Knee Surg Sports Traumatol Arthrosc (2013) 21:1523–1529
DOI 10.1007/s00167-012-2074-7
KNEE
Gradual correction of idiopathic genu varum deformity
using the Ilizarov technique
Young Eun Park • Sang Heon Song •
Hyeok Nam Kwon • Mohamed Ahmed Refai •
Kwang Won Park • Hae Ryong Song
Received: 29 November 2011 / Accepted: 22 May 2012 / Published online: 4 June 2012
Ó Springer-Verlag 2012
Abstract
Purpose Proximal tibial osteotomy is an effective treat-
ment option for genu varum deformity among the many
other described techniques. The purpose of this study is to
evaluate the clinical and radiological outcomes and the
complications in gradual correction of idiopathic genu
varum deformity using Ilizarov frame.
Methods Proximal tibial medial opening wedge osteot-
omy was performed in 21 lower limbs of 11 patients, with
whom the Ilizarov external fixator was used for gradual
correction of the varus deformity. The mean age of the
patients was 24.8 years (SD, 5.3). Deformity measure-
ments of conventional mechanical axis deviation,
mechanical medial proximal tibial angle, mechanical lat-
eral distal femoral angle, posterior proximal tibial angle,
Young Eun Park and Sang Heon Song contributed equally to this
work.
Y. E. Park
S. H. Song
H. N. Kwon
M. A. Refai

K. W. Park
H. R. Song (&)
Department of Orthopaedic Surgery, Institute for Rare Diseases,
Korea University Medical Center, Guro Hospital,
80, Guro-Dong, Guro-Gu, Seoul 152-703, Korea
e-mail: songhae@korea.ac.kr
Y. E. Park
e-mail: joeundr@dreamwiz.com
S. H. Song
e-mail: ssclick@paran.com
H. N. Kwon
e-mail: staphyloc@hanmail.net
M. A. Refai
e-mail: m_refai74@yahoo.com
K. W. Park
e-mail: kwpark77@gmail.com
joint conversion angle, tibio-femoral angle and tibial slope
were compared.
Results The mean time for removal of the Ilizarov fixator
was 24.7 weeks. At the last follow-up, the mean of Hos-
pital for Special Surgery knee score increased, and the
mean mechanical medial proximal tibial angle, tibio-fem-
oral angle and conventional mechanical axis deviation
improved. The differences between preoperative and
postoperative posterior proximal tibial angle, mechanical
lateral distal femoral angle, joint conversion angle and
tibial slope were not significant. Ten complications were
observed, of which 8 were minor complications and 2 were
minor complications.
Conclusion With a few complications, normal alignment
and orientation of lower extremity can be established in
patients with idiopathic genu varum deformity through
gradual correction using a Ilizarov fixator.
Level of evidence Retrospective case series, Level IV.
Keywords Genu varum deformity
Proximal tibial
osteotomy
Gradual correction
External fixator
Introduction
Idiopathic genu varum is any residual genu varum after the
age of 7 years, without any underlying diseases, when
the medial malleoli of the ankle are placed in contact and
the distance between the knees is more than 5.0 cm [10].
Proximal tibial osteotomies can be effective in reducing
pain and delaying the need for knee arthroplasty [21]. The
biomechanical principle of proximal tibial osteotomies is to
distribute the forces acting across the knee [1]. After
proximal osteotomies, the mechanical axis is shifted lat-
erally, unloading the medial compartment of the knee.
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Medial opening wedge osteotomy can correct the tibial The pre-operative, immediate postoperative and the last
varus deformity either acute or gradual. In the former, the follow-up full-length standing anterior–posterior (AP) and
tibia is osteotomized, and the osteotomy is stabilized in the lateral radiographs were reviewed. The conventional
corrected position with some form of fixation such as an mechanical axis deviation (MAD-C) was measured as the
osteosynthesis plate and the gap filled with bone graft [13] distance between the centre of the knee and a line drawn
and synthetic augments such as hydroxyapatite [12] and from the centre of the femoral head to that of the heel. And
b-tricalcium phosphate [26, 27]. Once the deformity has the mechanical medial proximal tibial angle (mMPTA),
been corrected and stabilized, there is very little scope for mechanical lateral distal femoral angle (mLDFA), posterior
further correction if the position is suboptimal without proximal tibial angle (PPTA), joint conversion angle
recourse to further surgery [15]. There are also the poten- (JCA), tibio-femoral angle (TFA) and posterior tibial slope
tial complications of nerve palsy, malalignment, loss of (PTS) were measured on full-length lower extremity
alignment, limb length inequality, compartment syndrome, standing AP and lateral radiographs (Fig. 1). Two observers
failure of fixation, recurrence of deformity, donor site (YEP and SHS) independently measured radiological
complications of autogenous bone graft and the compli- values to test interobserver reliability for concurrence.
cations of allograft [7]. Furthermore, each observer reviewed the radiographs twice
Various external fixator such as unilateral fixator [2] and within a 3-week period to test intraobserver reliability for
Taylor spatial frame (TSF) [23] had been used to correct reproducibility.
varus deformities. An alternative technique is gradual
deformity correction by distraction osteogenesis using
Ilizarov external fixator, which allows accurate deformity
correction and has the potential to allow fine-tuning of the
correction without any further surgical intervention to
achieve an optimal reduction. Rotational malalignment and
limb length inequality can also be managed simultaneously
with the gradual angular deformity correction by the
Ilizarov external fixator [5].
The aim of this study was to evaluate the clinical,
radiological outcomes and the complications in gradual
correction of idiopathic genu varum deformity in young
adult using Ilizarov technique.

