Mehmet Çakmak, Cengiz Şen, Levent PDF

Basic Techniques
for Extremity
Reconstruction
External Fixator
Applications According
to Ilizarov Principles
Mehmet Çakmak
Cengiz Şen
Levent Eralp
Halil Ibrahim Balci
Melih Cıvan
Editors
123
Basic Techniques for Extremity
Reconstruction
Mehmet Çakmak • Cengiz Şen
Levent Eralp • Halil Ibrahim Balci
Melih Cıvan
Editors
Basic Techniques
for Extremity
Reconstruction
External Fixator Applications
According to Ilizarov Principles
Editors
Mehmet Çakmak Halil Ibrahim Balci
Orthopaedics and Traumatology Orthopaedics and Traumatology
Istanbul University Istanbul Medical Istanbul University Istanbul Medical
Faculty Faculty
Istanbul, Turkey Istanbul, Turkey
Cengiz Şen Melih Cıvan

Orthopaedics and Traumatology Orthopaedics and Traumatology
Istanbul University Istanbul Medical Istanbul University Istanbul Medical
Faculty Faculty
Istanbul, Turkey Istanbul, Turkey
Levent Eralp
Orthopaedics and Traumatology
Istanbul University Istanbul Medical
Faculty
Istanbul, Turkey
ISBN 978-3-319-45673-7 ISBN 978-3-319-45675-1 (eBook)

https://doi.org/10.1007/978-3-319-45675-1
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© Springer International Publishing Switzerland 2018

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Foreword
Turkey sits at the crossroads of the East and West, between Asia and Europe.
The Ilizarov technique is a product of technology that developed in Asia and
migrated to Europe. It is therefore only fitting that a major work on the
Ilizarov method be compiled by the person who introduced the Ilizarov
method to Turkey. I first met Professor Mehmet Çakmak in 1992 in Pakistan
when we were both visiting professors. Professor Ilizarov had just died so
that this was a solemn occasion for our first meeting. I had the privilege to be
Dr. Mehmet Çakmak’s guest in Turkey. He has remained the first pioneer of
this method in Turkey and has stimulated many of his residents to pursue this
field of study. One of his most promising disciples is Dr. Mehmet Kocaoglu
who was my first Turkish fellow. It is through this friendship and collegiality
that a great cooperation has remained between myself and the Turkish ortho-
pedic specialists in this field. This cross-fertilization has spawned innovation
from across the Bosporus that has contributed significantly to the world
knowledge on all aspects of Ilizarov technology including limb lengthening,
deformity correction, treatment of nonunions, bone defects, and osteomyeli-
tis and the understanding and management of the complications of such com-
plex treatments. I wish to congratulate Professor Mehmet Çakmak and his
many coeditors and authors for this significant achievement, which stands as
another monument to Professor Ilizarov’s revolution in orthopedics more
than 30 years since his methodology was introduced to the West. The reader
will find this tome a great reference source to the most up-to-date understand-
ing and techniques associated with the Ilizarov method and device.
Florida, USA Dror Paley, MD, FRCSC
v
Preface from the Editorial Board
Dr. Gavril Abramovich Ilizarov coined the term “distraction osteogenesis” in

the 1950s, and most diseases that could not previously be treated or ended
with failure were treated with the method he developed. For a long time, the
method was used only for acute fractures or nonunions. After Russia, the new
method was first used in Italy and then in other European countries and the
United States. The method was appreciated by physicians in time. “The
Ilizarov philosophy” has been used more frequently in orthopedics, particu-
larly after the considerable contributions of Dror Paley in the United States in
the 1990s. The book entitled Principles of Deformity Correction written by
Dr. Paley has been widely accepted in orthopedics and successfully used in
the treatment of many patients.
The first textbook in Turkey, Ilizarov Surgery and Its Principles, was pub-
lished in 1999 with contributions of experienced colleagues after they per-
formed the method in their clinics. In 2004, the 3rd International ASAMI
Congress was held in Turkey, at which there were participants from all over
the world. We published books in Turkish Ilizarov in Trauma and then Ilizarov
in Deformity Surgery after about 30 years of experience using the Ilizarov
technique with the aim of contributing to the education of colleagues who
were willing to perform the method. We wanted to publish a book in English
that synthesizes the information of the latter books and offers a methodologic
approach to all basic and current information about Ilizarov surgery. We
believe that the correct performance of deformity analysis principles is the
core and essential element of this treatment. We think that Ilizarov applica-
tions are important weapons in a surgeon’s armory and sometimes the pri-
mary choice in traumatology. In this book, you will find examples of
computer-assisted fixator applications, which are frequently used in Turkey
and around the world. You will also find information about new methods
developed by some of our creative colleagues. We know that young col-
leagues will find the answers to all questions in their minds.
We want to thank and express our gratitude to our colleagues who spent
their valuable time preparing the chapters of the book, David Francis
Chapman and Kadriye Gümüş from the Publication Support Department in
Istanbul University for their support in translating and editing the book, Özge
Papakcı Aydın for her contribution to some of the illustrations, and Erol Al
for his endless rigorous work as the secretary of the Ilizarov patient archive.
vii
viii Preface from the Editorial Board
We hope this book will have a humble contribution to our colleagues

