Vol. 21, No.
6 June 1999 V 20TH ANNIVERSARY
CE Refereed Peer Review
FOCAL POINT
★Circular external fixation using
the Ilizarov method is a novel
surgical option for correcting
angular limb deformities and
lengthening deformed bones
of companion animals.
KEY FACTS
■ The Ilizarov circular external
fixation method involves placing
rings around the limbs; the rings
are fixed to the bone with wires
that are 1- to 1.5-mm in diameter
and under 0 to 90 kg of tension.
■ Joint malformations (except joint
subluxations) and degenerative
joint disease secondary to growth
deformities cannot be corrected
with circular external fixators
(CEFs); growth deformities
should be treated before irrevers-
ible joint damage occurs.
■ Mild angular deformities with
length deficits can be treated
with CEFs; severe angular
deformities are ideally treated
with hinged CEFs.
■ Following a delay of 2 to 7
days after osteotomy, the site
is distracted 0.5 to 2 mm daily,
in two to four steps, until the
deformity is corrected 2 to 8
weeks later.
Treating Bone
Deformities with
Circular External
Skeletal Fixation
North Carolina State University
Denis J. Marcellin-Little, DEDV
ABSTRACT: The Ilizarov method of circular external fixation has remarkable benefits in treat-
ing bone deformities. It relies on unique external fixation devices and distraction osteogenesis.
Rings placed around the limbs are interconnected with threaded rods and fixed to the bone
using small-diameter wires under tension. The angle and distance between rings can be
changed, leading to change in the shape of the bone. With distraction osteogenesis, new bone
forms at the osteotomy site when it is slowly distracted after surgery.
L
imb deformities in dogs are most frequently caused by abnormal bone
growth but can also be a consequence of fracture malunion, joint contrac-
ture, or polyarthritis. Abnormal bone growth may be secondary to physeal
injuries, dwarfism, hypertrophic osteodystrophy, multiple cartilaginous exos-
toses, or hyperparathyroidism.1–4 The most common angular limb deformities
are antebrachial, representing 0.74% of all bone problems.5 Limb deformities in
cats are rare. Tarsal hyperextension and torsion have been reported in kittens,6
but the prevalence, cause, and pathogenesis of these problems are unknown.
Bone deformities of the tarsus, carpus, and extremities also occur in Scottish-fold
cats with osteodystrophy.7
Conventional treatment options for limb deformities include conservative
management8; physeal resection with fat grafting9; physeal stapling10; transverse,
oblique, cuneiform, or dome osteotomies (transsection of bone)8,11; ostectomies
(removal of a fragment of bone) with or without fat grafting12,13; and stabiliza-
tion with external coaptation,8,11 bone plates,14 or conventional external fixa-
tors.15,16 The major drawback of all of these methods is that the shape of the
bone cannot be changed after surgery. Limb alignment is determined while the
patient is anesthetized and not bearing weight, making the cosmetic and func-
tional results of surgery less predictable. Because bone shape and length are set at
the time of surgery, additional surgeries may be necessary to treat incomplete de-
formity corrections and recurrent deformities in growing dogs. To address this
issue, adjustable fixation techniques have been attempted, with bone movement
made possible by the use of rubber bands or adjustable connecting bars on exter-
nal fixators.17–20 The results of these methods have been unpredictable.19
Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

Circular external fixators (CEFs) represent a new
surgical method for treating bone deformities in hu-
mans and companion animals.21–23 CEFs are also called
ring fixators, fine-wire fixators, or Ilizarov fixators (in
honor of the surgeon who developed their application
method and popularized their use in humans in the
Soviet Union in the 1950s).24 Originally developed for
fracture repair, the use of CEFs in treating bone defor-
mities has increased over time. Ilizarov introduced sev-
eral unique concepts: (1) Bone fixation is provided by
small-diameter wires that are under tension and con-
nected to rings surrounding the limbs; (2) rings con-
nected by articulated threaded rods can be assembled
in unlimited configurations; and (3) the bone can be
gradually distracted after osteotomy, and bone healing
will occur within the resulting gap—a phenomenon
called distraction osteogenesis. The combination of dis-
traction osteogenesis and the limitless geometric flexi-
bility of CEFs allows bone deformities to be corrected
progressively and precisely in a few weeks after surgical
placement of the frame and osteotomy of the de-
formed bone. This article presents the applications of
CEFs in treating limb deformities in companion ani-
mals.
DIAGNOSIS AND TREATMENT PLANNING
Classification of Bone Deformities
A precise understanding of the pathologic process is
necessary to treat bone deformities using CEFs. Bone
deformities may be classified as unifocal (i.e., abnormal
bone shape in one location; Figure 1) or multifocal
(i.e., abnormal bone shape in multiple locations; Figure
2). Unifocal deformities are common in dogs and in-
clude premature physeal closures in the first few weeks
after physeal injury as well as fracture malunions. Uni-
focal deformities originate at the intersection of two
lines representing the center of the long axis of the
proximal and distal parts of the limb (Figure 1). Prema-
ture physeal closures of a single bone (e.g., femur) or
paired bones (e.g., radius and ulna) as well as mal-
unions are treated with corrective osteotomy of the af-
fected bones. In puppies with significant remaining
growth potential, premature physeal closures of one
paired bone (e.g., ulna) are treated with ostectomy of
the restricting bone (e.g., ulnar ostectomy). After a few
weeks of growth, premature physeal closures of paired
bones often become multifocal deformities when the
bone with less growth potential impairs growth of the
bone with more growth potential. Multifocal deformi-
ties also result from metabolic
bone diseases and chondrodys-
plastic dwarfism. Multifocal de-
formities are treated with correc-
tive osteotomies of the affected
bones.