Materials and methods

The patients who underwent proximal tibial osteotomy and

gradual correction using the Ilizarov external fixator in
idiopathic genu varum deformity were retrospectively
investigated by one experienced paediatric surgeon after
receiving approval from the Institutional Review Board of
the respective hospital. Between 2004 and 2009, 30
patients underwent genu varum correction. The exclusion
criteria were as follows: post-traumatic genu varum (4
patients), achondroplasic patients (10 patients) and patients
who had marked arthritic changes in the medial compart-
ment of the knee (5 patients). So, 11 patients (21 segments)
were included in this study. Those patients had idiopathic
genu varum deformity for over 16 years at the time of
surgery and were treated by proximal tibial osteotomy
below the tibial tuberosity with gradual correction using
the Ilizarov external fixator. The mean age of the patients at
Fig. 1 Schematic diagram showing the techniques for determining
the time of surgery was 24.8 years (SD, 5.3). There were 8
mechanical lateral distal femoral angle (mLDFA), mechanical medial
males and 3 females. The mean duration of follow-up was proximal tibial angle (mMPTA), posterior proximal tibial angle
3.8 years (SD, 2.1). (PPTA), joint conversion angle (JCA) and posterior tibial slope (PTS)

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The ‘‘Hospital for Special Surgery’’ (HSS) knee scoring assessed using the Spearman’s rank correlation test and an
system was used for the clinical evaluation of the patients intraclass correlation coefficient.
pre- and postoperatively [9]. The duration of frame appli-
cation was reviewed, and complications were classified
into minor and major according to Paley classification [20]. Results
The major complications interfered with the original goals
of treatment and the minor did not. All 11 patients (21 segments) included in this study
achieved a correction without recurrence of genu varum
deformity (Fig. 2), and no limitation of functional activity
Surgical technique and postoperative protocol
was observed at the latest follow-up.
The mean time for union and removal of the external
The operative procedure was performed by one experi-
fixator frame was 24.7 weeks (SD, 6.1). At the last follow-
enced paediatric surgeon (HRS). The Ilizarov ring fixator
up, the mean of HSS score increased from 61.1 (SD, 3.3) to
was used for correction of all tibial deformities. The tibial
88.9 (SD, 5.4) (p \ 0.001) (Table 1). The intraobserver
frame consisted of three full rings placed at the proximal,
and interobserver reliability studies showed good reliability
middle, and distal tibia. The proximal ring was fixed with
of radiological measurements (with a correlation coeffi-
two wires and one or two half-pin, and the middle ring was
cient of between 0.86 and 0.90 and a p value = 0.02) in
fixed with two half-pins. The distal ring was fixed with one
this study. The mMPTA, MAD-C and TFA significantly
wire and one half-pin for monofocal osteotomy at the
improved. But the differences between preoperative and
proximal tibia. Paired lateral hinges were attached to the
postoperative PPTA, mLDFA, JCA and tibial slope were
proximal ring at the level of centre of rotation of angula-
not significant (Table 2). The alignment of 19 lower limbs
tion, and a single lengthening rod was placed opposite to
was normalized with varus angle less than 3°.
them. Each wire transfixed the proximal and distal tibio-
There were 10 complications, of which 8 were minor
fibular joints to prevent distal and proximal migration of
complications and 2 were major complications (Table 3).
the fibula, respectively. Construction of the external fixator
The minor complications were 5 pin tract infections of
did not include the ankle joint at initial surgery for the
grade 1 and 2. All pin tract infection responded well to
physiotherapy. The osteotomy was performed with multi-
local pin site care and oral antibiotics. The wire breakage
ple drill holes and an osteotome below the tibial tuberosity.
occurred in one segment in the consolidation stage, and this
Gradual correction and/or lengthening commenced after
wire was removed in the outpatient clinic without need to
7 days. The correction rate was determined as the ratio of
insertion of other wire as the regenerate was well consol-
the distance from the lateral hinge rod to medial cortex of
idated. 2 genu procurvatum deformities encountered during
the tibia and from the lateral hinge rod to the medial dis-
correction due to improper placement of the hinges, and
traction rod. The rate was adjusted accordingly via radio-
this problem was managed by replacement of the hinges
graphical callus features during follow-ups. Patients
and gradual correction without need to operative proce-
underwent daily supervised physiotherapy, including active
dures. The major complications were 1 compartment syn-
and passive range of motion of the knee and ankle begin-
drome immediately postoperatively and managed by
ning 2 days after the surgery. Physiotherapy was per-
fasciotomy without any residual effect. One insufficient
formed twice per day for 2 h during the 2 weeks of
callus formation required an additional allo-bone graft for
admission and 1 h per day after discharge until the end of
insufficient callus formation at postoperative 28 weeks. At
the correction phase. Removal of the fixator was done
the last follow-up, there were no patients with leg length
when 3 cortices of the regenerate showed corticalization on
discrepancy.
anteroposterior and lateral films. A long leg cast was
applied after the fixator removal and was removed
4–6 weeks after application.
Discussion

Statistical analysis
Statistical analyses were performed using the SPSS (SPSS
for Windows Release 15.0; SPSS Inc., Chicago, IL, USA).
The differences between preoperative and postoperative
measurements for MAD-C, mMPTA, PPTA, mLDFA,
JCA, TFA and PTS were compared using Mann–Whitney
test. Interobserver and intraobserver variability were
The most important finding of the present study was that
normal alignment and orientation of lower extremity could
be established, and also clinically pain was relieved, and
functional scores were improved in patients with idiopathic
genu varum deformity after gradual correction using a
Ilizarov fixator. The result of correction of mechanical axis
malalignment in this study was in agreement with Coogan
et al. [3] who reported mechanical axis malalignment

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1526 Knee Surg Sports Traumatol Arthrosc (2013) 21:1523–1529