worldwide who are willing to devote their lives to Ilizarov surgery and con-
tinuing the work in this area.
The Editors
Preface
I started my resident training in 1973 in Istanbul University, Orthopedics and

Traumatology Clinic. The biomechanical rules and principles in orthopedics
were very different in the 1980s than they are today when I first became the
chief resident in the same clinic. Communication and information exchanges
were not easy either. It was really hard to produce information and spread it
around the world. I have always felt lucky for being a member of this well-
established orthopedics clinic. I was just an apprentice in the challenging
nature of orthopedics; then I became a professor who was operating and
implementing techniques for the first time and teaching at the same time.
In 1983, I read in a newspaper that a physician in Russia had successfully
performed a 30-cm extremity lengthening without a need of an operation.
When I decided to investigate the news, the philosophy was very new in the
world, and all the articles were written in Russian. We brought the articles to
Turkey and had them translated. Ultimately, we had met “distraction osteogen-
esis.” Our journey started with our first operation in 1984, meeting Ilizarov in
person in 1988 and attending international symposium in limb lengthening in
Pakistan in 1992, and with the organization of the third international ASAMI
meeting in 2004. Today the journey continues with the organization of meet-
ings and congresses and with the academic studies of our fellow colleagues.
I will be grateful to present my thanks to my colleagues who teach the
Ilizarov philosophy and treatment methods for their contribution in this book.
They immediately supported me without any hesitation when I shared my
ideas about the project. They contributed with their knowledge and experi-
ences from all over the country. This book has arisen when all the knowledge
and Ilizarov’s basic principles and methods were gathered together. The aim
of this book is to convey this knowledge and experience to the next genera-
tion because these are secret weapons for each orthopedic physician and
sometimes it is a way of life. Despite all the recent developments and technol-
ogy, Ilizarov’s circular external fixator will always continue performing mir-
acles, such as it did on the first day.
I will be grateful to present my thanks to my dear wife for her support
throughout my life, to my distinguished professors who educated me, to all
authors who shared the same excitement, and to the editorial team who suc-
cessfully managed and organized this challenging process.
Istanbul, Turkey Mehmet Çakmak
ix
Contents
Part I External Fixator Applications for Complex Fractures

1 History and Phylosophy of Ilizarov’s Method�� 3
Levent Eralp
2 The Histology and Biology of Distraction Osteogenesis �� 11
Vecihi Kırdemir
3 Parts of Ilizarov-Type External Fixators �� 27
Melih Cıvan
4 K-Wire and Schanz Screw Application Techniques�� 37
Mehmet Çakmak and Melih Cıvan
5 Hinge Types and Positioning �� 45
6 Techniques for Building the Frame�� 59
7 Ten Basıc Rules for Ilizarov Applications�� 83
Cengiz Şen
8 Hardware and Osteotomy Considerations�� 89
Dror Paley
9 Definitive Surgery for Open Fractures of the Long Bones
with External Fixatıon�� 107
Cengiz Şen, Halil Ibrahim Balci, Mustafa Celiktaş,
Cenk Ozkan, and Mahir Gulsen
10 Treatment of Intraarticular Joint Fractures of the Lower
Extremity with External Fixators�� 129
Mehmet Erdem, Deniz Gulabi, Ibrahim Tuncay, Gokcer Uzer,
Mehmet Erdil, Ersin Kuyucu, and Gokhan Karademir
11 External Fixation for Upper Extremity Trauma�� 167
Ata Can Atalar and Ali Erşen
12 Forearm Fractures �� 177
Levent Eralp
13 Treatment of Pediatric Fractures with Ilizarov’s Method �� 189
Fuat Bilgili
xi
xii Contents
14 Role of External Fixators in Pelvic Fracture Treatment�� 197