Components of
Bone Deformities
Bone deformities have several
components, including angula-
tion, length deficit, rotation,
and translation. It is important
to identify and specifically treat
each of these components.

Angulation
Angulation can be measured
on both the animal and radio-
graphs. Angular deformities may
be overestimated if measured on
a weightbearing limb because
the deformity may cause joint
Figure 1A Figure 1B Figure 1C
instability. Angular deformities
Figure 1—(A) Craniocaudal and (B) mediolateral radiographic views of the antebrachium measured on radiographs may
of (C) an 11-month-old Siberian husky with a malunion secondary to an untreated Salter be underestimated if linear trac-
II fracture of the distal radial physis. A unifocal bone deformity is visible. Two lines are tion is placed on the extremities
drawn on the radiographs, in the center of the paw and in the center of the antebrachium. (e.g., by taping the foot). Angu-
These lines intersect at the distal radial physis, which is the origin of the deformity.
lation can be measured on ra-

CIRCULAR EXTERNAL FIXATORS ■ ILIZAROV ■ PREMATURE PHYSEAL CLOSURES

Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

diographs by comparing lines drawn in the center of
the proximal and distal parts of the normal and affected
limbs (Figure 1).
The general alignment of the limb should be evaluat-
ed in the medial-to-lateral (ML) and cranial-to-caudal
(CC) directions. Most deformities have ML and CC
components, which means that most deformed bones
are angled in a valgus or varus direction and are bowed.
As a general rule, the ML component of the deformity
is more critical than is the CC component because, un-
like the hip and shoulder joints, distal joints move only
in the CC direction. Within limits, a dog with a bowed
radius can correct for the deformity by flexing or ex-
tending its elbow or carpus, but a dog with a valgus de-
formity of the carpus cannot adjust the position of its
limb to compensate. However, these compensations
only partially correct angular deformities.
Length Deficit
The length deficit present in a deformed bone should
be determined by comparing the lengths of affected
and opposite limbs on ML and CC radiographic pro-
jections. The ML radiographic view is often more use-
ful than the CC view because the limb is more likely to
be parallel to the radiographic cassette with the ML
view. If both limbs are abnormal, a littermate may be
used for comparison. In antebrachial growth deformi-
ties, the length deficit of both the radius and ulna
should be measured; the length deficit is generally larg-
er in the bone that had the original growth problem.
When radiographs taken at different times are available,
length deficit should be measured for each time because
variations can help indicate the cause of deformity.
When angulation is present in a limb, the functional
length of the limb is less than the anatomic length of all
bone segments.
Rotation
Rotation of a deformed limb should be determined
during the orthopedic examination by comparing the
directions of the planes defined by flexion and exten-
sion of the joint above and below the deformity (Figure
3). Rotation cannot be reliably determined radiographi-
cally.
Translation
Translation within a bone is the displacement of a
bone segment in relation to the rest of that bone per-
pendicular to the long axis. Translation may be present
in the absence of angulation or rotation, creating an S-
shaped bone. Although rare in animals, translation may
be present in fracture malunion or nonunion.

Figure 3—Determination of the

rotational deformity of a bone in
a 6-month-old Boston terrier.
Comparing the plane of flexion
and extension of the proximal
joint (A) with the plane of flex-
ion and extension of the distal
Figure 2A Figure 2B Figure 2C
joint and extremity (B) deter-
Figure 2—(A) Craniocaudal and (B) mediolateral radiographic views of the antebrachium of mines the degree of rotation of a
(C) a 6-month-old Irish wolfhound with a bilaterally abnormal distal ulnar physeal growth. A limb segment. This dog has 65˚
multifocal bone deformity is present; the radius is curved throughout its length. of external rotation (arrow).

