ILIZAROV TECHNIQUE

PRESENTER: DR. NAVIN BALAJI R

MODERATOR: DR. PRABHU E SIR
 LESSON PLAN

 Name of the lecturer- Dr. Navin Balaji R

 Date-27/02/2024

 Time- 40 minutes

 Subject: Orthopaedics

 Topic- ILIZAROV TECHNIQUE

SPECIFIC LEARNING OBJECTIVES

At end of the class all participants should be able to know:

- History of invention of Ilizarov

- Principles of Ilizarov

- Components and procedure of application

- Indications

- Advantages and disadvantages

EXTERNAL FIXATORS

• A surgical procedure that stabilizes and joins the ends of fractured

bones by externally placed mechanical devices.

• EXTERNAL FIXATION is a safe, viable procedure to achieve

temporary rigid stabilization in patient with multiple injuries. On the
other hand, it is also a method for correcting skeletal deformities.
The 6 generations of external fixation are as
follows:
1.Unilateral
2.Uniplanar frames
3.Ring fixator
4.Articulated external fixator
5.Hexapod
6.Hybrid ring
1st GENERATION

• Unilateral external fixator are the first generations of external fixator.

These are the prototype models and are still in use today.
UNIPLANAR FRAMES – 2ND GEN
• Subject to cantilever bending
RING FIXATORS – 3RD GEN

• Ilizarov

• Superior biomechanically and implemented with improved results for

definitive care

• Allows axial micromotion

• Stable to angulation and rotation

• Good peri-articular fixation

 ARTICULATED EXTERNAL FIXATOR 4TH GEN

• Allow for joint range of motion

• Modified unilateral frame

• Tried to incorporate the benefits and versatility of

circular fixation with the ease of unilateral fixator design.

• Did not alter issues of bending, shear, and torque.

HEXA POD – 5TH GEN

• Taylor spatial frame (TSF)6

degrees of freedom (6 struts in
multi-planar configuration)

• Deformity correction

• Computer software to facilitate

correction
HYBRID RING- 6TH GEN
• Improved ease of use

• Mates the advantage of metaphyseal fixation with ease

of use of half pins

• Not biomechanically superior to full ring

• Combines the advantages of ring in periarticular areas

with simplicity of planar half pins in diaphysis

• Disadvantage of increased sheer secondary to half pin

use vs full circular ring frame

• Main advantage is for convenience

 HISTORY
• Professor Gavril Abramovich Ilizarov was

born in the Caucasus, in the Soviet Union in

1921.
• He was sent, without much orthopedic

training, to look after injured Russian soldiers

in Kurgan, Siberia in the 1950s.

• With no equipment he was confronted with
PROF. GABRIEL ABRAMOVITCH ILIZAROV
crippling conditions of unhealed, infected, and (1921-1992)

malaligned fractures.
• With the help of the local bicycle shop he devised ring
1954 published his first article
on Transosseous Osteosynthesis.
external fixators tensioned like the spokes of a bicycle.

With this equipment he achieved healing, realignment

and lengthening to a degree unheard of elsewhere.

• Accidently he found new bone formation

radiologically in a patient who turned compressing

rods between rings in distraction rather than

compression.
• He revolutionized the treatment of difficult

musculoskeletal problems.
Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics
PRINCIPLE
• Based on the principle "that growing bone changes its form and volume
according to external stimuli" (Wolff's law), Ilizarov subjected bone to continual
external tension in any direction, which can lengthen the bone or correct
deformities.

