Use of the Ilizarov Method to Correct Lower Limb

Deformities in Children and Adolescents

John G. Birch, MD, FRCSC, and Mikhail L. Samchukov, MD

Abstract
The introduction to the West in the early 1980s of the Ilizarov circular external fix- itations included the propensity to
ator and method resulted in rapid advances in limb lengthening, deformity correc- fracture and infection in the length-
tion, and segmental long-bone defect reconstruction. The mechanical features of and ened bone, which often prevented
biologic response to using distraction osteogenesis with the circular external fixator subsequent lengthening. These prob-
are the unique aspects of Ilizarov’s contribution. The most common indications for lems were sufficiently frequent that
children and adolescents are limb lengthening and angular deformity correction. authors such as Chandler et al,9 as re-
Surgical application and postoperative management of the device require diligent cently as 1988, stated that “Wagner
attention to detail by both patient and surgeon. Also required of the surgeon is a leg lengthening is generally recom-
thorough appreciation of the basic principles of the apparatus, mechanical axial re- mended when amputation is the only
alignment, potential complications, and biologic response to stretching. other surgical alternative and a full,
J Am Acad Orthop Surg 2004;12:144-154 complete informed consent is given
to the parents and patient.” Howev-
er, the application of Ilizarov’s meth-
od of low-energy osteotomy with
Codivilla1 is credited with the earli- tions are twofold. First is the design minimal soft-tissue injury and incre-
est description of limb lengthening. of the apparatus, a circular ring fix- mental distraction of fracture callus
He applied acute episodic traction of ator secured to bone by crossed, ten- after a latency period, in conjunction
up to 75 kg to the osteotomized fe- sioned wires. Second is the method, with Wagner’s monolateral external
mur through plaster encasing the which consists of low-energy osteot- fixator, has resulted in fewer soft-
lower limb, using a large nail through omy (corticotomy) with gradual in- tissue complications, better new bone
the calcaneus. He claimed that the cremental distraction of a fracture cal- formation, and only a rare need for
“…best results are obtained from lus after a latency period (callotasis).
forced lengthening, practiced under The importance of the application
narcotics; by using a sudden and in- of the Ilizarov limb-lengthening
tense force; and by then applying the method can best be appreciated by Dr. Birch is Professor, Department of Orthopedic
plaster apparatus to the limb while comparing the results of limb length- Surgery, University of Texas Southwestern Med-
ical Center at Dallas, and Assistant Chief of Staff,
it is still maintained in complete ex- ening using his concepts with those
Texas Scottish Rite Hospital for Children, Dallas,
tension.” Codivilla reported length- of others, especially Wagner.6 Wag- TX. Dr. Samchukov is Assistant Professor, De-
ening of 3 to 8 cm with this technique. ner’s technique included bone fixa- partment of Orthopedic Surgery, University of
Subsequent contributors to the devel- tion with heavy Schanz screws, os- Texas Southwestern Medical Center at Dallas, and
opment of the technique include Put- teotomy with resection of fascial Director of Research, Department of Orthopedics,
Texas Scottish Rite Hospital for Children.
ti (a student of Codivilla), Coleman, tissue and acute intraoperative
Wagner, and, most recently, De Bas- lengthening of 1 cm or more, and Dr. Birch and Dr. Samchukov or the departments
tiani and Ilizarov.2-7 gradual continued lengthening at a with which they are affiliated have received roy-
Ilizarov’s concepts have signifi- rate of 1 to 2 mm per day. This was alties from Encore Orthopaedics.
cantly advanced the fields of limb followed by a second surgical proce-
Reprint requests: Dr. Birch, Texas Scottish Rite
lengthening and deformity correc- dure to graft the distraction gap with
Hospital for Children, 2222 Welborn Street, Dal-
tion. English-language publications iliac crest bone and bridge it with a las, TX 75219.
by Ilizarov first appeared in 1989,3,4 special plate. Finally, plate removal
but Ilizarov had begun using his tech- required another procedure. In addi- Copyright 2004 by the American Academy of
niques in the former Soviet Union in tion to the multiple procedures re- Orthopaedic Surgeons.
the late 1940s.8 Ilizarov’s contribu- quired by the Wagner method, lim-