Fig. 2 Standing full-length lower extremity radiographs of 22-year-old male. a Preoperative radiograph showing severe genu varum deformity.
b Radiograph taken during correction. c Radiograph taken after fixator removal showed markedly improved MAD-C after gradual correction

correction from 26° preoperative to 8° postoperative using Table 1 This is a summary of the mean of preoperative and post-
operative HSS (Hospital for Special Surgery) knee score
gradual correction by Ilizarov frame. Stanitski et al. [25]
reported correction of the mechanical axis deviation 27° Preoperative Postoperative p value
preoperative to 5° postoperative with gradual correction Pain
using Ilizarov technique, and all their patients rated as Walking 2.5 13.1 \0.05
having good results and pain free. Feldman et al. [4]
At rest 13.5 13.9 NS
reported that the angular correction was more accurate with
Function
the gradual correction group by TSF (100 %) than in the
Walk 5.7 10.9 \0.05
acute correction group by EBI external fixator (57.1 %).
Stairs 3.2 4.2 \0.05
Accuracy of correction is an important determinant for
Transfer 3.0 3.8 \0.05
the postoperative results and the longevity of pain relief
ROM 14.7 16.8 NS
[14]. Manual methods for preoperative planning in lower
Muscle strength 8.7 9.0 NS
limb deformity may have significant intraobserver vari-
Flexion deformity 8.8 9.3 NS
ability [6, 18]. Intraoperative assessment of the lower limb
Instability 8.3 9.5 NS
mechanical axis is always the most difficult step in tibial
Subtraction
osteotomies. Many techniques were used to assess the
Cane or crutch 0.8 0.2 \0.05
correction intraoperatively such as visual inspection and
cable method [14, 19]. All techniques of intraoperative Extension lag 0.1 0.1 NS
assessment of the lower limb mechanical axis ignore the Deformity 6.4 1.3 \0.05
effect of weight bearing on the mechanical axis [11]. Knee score 61.1 88.9 \0.05
Gradual correction of deformity using the Ilizarov fixation NS, non-significant

