 805–840 knee, 257, 1121–1150
deformities lengthening, 9, 1148, 1150
false, 807 Lisfranc joint, 973, 978, 980, 981, 1010, 1018–1023
true, 550, 557, 558, 809, 810 panarthrodesis of the foot, 1010, 1017–1018, 1022
reconstruction, 767, 807, 808, 810, 831–833, 836 subtalar joint, 984, 1012
surgery, 9, 52, 569, 805, 807, 840 wrist, 1059–1062
Ankle, 9, 139–141, 168, 169, 171, 172, 174, 261, 263, 264, 433, 439, Arthrodiatasis, 1107–1118
454, 484, 494–505, 520, 524, 541, 562, 564, 568, 658, 665, Arthrolysis, 793, 1069, 1125, 1132, 1134, 1141, 1145, 1149, 1489
667, 679, 680, 787, 805, 809–811, 816, 840, 880, 893, 974, Arthroscopic monitoring, 412, 417, 442
978, 981, 982, 985, 987, 1010–1013, 1017, 1064, 1075, Arthroscopic release, 1125, 1149, 1150
1150–1156, 1365, 1370, 1444, 1449, 1451, 1454, 1466, Assemblies, 31, 49, 51, 195, 264, 284, 285, 484, 507, 521, 522,
1472, 1473, 1523–1525 549, 570, 576–614, 619–632, 657, 961, 1454,
Apex of deformation, 544–546, 549, 550, 552, 614, 635, 637–640. 1531–1543. See also Apparatus; Devices;
See also Centre of rotation of angulation (CORA); Fulcrum External supports; Modules
Apparatus, 9, 10, 18, 47, 49, 51, 52, 167, 284, 521, 568, 617, 652, components (see Modules)
657, 659–664, 666, 670, 831, 879, 881, 883, 885–887, external devices, 181, 548, 935–960, 1531, 1536
889, 891, 892, 936, 943, 946, 965, 967, 1023, 1024, external supports, 181, 182, 191, 357, 705
1033, 1036, 1038, 1042, 1043, 1158, 1239, 1309, 1363, Atlas for Insertion of Transosseous Element “Reference Positions,” 64.
1380, 1391–1393, 1449, 1454, 1489, 1495, 1497–1499, See also Method for the Unified Designation of External
1507, 1538. See also Assemblies; Devices; External Fixation (MUDEF)
supports; Modules Axis
Barabash, 5, 10, 14 anatomic, 19, 58, 59, 186, 199, 201, 306, 313, 314, 319, 331,
Biomet, 6, 8 339–341, 343, 347–349, 351, 355, 357, 359, 360, 369–371,
Demianov, 4, 8 375–377, 385, 390, 391, 397, 405–407, 411, 413, 417, 433,
Gudushauri, 5, 8, 257 435, 437–441, 454, 459, 460, 474, 484, 494, 502, 535, 541,
Hoffman-Vidal, 4 542, 544–546, 548, 552, 557, 562, 564, 566–569, 581, 583,
Ilizarov, 10, 49, 521, 568, 617, 652, 657, 664, 670, 883, 967, 1043, 586, 589, 595, 598, 601, 605, 608, 611, 614, 616, 619, 748,
1239, 1381, 1449, 1454, 1495, 1498, 1499, 1538 749, 757, 758, 765, 787, 802, 803, 828, 853, 900, 906–908,
Ilizarov hexapod system, 6, 25, 561, 706, 708, 1364 920, 923, 956, 970, 974, 976–978, 1009, 1047, 1048, 1108,
Kalnberz, 4, 8, 54 1120, 1125, 1160, 1310
Lambotte, 4, 7 mechanical, 168, 171, 413, 414, 443, 454, 456, 502, 541, 542, 545,
Lee, 5, 8 547–549, 558, 562–564, 566, 568–576, 578, 581–583, 586,
Malgaigne fixator, 3 589, 593, 612, 614, 615, 619, 673–675, 688, 765, 779, 787,
OrthoFix, 6, 8, 241, 510 805, 807, 810, 812, 821, 1066, 1067, 1075, 1310, 1363,
Ortho-SUV Frame, 6, 8, 18, 25, 50, 62, 284, 288, 290, 291, 430, 1366, 1490
531, 532, 537, 547, 561, 570, 705–803, 823, 1000, 1066,
1068, 1121, 1145, 1154, 1330, 1348, 1350, 1355, 1364,
1454, 1548 B
Sivash, 5, 8 Bandage
Stryker, 6, 1418 cravat, 359, 362, 370, 929
Synthes, 5, 510, 511 plaster, 885, 912, 1062, 1083, 1472, 1504
Taylor Spatial Frame, 6, 8, 25, 52, 284, 561, 670, 673, 679, 687, sling, 215, 217
696, 699, 703, 706, 708, 1330, 1363, 1364, 1374, 1454 Barabash cube, 10, 14
Tkachenko, 5, 8 Biomechanical principles, 23–46, 261, 895
Volkov-Oganesyan, 8 Biomechanics
Arthrodesis, 9, 181, 195, 257, 432, 502, 980, 984, 985, 988, 1018, bone-metal block, 23, 41
1047, 1050, 1051, 1057, 1059–1061, 1119–1121, 1148, displacing forces, 41, 45
1150, 1158, 1380, 1384, 1456, 1471. See also Fusion Bolts, 12, 13, 210, 212, 304, 459, 474, 535, 709, 714, 732, 734, 735,
ankle, 1010, 1150–1156 737, 751, 754, 1064, 1247, 1497, 1498, 1520
1588 Index
Bone fragments, 8, 9, 19, 23, 25–40, 49, 51, 54, 60, 63, 64, 74, 167, 882, 888–892, 929, 979, 984, 1042, 1046, 1072–1081,
181, 182, 184, 191, 199, 201, 208, 212, 219, 223. 1083–1092, 1106, 1107, 1113, 1121, 1125, 1128, 1150,