LIMB ALIGNMENT ■ COMPENSATION ■ ANTEBRACHIAL GROWTH DEFORMITIES

Small Animal/Exotics
Indications for Circular
External Fixation
In my experience, the indica-
tions for using CEFs to treat
bone deformities are (1) a length
deficit of 20% or more, (2) pre-
mature physeal closure in pup-
pies with significant growth po-
tential (with the exception of
premature closure of the distal
ulnar physis treated with ulnar
ostectomy), or (3) joint subluxa-
tion of 3 mm or more without Figure 4A
degenerative joint disease. An-
gular deformities of 20˚ or more
without a length deficit or joint
subluxation may be treated with
CEFs, plates, or conventional
external fixation. CEFs are rare-
ly used to treat dogs with de-
formed limbs with subluxated
joints and severe degenerative
joint disease. Severely abnormal Figure 4B
joints are likely to remain pain-
ful, and therefore limb function
may not improve after surgery.
GENERAL PRINCIPLES OF
THE ILIZAROV METHOD
Frame Structure
Several CEF systems are com-
mercially available.22 The cost of
frames ranges from $250 to
$500, depending on size and
complexity. CEFs should have
at least four rings and span the
entire length of each bone seg-
ment. Rings should be placed at
the proximal metaphysis, 5 to
10 mm proximal to the osteoto-
my site, 5 to 10 mm distal to the
osteotomy site, and at the distal
metaphysis. Two transosseous
wires are placed on each ring,
one wire above and one below
the ring. Ideally, wires should be
placed at a 90˚ (but not less than
45˚) angle to one another, meet
near the center of the bone, and
always avoid neurovascular bun-
dles.
Tension should be applied to
the wires using wire tensioners.
COST ■ WIRE DIAMETERS ■ TENSION ■ OLIVE WIRES
20TH ANNIVERSARY
Figure 4—Standard circular external fixator for treat-
ment of bone deformity. (A) A severe, multifocal,
antebrachial deformity is present in a 1-year-old
mixed-breed dog. (B) A two-ring standard fixator to the short bone segment. Spe-
has been placed with acute correction of angular and cialized wires with a larger di-
rotational deformities.
Figure 5A Figure 5B
Figure 5—(A) Circular external fixator with hemi-
spheric washer for treatment of a tibial fracture. A
three-ring frame is secured to the tibia with four
wires proximally and two wires and a half-pin distal-
ly. (B) Hemispheric washers are placed between the
connecting rods and the distal ring to allow angula-
tion of the ring in relation to the rods.
Compendium June 1999
A dynamometric tensioner (Small
Bone Fixator; Hofmann S.a.S.,
Monza, Italy) is optimal because
it has graduations that corre-
spond to wire tension. In dogs
weighing less than 5 kg, 1-mm
(diameter) wires are used with-
out tension. In 5- to 10-kg dogs,
1-mm wires are used with 20 to
30 kg of tension. In 10- to 20-
kg dogs, 1.2-mm wires are used
with 30 to 50 kg of tension. In
dogs weighing more than 20 kg,
1.5-mm wires are used with 60
to 90 kg of tension.25 To avoid
frame deformation, tension on
wires fixed to posts and partial
rings should not exceed 30 kg.
When the osteotomy site is in
the metaphysis and the space is
too limited to place two rings, a
single ring may be used. A third
wire connected to a post or an
end-threaded half-pin connect-
ed to a cube should be added to
enhance the stability of fixation
ameter ball at their midpoint
(called olive wires) may also be
used. These wires prevent trans-
lation of the bone segment in
relation to the wires. Incom-
plete rings may be used to
avoid interfering with the
joint’s range of motion (ROM);
the rings are interconnected
with three or four connecting
rods, depending on the size of
the patient. Hinges or hemi-
spheric washers may be used to
place rings at an angle to each
other.
Surgical Placement
of the Frame
Several methods have been
used to treat bone deformities
with CEFs, including standard
circular external fixation, hemi-
spheric washer fixation, hinged
circular external fixation, and
push constructs. When stan-
Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