• Distraction osteohistiogenesis
• Mechanical induction of new bone formation
• Neovascularisation
• Stimuli of biosynthetic activity
• Activation and recruitment of osteoprogenitor cells
• Intramembranous ossification
Law of tension stress

 Ilizarov developed the law of tension-stress, which describes the process of

new bone and soft tissue regeneration under the effect of tension-stress caused
by slow and gradual distraction.
Biological principles of Ilizarov:

❑ Minimal disturbance of bone and soft tissues

❑ Delay before distraction
❑ Rate and rhythm of distraction
❑ Site of lengthening
❑ Stable fixation of the external fixator
❑ Functional use of the limb and intense physiotherapy.
 Distraction osteogenesis
■ Distraction osteogenesis, also called callus distraction, callotasis and
osteodistraction is a surgical process used to reconstruct skeletal deformities
and lengthen the long bones of the body.
■ A corticotomy is used to fracture the bone into two segments, and the two
bone ends of the bone are gradually moved apart during the distraction
phase, allowing new bone to form in the gap.
■ When the desired or possible length is reached, a consolidation phase follows in
which the bone is allowed to keep healing.
■ Distraction osteogenesis has the benefit of simultaneously increasing bone
length and the volume of surrounding soft tissues.
■ Distraction is done @ 1mm/day in four interval i.e. 0.25mm four times per day.
Histology

7 days -Fibrovascular network no mineralisation

14 days New bone formation over whole circumference
21 days New bone differentiates into micro columns
77 days -Osteogenic area remodelling to cortex
119 days -Lamellar bone with haversian system and haemopoietic marrow
Distraction – 1st week
• Tensile forces across the osteotomy site arrange proliferating
fibroblast into linear fibrils
• Fibrous interzone divides the regenerated bone in equal parts,
and it is rich in chondrocytes, fibroblast, and ovoid cell
morphologically intermediate between a fibroblast and
osteoblast
• The FIZ remains avascular during most part of the distraction,
after its completion, it is rapidly vascularized and mineralized
during the consolidation period
Distraction – 2nd week
• As the distraction gap increases the FIZ
remains 4-mm thick, and at the conclusion
of the process the FIZ is the last region to
ossify.
• Adjacent to the FIZ on either side is the
primary mineralization front (PMF), which
contains a high density of proliferating
osteoblasts.
Distraction – 3rd week
• These osteoblasts undergo primary mineralization
in regions of newly formed capillaries and vascular
sinuses, leading to the formation of columns of
bone resembling stalagmites and stalactities,
known as the zone of microcolumn formation
(MCF).
Post Distraction Consolidation
• When distraction ends the PMF advances from
each end toward the center, bridging the FIZ.
• Sequential mineralization of osteoid occurs during
the activation and especially during the
consolidation phase, starting within the
surrounding MCF, which then proceeds to bridge
the FIZ.
Remodelling
• During the consolidation period
mineralization of new bone is completed and
bony remodeling occurs resulting in the
formation of mature, lamellar bone with
marrow.
Distraction Osteogenesis
INSTRUMENTATION

• Primary components- elements used to correct skeletal deformities.

Eg- ring, wire, wire fixation bolt and buckles, pin and pin clamps.

• Secondary element component- necessary assembly of frame.

Eg- rods, plates, support, post, hinge, washer, sockets, bushing, bolts
and nuts.
Instruments used in ilizarov
 Rings - Principle component
• All rings are placed perpendicular to long axis of
bone.

• Made up of stainless steel or carbon fiber to bear

high stress (up to 150 kg)

• Internal diameter measures from 80- 240 mm.

• Function-Support transfixation of ilizarov, olive

wires and half pins

• Builds a fixator frame connecting two or more rings.

RINGS
• Holes in the ring used for introduction of threaded rod, a hinge or connector
plate.

• Two half ring can be connected to form full ring or oval ring.

• Five-eight ring facilitate joint motion and is commonly deployed near knee
and elbow joint.

• It also facilitate introduction of cross wires, distinct advantage near these joint.

• Omega rings is modified five-eight ring fits deltoid area of shoulder.

Arches

• Larger diameter than half rings.(290-

300mm)

• Multiple holes for use at the level of

proximal femur or humerus.

• Does not limit joint motion.

• Disadvantage: Wires inserted in fan like

pattern – Close to Sciatic nerve
Ilizarov wires

• Stainless steel of critical hardness and elasticity.

• Types-beaded and non-beaded.

• Trocar point- better directional hold when drilling cancellous bone

such as metaphysis and epiphysis.