See also Repositioning 1290, 1324–1330, 1340–1344, 1346, 1362–1364, 1379,
displacement, 160, 525, 531, 537, 575, 1486, 1489 1413–1414, 1423, 1435, 1440, 1446–1447, 1449, 1451,
distal, 183, 188–190, 196, 209, 215, 243, 306, 307, 309, 310, 313, 1475–1491, 1501, 1503, 1504, 1531. See also Dermatitis;
315, 317, 319, 321, 326, 347, 349, 351, 353, 355, 357, 360, Inflammation of soft tissues; Necrosis
375, 382, 385, 386, 390, 391, 396–398, 406, 407, 418, 439, infectious, 63, 168, 263, 854, 1106, 1157–1247, 1279, 1344,
459, 460, 474, 485, 486, 513, 514, 524, 530, 535, 547, 548, 1346, 1451, 1476, 1480 (see also Osteomyelitis;
551, 561, 564, 567, 569–571, 578, 581–583, 586, 589, Pin-tract infection)
593–595, 598, 601, 604, 605, 608, 611–614, 616, 624, 631, Compression
639, 640, 749, 758, 772, 802, 803, 832, 833, 1471 axial interfragmentary, 349
icicle-shaped form, 860, 883 microcompression, 847
intermediate, 525, 860, 1148, 1172, 1331–1333 rate, 1181, 1456, 1488
proximal, 188–190, 196, 227, 307, 308, 314, 315, 319, 332, Computer navigation, 25, 47, 50, 281, 290, 531, 537, 557, 562, 705
347–349, 352, 353, 355, 357, 385, 386, 390, 396, 401, 414, Contracture, 9, 24, 168, 238, 244, 260, 264, 295, 303, 508, 535, 547,
418, 459–461, 469, 474, 475, 486, 490, 546–548, 564, 595, 568, 590, 595, 641, 652, 661, 663, 684, 686, 840, 854, 875,
598, 608, 614, 616, 748, 756, 757, 759, 1332, 1335, 1458 893, 1000, 1010, 1023, 1032, 1035, 1038–1046, 1062,
reduction, 10, 16, 18, 47, 52, 53, 186, 192, 196, 198, 200, 203, 1074, 1081, 1083, 1092, 1107, 1113, 1133, 1140, 1146,
206, 207, 306, 317, 323, 328, 353, 380, 381, 394, 410, 1181, 1255, 1299, 1324, 1458, 1489, 1491, 1504. See also
464, 470, 519, 521, 530, 531, 537, 757, 803, 1158, 1486, Polylocal myofasciodeses
1490, 1495 ankle joint, 568, 840, 893
relocation, 435, 459, 460, 474, 524, 725 elbow joint, 641
rigidity, 40–48, 186, 195, 263, 481, 546, 1486, 1489, 1531 shoulder joint, 303
spatial orientation, 36, 45, 53, 74, 195, 304, 339, 376, 435, 530, transfixion, 24, 244, 1299
632, 902, 903, 1279 wrist joint, 1023
Bone-metal block, 23, 41, 934, 1406 Coordinates, 53, 54, 63, 541, 557, 705, 814, 1509, 1519
Bone transport, 61, 291, 861, 872, 875, 1157, 1158, 1172, 1180, 1218, CORA. See Centre of rotation of angulation (CORA)
1239, 1244, 1309, 1380, 1381, 1383–1385, 1389, 1430, Corticotomy, 10, 215–217, 220, 223, 224, 228, 527, 537, 547,
1446, 1457, 1458, 1475, 1491. See also Defects; 568–570, 617, 619, 653, 661, 663, 665, 793, 818, 853, 860,
Intermediate fragment relocation 870, 872, 883, 1001, 1022, 1033, 1064, 1066, 1072, 1093,
cross-wire, 1458, 1475 1094, 1101, 1132, 1149, 1158, 1331, 1332, 1353, 1457,
oblique-wire, 418, 1172, 1180, 1457, 1458, 1491 1491
over nail (bone transport over nail-BTON), 291, 875, 1329–1344 Coxa vara, 576, 593, 1467
Weber’s technique, 861 CRM. See Image intensifier
CSF. See Combined strained fixation (CSF)
Curvature
C false curvature, 809
Calcaneus, 679, 888, 970, 971, 973–975, 978, 980, 981, 984–989, 993, X-shaped, 809
1003, 1010–1013, 1015, 1017, 1150, 1355
Carpals (metacarpals), 95–97, 265, 340, 341, 369, 370, 373, 686,
1023, 1024, 1027, 1032, 1033, 1035–1038, 1040, 1042, D
1060, 1362, 1525 Debridement, 507–518, 524, 526, 1158, 1331, 1475, 1488
CEF. See Combined external fixation (CEF) Defects, 3, 9, 52, 215, 238, 243–246, 252, 261, 263, 265, 287, 442,
Centre of rotation of angulation (CORA), 544–546, 549, 550, 556, 507, 508, 510, 515, 518, 520, 524, 531, 686, 807, 813,
574, 582, 614, 619, 621, 635, 636, 638, 639, 673, 698, 853, 841–893, 896, 899–901, 905, 907, 909, 920, 922, 923,
983, 1051, 1363, 1365, 1366, 1371. See also Apex of 1001, 1010, 1061, 1062, 1098, 1157, 1158, 1249, 1260,
deformation 1265, 1329–1331, 1340, 1379, 1380, 1383, 1384, 1426–
Classification 1431, 1454, 1497. See also Bone transport
AO/ASIF (fractures), 9, 507, 899, 902, 923, 936 defect-diastasis, 841, 854, 864, 865, 871, 872
Kaplan–Markova (open fractures), 507 defect-pseudoarthrosis, 841, 842, 858, 1266