dard CEFs are used with or with- and the stress placed on the
out hemispheric washers (Fig- frame. In my experience, post-
ures 4 and 5), the angular and operative limb function after
rotational deformity is corrected standard external fixation is
acutely during surgery and not as good as with hinged fix-
frame adjustments are limited ation; studies show that an ad-
to lengthening or longitudinal ditional surgery was needed in
displacement of bone. When 29% to 67% of dogs treated
lengthening is performed with- with this method. 29–31 In a
out angular correction, distrac- study of 38 dogs, the clinical
tion occurs at the connecting results were considered to be
rods separating the rings above good or excellent in 68% of
and below the osteotomy site; dogs.29
these rods are called linear mo- Figure 6A Figure 6B
tors of distraction or simply lin- Hemispheric Washer
ear motors. Angular correction Fixation
and lengthening are both per- Hemispheric washers can be
formed progressively after sur- used to assemble CEF frames.
gery when using hinged CEFs Using this method, the con-
(Figures 6 and 7) or push con- necting rods do not have to be
structs (Figure 8). perpendicular to the rings (Fig-
ure 5). A ring is placed at an
Standard Circular angle perpendicular to the long
External Fixation axis of both the proximal and
In standard circular external distal parts of the deformed
fixation, the frame is built dur- limb, an osteotomy is per-
ing surgery. The most proximal formed, and the deformity is
and distal rings are attached corrected acutely. Adjusting the
perpendicular to the proximal hemispheric washers minimizes
and distal parts of the deformed the osteotomy gap and helps
bone, respectively. Osteotomy is Figure 6C maintain limb alignment. Al-
then performed. Rotational and Figure 6—Hinged circular external fixation for treat- though this method is rapid, its
angular deformities are correct- ment of a forelimb deformity in a 7-month-old male use should be limited to mod-
ed acutely (Figure 4). Connect- Australian shepherd dog. (A) Preoperatively, a valgus erate deformities because the
ing rods and additional rings deformity, cranial bowing, and a length deficit are connecting rods can only be
present. (B) A three-ring, hinged circular external fix-
are placed. When necessary, pro- ator was placed and a radial osteotomy was per- angled by 6˚ using the Imex
gressive lengthening is started formed. A partial ring has been used proximally to Circular External Fixator Sys-
after a delay of 2 to 3 days at a avoid restricting the range of movement of the elbow tem (Imex Veterinary Inc.,
rate of 1 to 2 mm daily divided joint. (C) After 9 days of correction, the osteotomy Longview, TX) or 12˚ using
in two to four increments.26–28 site is distracted to lengthen the bone and the angular Hofmann’s Small Bone Fixator
Standard circular external fix- deformity is corrected. System. As with standard cir-
ation requires limited preopera- cular external fixation, length-
tive planning and is simple to perform because ring ening is begun after a delay of 2 to 3 days at a rate of 1
placement is based on visual estimation of the limb to 2 mm daily divided in two to four increments.
shape. However, this method has several disadvantages
compared with hinged fixation. It is more traumatic Hinged Circular External Fixation
than is hinged fixation because the periosteum has to Hinged CEFs have two connecting rods with a
be transected or elevated beyond the osteotomy site to strategically placed hinge (Figure 6). The angular defor-
allow immediate movement at the site. In addition, the mity is corrected when the limb pivots around the
immediate realignment of the distal part of the limb in hinge. A connecting rod called the angular motor of dis-
relation to the proximal part results in limited contact traction or angular motor allows progressive correction
between proximal and distal bone segments; this un- of the deformity (Figures 6 and 7). The frame is pre-
even osteotomy gap may increase bone-healing time assembled so that the rings are placed at an angle corre-

LINEAR MOTORS OF DISTRACTION ■ PROGRESSIVE LENGTHENING ■ OSTEOTOMY GAP

Small Animal/Exotics 20TH ANNIVERSARY
Figure 7A Figure 7B
Figure 7—Hinged frame with two sets of hinges for treatment of
(A) a multifocal bone deformity in a 1-year-old dog. (B) A
three-ring circular external fixator with two sets of hinges is
fixed to the radius with a combination of wires and half-pins to
treat a varus deformity of the radial midshaft, a valgus deformity
of the distal radius, and a length deficit.
sponding to the amount of deformity. The line joining
the hinges is perpendicular to the direction of the de-
formity and tangential to the bone at the level of the
origin of the deformity. With this particular hinge
placement, the deformity is corrected in CC and ML
directions simultaneously and progressively after sur-
gery.28 If the deformity is a combination of valgus and
cranial bowing, the hinge will be at the craniomedial
aspect of the bone and both components of the defor-
mity will be corrected when the frame pivots around
the hinge’s axis.
Although mathematic equations can be used to de-
termine frame structure, in practice I use graphic meth-
ods to prepare the frame before surgery.28 During sur-
gery, the preassembled frame is placed around the limb.
The wires are placed and secured to the proximal and
distal rings. An osteotomy of the bone is performed
with an oscillating saw or osteotome. The rotational
component of the deformity is corrected acutely by dis-
connecting the two hinged connecting rods and the an-
gular motor from the distal ring, rotating the distal ring
by a predetermined number of holes, and reconnecting
it to the connecting rods. Angular correction and
PREPARING THE FRAME ■ WOUND MANAGEMENT ■ PHYSIOTHERAPY
Compendium June 1999
lengthening are both initiated 2 to 3 days after surgery
at a rate of 1 to 2 mm daily divided in two to four in-
crements.
Hinged CEFs may include several sets of hinges to
treat multifocal deformities. Each set is placed at the
origin of the deformity, and correction is performed
with separate angular motors (Figure 7). The results of
using hinged CEFs to treat limb deformities have been
fair to excellent. In a series of eight treatments in seven
dogs with antebrachial deformities using hinged CEFs,
postoperative limb function and cosmesis were good to
excellent, with mean residual deformities of 2.7˚ and
2.7% of bone length (mean deformities before surgery
were 32˚ and 12%).28 Treatment duration ranged from
29 to 71 days. The dogs spent 4 to 6 days in the hospi-
tal in the perioperative period, and owners did most of
the adjustments at home. Owner errors leading to clini-
cal problems did not occur.
Push Constructs
Push constructs are sometimes used to treat multifo-
cal bone deformities. The frames include two full rings
separated by two half rings (Figure 8). An angular mo-
tor joins the two full rings on the concave aspect of the
bone. An osteotomy is performed in the midsection of
the bone. The deformity is corrected progressively by
increasing the length of the angular motor and “push-
ing” the two half rings. Push constructs have been used
successfully in large dogs32 but are, however, cumber-
some and complex to manage.
POSTOPERATIVE CARE AND
DEFORMITY CORRECTION
Pain medications (e.g., oxymorphone or carprofen)
are given during and shortly after surgery. Triple antibi-
otic ointment is placed at the wire–skin interface im-
mediately after surgery and is reapplied daily. Gauze
sponges are loosely packed under the rings, and the
frame is wrapped to secure the sponges. This bandage is
changed daily for 3 to 5 days. After this time, wound
management is limited to the application of triple an-
tibiotic ointment and a wrap or sleeve around the
frame. The limb is not bandaged to avoid interfering
with weightbearing.
Physiotherapy starts on the day after surgery and
continues as long as postoperative limb edema is pres-
ent or the dog is not able to bear its full weight. Physio-
therapy includes massaging the swollen extremity with
gentle finger strokes in a distal to proximal direction,
applying a hot pack, and performing passive ROM ex-
ercises of the joints above and below the frame. Outside
activity is limited to leash walks, but low-impact exer-
cises (e.g., climbing steps or indoor play with a ball) are
Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