• Bayonet point- better directional hold when drilling cortical bone such
as diaphysis.
Olive wires

• Metallic bead in wire.

Function:
- Interfragmentary compression
- Increasing stability of the construct
- Gradual distraction
- Translation of fragment
 Bolts
• Hexagonal head of 10mm

• Threaded shaft of 6mm diameter

• Pitch of thread is 1 mm

• Length of 10, 16, and 30 mm used.

• Have longitudinal holes or slot just below head to fix wires to the ring or other
components of the frame.

• It is use to connect the threaded socket and bushing through the rings, for connecting
plate, for fastening rods and half pins through socket aperture.
Bolts
• To achieve stability wire must be tensioned, by turning
2 wrenches simultaneously tension is applied on wire
as it wrap around the bolt.

• To obtain optimal stability each wire should be place

on top and bottom of each ring.

• Coupled effect avoids torque of each bone segment

fixed to the ring.

• Fixing the wire on the both surface also prevent

wrapping of the ring.
Nuts
• Diameter-6 mm

• Height- 6, 5 and 3 mm

• Pitch of thread-1mm

• 1 / 4th turn four times per day is

recommended distraction compression
rate.

• Turn of nut is used as driving force in

Ilizarov system.
NUTS

Function:

1. Tighten the connecting bolts

2. Stabilize the connecting rod

3. Tighten the wire fixation bolt

4. Act as driven force for the ring in a distraction-compression movement

5. Lock the socket and/or bushing onto a threaded rod

6. Affix the pulling wire of a distraction device

7. Achieve fixed positioning of a male support

8. Secure hinge clearance

9. Secure a gap on the threaded rod.

 Buckle

• Combine a plate with 2 fixed threaded

rod with two hole plate held together
with 2 nuts.

• A longitudinal groove hold a wire to ring

like a slotted bolt.

• Allow mechanical derotation or angular

correction.
Rods
• 6 mm thick stainless steel rod is main connector in the Ilizarov system.

• The threaded rods come in 10 lengths: 60, 80, 100, 120, 150, 200, 250, 300,
350 and 400 mm.

• 4 rods at equidistant are used to connect 2 neighboring rings.

• We can produce desired compression or distraction needed.

• Rods are machined so that thread causes 1mm translational along its
longitudinal axis with each complete 360 revolution of nut.
Partial views of three types of threaded rods. A, end of a standard threaded rod. B, end of a slotted threaded rod. 2 x 2-
mm slot extends the length of 20 threads. C, end of a cannulated threaded rod. A 2-mm aperture is drilled out at the top.
D, slotted threaded rod with an introduced K-wire. The K-wire must be bent 90 degrees and locked in by the two 5-mm
nuts. E, cannulated threaded rod with an introduced K-wire. To tension and affix the K-wire, it must be bent 90 degrees
and locked in by the nuts
RANCHO CUBES
• Used to fix pins to the ring
 Plates
• Use to reinforce ring fixator.

• Short plates used as extension of rings.

• Long plates used to reinforce large frames during bone fragment transport.

• Plates with threaded rod use to support a hinge as well as a frame.

• Twisted plates used to connect two components positioned at right angle to one
another.

• Curved plates used to increase circumference of half ring and connect two half
ring.
Telescopic rod
• The telescopic rods are the mainstays of ring connection in the original
Ilizarov set.

• Telescopic rods are used to connect arches and rings and are significantly
stiffer than threaded rods.

• Head has 2 holes- 1st for threaded rod. 2nd for bolt to lock rods.

• Provide stability when long distance spanning is required between rings

• Now hollow tube may contain slotted window with graduated metric
marking on one side.
SUPPORTS AND POSTS

• Type- male and female post.

• Male post-threaded projection fixed with nut.

• Female post- threaded hole fixed with bolt.

• Function-Third wire can be connected to post. Can also work as hinge.

Can be connected to other part of apparatus to provide additional
stability. Wire can be tensioned
 Hinge post
• Have supporting base with two flat surface matching the standard 10 mm
wrench

• Important function is correction of angulation.