Clavicle, 9, 52, 898, 920–930 Deformities (Deformations)
Clinical testing, 967, 1024, 1247, 1466, 1471, 1472 jaws, 209
Combined external fixation (CEF), 47–52, 183, 195, 261, 281, 290, recurvation valgus deformity, 568
307, 308, 314, 315, 319, 320, 326, 331–333, 339, 347, 349, spine, 1402, 1404
350, 352, 355–358, 360, 363, 369, 375, 377, 379, 381, 386, torsion, 169, 558–561, 575, 619
390, 391, 397, 401, 402, 405, 406, 412, 413, 433, 435, 438, transverse, 25
442, 443, 459–461, 468, 474, 475, 481, 484, 485, 489, 496, Delayed union, 263, 696, 1324
498, 571, 574, 775, 787, 793, 821, 849, 895, 1052, 1122, Dermatitis, 1046, 1475, 1479, 1488, 1504
1128, 1280, 1283, 1286, 1290, 1291, 1294, 1300, 1302, Devices. See also Apparatus; Assemblies; External supports; Modules
1306, 1458, 1460, 1467, 1481 Dislocation fractures
Combined strained fixation (CSF), 18, 291, 872, 895–931, 1459, dislocation of the head of the radial bone (Monteggia fractures),
1460, 1471 350–351, 353, 696, 701, 906
Complications, 10, 23, 53, 62, 63, 167, 168, 234, 241, 244, 263, 288, Lisfranc joint, 973, 978, 980, 981, 1010, 1018–1023
325, 508, 510, 512, 515, 517, 531, 549, 661, 663–666, 670, Displacement
682, 686, 693, 794, 801–803, 808, 830, 840, 854, 864, 875, angular, 341, 347, 350, 355, 536, 549, 820, 842, 1024, 1536
Index 1589
residual, 304, 314, 319, 332, 336, 339, 340, 347, 349, 352, 353, forefoot, 970, 978–979, 981, 985–987, 1150, 1153, 1512
355, 357, 360, 377, 386, 390, 396, 405, 412, 436, 437, 442, hindfoot, 174, 793, 970, 978, 981–984, 986, 1012, 1050
459, 460, 474, 484, 496, 502, 535, 772, 803, 1051, 1414 midfoot, 793, 978–981
rotational, 306, 352, 355, 357, 359, 360, 385, 390, 396, 434, 770, planus, 985
943, 960, 961, 963, 964, 1519, 1541 supinatus, 985
soft-tissue, 24, 25, 40, 52, 63, 65–73, 77–82, 85–98, 100–102, talipes (see Talipes)
108–123, 127–129, 132, 134–136, 138–142, 160, 192, Forearm, 9, 40, 51, 52, 54–56, 58–60, 74, 77–82, 85–90, 93–99, 106,
281–283, 1279, 1488, 1489, 1519–1530 107, 114, 122, 123, 174, 215, 261, 284, 287, 288, 303, 336,
splinter, 347, 349, 350, 355, 357, 912 339–373, 507, 512, 513, 518, 524, 539, 615–640, 651, 686,
transverse, 27, 29, 34 691, 696–703, 841, 842, 851, 854, 860, 864, 896, 899,
Displacing forces, 41, 45, 525, 920. See also Biomechanics 905–919, 923, 929, 1024, 1027, 1028, 1051, 1052, 1057,
modeling, 1536–1537, 1539 1060, 1061, 1158, 1260, 1269, 1283, 1299, 1323, 1329,
standard, 1531 1355–1362, 1449, 1453, 1458, 1460, 1471, 1473,
Dissection, 442, 684, 995, 1032, 1066, 1092, 1312, 1370, 1406, 1420, 1499–1501, 1513, 1516, 1522–1530. See also Radius; Ulna
1429 Fork device, 10, 14, 377, 435
acute, 964 Fractures
Distraction, 3, 25, 51, 61, 167, 196, 219–256, 261, 305, 341, 377, 433, arthroscopy management, 457–458
521, 535, 547, 749, 808, 841, 898, 937, 978, 1047, 1157, calcaneal, 981–984
1260, 1309, 1379, 1391, 1417, 1426, 1437, 1449, 1475, clavicle, 920, 923, 927
1497, 1536. See also Skeletal traction compound, 507, 524, 854, 969, 978, 979, 1504
microdistraction, 263, 847, 1128 cuboid, 980
Dressings cuneiform, 980
bandages, 168, 215, 217, 359, 362, 370, 521, 885, 912, 929, 967, femoral condyle, 405
1010, 1062, 1082, 1083, 1106, 1370, 1472, 1503, 1504 femoral neck, 378, 1089, 1107
slings, 215, 217, 336, 346, 351, 359, 370, 929, 1449, 1453 femur, 248, 261, 787
Dynamization, 245, 402, 454, 1009, 1162, 1362, 1460, 1466, 1471, 1472 fibula, 433–505
humerus, 303–337, 1473
infected, 370, 969, 1158
E intraarticular, 174, 303, 305, 307, 313, 332, 336, 339, 342, 370,
Element Reference Positions, 63–166 375, 405, 412, 413, 433, 437, 484, 489, 514, 1024, 1032,
Elongation, 303, 339, 433, 524, 547, 661, 830–832, 860, 861, 863, 1125, 1132, 1150, 1531
870, 875, 883, 884, 887, 889, 893, 1023, 1035–1037. juxtaarticular, 182, 303, 305, 339, 342, 343, 369, 375, 433,
See also Lengthening 979, 1032
Exercise therapy, 167, 664, 665, 840, 1066, 1074, 1106, 1150, 1255, malunited, 182, 418, 535–539, 574, 847, 960, 1158, 1457, 1460