Cengiz Şen
15 External Fixator Use in Femur Diaphysis Fractures�� 213
16 Principles of Ilizarov Treatment in Fractures of Diaphyseal
and Metaphyseal Tibia Fractures�� 227
Ahmet Salduz
Part II Ilizarov Approach in Deformity Surgery
17 Introduction to Deformity Analysis and Planning�� 241

İlker Eren
18 Frontal Plane Deformities and Drawing Axes of the
Long Bones �� 245
19 Malalignment Test�� 255
20 Sagittal Plane Deformities and Malorientation Test�� 267
21 Oblique Plane Deformities�� 277
22 Multiapical Deformities�� 285
23 Anatomic and Mechanical Planning and Finding the Cora�� 295
Cengiz Şen and Gökhan Polat
24 Translation and Angulation-Translation Deformities�� 309
Cengiz Şen and Turgut Akgül
25 Rotation and Rotation-Angulation Deformities�� 327
Cengiz Şen and Omer Naci Ergin
26 Osteotomy Rules and Types�� 339
Mustafa Uysal
27 Hip Deformities: Pelvic Support Osteotomy for Neglected
High Hip Dislocation and Other Sequelae Around the Hip�� 351
Levent Eralp
28 Femur Deformities �� 367
Halil Ibrahim Balci
29 Knee Deformities�� 383
Cengiz Şen and Ahmet Salduz
30 Knee Arthrodesis�� 395
Halil Ibrahim Balci
Contents xiii
31 Diaphyseal Deformities of the Tibia �� 403

32 Ankle Deformities�� 413
33 Foot Deformities �� 441
34 Upper Limb Deformities �� 461
Yılmaz Tomak and Engin Eren Desteli
35 Congenital Lower Limb Deformities�� 493
Gamal Ahmed Hosny, Fuat Bilgili, and Halil Ibrahim Balci
36 Deformities of Metabolic Disorders�� 541
Levent Eralp
37 Computer-Assisted Fixators for Deformity Surgery�� 553
Mustafa Celiktas, Mahir Gulsen, and Cenk Ozkan
Part III Ilizarov Approach in Postraumatic Complications
38 Pseudoarthrosis�� 567
39 Chronic Osteomyelitis, Biofilm, and Local Antibiosis�� 605
R. Schnettler, K. Emara, D. Rimashevskij, R. Diap,
A. Emara, J. Franke, and V. Alt
40 External Fixator Applications in Warfare Surgery�� 629
Mustafa kürklü, Yüksel Yurttaş, Harun Yasin Tüzün,
and Mustafa Başbozkurt
41 Limb Lengthening�� 645
Cengiz Şen, Yavuz Sağlam, Mehmet Kocaoğlu,
F. Erkal Bilen, and Halil Ibrahim Balci
42 Joint Contractures �� 683
Levent Eralp
43 The Treatment of Complications in Ilizarov Technique �� 691
Mustafa Uysal
44 Postoperative Rehabilitation�� 701
Arman Apelyan
45 Psychiatric Evaluation of Patients Using External Fixators�� 711
İrem Yaluğ Ulubil
Index�� 717
Contributors
Turgut Akgül Istanbul University, Istanbul Faculty of Medicine, Department

of Orthopedic Surgery and Traumatology, Istanbul, Turkey
Volker Alt Justus-Liebig-University, Giessen, Germany
Arman Apelyan Kinemed Physical Therapy and Rehabilization Center,
Istanbul, Turkey
Ata Can Atalar Istanbul University, Istanbul Faculty of Medicine,
Department of Orthopedic Surgery and Traumatology, Istanbul, Turkey
Halil Ibrahim Balci Istanbul University, Istanbul Faculty of Medicine,
Mustafa Başbozkurt Department of Orthopedics Surgery and Traumatology,
Private Keçiören Hospital, Ankara, Turkey
Ishwar Bhattarai Department of Orthopaedic Surgery, Hervey Bay
Hospital, QLD, Australia
F. Erkal Bilen Faculty of Health Sciences, Istanbul Yeni Yuzyil University,
Istanbul, Turkey
Fuat Bilgili Istanbul University, Istanbul Faculty of Medicine, Department
Mehmet Çakmak Istanbul University, Istanbul Faculty of Medicine,
Mustafa Çeliktaş Ortopedia Hospital, Adana, Turkey
Melih Cıvan Istanbul University, Istanbul Faculty of Medicine, Department
Engin Eren Desteli Hospital of Üsküdar, Department of Orthopedic Surgery
and Traumatology, Istanbul, Turkey
Rami Diab Ain Shams University, Faculty of Medicine, Cairo, Egypt
Adel Emara Ain Shams University, Faculty of Medicine, Cairo, Egypt
Khaled Emara Ain Shams University, Faculty of Medicine, Cairo, Egypt
Levent Eralp Department of Orthopedic and Traumatology, Istanbul Faculty
of Medicine, Istanbul, Turkey
xv
xvi Contributors
Mehmet Erdem University of Sakarya, Department of Orthopedic Surgery