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Table 2 This is a summary of the mean values of preoperative,
postoperative, radiographical measurements with their corresponding
standard deviations and p values
Preoperative (SD) Postoperative (SD)
mMPTA (°) 72.4 (2.1) 90.1 (2.8)
mLDFA (°) 88.1 (2.0) 88.2 (2.7)
MAD-C (mm) Varus 28.3 (6.1) Varus 5.8 (2.1)
PPTA (°) 79.4 (3.2) 78.8 (3.1)
Tibial slope (°) 9.2 (1.1) 9.8 (1.3)
JCA (°) 1.1 (0.6) 0.8 (0.4)
TFA (°) 8.8 (2.7) 1.7 (1.4)
mMPTA, mechanical medial proximal tibial angle, mLDFA,
mechanical lateral distal femoral angle, MAD-C, conventional
mechanical axis deviation, PPTA, posterior proximal tibial angle,
JCA, joint conversion angle, TFA, tibio-femoral angle, SD, standard
deviation, NS, non-significant
decreases the intraoperative difficulty, as it enables accu-
rate correction postoperatively. It considers the effect of
weight bearing on the mechanical axis as the radiographs
were taken as standing full-length radiographs.
Open-wedge proximal tibial osteotomy using internal
fixation has complication rates ranging from 5.6 to 36 %
[8, 17]. Lateral cortex fractures reported by many authors
during acute correction of deformity due to oblique oste-
otomy directed to the lateral tibial condyle [17, 24]. Spahn
[24] reported 10 (11.8 %) such complications in his series.
Disruption of the lateral cortex during the medial opening
high tibial osteotomy results in marked instability at the
osteotomy site. This complication, if unrecognized or left
unaddressed, likely contributes to loss of angular correction
and delayed or non-union of the osteotomy [16]. To avoid
this complication, the external fixator, such as TSF [22, 23]
or Ilizarov frame [1], had been used. In this study, no lat-
eral cortex fracture occurred, as the osteotomy was directly
horizontal osteotomy. This osteotomy avoids violation of
the lateral cortex with sufficient bone stock proximal to the
osteotomy, which gives chance for more stable fixation of
the proximal fragment.
In this study, the change in the posterior tibial slope was
not significant. It was due to the high versatility of the
frame, which might be one of the main advantages of the
gradual correction. Any postoperative change in the
posterior tibial slope was controllable through a manipu-
lation of the position of the hinges and distractors as an
outpatient procedure that can adjust the correction without
p value the need of operative interference.
Use of the gradual correction by Ilizarov frame allowed
\0.05
mini-open osteotomy with surgical wound less than 3 cm.
NS
This could minimize the wound problems and postopera-
\0.05
tive haematoma and soft tissue dissection that are always of
NS
great concern for acute correction with internal fixation.
NS
Miller et al. [17] reported 2 haematomas, 4 infections and 9
NS
hardware failures occurred in their series of seventeen
\0.05
patients treated by medial opening wedge osteotomy. In
this study, there was no case of deep infection or postop-
erative haematoma, and also, there were no hardware left in
the patients after removal of the frame unlike the acute
correction. Initiation of early weight bearing and range of
motion exercises might be another advantage.
The major disadvantages of the methods done with an
Ilizarov apparatus include a long learning curve for the