1398, 1410, 1413, 1449, 1451–1454, 1458, 1489, 1503 metatarsal, 978, 979
External fixation. See also Osteosynthesis; Transosseous elements navicula, 979, 980
combined (see Combined external fixation (CEF)) oblique, 347, 349, 350, 355, 357, 417, 512, 899, 905, 920, 1456
External Fixation Assisted Nailing (EFAN), 1363–1377 olecranon, 3, 343, 344, 346
Sequential External Fixation and Nailing (SEFaN), 1344–1362 open, 263, 336, 507, 510, 516, 517, 531, 532, 869, 1023, 1024,
strained (see Combined strained fixation (CSF)) 1125, 1158, 1159, 1280, 1330, 1344, 1364
External supports, 3, 25, 47, 53, 167, 181, 281, 303, 339, 375, 433, 524, patella, 3, 417, 418
535, 549, 705, 860, 896, 935, 1047, 1159, 1249, 1347, 1454, pelvis, 961
1488, 1505, 1532. See also Assemblies; Devices; Modules phalangeal, 978–980
Extracortical bone clamp, 10, 14 radius, 340, 343, 357, 909, 1473
spine, 1393, 1397
spiral, 223, 224, 347, 349, 350, 355, 357, 770
F subtrochanteric, 385, 902
False joints, 223, 238, 261, 263, 844, 847, 853, 854, 858, 860, 875, talus, 981
895, 897, 905, 906, 909, 923, 930, 960, 964. See also ulna, 340, 360, 369, 906, 1473
Nonunion; Pseudoarthrosis Fragments. See Bone fragments
Femur, 9, 40, 51, 55, 124–132, 168, 195, 248, 261, 375, 434, 513, 541, Fulcrum, 544, 1170
757, 805, 841, 895, 943, 1062, 1253, 1310, 1383, 1441, Fusion, 171, 195, 614, 686, 980, 989–991, 1000, 1006, 1010–1023,
1449, 1491, 1502, 1520, 1552 1047, 1050, 1051, 1056, 1109, 1119–1121, 1133, 1299,
Fibula, 433–505. See also Tibia 1391, 1393, 1397, 1400, 1401, 1405–1408, 1410.
tibialization, 9, 872, 875, 877, 878, 1158, 1244 See also Arthrodesis
Fixation. See also External fixation
fixator, 200, 815–818, 1064–1066, 1312–1324, 1354, 1365–1370
large splinters, 304, 307, 332, 340, 347, 355, 362, 377, 435, 459, G
474, 481, 490 Galeazzi, 357
Foot
abductus, 985, 998
adductus, 985, 997 H
calcaneus, 679, 888, 970, 971, 973–975, 978, 980, 981, 984–989, Half-pin, 3, 23, 47, 53, 63, 182, 265, 303, 339, 375, 433, 511, 535,
993, 1003, 1010–1013, 1015, 1017, 1150, 1355 549, 803, 842, 900, 934, 979, 1048, 1158, 1249, 1310,
excavatus, 985 1380, 1391, 1429, 1472, 1475, 1497, 1519, 1532
1590 Index
Hinges, 10, 19, 21, 25, 30, 61, 209, 213, 336, 340, 344, 346, 405, 411, L
417, 440, 441, 520, 524, 525, 529, 535, 537, 548–557, 561, Lengthening
562, 573, 574, 597, 610, 661, 670, 672, 793, 820, 840, 844, in accordance with the anatomical axis, 568, 569, 578
847, 850, 851, 896, 900, 902, 903, 937, 940, 944, 983, 987, in accordance with the mechanical axis, 568, 569, 578
991, 992, 997–999, 1011, 1032, 1047, 1051, 1053, 1060, arthrodesis, 9, 181, 185, 257, 432, 502, 980, 984, 985, 988, 1018,
1066, 1068, 1081, 1107, 1109–1111, 1119, 1121, 1122, 1047, 1050, 1051, 1057, 1059–1061, 1119–1121, 1148,
1124, 1126–1128, 1149–1151, 1154, 1158, 1165, 1169, 1150, 1158, 1380, 1384, 1471
1392, 1393, 1397, 1410, 1411, 1432, 1458, 1489, 1505 femur, 52, 568, 572, 573, 653, 656, 657, 664, 665, 830, 965, 1066,
Humerus, 9, 40, 55, 56, 60, 65, 68, 217, 284, 303–337, 512, 513, 518, 1253, 1341, 1384, 1491
531, 553, 615–640, 645, 648–651, 653, 661, 663, 691, 693, foot, 263, 1501
696, 831, 842, 857, 864, 896, 898–901, 905, 929, 930, forearm, 1489
1047–1051, 1053, 1055, 1057, 1250, 1260, 1265, 1290, functionally permissible elongation, 831
1299, 1302, 1330, 1449, 1459, 1471, 1473, 1481, 1525 monolocal, 568
Hypercorrection, 303, 339, 375, 396, 405, 407, 411, 435, 440, 535, over the intramedullary nail (LON), 241, 243, 562, 1309, 1384
757, 810, 828, 844, 936, 961, 962, 1065, 1066, 1260, 1323, soft-tissue, 1160, 1172, 1458
1325, 1326, 1345, 1350, 1355 tibia, 244, 653, 657, 659, 1384
Levels, 10, 41, 53, 63, 167, 181–186, 247, 284, 303, 339, 375, 433,
512, 546, 770, 827, 855, 923, 1038, 1094, 1160, 1299, 1347,
I 1439, 1471, 1480, 1509, 1522, 1536. See also Method for
Ilizarov, G.A. the Unified Designation of External Fixation (MUDEF)
apparatus, 10, 49, 521, 568, 617, 652, 657, 664, 670, 883, 967, Ligamentotaxis, 411, 412, 437, 440, 442–444, 448, 451, 484, 495,