144 Journal of the American Academy of Orthopaedic Surgeons

 Use of the Ilizarov Method to Correct Lower Limb Deformities in Children and Adolescents
bone grafting and internal fixation.10
These results also suggest that, al-
though the method of lengthening is
important, the external fixation de-
vice used may be less critical.
Indications for Use
The Ilizarov apparatus and method
may be used for angular deformity
correction; upper and lower limb
lengthening; segmental bone trans-
port to replace bone defects second-
ary to tumor, infection, or trauma
(Fig. 1); soft-tissue contracture correc-
tion (eg, with congenital knee flexion
contracture, clubfeet) (Fig. 2); or in
unique applications in which exter-
nal bone fixation and limb segment
manipulation are required. Although
comminuted periarticular fractures,
such as tibial plateau or pilon frac-
tures, may be amenable to manage-
ment with the Ilizarov apparatus,
such injuries are exceptionally rare in
children. Therefore, initial fracture
management can be achieved by sim-
pler, more conventional means. The
most common applications of the
Ilizarov apparatus and method in
children and adolescents are for
lower-limb lengthening and deformi-
ty correction.
An advantage of the Ilizarov ap-
paratus over monolateral fixators for
limb lengthening is the ability to
gradually correct angular or rotation-
al deformities by adjusting the con-
figuration of the frame without use
of anesthetic. Also, the Ilizarov appa-
ratus allows fixation to extend be-
yond the segment undergoing length-
ening (ie, below the knee during
femoral lengthening, or across the an-
kle during tibial lengthening) to sta-
bilize the adjacent joint or improve
fixation. Because of its complexity, ap-
plication of the Ilizarov apparatus for
deformity correction and limb length-
ening requires intimate familiarity
with the device, the surgical applica-
tion technique, and the postoperative
management protocol. However, the
Vol 12, No 3, May/June 2004
complexity of the application of the
device should appropriately reflect
the complexity of the clinical problem
it is intended to correct.
Ilizarov Apparatus and
Method
Frame Fixation
The Ilizarov apparatus has three ma-
jor components: bone fixation elements
(ie, wires, half-pins); external support-
ing elements (ie, rings, arches); and
connecting elements (ie, rods, plates,
hinges) to connect the rings and arches
and to allow manipulation of the re-
lationship between them (Fig. 3).
Ilizarov used crossed, tensioned
wires exclusively to fix his apparatus
to the bone, thinking that the axial
flexibility of the fine wires was impor-
tant to the overall outcome of limb de-
formity correction and lengthening.
Most surgeons now use a combina-
tion of wires and half-pins (ie, hybrid
fixation) to stabilize bone segments Figure 1 Anteroposterior radiograph of a
6-year-old boy demonstrating application of
because half-pins are potentially eas- the Ilizarov apparatus for bone transport to
ier to insert without injury to neu- reconstruct segmental tibial bone loss after
rovascular structures. Half-pins also fracture. The apparatus holds the limb to
length while the oblique olive wires internal-
can reduce soft-tissue impingement ly lengthen the transported bone fragment.
by less transfixation of the soft-tissue
compartments. Crossed, tensioned
wires still have distinct advantages
when bone is osteopenic or when ble the fixation. Large angular correc-
very prolonged fixation is anticipat- tions in patients with stiff soft tissues
ed (eg, extensive lengthenings). The or osteopenic bone require stable fix-
surgeon must tailor the bone fixation ation of the bone fragments. Howev-
method according to the local bone er, it also can be important to have fix-
condition and individual preference. ation closer to the osteotomy for limb
The following principles of bone seg- lengthening. Fixing the bone frag-
ment fixation should be noted.11,12 ments near the joints (away from the
1. The selection of wires and/or osteotomy) sacrifices some bending
half-pins and their orientation must stability, creating the possibility of an-
balance the need for stable bone frag- gular deformity developing during
ment fixation, with the goals of lengthening.
minimizing both their soft-tissue en- 3. In theory, two wires oriented at
croachment and the risk of neurovas- 90° to each other and tensioned to 90
cular injury on insertion. to 130 kg provide optimum stability
2. Stable fixation of each bone frag- per ring when wires alone are used
ment is essential for control of bend- for bone fixation. In practice, this ori-
ing moments. The greater the distance entation frequently must be modified
between the fixation elements on a to accommodate soft-tissue struc-
given bone fragment, the more sta- tures.
145
John G. Birch, MD, FRCSC, and Mikhail L. Samchukov, MD

Figure 2 Use of the Ilizarov apparatus in a 2-year-old girl to extend the knee in multiple pterygium syndrome. A, Preoperative appearance
of the knee. B, Appearance after application of the pediatric Ilizarov apparatus and straightening of the knee through the joint (without
osteotomy). (Courtesy of C. E. Johnston II, MD, Dallas, TX.)