encouraged to stimulate the use of I distract the osteotomy site by 1

the affected limb. Owners of dogs mm daily as a baseline for limb
in which bone lengthening of more lengthening. I increase this amount
than 10% of bone length is planned to 2 mm daily in large dogs
are instructed to recognize early younger than 6 months of age that
signs of contracture of the flexor have undergone metaphyseal os-
muscles (e.g., reluctance to bear teotomies. I decrease this amount
weight, loss of ROM when extend- to 0.5 mm daily when contracture
ing the joint). If flexor contracture of the flexors is developing.
occurs, the distraction rate is de- When progressive angular correc-
creased and exercise and physical tion with hinged CEFs is per-
therapy are increased. formed without lengthening, an
In dogs, frame adjustments for opening wedge is created at the
correcting angular deformities and transcortex (from the hinge) with-
lengthening are started after a delay out bone displacement at the cis-
of 0 to 10 days.19,27,33–35 In my expe- cortex. The angular motor is ad-
rience, a delay of 2 to 3 days before justed so that the displacement of
distraction of metaphyseal deformi- the transcortex is 1 mm daily. This
ties is ideal in medium to large dogs amount is increased to 2 mm daily
younger than 1 year of age.28 This Figure 8A in large-breed puppies that have
delay should be increased in smaller undergone metaphyseal osteotomies.
or older dogs, when the osteotomy When lengthening and angular cor-
is diaphyseal, 35 or when an acute rection are combined, the overall
correction of the angular deformity distraction rate in large-breed pup-
is performed. pies with metaphyseal osteotomies
The original distraction rate is is 1.6 mm divided evenly between
0.25 mm every 6 hours.36 Because lengthening (0.8 mm) and angular
this rate may lead to premature distraction (0.8 mm at the transcor-
union of the distracted bone in im- tex).
mature, large-breed dogs,28 it may The optimal distraction frequen-
be adjusted if an increase or de- cy (i.e., the number of times the
crease of the osteogenic potential of frame is adjusted daily) is unknown.
the bone is suspected. Factors influ- Ilizarov found that the greater the
encing bone healing during distrac- frequency, the better the outcome
tion include the age of the dog, size would be. 40 Welch, however,
of the bone, location of the osteoto- showed that a higher frequency did
my, and proposed amount of not enhance the biologic nature
lengthening. Dogs younger than 6 and mechanic strength of the new
months of age heal faster than do bone.41 Many surgeons in Europe
older dogs.29 Large bones appear to recommend four adjustments daily.
heal faster than do small bones, per- Figure 8B Surgeons in North America gener-
haps because the blood supply of Figure 8—(A) Mediolateral radiograph of the ally recommend two adjustments
smaller bones is less than that of antebrachium of (B) a 9-month-old Great daily because most owners do not
larger bones and less vascular bones Dane with a forelimb deformity. A push have the opportunity to adjust the
heal slower. 37,38 Metaphyseal os- construct is used to correct the caudal defor- frame in the middle of the day. I
teotomies heal faster than do dia- mity (cranial bowing). (From Thommasini have had good clinical results ad-
physeal osteotomies.35 The distrac- MD, Betts CW: Use of the “Ilizarov” exter- justing frames twice daily.28 With
tion rate is decreased when a large nal fixator in a dog. Vet Comp Orthop Trau- antebrachial deformities, elbow
amount of lengthening is required matol 4(3):70–76, 1991. Reproduced with joint subluxation can be corrected
permission.)
to let soft tissue adapt to the trac- by displacing the ulna in relation to
tion placed during lengthening.28 the radius. I start these adjustments
Experimentally, daily distraction rates ranging from immediately after surgery at the rate of 0.5 mm twice
0.5 to 2 mm have led to bone formation.39 In practice, daily.