1043, 1239, 1380, 1449, 1454, 1495, 1498, 1499, 1538 969, 979
device, 49, 60, 182, 191, 257, 262, 263, 284, 303, 519–525, 531, L-shaped clips, 209, 304, 339, 376, 435
562, 619, 865, 923, 1000, 1018, 1052, 1058, 1081, 1083,
1122, 1165, 1329
external fixation, 306, 307, 313, 314, 319, 325, 332, 336, 339, 343, M
346, 348, 349, 351, 352, 355, 357, 359, 375, 376, 378, 379, Metacarpals, 340, 341, 686, 1023, 1024, 1027, 1032, 1033,
385, 390, 397, 405, 411, 412, 440, 441, 459, 460, 474, 484, 1035–1038, 1040, 1060
494, 495, 519, 969, 985, 1080, 1092, 1098, 1099, 1101, Metatarsals, 679, 976, 978, 979, 981, 988, 1001, 1009, 1018, 1023
1103, 1105, 1106, 1150, 1452, 1473 Method for the Unified Designation of External Fixation (MUDEF)
hinges, 25, 30, 537, 548, 562, 610, 1165, 1458 contraindicated positions, 63–166, 1519, 1549–1553
method, 215–217, 257, 263, 303, 352, 516, 520, 528, 531, 562, coordinates, 53, 54
652, 656, 673, 830, 854, 860, 879–893, 988, 1010, 1101, designation of external support frame, 58–60
1132, 1159, 1160, 1172, 1239, 1309, 1379, 1387, 1458, designation of half-pins, 58, 1547
1495 designation of K-wires, 54–58, 1546
mini-device, 417, 1060 designation of the Entire Device, 60–61
Image intensifier, 200, 307, 313, 314, 319, 332, 347, 349, 355, 357, device for division of an extremity into levels, 15
360, 377, 378, 385, 390, 396, 405, 411, 412, 417, 433, 440, levels, 10, 15, 41, 53–56, 58, 61, 63, 65, 74, 99, 124, 133,
442, 457, 459, 460, 474, 484, 1107, 1310–1312, 1392. 186–195, 303, 307, 314, 339, 342, 347, 349, 352, 355, 360,
See also CRM 362, 364, 371, 375, 377, 381, 386, 413, 433, 436, 438, 514,
Infection. See Arthrolysis; Complications; Inflammation of soft tissues 1299, 1347, 1355, 1439, 1480, 1522–1524, 1538
Inflammation of soft tissues, 24, 244, 830, 930, 1012, 1046, 1158, reference positions, 47, 49, 63
1413, 1414, 1488. See also Pin-tract infection safe positions, 65–159, 186–190, 195, 304, 307, 314, 332, 340,
Insertion of transosseous elements, 8, 24, 41, 47, 51, 63–166, 347, 349, 353, 362, 377, 386, 436, 512, 524, 935, 1148,
181–186, 189, 196, 281, 284, 303, 339, 362, 378, 422, 433, 1157, 1519, 1549–1553
524, 661, 864, 912, 935, 1051, 1060, 1067, 1121, 1157, standard and additional symbols, 54
1335, 1342, 1488, 1490, 1519–1530, 1536, 1549. See also Modules. See also Assemblies; Devices; External supports
Atlas for Insertion of Transosseous Element “Reference bolts, 12, 13, 304, 459, 474, 535, 732, 734, 735, 1064, 1247, 1497,
Positions”; Transosseous elements 1498, 1520
Intermediate fragment relocation. See also Bone transport; Defects classification, 1532–1536
cross-wire, 860, 1458, 1475 first-order, 1532, 1533, 1536, 1538–1541
oblique-wire, 418, 860, 1172, 1180, 1457, 1458, 1491 hinges, 344
Weber’s technique, 861 nuts, 12, 34, 202, 347, 348, 351, 352, 355, 437, 440, 459, 474, 484,
Ischemia, 522, 1106, 1107, 1425, 1428, 1431, 1435–1447 725, 827, 896–898, 934, 1009, 1011, 1065, 1069, 1392,
1393, 1410, 1454, 1478, 1498, 1505–1507, 1520, 1529
rings, 8, 11, 45, 192, 203, 306, 314, 324, 329, 339, 347, 350, 360,
J 375, 405, 411, 417, 433, 435, 440, 442, 446, 450, 457, 459,
Joint (orientation) line, 171, 391, 397, 406, 438, 454, 541, 544–546, 474, 481, 484, 494, 518, 869, 897, 997, 998, 1010, 1013,
562, 564, 566, 567, 589, 595, 598, 608, 615–617, 619, 621, 1018, 1065, 1160, 1165, 1172, 1239, 1279, 1323, 1332,
765, 779, 787, 805, 810, 812, 974, 977, 978, 1165, 1323, 1383, 1430, 1498
1444, 1491 second-order, 1532, 1534, 1536–1541
third-order, 1532, 1535, 1537, 1538, 1541–1543
washers, 12, 34, 36, 201, 208, 209, 304, 339, 376, 435, 502, 709,
K 714, 934, 1065, 1066, 1110, 1279, 1383, 1386, 1392, 1498
Kirschner wires (K-wires), 7, 8, 18, 53–58, 60, 65, 139, 223, 372, 454, Monteggia fracture, 350–351, 353, 696, 701, 906, 914, 1460
684, 922, 978, 980–982, 1010, 1012. See also Wires Myolysis, 793, 1125, 1132, 1134, 1141, 1145, 1149
Index 1591
N 1363, 1383, 1423, 1435, 1450, 1458, 1460, 1475, 1488,