4. Paired wires forming an angle
<90° resist bending when oriented
along the acute angle axis of the wires,
but they poorly resist bending when
oriented along the obtuse angle (Fig.
4). Half-pins (ideally oriented in the
plane of bending) should be consid-
ered when large bending moments
are anticipated. For correction of knee
flexion or extension deformities, half-
pin fixation of the distal fragment
usually provides better stability
against the anticipated bending mo-
ments (Fig. 3).
5. External supporting elements
(ie, rings, arches) should be oriented
perpendicular to the mechanical axis
of the bone segment. To prevent
either eccentric pressure at the bone-
wire/half-pin interface or undesir-
able bone displacement after osteot-
omy, wires and half-pins should not
be bent when secured to the rings and
arches.

Distraction Protocol
Both Ilizarov5,8 and De Bastiani et
al2,13 described gradual distraction ei-
ther of the physis (ie, chondrodiasta-
sis, distraction epiphysiolysis) or of
the fracture callus that develops be-
tween bone fragments (ie, callotasis).
The fracture callus develops during
the latency period after a low-energy
osteotomy (corticotomy), which pre-
serves the soft tissue and medullary
tissue. Although Ilizarov thought that
preservation of the intramedullary
blood supply was desirable, subse-
quent work suggests that minimizing
periosteal and soft-tissue devitaliza-
tion is more important than preser-
vation of the intramedullary ar-
tery.14,15 Ideally, there should be
minimal displacement of the bone
Figure 3 Intraoperative photograph of the Ilizarov apparatus. The fundamental components fragments after osteotomy. However,
are bone fixation elements (ie, wires [A], half-pins [B]), external supporting elements (ie, rings successful lengthening of fracture cal-
[C], arches [D]), and connecting elements (ie, rods [E], plates, hinges). Because they provide lus after acute intraoperative correc-
better bending resistance, oblique half-pins (B) are indicated when significant anteroposte-
rior bending forces at the knee are anticipated. Compare with Figure 4. tion of milder angular deformities is
preferred by some.16