surgeon, wire and pin tract infections, patient’s discomfort
of having to cope with a bulky circular ring fixator and the
potential risk of introducing deep infection. The overall
infection rate of this study was 23 %. This was consistent
with the 16–41 % infection rate reported by some series
doing deformity correction done by using external fixators
[1, 2]. The complication of pin tract infection during the
time of external fixation was successfully treated with
either oral antibiotic alone or in combination with wire
removal. Timely recognition of the pin tract infections and
good pin site care are crucial in preventing major infec-
tions. Patient education and close monitoring are essential,
making the postoperative course of the Ilizarov method
somewhat more burdensome for both the patient and the
physician.
The present study certainly has some limitations. Firstly,
it is a small retrospective series without control groups.
And secondly, even though 8 minor complications in this
study were easily controllable without disturbing the
treatment goals, the total complication rate including major
and minor in this study was almost 100 %. This might be
due to the small number of patients in this study, so a large
numbered prospective controlled study is needed to eval-
uate true major complications of this technique.

Table 3 Summary of the

Type Complication Number Treatment
complications encountered and
of cases
how they were managed
Minor complications Wire breakage 1 Wire removal
Pin track infection 5 Routine pin care, oral antibiotics
Procurvatum deformity 2 Adjustment of the frame
DBM, demineralized bone Major complications Compartment syndrome 1 Fasciotomy
matrix, PRP, platelet-rich Insufficient callus formation 1 Bone graft with DBM and PRP injection
plasma

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The results of this study may be of clinical relevance for
the treatment of idiopathic genu varum in young adults, as
the gradual correction using Ilizarov frame is clinically and
radiologically beneficial procedure when the appropriate
indications are chosen (e.g. patients with idiopathic genu
varum deformity with good cooperation and without
arthritic change). Moreover, gradual correction technique
allows early weight bearing and motion, and all deformed
components could be corrected with the aid of Ilizarov
frame without disturbing the posterior tibial slope or
extensor mechanism.
Conclusion
In conclusion, this study demonstrated that valgus-pro-
ducing proximal tibial osteotomy using Ilizarov is an
accurate and reliable technique for correction of idiopathic
genu varum deformity in young patients. Clinically HSS
knee score including pain and function was increased
postoperatively, and radiologically, mMPTA, MAD-C and
TFA were significantly improved postoperatively without
disturbing the posterior tibial slope. However, sufficient
preoperative discussions are needed with patients or their
care-givers regarding possible complications, since
patients’ acceptance and compliance with the frame could
be a problem.
Acknowledgments This study was supported by a grant of the
Korea Healthcare technology R&D Project, Ministry of Health &
Welfare, Republic of Korea (A110416).
Conflict of interest All authors report that there was no conflict of
interest.
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