Navicula (navicular bone), 970, 973, 979, 980, 988, 995, 997, 998, 1504, 1519. See also Complications; Infections;
1000, 1003, 1011, 1013, 1017 Inflammation of soft tissues
Neck-shaft angle, 564, 574 Plate, 12, 23, 51, 68, 183, 223, 300, 303, 347, 375, 508, 549, 709, 814,
Necrosis, 508, 515, 517, 572, 864, 979, 1011, 1060, 1107, 1149, 1159, 844, 896, 934, 978, 1048, 1158, 1290, 1310, 1383, 1391,
1194, 1200, 1229, 1241, 1313, 1428, 1478, 1480, 1488, 1504 1423, 1430, 1445, 1460, 1495, 1525
Nerves, 3, 10, 40, 48, 49, 63, 142, 160, 215, 217, 281, 283, 304, 305, Pliers, 16, 211, 897, 902, 906, 908, 909, 920, 930, 931
307, 314, 332, 340, 347, 349, 352, 362, 377, 386, 436, 511, Polylocal myofasciodeses, 48, 1125
515, 516, 521, 524, 537, 547, 549, 770, 771, 779, 787, 793, Positions. See Atlas for Insertion of Transosseous
876, 1023, 1024, 1027, 1051, 1052, 1060, 1081–1083, Postoperative period, 33, 51, 167, 181, 339, 502, 524, 525, 818–827,
1122, 1149, 1150, 1157, 1159, 1458, 1488, 1519, 1521 898, 1027, 1046, 1066–1072, 1081–1083, 1106, 1113,
radial, 68, 69, 101, 108, 109, 116, 117, 325–332, 693 1121, 1258, 1279, 1362, 1391, 1397, 1413, 1414, 1433,
Neurovascular disorders, 1488, 1504 1436, 1446, 1449–1473, 1475, 1499, 1501–1502, 1504
Nonunion. See also False joints; Pseudoarthrosis Posts
atrophic, 248, 1132, 1184, 1187, 1189, 1192, 1219, 1234, 1291, female, 10, 34, 208, 209, 1064
1330 female slotted, 10, 11
hypertrophic, 853, 1159, 1165, 1168, 1170, 1196, 1290 male, 11, 201, 252, 304, 339, 376, 435, 664, 998, 1043, 1064
hypotrophic, 847, 860, 863 Preoperative preparation, 167–179, 808, 895, 1157, 1255
Nuts, 12, 34, 202, 347, 348, 351, 352, 355, 437, 440, 459, 474, 484, Pseudoarthrosis, 841, 842, 845, 847, 850, 851, 853, 858, 879–893,
725, 827, 896–898, 934, 1009, 1011, 1065, 1069, 1392, 1033, 1062, 1159–1195, 1266, 1471. See also False joints;
1393, 1410, 1454, 1478, 1498, 1505–1507, 1520, 1529 Nonunion
O R
Orthopaedic (traction) table, 305 Radius, 11, 40, 51, 54–56, 58–60, 74, 99–123, 217, 340, 343, 344,
Osteoclasia, 223, 225, 547, 619, 661, 818, 860, 870, 881 346, 347, 350–371, 375, 539, 615, 619, 620, 640, 651,
Osteogenesis. See also Regenerate 686, 691, 702, 703, 860, 905–909, 911, 912, 923,
hyperplastic type, 844, 1158 1060–1062, 1064, 1158, 1255, 1260, 1361, 1362,
hypoplastic type, 238, 570, 641, 863, 872, 1081, 1083, 1490 1473, 1524–1527, 1529
Osteomyelitis, 248, 288, 429, 546, 547, 572, 693, 702, 840, 842, 1061, Range of motion, 53, 81, 100–107, 125, 127–132, 134–141, 263, 446,
1062, 1072, 1092, 1125, 1132, 1133, 1158, 1239, 1250, 645, 652, 653, 661, 664, 665, 670, 794, 1309, 1324, 1340,
1253, 1255, 1258–1261, 1265, 1266, 1269, 1344, 1362, 1449, 1460, 1491, 1504
1364, 1414, 1423, 1439, 1475, 1477 Reamers, 896, 898, 1344, 1346, 1347
Osteosynthesis. See also External fixation Reference lines and angles (RLA), 541, 616, 805, 807, 819, 969–978,
alternating, 51, 525, 847, 856, 857 1554, 1558, 1563
bilocal, 9, 246, 339, 375, 433, 524, 525, 570, 571, 574, 575, 832, Reference positions, 24, 47, 49, 63–166, 181, 186–190, 281, 282, 303,
854, 859, 860, 862, 864, 865, 870, 871, 1139, 1149, 1160, 339, 343, 375, 422, 433, 512, 524, 912, 1051, 1060, 1121,
1260, 1347, 1458, 1491 1148, 1157, 1249, 1279, 1485, 1488, 1489, 1519–1530,
bilocal consecutive distraction-compression, 9 1549–1553. See also Positions; Safe positions
bilocal distraction, 570, 571, 854, 860, 862, 1260 Reflexotherapy, 167, 290, 291
bilocal distraction-compression, 9, 854, 860, 862, 1260 Refracture, 888, 1131, 1196, 1490, 1504
combined, 50, 51, 1061, 1279 Regenerate. See also Osteogenesis
compression, 257, 261, 263, 845, 853, 854, 860, 862, 1265, 1277, hypoplastic distraction, 570, 863, 1490
1340, 1401 interfragmentary, 535, 1466, 1471
conjunctive, 51 trapezoidal, 524, 550, 555, 573, 999, 1000, 1095, 1097, 1260, 1344
Osteotomy wedge-shaped, 524, 533, 877, 998, 1000, 1260
parafocal, 842, 853–855 Release, 125, 126, 214, 418, 504, 518, 675, 684, 749, 895, 930, 981,
pelvic support osteotomy, 757, 807, 1067 985, 988, 1125, 1149, 1150, 1420, 1466, 1472
trochanteric, 574, 614, 642, 665, 902, 904, 1062, 1064, 1066, arthroscopic, 1125, 1149, 1150
1072, 1092, 1093, 1095, 1311 Repositioning, 9, 25, 27, 33, 36, 39, 40, 52, 181, 182, 186, 191,
V-shaped, 793, 988, 992, 993 192, 201, 209, 212, 353, 355, 379, 386, 390, 433, 442,
Outpatient treatment, 1458–1471, 1502 517, 519–521, 524, 530, 535, 537, 844, 885, 936, 946,
957, 958, 961–963, 967, 1018, 1024, 1027, 1058,
1081, 1083, 1391, 1392. See also Barabash cube;
P Bone fragments; Reduction
Patella, 3, 169, 417–419, 434, 1128, 1133, 1142, 1150, 1312, 1324, Rigidity
1380, 1383, 1386, 1387 abduction, 1536, 1541
Pelvis, 9, 160–166, 168, 290, 291, 377, 814, 902, 933–936, 938–941, adduction, 1541
959–962, 964–967, 1062, 1063, 1067, 1072, 1079, 1092, bone fragment, 23, 40–47, 51, 181, 192, 201, 220, 1157, 1505,
1094, 1096, 1112, 1120, 1160, 1331, 1511, 1517 1531, 1536
Phalanges, 977, 988, 1008, 1009, 1023, 1024, 1032, 1035, 1038, 1042 coefficient, 1536, 1539–1543
Pharmacotherapy, 1054, 1488 compression, 1536, 1539, 1540, 1542