and Traumatology, Sakarya, Turkey
Mehmet Erdil Medipol University, Department of Orthopedic Surgery and
Traumatology, Istanbul, Turkey
İlker Eren Koç University, Department of Orthopedic Surgery and
Omer Naci Ergin Istanbul University, Istanbul Faculty of Medicine,
Ali Erşen Istanbul University, Istanbul Faculty of Medicine, Department of
Orthopedic Surgery and Traumatology, Istanbul, Turkey
Jörk Franke Elbe Klinikum Stade, Department of Orthopedic Surgery and
Traumatology, Hamburg, Germany
Deniz Gulabi Kartal Dr. Lütfü Kırdar Education and Research Hospital,
Istanbul, Turkey
Mahir Gülşen Ortopedia Hospital, Adana, Turkey
Gamal Ahmet Hosny Benha Faculty of Medicine, Department of Orthopedic
Surgery and Traumatology, Benha, Egypt
Gökhan Karademir Istanbul University, Istanbul Faculty of Medicine,
Vecihi Kırdemir Suleyman Demirel University, Department of Orthopedic
Surgery and Traumatology, Isparta, Turkey
Mehmet Kocaoğlu Department of Orthopedic Surgery, American Hospital
Istanbul, Istanbul, Turkey
Mustafa Kürklü Division of Hand Surgery, Department of Orthopedics
Surgery and Traumatology, University of Health Sciences, Ankara, Turkey
Ersin Kuyucu Medipol University, Department of Orthopedic Surgery and
Cenk Özkan Çukurova University, Department of Orthopedic Surgery and
Traumatology, Adana, Turkey
Dror Paley The Paley Institute, Florida, USA
Gökhan Polat Istanbul University, Istanbul Faculty of Medicine, Department
Denis Rimashevskij Scientific Research institute of Traumatology and
Orthopedics, Healthcare Ministry of Republic of Kazakhstan, Qaraghandy,
Kazakhstan
Yavuz Sağlam Biruni University, Department of Orthopedic Surgery and
Ahmet Salduz Istanbul University, Istanbul Faculty of Medicine, Department
Contributors xvii
Reinhard Schnettler Justus-Liebig-UniversityGiessen, Germany