• Type - male and female hinge post

Threaded socket & bushing
• The threaded rods can be reinforced
and lengthened by adding two types of
connectors: a threaded socket and a
bushing.

• Bushing is 12 mm long spacer with

smooth longitudinal hole that provide
free motion of threaded rod length
wise.
 Washers

• Washer use to raise a wire fixation bolt to the wire that does not sit directly on
ring.

• Types- simple, slotted and conical

• Slotted washer allow wire fixation on one side in special circumstances.

• Conical washer act as swivel for connecting rings or plates which are not
parallel.
Washers used in construction of the Ilizarov fixator. A, 1.5-mm washer. e, 2.0-mm washer. C, 2.o-mm "wide"
washer, used only for femoral arch-threaded rod interface. D, 3.o-mm washer. E, 4.o-mm washer. F, conical
washer-couple, used for positioning with angulation
Tensioners
• Used to tension wire to an exact force, thus improvising stability for entire
bone frame construct.
• Types- dynamometric and standard wire tensioner.
• Wire should be tensioned from 50-130 kg.
Amount of tensioning depends upon-
• Weight of patient
• Local bone quality
• Treatment plan
• Local frame construct
Standard wire tensioner not calibrated and cumbersome to use.
Dynamometric wire tensioner

• Rotate handle anti clockwise until

wire get inside

• Engage the fix jaw to the ring

• Rotate handle clockwise until

desired tension is achived.

• Tighten the nut at desired tension.

Assembly of circular fixator
• Major considerations-

- Stability of fixation of the frame to the bone.

- The prevention of gross bone fragment motion.

- Ability to manipulate bone and to perform necessary fragment movement such as

straightening, bending, distraction, compression, rotation and combination of these
movement.

• Construction of frame can be done in advance or during surgery.

Ring positioning

• Main proximal frame supporting ring it bears weight of entire construction. Located 3-5
cm away from joint.

• Stabilizing frame supporting ring- may be stationary or moveable. Located 3-5 cm away
from joint.

• Pushing pulling ring- moveable ring used for compression or distraction. Located 3-5 cm
distal to fracture- osteotomy-nonunion site.

• Reference ring- used as reference for supporting rings or distraction-compression rings.

It corresponds to apex of bone angulation.

• Correcting rings- used for application of special forces in transverse or oblique direction
for correcting deformities.
Spacing between skin and ring

• At the narrowest gap space of at least 3cm should be maintained between

inner curve of ring and skin.

• Achieved in 3 ways.

- Limb measured in 2 plane and largest diameter is considered. Add 6cm to

this diameter which provide you size of ring.

- Attach most anticipated size and seek a space of 3cm.

- Use plastic template.

Indications of Illizarov
■ In treating of bone infections
■ In Poliomyelitis Sequelae (in limb lengthening and correction of deformities)
■ In treating of malunited fractures and non-unions
■ Complex open and closed fracture of long bones
■ Intraarticular fracture
■ Comminuted fracture
■ Compound fracture
■ To correct deformities of the limbs, both congenital and acquired
■ In treating badly comminuted fractures (multiple fragments) in the limbs
■ Lengthening of limb stumps, foot stumps and fingers
■ To increase height
SAFE ZONES FOR TIBIA

Proximal part of the proximal tibia

The peroneal nerve runs posteriorly at the level of
the fibular head and curves anteriorly as it goes
caudal.
Transfixation
The medial and the lateral zones at the level of and
ventral to the fibular head are the only safe zones for
tibial transfixation.
Unilateral fixation
The anterior zone on both sides of the patellar
ligament is safe for unilateral fixation.
 Proximal third – distal of the tibial tuberosity

Distal to the tibial tuberosity only unilateral external

fixation is safe.
It is best to insert the pins where soft-tissue coverage
is minimal as the risk of pin track infection is
lowest.
Middle zone of the tibia

• The neurovascular bundle with the

anterior tibial artery and vein together
with the deep peroneal nerve are running
close to the posterolateral border of the
tibia.