FLEXOR CONTRACTURE ■ DISTRACTION RATE ■ DISTRACTION FREQUENCY

 Compendium June 1999
ENDIU
MP
M’
20th

CO
S

1 9 7
9 - 1
9 9 9
ANNIVERSARY
A LookBack
The common bone growth
deformities in dogs were described
in the 1960s and 1970s. At that
time, the bone stabilization
options after corrective osteotomies
were limited to plate or
rudimentary external fixation.
Gavriil Ilizarov, MD,
popularized circular external
fixation in the 1950s in Siberia.
His method, however, was not
made available to treat pets at
that time. Antonio Ferretti, a
veterinarian from Milan, Italy,
first introduced the Ilizarov
method and the use of ring
fixators in veterinary medicine in
1984. Over the years, specific
frames and surgical methods were
designed to treat companion
animals. Through publications,
seminars, and courses, thousands
of veterinarians have been
exposed to the Ilizarov method
over the years. The method is
now used by a growing number
of veterinarians worldwide.
Without a doubt, the most
dramatic enhancement that the
Ilizarov method has brought to
the treatment of limb deformities
in humans and animals is the
ability to design a treatment
based on specific geometric
anomalies. Angulation, rotation,
translation, and particularly
length can now be corrected
progressively after surgery.
RADIOGRAPHY ■ FRAME REMOVAL ■ SURGICAL TECHNIQUE ERRORS
20TH ANNIVERSARY
Radiographs are obtain-
ed every 7 to 10 days dur-
ing distraction. Because a
25% difference is routinely
present between planned
and actual adjustments,28
the distraction rates are ad-
justed based on the most
recent radiographs. Dis-
traction is continued until
the proper limb length is
achieved. The frame is re-
moved when the new bone
bridges the osteotomy site
on radiographs. Frame re-
moval generally takes place
3 to 5 weeks after the end
of adjustments. The pa-
tients are sedated with oxy-
morphone or medetomi-
dine, the wires are cut, and
the frame is removed from
the limb. The wires and
wire–skin interface are pre-
pared with chlorhexidine
diacetate solution, and the
wires are pulled through
the limb. No bandage is
placed on the limb after
frame removal. For 3 weeks
after frame removal, activi-
ty is limited to leash walks
and low-impact exercises.
COMPLICATIONS
Complications of circu-
lar external skeletal fixa-
tion include serous pin-tract
drainage, wire breakage,
skin irritation from the
rings, vascular injuries,
denervation, muscle con-
tractures, persistent angu-
lar deformities, persistent
length deficit, premature
union, delayed union,
nonunion, bone fracture,
bone infection, loss of
ROM of adjacent joints,
and luxation of adjacent
joints. 42 Serous pin-tract
drainage occurs in a ma-
jority of dogs and is gener-
Small Animal/Exotics
ally left untreated unless limb function is impaired or a
pain response is present on palpation. If focal signs of
infection are present, bacterial culture and sensitivity
are performed and antibiotics are given. Skin irritation
from the rings can be avoided if a space of 10 mm or
more is present between the rings and the skin and if
partial rings are used near the flexor side of the joints
adjacent to the frame (Figure 6).
In my experience with antebrachial lengthening of
20% of radial length or more, the ROM of the carpus
is decreased in all dogs at the time of frame removal but
returns to preoperative values after a few months.28
Physiotherapy and controlled activity (walking and
low-impact exercises) are critical to promote flexion
and extension of the carpus during and in the few
weeks after lengthening.
Complications may be secondary errors in surgical
technique.42 Some errors originate at the time of sur-
gery, including bone misalignment, thermal trauma to
the bone, and vascular or neurologic injury. Some er-
rors are secondary to an excessively weak frame struc-
ture, including too few rings, low wire tension, small-
diameter wires, or an excessively stiff frame. Finally,
some errors are secondary to inappropriate postopera-
tive management, such as when the delay before dis-
traction is too short, distraction is too rapid or erro-
neous, the frequency of distraction is low, or muscle