Cengiz Şen Istanbul University, Istanbul Faculty of Medicine, Department
Kevin Tetsworth Department of Orthopaedic Surgery, Royal Brisbane
Hospital, Herston, QLD, Australia
Yılmaz Tomak Ondokuz Mayıs University, Department of Orthopedic
Surgery and Traumatology, Samsun, Turkey
İbrahim Tuncay Bezmialem University, Department of Orthopedic Surgery
Harun Yasin Tüzün Division of Hand Surgery, Department of Orthopedics
Surgery and Traumatology, Gulhane Research and Training Hospital, Ankara,
Turkey
İrem Yaluğ Ulubil Kocaeli University, Psychiatry Department, Kocaeli,
Turkey
Mustafa Uysal University of Sakarya, School of Medicine, Department of
Orthopedic Surgery and Traumatology, Sakarya, Turkey
Gökçer Uzer Bezmialem University, Department of Orthopedic Surgery
Yüksel Yurttaş Department of Orthopedics Surgery and Traumatology,
Private Doctor Bayram Öztürk Hospital, Ankara, Turkey
Part I
for Complex Fractures
History and Phylosophy
of Ilizarov’s Method 1
Levent Eralp
External fixation was first used by Hippocrates Consequently, he started working on a distraction
around 2500 years ago for the treatment of tibia method for osteogenesis [5, 6].
fractures [1]. Jean Francois Malgaigne described He studied distraction osteogenesis in animal
a fixator device and named it “Griffe” in 1840. In models. Because of the strict political structure of
1843, he used the device to hold the fragments of the Soviet Union, his work remained unpublished
a tibia [2, 15]. In 1897 Clayton Parkhill invented internationally until 1972. The Ilizarov method
a modern unilateral fixator known as a “bone reached high national attention with the treat-
clamp” and published the first series of 14 ment of nonunion of Valeriy Brumel in 1968, the
patients treated with external fixation [3]. The Soviet gold medal high Jumper. Valeriy Brumel
first biomechanically tested fixator used for frac- was an Olympic champion and a longtime world
ture treatment was invented by Italian surgeon record holder in the men’s high jump. He injured
Della Mano. The device was the first structural his right foot in a motorcycle accident. Before he
example of rings and wires [4]. Various types of was accepted to Kurgan, he was unsuccessfully
external fixators were used during the First and treated in various clinics [7, 12, 17].
Second World Wars for treating open or closed After attracting the attention of his country,
fractures with or without bone defects. Ilizarov appeared in Western press with the success-
In the early 1950s, a Russian physician named ful treatment of infected tibia pseudarthrosis of
Gavril Abramovich Ilizarov invented an external Carlo Mauri, an Italian mountain climber, explorer,
fixator. He patented his device in 1951 while he and journalist. After 10 years of unsuccessful treat-
was working in the General Surgery Department ment, Mauri heard about Ilizarov and went to Kurgan
of the Kurgan Regional Hospital. Initially, he in November 1977. Ilizarov treated him in 6 months
used this device for compression at fracture sites. and Mauri called him the “Michelangelo of
Thereafter, he observed some patients were mak- Orthopedics” [8, 16]. Because of the amazing recov-
ing distractions instead of compressions errone- ery of his leg, Italian orthopedic surgeons invited
ously and yet there was still new bone formation. Ilizarov as a guest speaker to the 22th AO Italy con-
ference in Bellagio in June 1981. Under the chair-
manship of Professor Roberto Cattaneo, Chief of
Orthopedics and Traumatology of Lecco General
L. Eralp, Prof. MD Hospital, he gave three lectures about the treatment
Istanbul University, Istanbul Faculty of Medicine,
of open fractures and posttraumatic osteomyelitis
Orthopaedic and Traumatology Department,
34190 Istanbul, Turkey and bone lengthening, and this was the first time
e-mail: drleventeralp@gmail.com Ilizarov lectured outside his motherland.
© Springer International Publishing Switzerland 2018 3

M. Çakmak et al. (eds.), Basic Techniques for Extremity Reconstruction,
https://doi.org/10.1007/978-3-319-45675-1_1
4 L. Eralp
After the meeting, Italian orthopedic surgeon June 1983. Ilizarov directed the first course with his
Prof. R. Cattaneo and his associates, A. Villa, assistant Dr. V.I. Schevstov with the attendance of
M. Catagni, and L. Tentori, started experimental tri- more than 300 surgeons from all over the world.
als with the set that was donated by Ilizarov to Lecco In September 1983, the First International
General Hospital. In 1982, the Association for the Transosseous Osteosynthesis Symposium was
Study and Application of the Methods of Ilizarov organized in Kurgan. More than 800 orthopedic sur-
(ASAMI) was founded in Lecco, Italy. After Prof. geons attended the meeting from outside the
Ilizarov moved to the new building in Kurgan named USSR. This meeting introduced Prof. Ilizarov to the
The Russian Ilizarov Scientific Center for Restorative whole world, and he subsequently supervised meet-
Traumatology and Orthopedics (RISC RTO) as a ings and gave lectures in courses organized in Spain,
chief scientist, an Italian delegation of surgery con- France, Switzerland, Portugal, Greece, Brazil, and
sisting of professors A. Bianchi Maiocchi, G. B. the United States of America (USA) between 1983
Benedetti, A. Villa, and M.A. Catagni visited him in and 1985. He gave a “professorial lecture” on the
Kurgan in April 1982 (Fig. 1.1). “treatment of nonunion” on the last day of second
The RISC had 1200 beds, 12 operation rooms, instructional course of Ilizarov’s method in
15 experiment labs, and an experimental animal Bergamo, Italy, in front of the president of SICOT
laboratory. The knowledge about distraction and the founder of AO International, Prof. Maurice
osteogenesis was enhanced in the following years Müller. After the method had been accepted in the
because of the integrated work between Russian USA in the late 1980s, the whole world used the
and Italian surgeons (Fig. 1.2). method for specific fields of orthopedics (Fig. 1.3).
ASAMI started courses named “Theoretical and From North America, Sarmiento, MacEwen,
Practical Application of Ilizarov’s Method” in Lecco, and Victor Frankel were the first surgeons who
Fig. 1.1 Prof. Dr.