• They are at risk if the pin is inserted in

the way indicated by the red dotted line.
 Distal zone of the tibia

• Percutaneous insertion of pins in this area is

dangerous. A minimal incision will allow preparation
and safe insertion.

• Pins at this level should be inserted as shown in the

illustration from anteromedial to posterolateral. A
second pin can be inserted from medial to
anterolateral, ventral to the fibula
 PROCEDURE
■ Wires of 1.5 mm or 1.8 mm diameter are passed percutaneously (through the
skin) through bones by means of a drill.
■ The protruding ends of these wires are then fixed to rings with special "wire-
fixation" bolts.
■ These rings in turn are connected and fixed to one another by threaded rods.
■ Once it is fixed, the Ilizarov frame affords a stable support to the affected limb.
■ A Corticotomy is then performed; it is an osteotomy (cutting the bone)
where the periosteum of the bone is preserved.
■ Adjustments in the rods produce compression or distraction as desired
between the bone ends, and simultaneously, deformities are also corrected.
■ The ring fixator is removed at the end of the treatment.
CORTICOTOMY
Cortical osteotomy with transection of only bone cortex ,preserving periosteum and
medullary canal.
Latency: Period after corticotomy and before bone distraction
For Children 3-5 days
For Young adolescent 5-7 days
F0r Adults and old people 7-10 days
Rate: 1mm/day bone surface distracted apart
Rhythm(Frequency of applied distraction):0.25mm four times a day
Removal of Apparatus

■ The x-rays must show at least three cortices; i.e. out of four cortices (anterior,
posterior, medial and lateral) in AP & lateral projections, at least three should
be fully ossified, with a sharp outline of the cortical bone.
■ Before removing the frame the patient may be administered a 'stress test‘ and
asked to use the limb in a functional manner ( weight bearing for the lower
limb and functional activities for the upper limb).
■ If the patient is able to do this the frame can then be removed with confidence.
COMPLICATIONS
Early complications:
• Vascular complications
• Neurological complications
• Comminuted fracture of osteotomized bone
• Local skin tightness
• Psychologic incompatibility
LATE COMPLICATIONS
• Pin site infection
• Pain at corticotomy site and during lengthening
• Soft tissue contractures and joint stiffness
• Osteoporosis
• Progression of angular deformity or creation of new one after fixator removal
• Limb swelling
• Non union or premature consolidation at lengthening site.
• Compartment syndrome
• Joint subluxation
Advantages

■ No skin incision is made as in a conventional operation. Incidents of

haemorrhage, tissue trauma and infection are much fewer.
■ Minimally invasive as only wires fix the bones to the rings and there is very
little soft tissue damage.
■ The Ilizarov fixator is very versatile; the cylindrical shape of the fixator allows
deformities to be corrected simultaneously in 3 dimensions.
• The patient remains mobile throughout the course of the treatment. Intensive
physiotherapy is instituted early; as a consequence, problems of joint
stiffness and contractures are rare.
• patient's stay in the hospital is considerably reduced.
• The advantages of using the Ilizarov fixator in fracture cases are:

1. Possibility of simultaneous anatomical reduction

2. Stable fixation by multiplanar direction with the K-wires
3. Introduction of olive stop wires for correction of deformities
4. Early functional treatment, including joint range of motion and weight bearing
5. Possibility of correction of the secondary displacement by the frame adjustment
6. Reinforcement of the frame with secondary displacement
7. Easy approach to the wound in case of compound fractures
Disadvantages
■ Mechanical
❑ Distraction of fracture site
❑ Inadequate immobilization
❑ Pin-bone interface failure
❑ Weight/bulk
❑ Refracture (pediatric femur)
■ Biologic
❑ Infection (pin track)
❑ Neurovascular injury
❑ Tethering of muscle
❑ Soft tissue contracture
REFERENCES

• Textbook of ILIZAROV SURGICAL TECHNIQUES Bone Correction

and Lengthening -VLADIMIR GOLYAKHOVSKY

• Elements of fracture fixation - AJ Thakur

THANK YOU

80