146 Journal of the American Academy of Orthopaedic Surgeons

 Use of the Ilizarov Method to Correct Lower Limb Deformities in Children and Adolescents
Figure 4 Two wires oriented at a <90° an-
gle on a ring resist bending relatively well
along the axis bisecting their acute angle (hor-
izontal arrows), but poorly along the obtuse
angle axis (vertical arrows).
The 3- to 21-day latency allows
development of fracture callus at the
site of corticotomy. This is followed
by the distraction period, which
continues until achievement of the
desired amount of lengthening or
the maximal amount attainable sec-
ondary to soft-tissue constraints. Af-
ter lengthening, the limb remains in
the external fixator until adequate
consolidation of the new bone has
occurred. Typically, the consolida-
tion period is approximately twice
the distraction period. Because
lengthening usually is done at an
average rate of 1 mm per day, total
time in the traditional apparatus is
approximately 1 month per centime-
ter of lengthening. The regenerate
bone that forms in the distraction
gap usually will consolidate and re-
model without the need for supple-
mental bone graft or internal fixa-
tion, and with minimal risk of
infection. In addition to being ad-
vantageous in individual sessions of
limb lengthening, these favorable
responses allow the surgeon to con-
sider repeated lengthening of the
same limb segment, which in turn
makes staged reconstruction of sig-
nificant limb-length inequality pos-
sible (Fig. 5).
Vol 12, No 3, May/June 2004
Effect of Gradual Lengthening
on Tissues
The impact of lengthening on bone
and soft tissues is probably more im-
portant than the choice of external fix-
ator or the precise method of length-
ening used. Ilizarov extensively
studied the effect of stretching on
bone and soft tissues3-5,8 and termed
the tissue response to gradual stretch-
ing the tension-stress effect.4 In gen-
eral, tension created by gradual dis-
traction stimulates the formation of
new bone, skin, blood vessels, periph-
eral nerves, and muscle.
Experimental data suggest that a
continuous distraction of 1 mm per
day leads to maximal new bone for-
mation in the distraction gap. For
practical purposes, this total daily dis-
traction has been divided into four
0.25-mm increments. Histologic ex-
amination of the distraction gap in an-
imals shows the development of
dense, longitudinally arranged col-
lagen bundles with no cartilaginous
tissue evident (Fig. 6). Some authors
have described cartilage tissue in the
distraction gap, but most have ob-
served primarily intramembranous
ossification in experimental animal
models.17,18
Although new bone formation is
the most identifiable and dramatic ef-
fect of limb lengthening, it is the im-
pact of lengthening on the soft tissues
and articular surfaces that dictates the
ultimate function of the lengthened
limb. In 1904, Codivilla stated that
“[w]e are in fact, without the requi-
site knowledge as to how the normal
muscles and other tissues act, when
subjected to forced distension; [as
well] as to how great an extent they
are capable of being lengthened,
without their physiologic action be-
ing altered.…”1 The observations
made by Putti in 1934 are still true:
“My experience with bone lengthen-
ing since the Great War has empha-
sized in my own mind that one must
give much study to the muscular and
ligamentous structures attached to
the femur, as the handling of these
structures in my opinion presents the
greatest difficulty encountered in ob-
Figure 5 A, Antero-
posterior radiograph of
the femur in a 12-year-
old boy at fixator remov-
al after 6-cm lengthen-
ing. B, Appearance of
same femur 2 years lat-
er, after repeat fixator
application and early
distraction.
147
John G. Birch, MD, FRCSC, and Mikhail L. Samchukov, MD
Figure 6 Histologic appearance of gap tis-
sue during lengthening in a goat model. The
gap tissue is characterized by dense longitu-
dinally arranged bundles of collagen. (Repro-
duced with permission from Samchukov ML,
Cope JB, Cherkashin AM: Biologic founda-
tion, in Rudolph P, Pendill J, Stein D [eds]:
Craniofacial Distraction Osteogenesis. St. Lou-
is, MO: Mosby, 2001, p 24.)
taining a successful result.”19
The response of muscle to gradu-
al lengthening also has been studied.
Sun et al20 observed myofibrillogen-
esis, primarily near the myotendi-
nous junction, while Matano et al21 re-
ported that the average sarcomere
length increased initially with stretch
but then decreased. These data sug-
gest that skeletal muscle does indeed
add sarcomeres in response to grad-
ual stretching. Clinically, the thresh-
old of soft-tissue tolerance to gradu-
al lengthening is often limited to 15%
to 20% of the original length of the
lower limb segment; lengthenings
greater than this amount may be as-
sociated with a higher incidence of
complications.22,23
Articular cartilage appears to in-
cur only negative effects from length-
ening of adjacent bone. Shevtsov and
Asonova24 noted severe degenerative
changes in the knee directly related
to the duration of immobilization in
an Ilizarov apparatus in an animal
model. Stanitski and colleagues25,26
148
reported gross cartilage fibrillation
and loss of proteoglycan staining in
the knees of dogs that had 30% fem-
oral lengthening. However, the au-
thors noted that when the apparatus
was extended across the knee, these
changes could be ameliorated, pre-
sumably by preventing joint com-
pression during lengthening.
Lower Extremity Leg
Lengthening
Comprehensive management of
limb-length inequality requires eval-
uation of the presenting discrepancy
and limb function, identification of
the etiology of the deformity, an un-
derstanding of the normal growth of
the lower limb, and the ability to es-
timate the ultimate discrepancy at
skeletal maturity as well as to appro-
priately guide the patient and fam-
ily in selecting the ideal treatment
method.
Impact of Leg-Length Inequality
Asymptomatic leg-length inequal-
ity is relatively common in the pedi-
atric population.27,28 Although it
seems intuitive that leg-length ine-
quality would produce deleterious
long-term effects on the lumbar spine
and lower extremity joints, firm ev-
idence for this assumption is lacking
in the literature. In a gait analysis
study of 35 children with leg-length
inequality, Song et al29 could not pre-
dict the use of compensatory mech-
anisms (eg, circumduction, increased
long-limb flexion, toe-walking) based
on absolute limb-length inequality, al-
though they could make a prediction
based on percentage of shortening.
Discrepancies of <3% were not asso-
ciated with the adoption of compen-
satory mechanisms. When discrepan-
cies exceeded 5.5% (approximately 4
cm in a 50th-percentile, skeletally ma-
ture male), more mechanical work
was done by the longer leg, with
greater vertical displacement of the
center of body mass. Therefore, leg