contracture is not recognized early.
The complications present in my first 16 patients
with deformities that were treated with CEFs included
serous wire drainage in most dogs, skin irritation in one
dog in which the frame contacted the skin, wire break-
age in two dogs (related to weak frames), a premature
bone union in one dog (resulting from a slow distrac-
tion rate), a delayed union after distraction of a diaphy-
seal osteotomy in a 1-year-old Labrador retriever, a
minimally displaced radial fracture, and focal os-
teomyelitis in two dogs. One owner adjusted the frame
incorrectly for 5 days at home. The frame was readjust-
ed in one step at the time of reevaluation, and the de-
formity was successfully treated.
CONCLUSION
The Ilizarov method is a revolutionary method of
treating limb deformities. Length deficits can be treated
by slow distraction of the bone, and complex angular
deformities can be treated with hinged frames. Optimal
treatment of bone deformities requires a good under-
standing of the pathologic process and the geometry of
the deformity. In order to evaluate the benefits of this
method, it is important to document limb cosmesis
and function before surgery and compare these findings
with the long-term limb cosmesis and function after
Small Animal/Exotics 20TH ANNIVERSARY
deformity correction. Although most of the clinical ex-
perience with the Ilizarov method comes from dogs and
humans, the principles of the method have been ap-
plied successfully in other species as well, including
cats, goats, calves, horses, llamas, emus, and iguanas.
REFERENCES
1. Carrig CB: Growth abnormalities of the canine radius and
ulna. Vet Clin North Am Small Anim Pract 13(1):91–115,
1983.
2. Meier H, Clark ST, Schnelle GB, et al: Hypertrophic os-
teodystrophy associated with disturbance of vitamin C syn-
thesis in dogs. JAVMA 130(11):483–491, 1957.
3. Breur GJ, Zerbe CA, Slocombe RF, et al: Clinical, radio-
graphic, pathologic, and genetic features of osteochon-
drodysplasia in Scottish deerhounds. JAVMA 195(5):606–
612, 1989.
4. Sande RD, Bingel SA: Animal models of dwarfism. Vet Clin
North Am Small Anim Pract 13(1):71–89, 1983.
5. Johnson JA, Austin C, Breur GJ: Incidence of canine appen-
dicular musculoskeletal disorders in 16 veterinary teaching
hospitals from 1980 to 1989. Vet Comp Orthop Traumatol
7(2):56–69, 1994.
6. DeCamp CE: A potpourri of developmental disease. Proc
7th ACVS Symp:170–171, 1997.
7. Mathews KG, Koblik PD, Knoeckel MJ, et al: Resolution of
lameness associated with Scottish fold osteodystrophy fol-
lowing bilateral ostectomies and pantarsal arthrodeses: A case
report. JAAHA 31(4):280–288, 1995.
8. Shields Henney LH, Gambardella PC: Premature closure of
the ulnar physis in the dog: A retrospective clinical study.
JAAHA 25(5):573–581, 1989.
9. VanDeWater A, Olmstead ML: Premature closure of the
distal radial physis in the dog. A review of eleven cases. Vet
Surg 12(1):7–12, 1983.
10. Vaughan LC: Growth plate defects in dogs. Vet Rec 98(10):
185–189, 1976.
11. MacDonald JM, Matthiesen D: Treatment of forelimb
growth plate deformity in 11 dogs by radial dome osteotomy
and external coaptation. Vet Surg 20(6):402–408, 1991.
12. VanDeWater A, Olmstead ML, Stevenson S: Partial ulnar
ostectomy with free autogenous fat grafting for treatment of
radius curvus in the dog. Vet Surg 11(3):92–99, 1982.
13. Van Vechten BJ, Vasseur PB: Complications of middiaphy-
seal radial ostectomy performed for treatment of premature
closure of the distal radial physis in two dogs. JAVMA 202
(1):97–100, 1993.
14. Fjeld T: Korreksjon av aksefeilstillinger etter prematur epify-
seskivelukning i distale ulna hos hund. Nord Vet 38(4):
201–208, 1986.
15. Forell EB, Schwarz PD: Use of external skeletal fixation for
treatment of angular deformity secondary to premature dis-
tal ulnar physeal closure. JAAHA 29(5):470–476, 1993.
16. Ross JT, Matthiesen DT: The use of multiple pin and
methylmethacrylate external skeletal fixation for the treat-
ment of orthopaedic injuries in the dog and cat. Vet Comp
Orthop Traumatol 6(2):115–121, 1993.
Compendium June 1999
17. Newton CD, Nunamaker DM, Dickinson CR: Surgical