G. A. Ilizarov
examining a patient
(From the International
Advertisement
Brochure of Kurgan
Research Institute of
Experimental and
Clinical Orthopedics
and Traumatology,
1989)
1 History and Phylosophy of Ilizarov’s Method 5
were introduced with this technique in 1983 and visited Lecco for 2 weeks, and because of the
1984. Dr. James Aronson learned the technique slow learning curve, he decided to do a fellow-
from Prof. R. Bombelli in 1984, Lecco. While ship for 6 months in Lecco, Bergamo, and
Bombellini was a visiting Professor in Toronto, Kurgan. After learning the technique in detail, he
Dr. Dror Paley, a senior resident in orthopedic clinically applied the technique first in Toronto
surgery heard about the method. In 1985, Paley and then in Baltimore, Maryland, in 1987.
Fig. 1.2 RF Ministry of Healthcare (2015), The Russian ilizarov.ru/index.php/about-center/center-today

Ilizarov Scientific Center for restorative traumatology [Accessed 16 November 15]
and orthopedics [ONLINE]. Available at http://en.
Fig. 1.3 Ilizarov
lecturing about his
techniques (From the
International
Advertisement Brochure
of Kurgan Research
Institute of Experimental
and Clinical
Orthopedics and
Traumatology, 1989)
6 L. Eralp
Fig. 1.4 Prof. Dr.