Journal of the American Academy of Orthopaedic Surgeons
lengthening often is considered when
limb-length inequality is estimated to
be 4 cm or more at skeletal maturity.
However, no absolute indications for
lengthening can be set because of the
higher rate of complications associ-
ated with lengthening compared with
other treatment modalities (ie, shoe
lift, epiphysiodesis, acute surgical
shortening). Lengthening usually is
done when the expected shortening
at skeletal maturity approaches 10%
(8 cm) because attempts to correct dis-
crepancies of this magnitude by
shortening procedures may result in
unacceptably reduced stature or, in
the case of acute shortening proce-
dures, excessive muscle weakness.30
Angular deformities that require cor-
rection and are associated with any
amount of shortening are a relative
indication for limb lengthening.
Assessment of Lower Limb
Leg-Length Inequality
Many congenital and acquired ab-
normalities may result in leg-length
inequality in children. Congenital
causes of inequality that may result
in the need for limb lengthening in-
clude congenital femoral deficiency,
fibular deficiency, tibial hemimelia,
hemiatrophy disorders (eg, Silver-
Russell syndrome), and hemimy-
elomeningocele. Acquired causes in-
clude physeal growth disturbance
from fracture, infection, irradiation,
and tumor (eg, osteochondromatosis,
enchondromatosis, unicameral bone
cyst); infantile or adolescent Blount’s
disease; fracture malunion; or global
growth deceleration in association
with melorheostosis, congenital club-
foot deformity, or congenital pseudar-
throsis of the tibia.
In addition to the actual limb-length
inequality, clinical assessment should
include documentation of lower ex-
tremity joint range of motion; limb
alignment; and vascular, soft-tissue,
and neuromuscular status. A simple
and effective estimation of leg-length
inequality can be made by having the
patient stand on graduated blocks
 Use of the Ilizarov Method to Correct Lower Limb Deformities in Children and Adolescents
placed under the shorter leg until the
pelvis is level. Watching the child walk
or run gives the examiner some sense
of the impact of deformity or leg-length
inequality on lower-limb function and
the adoption of compensatory strat-
egies. Radiographic assessment can
be made with either scanogram or
computed tomography scanogram.
The latter is more accurate and desir-
able when the patient has joint defor-
mities such as flexion contracture of
the hip or knee or is immobilized in
a circular fixator.
Timing of Lengthening
Procedures
Whenever leg-length inequality is
10% or less of the contralateral limb,
lengthening can be delayed until skel-
etal maturity unless limb function is
compromised. Delaying lengthening
avoids the risk of subsequent growth
disturbance and allows more precise
estimation of the amount of length-
ening required. If greater discrepan-
cy is anticipated, lengthening can be
combined with appropriately timed
contralateral epiphysiodesis. Alterna-
tively, staged lengthenings, each in-
volving 15% to 20% of the bone seg-
ment, can be initiated as soon as the
child can be an active participant.
Angular deformity correction
combined with lengthening should
be done in skeletally immature pa-
tients whenever functional or cosmet-
ic complaints require. This index pro-
cedure also can be combined with
epiphysiodesis of the affected extrem-
ity, contralateral epiphysiodesis, or
secondary lengthening at skeletal ma-
turity if the amount of growth re-
maining in the contralateral physes
warrants this consideration.
Aftercare
As soon as is feasible, the patient
is mobilized with weight bearing as
tolerated. Most pediatric patients
need crutches or a walker and often
rely on a wheelchair for long distanc-
es or to attend school when prolonged
reconstructive procedures are neces-
Vol 12, No 3, May/June 2004
sary. Range-of-motion exercises are
begun as soon as possible. Particular
emphasis is placed on maintaining as
much flexibility as possible and pre-
venting contractures that can lead to
joint subluxation (ie, hip adduction,
hip flexion, knee flexion). Pin sites
should be kept clean, and the soft tis-
sues around them stabilized to min-
imize tissue necrosis. Exact protocols
vary widely; one example is daily
showering after the fifth postopera-
tive day, with cleansing of all pin sites
with a cotton swab and sterile saline.
Distraction begins 5 to 7 days af-
ter surgery and continues until the
desired correction has been achieved.
During that time the patient is as-
sessed clinically and radiographical-
ly every 2 weeks. Monthly assessment
is adequate during the consolidation
period; after consolidation, the appa-
ratus is removed under general an-
esthetic, and a splint or cast is applied
to the limb for 3 weeks. Figure 7 Normal frontal plane axial align-
ment. The mechanical axis (MA) is 0° to 1°.
The angle between the mechanical axis and
the transverse axis of the knee (TAK) is 87°
at the lateral distal femur (mechanical lateral
Lower Extremity Angular distal femoral angle) and 87° at the medial
Deformity Correction proximal tibia (mechanical medial proximal
tibial angle). The angle between the mechan-
Etiology and Assessment ical axis and the transverse axis of the ankle
(TAA) is 90°.
The etiology of most lower extrem-
ity angular deformities in the pedi-
atric population can be readily deter-
mined from patient history and tibial angle) is 5° to 7° valgus; it is
physical examination. The rest can slightly higher in skeletally mature fe-
easily be diagnosed with radiograph- males than males. In the frontal plane,
ic studies. A 36-inch standing radio- the normal angle between the me-
graph of the lower extremities with chanical axis and the transverse axis
the hips, knees, and ankles visible is of the knee at the distal femur is ap-
best for the quantification of lower ex- proximately 87°. The angle between
tremity alignment. Lateral radio- the axis of the tibia and the tibial ar-
graphs are obtained to assess sagit- ticular surface (medial proximal tib-
tal and oblique plane deformities. ia–mechanical axis angle) is usually
Coexisting limb-length inequality is 87° proximally and 90° distally.
assessed by having the patient stand Careful analysis of the mechanical
on blocks to level the pelvis or by ob- axis and joint relationships in a child
taining a scanogram. with a long-standing, presumably
The mechanical axis is typically a isolated deformity of one lower limb
straight line (±1°) from the center of segment often reveals the presence of
the femoral head through the middle subtle, usually compensatory, defor-
of the knee to the middle of the dis- mity in the adjacent bone segment
tal tibial articular surface (Fig. 7). The (Fig. 8).31 In such cases, complete cor-
normal anatomic axis (ie, femoral- rection of one deformity will unmask
149
John G. Birch, MD, FRCSC, and Mikhail L. Samchukov, MD