management of radial physeal growth disturbance in dogs.
JAVMA 167(11):1011–1018, 1975.
18. Mason TA, Baker MJ: The surgical management of elbow
joint deformity associated with premature growth plate clo-
sure in dogs. J Small Anim Pract 19:639–645, 1978.
19. Yanoff SR, Hulse DA, Palmer RH, et al: Distraction osteo-
genesis using modified external fixation devices in five dogs.
Vet Surg 21(6):480–487, 1992.
20. Hay CW, Manley P: Use of the Wagner apparatus to length-
en the antebrachium of a growing dog. J Small Anim Pract
37(11):543–548, 1996.
21. Ilizarov GA: The principles of the Ilizarov method. Bull
Hosp Joint Dis 48(1):1–11, 1988.
22. Marcellin-Little DJ, Ferretti A: Improving bone healing with
the circular external fixation method. Vet Forum 14(11):40–
47, 1997.
23. Stallings JT, Lewis DD, Welch RD, et al: An introduction
to distraction osteogenesis and the principles of the Ilizarov
method. Vet Comp Orthop Traumatol 11(2):59–67, 1998.
24. Bianchi Maiocchi A: Historical review of the method ac-
cording to Ilizarov. 15 years after its worldwide application.
Bull Hosp Joint Dis 56(1):16–18, 1997.
25. Lewis DD, Bronson DG, Samchukov ML, et al: Biome-
chanics of circular external skeletal fixation. Vet Surg 27(5):
454–464, 1998.
26. Ferretti A, Faranda C, Monelli M: Il metodo di Ilizarov: Un
nuovo trattamento delle deviazioni e della dismetria del ra-
dio e ulna. Veterinaria 1(1):57–60, 1987.
27. Latte Y: A specific vet Ilizarov apparatus for the treatment of
fractures, delayed union, non union and malunion. Proc Vet
Orthop Soc:51, 1991.
28. Marcellin-Little DJ, Ferretti A, Roe SC, et al: Hinged
Ilizarov external fixation for correction of antebrachial defor-
mities. Vet Surg 27(3):231–245, 1998.
29. Latte Y: Bilan de 75 applications de la méthode d’Ilizarov:
Deuxième partie. Prat Méd Chir Anim Comp 30(2):141–
160, 1995.
30. Langley-Hobbs SJ, Carmichael S, Pead MJ, et al: Manage-
ment of antebrachial deformity and shortening secondary to
a synostosis in a dog. J Small Anim Pract 37(8):359–363,
1996.
31. Poy N, DeCamp CE, DeJardin L: Acute angular correction
and distraction osteogenesis for distal radial physeal closure
in seven dogs. Proc Vet Orthop Soc:48, 1998.
32. Thommasini MD, Betts CW: Use of the “Ilizarov” external
fixator in a dog. Vet Comp Orthop Traumatol 4(3):70–76,
1991.
33. Elkins AD, Morandi M, Zembo M: Distraction osteogenesis
in the dog using the Ilizarov external ring fixator. JAAHA
29(5):419–426, 1993.
34. Lesser AS: Segmental bone transport for the treatment of
bone deficits. JAAHA 30(4):322–330, 1994.
35. Aronson J, Shen X: Experimental healing of distraction os-
teogenesis comparing metaphyseal with diaphyseal sites.
Clin Orthop 301:25–30, 1994.
Compendium June 1999 20TH ANNIVERSARY
36. Ilizarov GA: Clinical application of the tension-stress effect
for limb lengthening. Clin Orthop 250:8–26, 1990.
37. Welch JA, Boudrieau RJ, Dejardin LM, et al: The in-
traosseous blood supply of the canine radius: Implications
for healing of distal fractures in small dogs. Vet Surg 26(1):
57–61, 1997.
38. Aronson J: Limb-lengthening, skeletal reconstruction, and
bone transport with the Ilizarov method. J Bone Joint Surg
Am 79(8):1243–1258, 1997.
39. Aronson J: Temporal and spatial increases in blood flow
during distraction osteogenesis. Clin Orthop 301:124–131,
1994.
40. Ilizarov GA: The tension-stress effect on the genesis and
growth of tissues. Part II. The influence of the rate and fre-
quency of distraction. Clin Orthop 239:263–285, 1989.
41. Welch RD, Birch JG, Makarov MR, et al: Histomorphome-
Small Animal/Exotics
try of distraction osteogenesis in a caprine tibial lengthening
model. J Bone Miner Res 13(1):1–9, 1998.
42. Paley D: Problems, obstacles, and complications of limb
lengthening by the Ilizarov technique. Clin Orthop 250:81–
104, 1990.
About the Author
Dr. Marcellin-Little is affiliated with the Department of
Companion Animal and Special Species Medicine, Col-
lege of Veterinary Medicine, North Carolina State Univer-
sity, Raleigh, North Carolina. He is a Diplomate of the
American College of Veterinary Surgeons and the Euro-
pean College of Veterinary Surgeons.