Physiotherapy, 530, 661, 665, 892, 962, 963, 1158, 1258, 1458, 1488, extension, 1536
1501, 1503–1504, 1515, 1517 flexion, 1536
Pin-tract infection, 9, 23, 48, 49, 53, 63, 160, 281, 288, 350, 418, 514, index, 1531, 1539
519, 840, 890, 1049, 1107, 1113, 1309, 1310, 1324, 1340, inward rotation, 1536
1592 Index
Rigidity (cont.) pliers, 16, 211, 897, 902, 906, 908, 909, 920, 930, 931
longitudinal, 1539–1542 reamers, 896, 898, 902
osteosynthesis, 223, 1298, 1531, 1536 wrenches, 10, 15, 16, 709, 712, 1505, 1507
outward rotation, 1150, 1536, 1539, 1540, 1542 Transosseous elements
testing, 45, 52, 1531–1543 console, 3, 7, 41, 58, 61, 66–69, 71–73, 75–98, 100–123, 125–132,
Rod, 8, 26, 47, 54, 195, 265, 304, 340, 375, 433, 520, 535, 547, 705, 134–140, 934
820, 850, 896, 948, 978, 1050, 1159, 1290, 1346, 1392, half-pins (see Half-pins)
1418, 1430, 1449, 1497, 1529, 1538 insertion (see Insertion of transosseous elements)
K-wires, 7, 8, 18, 53–58, 60, 65, 139, 223, 372, 454, 684, 922,
978, 980–982, 1010, 1012
S reinsertion, 167, 1413, 1491, 1502
Safe positions, 63–159, 181, 186–190, 195, 304, 307, 314, 332, 340, S-screws, 8, 18, 47, 53, 58, 281
347, 349, 353, 362, 377, 386, 436, 512, 524, 935, 1148, Steinmann rods, 8, 47, 54, 281
1157, 1519, 1549–1553. See also Positions; Reference transsegmental elements, 18
positions wires (see Wires)
Scapula, 62, 305, 307, 313, 900, 920, 922–924, 1047, 1050, 1057, Transport
1260, 1267 bone, 61, 291, 861, 872, 875, 1157, 1158, 1172, 1180, 1218, 1239,
Schanz screws (S-screws), 8, 18, 47, 53, 58, 60, 61, 281, 511, 514 1244, 1309, 1329–1332, 1334–1336, 1339, 1340, 1342,
Shape of lower extremities, 809 1343, 1380, 1381, 1383–1385, 1389, 1446, 1457, 1458,
Shortening, 64, 171, 248, 296, 428, 515, 536, 543, 705, 828, 841, 906, 1475, 1491
965, 980, 1062, 1160, 1249, 1329, 1380, 1491, 1497 cross-wire bone, 1458, 1475
Skeletal traction, 18, 52, 195, 196, 207, 305–308, 311, 313–315, 317, fibula, 852, 1158, 1239, 1242, 1246, 1329
319, 320, 326, 332, 333, 335, 337, 340, 342, 349–352, 357, oblique-wire bone, 1147, 1172, 1180, 1458, 1491
359, 362, 364, 371, 372, 377, 379, 383, 385, 386, 389–391, Trochanter, 55, 160, 200, 378, 564, 574, 582, 642, 645, 665, 675, 779,
395–397, 399, 401, 405, 406, 410, 433, 434, 437, 438, 443, 780, 898, 902, 1064, 1065, 1072, 1081, 1083, 1089,
459–461, 465, 468, 471, 474, 475, 477, 481, 484–486, 489, 1091–1099, 1101, 1102, 1106, 1121, 1131, 1265, 1365
490, 493, 496, 498, 500, 535, 842, 936, 943, 950, 960, 967, osteotomy, 614, 1064, 1072, 1092, 1094–1097, 1099
1421
Skull Surgery, 1425–1436
Sliver. See Bone fragments U
Smith’s fractures, 370 Ulna, 40, 51, 56, 74–98, 217, 340, 508, 541, 865, 898, 1027, 1051,
Steinmann rod, 8, 47, 54, 281 1158, 1260, 1360, 1460, 1524, 1550
Surgical drill, 10, 15, 199
W
T Washers
Talipes, 1150 conical, 160, 198, 880, 1160, 1344
Talus, 62, 496, 502, 505, 679, 970, 974, 975, 981, 984, 987, 991, 992, lock, 709
994, 995, 1000, 1010–1013, 1015, 1017, 1151, 1355 slotted, 12, 34, 502
fracture, 981 spherical, 12, 34, 36, 1065
Tarsals, 495, 976, 979, 980, 1000 Weight-bearing, 245, 437, 454, 493, 520, 656, 684, 877, 879, 888,
Tendons, 10, 142, 495, 500, 507, 519, 521, 575, 619, 679, 680, 962, 960, 967, 1010–1012, 1063, 1082, 1113, 1132, 1160, 1247,
984, 985, 988–990, 1000, 1010, 1024, 1027, 1035, 1081, 1279, 1290, 1299, 1324, 1340, 1370, 1446, 1451, 1452,
1121, 1125, 1127, 1150, 1365, 1383, 1386, 1432, 1489, 1454, 1458, 1460, 1466, 1471, 1472, 1490, 1504, 1508,
1519, 1520 1509
Achilles, 495, 500, 504, 985, 988–990, 1000, 1141, 1150 Wires. See also Insertion of transosseous elements; Kirschner wires
Testing (K-wires); Transosseous elements
biochemical, 854, 1454, 1457, 1458 arched bending, 332, 347, 349, 353, 435, 459, 460, 504
clinical, 225, 967, 1024, 1050, 1247, 1466, 1471, 1472, 1504 console, 7, 13, 18, 39–41, 47, 58, 59, 135, 241, 303, 304, 307, 332,
rigidity, 45, 52, 195, 1531–1543 339, 347, 352, 355, 357, 359, 362, 363, 369, 372, 373, 375,
Tibia. See also Fibula 377, 378, 385, 416, 433, 435, 459, 460, 474, 481, 484, 490,
defect, 60, 246, 860, 866, 872, 875–877, 879, 1158, 1239, 1240, 496, 499, 500, 503, 524, 864, 909, 922, 923, 926–929, 934,
1330, 1383 979, 980, 1001, 1003, 1024, 1066, 1094, 1249
fracture, 182, 512, 514, 520, 1198, 1244, 1330 designation, 54, 57, 58
nonunion, 853, 855, 1153, 1178, 1181 diafixing, 181, 314, 328, 332, 346, 347, 349, 352, 357, 362, 369,
Tibiofibular diastasis, 494, 496, 502, 504 370, 386, 398, 414, 415, 417, 459, 460, 463, 474, 490, 535,
Tools 1098, 1454, 1472
clip, 10, 13, 212, 307, 343, 496, 535, 829, 906, 909, 923, 924, 928, distraction-guiding, 860, 864, 866, 867, 869, 870, 872, 887, 890
956, 1441, 1442, 1454, 1457 feather, 23
drills, 10, 16, 199, 1279, 1324, 1344 fixation bolts, 13, 210, 212, 304, 1064, 1247
extracortical bone clamp, 10, 14 insertion, 10, 24, 48, 52, 197, 265, 307, 344, 352, 390, 417, 884,
one-stage forced, 535 896, 897, 900, 902, 903, 906, 909, 920, 923, 926, 929,
Index 1593
981, 1012, 1018, 1024, 1064–1066, 1074, 1106, three-facet, 23