formity should be considered inde- wedge, combined opening and clos-

Figure 8 Anteroposterior radiograph of a
16-year-old girl with midshaft femoral varus
deformity from malunion that has been par-
tially compensated by spontaneous develop-
ment of distal femoral valgus deformity.
pendently. If the secondary deformity
is sufficiently severe to warrant cor-
rection, both should be done, either
simultaneously or in a staged fash-
ion. Any deformity clinically or radio-
graphically subtle enough to be of no
concern to the patient for which cor-
rection would not normally be done
is left uncorrected, and the primary
deformity is then undercorrected.
Principles
Ideally, angular deformity correc-
tion by osteotomy should be done at
the level of the apex of the deformity.
Such correction is not difficult when
the apex of deformity is in the me-
taphysis or diaphysis of a long bone.
Either a closing or opening wedge os-
teotomy can be made at the level of
deformity, with the desired angular
deformity correction and internal or
external fixation method preferred by
the surgeon. With the Ilizarov appa-
ratus, the direction and distance of
the hinge location from the actual in-
tersection point of the fragment axes
determines whether the hinge func-
tions as a closing wedge, an opening
ing wedges, an opening wedge with
lengthening, or an opening wedge
with horizontal translation hinge
(Figs. 9 and 10). Compression of in-
tact bone is very poorly tolerated by
patients; therefore, opening wedge,
opening wedge with lengthening, or
opening wedge with translation hing-
es are almost always used.
In angular deformities acquired
during childhood, the apex of defor-
mity often is at the level of the phy-
sis or epiphysis, where osteotomy
usually is not advisable. When ana-
tomic reasons necessitate osteotomy
at a level remote to the apex of an-
gular deformity (typically in the ad-
jacent metaphysis), then, in addition
to angular correction, translation of
the distal fragment must be done to
restore the anatomic axis. If angular
correction alone is performed at a lev-
el remote to the level of deformity, a
translational deformity of the me-
chanical axis will result (Fig. 11). An-
gular deformity correction with frag-
ment translation is most easily
accomplished with external fixation
and gradual correction, with the hing-

a more subtle compensatory one.

However, if the deformity is correct-
ed until the limb appears clinically
straight, offsetting residual deformi-
ties can leave the intervening joint
maloriented to the mechanical axis.
Complete correction to anatomic nor-
malcy in such cases may require a
two-level osteotomy—a significant
surgical intervention. It is not clear
what degree of deformity is sufficient
to warrant a two-bone, two-level os-
teotomy or, alternatively, how much
angular deformity of the bone or joint
obliquity can be left untreated with-
out long-term detriment to the
patient.32-34 No clinical longitudinal
studies establish a clear threshold of Figure 9 Placement of hinges at the apex of the deformity may result in closing wedge (A),
deformity above which degenerative a combination of closing and opening wedges (B), opening wedge (C), or opening wedge
arthritis or other limb function im- with lengthening (D) angular deformity correction. Clinically, only opening wedge config-
urations are tolerated by the patient.
pairment is to be expected. Each de-

150 Journal of the American Academy of Orthopaedic Surgeons

 Use of the Ilizarov Method to Correct Lower Limb Deformities in Children and Adolescents
Figure 10 A, The intersection of the me-
chanical axes of the proximal (a) and distal
(b) fragments is proximal to the level of in-
tended osteotomy. B, Hinge placement at the
level of the osteotomy allows angular defor-
mity correction, but with residual translation
of the distal mechanical axis (c) relative to that
of the proximal segment (d).
es located to effect the needed trans-
lation. A pair of hinges with co-
aligned axes of rotation placed on the
line bisecting the angle of intersection
of the proximal and distal bone-
segment mechanical axes will effect
the proper translation to normalize
the limb-segment mechanical axis
(Fig. 10).
External fixation of corrective an-
gular osteotomies with the Ilizarov
apparatus has several theoretical ad-
vantages. The amount of soft-tissue
dissection is typically less, and the
risk of infection is less, than with the
use of internal fixation; postoperative
adjustment of correction can be done
without difficulty or need for an an-
esthetic; bone fragment translation to
restore the mechanical axis is easier;
and angular deformity correction can
be combined with lengthening as de-
sired. Disadvantages of angular de-
formity correction using external fix-
ation include possibly longer healing
time, slower mobilization, potential-
Vol 12, No 3, May/June 2004
ly more complex surgery with the ap-
plication of the device, and the need
postoperatively for patient accep-
tance and compliance.
The basic surgical principles of an-
gular deformity correction with ex-
ternal fixation include orienting the
device components perpendicular to
the mechanical axis of the bone seg-
ments and locating the axis of hinge
rotation along the line bisecting the
angular deformity at a location effect-
ing opening wedge correction. Cor-
rection may be done acutely or grad-
ually.16 Subsequent lengthening of the
limb through the osteotomy site can
be done with callotasis.
Complications
Sofield et al35 evaluated the long-term
function of 40 patients who had un-
dergone lengthening and reported
that “we cannot escape the funda-
mental concept that improved func-
tion, not just increased length, is the
objective, and that these terms are not
synonymous.” Although use of the
Ilizarov method has markedly im-
proved the short-term results of limb
lengthening and reduced the frequen-
cy of complications, the complication
rate is still high, and long-term assess-
ments of the impact of lengthening
by this method are lacking. The in-
cidence of complications associated
with gradual leg lengthening has
been reported to be as infrequent as
14% and as high as 134% (ie, more
than one complication for each bone
segment lengthened).22,36-41 These
widely divergent reports reflect dif-
ferences in the definition of “compli-
cation” adopted by different authors.
Any surgeon undertaking lengthen-
ing must be thoroughly versed in the
myriad complications that can arise.
Neurovascular Injury
Nerve or major vessel injury can
occur perioperatively by direct inju-
ry during fixation or in association
with postoperative compartment syn-
Figure 11 Same deformity as in Figure 10.
A, Hinge placement along the line (a) bisect-
ing the intersection of the axes of the prox-
imal (b) and distal (c) bone segments corrects
angular deformity while preserving the
mechanical axis by fragment translation.
B, Opening wedge deformity correction with
restoration of the mechanical axis of the
limb.
drome. Injury can occur secondarily
during lengthening because of exces-
sive distraction or impingement of
nerves or vessels against wires or
half-pins. Although rare, permanent
nerve injury from leg lengthening can
occur.
Incomplete Corticotomy
Incomplete corticotomy may result
from osteotomy with limited soft-
tissue stripping and exposure. When
the patient begins distraction, tension
develops at all wire/half-pin and
bone interfaces, leading to increasing
global limb pain. Early radiographs
show bending of the fixation elements
without distraction of the osteotomy
site. Sudden spontaneous completion
of the osteotomy, if it occurs, results
in acute distraction with severe pain.