1157, 1384, 1489 transsegmental, 47, 281
module, 344, 900, 903
reamers, 896, 898
single-facet, 23 X
smooth, 898, 1065 X-ray contrast markers, 305, 315, 320, 341, 377, 386, 461, 468,
stop wires, 344, 345, 896, 906, 908, 1065 475, 478
tensioner, 10, 15, 210–212, 494, 1454

Solomin LN Ed The Basic Principles of External Skeletal Fixa

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The Basic Principles of External Skeletal Fixation

Using the Ilizarov and Other Devices

The Basic Principles

Professor of the Surgery Chair

Honourable Professor of Russian Ilizarov

ISBN 978-88-470-2618-6 ISBN 978-88-470-2619-3 (eBook)

Library of Congress Control Number: 2012956313

© Springer-Verlag Italia 2008, 2012

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Dror Paley, M.D., FRCSC

Alexander V. Gubin, M.D., Ph.D.

Part I General Aspects of External Fixation

1 General and Special Aspects of External Fixation . . . . . . . . . . . . . . . . . . . . . . 3

4 Method of Unified Designation of External Fixation (MUDEF) . . . . . . . . . . . 53

7.5 Identification of the Type and Size of the External Supports

10 Fractures of the Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

11 Fractures of the Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

15 Malunited Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535

16.8 Principles of Limb Lengthening and Deformity Correction

18.2.7 Postoperative Period

22 Foot and Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 969

23.4.3 Deformity Correction of the Proximal Femur Before

26.3 Sequential External Fixation and Nailing (SEFaN) (A.N. Chelnokov,

28.8 Transosseous Osteosynthesis in the Management

31.9 Stimulation of the Blood Circulation and Microcirculation by

Part III Supplementary Materials

34 External Fixation: a Brochure Containing

35 Method for the Definition of “Reference Positions”

Instead of the Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1569

Maxim Vasil’evich Andrianov, M.D., Ph.D. Department of Orthopedics, City Adult

Katsuhiro Hayashi, M.D., Ph.D. Department of Orthopedic Surgery, Graduate School

Oksana Germanovna Prudnikova, M.D., Ph.D. Department of Neurosurgery, Russian

Information concerning basic training in external fixation can be obtained at http://rniito.

1.1 Historical Background and Classiﬁcation

The first external fixator was described by the American J.

Table 1.1 Principal types of external fixation devices

II. Bilateral Charnley, Hoffmann, Vidal- 1. Built on through-and-through Steinmann pins or

Table 1.1 (continued)

Table 1.2 External fixation components set

2 Arches 3/4, Diameter (mm): 80, 100, 110,

3 Wire arches Radius (mm): 80, 100, 110,

4 Half-pin arches <or> 90°, 120°

5 Post: male Number of holes: 1, 2, 3, 4

6 Post: female Number of holes: 1, 2, 3, 4

7 Posts: female, Number of “holes”: 2, 3, 4

Table 1.2 (continued)

9 Connection Number of holes: 1 + 1, 1 + 2, 2 + 2

10 Connection Number of holes: 9, 11, 13, 15

11 Threaded rods Length (mm): 30, 60, 80, 100, 120,

12 Telescopic rods Length (mm): 100, 190, 220,

14 Sockets and Length (mm): 20, 40, 60

Table 1.2 (continued)

19 Console wires Intraosteal part length (mm):

20 Wire fixation Slotted; cannulated

22 Threaded rods- Length (mm): 40, 50, 60, 80, 100

24 Metaphyseal Diameter (D) 6 mm, length

25 Cortical Diameter (D) 6 mm, length (L)