Premature Consolidation
Consolidation of the new bone
may result if the rate of distraction is
inadequate to maintain continued
fragment separation or if the patient
151
John G. Birch, MD, FRCSC, and Mikhail L. Samchukov, MD
is noncompliant with the distraction
prescription. The clinical scenario will
be similar to that of incomplete cor-
ticotomy after a period of lengthen-
ing.
Poor Regenerate Bone
Formation
Poor regenerate bone formation is
a troublesome complication because
it may lead to prolonged time in the
fixator and creates a higher risk of re-
generate bone fracture or bending.
Poor new bone formation may be not-
ed throughout the lengthened gap, or
there may be a localized defect (Fig.
12). Poor regenerate bone may result
from too short a latency period, too-
rapid distraction, or poor local blood
supply.
Joint Subluxation
Joint subluxation is a serious com-
plication that can permanently jeop-
ardize the function of the affected
limb. The hip and knee are at risk dur-
ing femoral lengthening. Although
subluxation of the knee has been re-
ported during tibial lengthening, it is
exceedingly rare. Ankle equinous
contractures are frequent during and
after tibial lengthening, but true sub-
luxation or dislocation is seldom re-
ported. Subluxation may occur when
the lengthening exceeds soft-tissue
tolerance; when lengthening contin-
ues despite the development of con-
tractures, especially hip flexion or ad-
duction and knee flexion; or when
lengthening is done without correc-
tion of joint dysplasia or instability.
Development of prevention strat-
egies is critical during the planning
stage. Acetabular dysplasia should be
reconstructed by appropriate osteot-
omy before lengthening. Exercises to
maintain hip abduction and extension
and knee extension must be per-
formed daily. Regular clinical exam-
ination on a weekly or biweekly
basis is needed to identify the devel-
opment of hip flexion and adduction
or knee flexion contractures that pre-
dispose to subluxation. If such con-
152
tractures develop, lengthening must
be stopped or reversed. Vigorous
physical therapy with the goal of re-
storing motion must be instituted. If
the subluxation does not respond
promptly to such treatment, the joint
can be reduced by extending the ap-
paratus across the affected joint with
gradual reduction of the deformity. A
major advantage of the Ilizarov ap-
paratus is that it is readily adaptable
to therapeutic or prophylactic stabi-
lization of the at-risk joint by extend-
ing the external fixation beyond that
joint. Even with successful treatment
of joint subluxation, permanent loss
of range of motion often results.
Pin Site Infection
Local soft-tissue irritation and low-
grade pin site infection are common
with external fixation. In most pa-
tients, irritation and infection can be
managed by careful avoidance of ten-
sion on the soft tissue at the time of
wire/half-pin placement, compres-
sive dressings around pin sites where
Journal of the American Academy of Orthopaedic Surgeons
Figure 12 A, Antero-
posterior radiograph of
a focal fibrous defect in
the regenerate bone col-
umn of a 14-year-old girl
after removal of the
lengthening apparatus.
A defect in the regener-
ate bone column is vis-
ible on the medial side.
B, One year later, the de-
fect has filled in, but
mild varus deformity is
evident.
they are subjected to movement dur-
ing therapy, and intermittent oral an-
tibiotics. Although rare, deep infec-
tion or ring sequestra should be
suspected when there is persistent in-
fection or drainage after wire or half-
pin removal.
Regenerate Fracture
The regenerate bone column is
subject to bending and compressive
stress generated by the resistance of
the soft tissues to lengthening. Grad-
ual bending or acute fracture after the
removal of the external fixator are de-
moralizing events that occur in 10%
to 15% of patients. Although the bone
typically heals very rapidly after such
a fracture, regenerate fracture usual-
ly results in loss of length or the de-
velopment of angular deformity.
Growth Disturbance of the
Lengthened Limb
Deceleration of expected growth
or development of deformity after leg
lengthening in skeletally immature
 Use of the Ilizarov Method to Correct Lower Limb Deformities in Children and Adolescents
patients is reported frequently.23,42-45
Presumably, these are responses to in-
creased pressure across physes after
lengthening or to hyperemia as an in-
direct consequence of increased blood
flow to the limb during lengthening.
When possible, if the discrepancy is
<7 cm and if limb function will not
be impaired by the delay, leg length-
ening should be postponed until skel-
etal maturity.
Psychological Stress
Prolonged management protocols
and chronic pain, even if mild or
moderate, can cause significant psy-
chological stress for both the child
and parents. Pediatric patients often
have sleep disturbance, have trouble
maintaining schoolwork, and may
lose weight during the active phases
of lengthening. Preoperative assess-
ment by a clinical psychologist to
identify areas of family stress and to
provide counseling to families is very
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Results
Several published studies address
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