Mehmet Çakmak
(right) was the first
surgeon to use
Ilizarov’s technique and
limb lengthening with
circular external
fixators in Turkey. Also
in the photograph is Dr.
Cerkez-Zade (center)
and Dr. Schevstov (left)
In 1987 Dr. Paley and V. Frankel organized the tinue with his own words for describing our clin-
first meeting with the attendance of Prof. Ilizarov, ic’s story with this epic discovery (Fig. 1.4).
which was held in New York and the next year in I was chief resident in 1980 and the whole world
had been using compression for union of the frac-
Washington, D.C. Dr. Stuart Green from Los ture site. Limb lengthening had been performing
Angeles translated all the work of Ilizarov with very rarely and maximum amount of the lengthen-
his approval and trust for Western countries to ing couldn’t have been more than 2 or 3 centime-
use and published the entire works in Clinical ters. Plates had been commonly used in those days,
and fixation after osteotomy and traction was the
Orthopedics and Related Research in 1989 and ultimate solution. Until 1983, limb lengthening
Ilizarov’s book in 1992 [9, 13]. procedures had been performed by the method of
After the method was accepted worldwide and shortening osteotomy or epiphysiodesis. However,
its use began, many clinical and biomechanical these procedures were planned for healthy limbs
and parents or patients were hardly accepting these
trials and experiments were done. The system procedures.
was improved in the 1990s with additional parts Ilizarov showed us that some of the knowledge
and modifications and became more modular and popular in those days could have been wrong or
useful. Superposition problems were solved in insufficient and against the physiology of the
human body. The philosophy of the Ilizarov had
imagining with the use of carbon fiber rings [14]. been learned by Italian Orthopedic Surgeons and
In Turkey, external fixators were first used by with the treatment of the tibia pseudarthrosis of
Dr. Orhan Aslanoğlu for limb lengthening proce- Carlo Mauri, Italian journalist and climber. That
dures. Dr. Orhan Girgin used his own designed case was the gate for the knowledge and Europe
had been finally informed about this new
fixator for tibia lengthening in Numune Hospital, innovation.
Ankara, in 1978. Although he failed in the first Two years after the Italian surgeons in 1983,
procedures, he revised his device and started Turkey was the second stop for this knowledge, and
lengthening again in 1979. I was very curious about this new technique and
was determined to learn it. In 1983 I heard about
The history of the application of the Ilizarov’s this “magician” in a newspaper. This newspaper
method in our clinic has been presented as a lec- article was saying that a man called Ilizarov in
ture by Prof. Dr. Mehmet Çakmak who was the Russia were lengthened a patient’s limb by about
first surgeon to use this technique. I prefer to con- 30 cm without bleeding. I can say that this news
a b
Fig. 1.5 The first patient who underwent a lengthening procedure in our clinic. Clinical photo and follow up X-rays
was more likely to be fake. But I followed the takenly prepared using old X-rays before s urgery.
source and because of the empty literature I In other words, we were unaware of the discovery
requested the scientific publishing about this tech- of this method by the time we started to use it in
nique from the USA. With the help of our nurses our patients in 1987.
who knew Russian, my colleague Dr. Kocaoğlu and We heard that Ilizarov himself had started to
I finally got the translated documents and articles. visit various countries for lectures and he was visit-
Distraction osteogenesis was the main subject ing Turkey in 1989 because of one of his patients.
and some illustrations had been in the papers. We Thankfully, he accepted our invitation and the
decided to prepare the parts after getting g deeper CEO of the Enka Corporation Şarık Tara spon-
in this subject. The first experimental studies were sored the conference. He showed very interesting
performed using amputated materials of patients, cases, and we were deeply surprised after we lis-
and some biomechanical studies had been applied tened to his presentation (Fig. 1.7).
[10, 11]. I met with Dr. Paley in the conference held in
Successful results encouraged us to apply this Pakistan in 1992. Dr. Paley had contributed math-
method in a human subject. Our first patient was an ematical aspects to deformity surgery. I had the
adolescent boy with significant shortness in his left chance to invite them to Turkey as well. At same
limb. His father trusted us and we informed them time, Schevstov invited me to Kurgan, Russia. My
about the procedure. visit to Kurgan was also very inspiring and made
The patients X-rays can be seen in the figures me realize that this scientific work and methods
below and this patient zero (as we call him) gladly were new and magnificent innovations in the field
volunteered for more clinical photos 22 years after of orthopedics and were all worth spending a
the procedure (Figs. 1.5 and 1.6). lifetime.
There was a significant risk about arrest of the Routine lengthening procedures started after I
growth plate with the method of distraction epi- visited the RISC, Kurgan, in 1993 with Dr.
physiolysis. And the method could be used until Kocaoğlu and Dr. Kılıçoğlu. Dr. Ilizarov had
the growth plate is closed. Callotasis was the ulti- recently passed away and Dr. Schevstov was the
mate innovation after work started on this part of president of the institute (Figs. 1.8 and 1.9). After
the orthopedics. Thus, we performed distraction 1991, we published a number of studies about
epiphysiolysis on a patient whose growth plate we Ilizarov’s method. In 1994 at the annual Professor
thought was still open. But his growth plate was Akif Şakir Şakar Memorial Days (founder of the
closed and the K-wires started to bend after seven Orthopedics Department of Istanbul University),
days of distraction. We realized that we had misunder the chairmanship of Dr. Schevstov and Dr.
8 L. Eralp
Cherkez-Zhade, with more than 300 participants,

the methods and studies from all over the world
were discussed. Instructional courses for Ilizarov’s
method had started in Çukurova University, Adana,
and courses have been organized every year since
then. There has been an active Ilizarov Polyclinic
and Ilızarov Archive since 1995 in Istanbul
University Orthopedics and Traumatology
Department, which includes more than 5000 cases.
The Turkish ASAMI was established in 1999
and organizes postgraduate courses that help our
young fellows to learn this knowledge. They lec-
ture all over the country, and some of their work
has reached around the world and carried this flag
to the future. Our hope for our young colleagues is
to be open to new ideas and keep imagining.
Fig. 1.6 22 years after the first lengthening procedure,

clinical photo of “patient zero”
Fig. 1.7 Ilizarov’s only

presentation in Turkey,
in 1989, Dr. Mehmet
Çakmak (left) and Prof.
Gavril A. Ilizarov
(center) and Russian
interpreter (right)
Fig. 1.8 Prof. Dr. Mehmet Çakmak with the statue of

Ilizarov
Fig. 1.9 Prof. Dr. Mehmet Çakmak with Dr. Schevstov

10 L. Eralp
Photo from 3rd Asami Meeting held in Istanbul, 2004 (From left to right; Dr. Levent Eralp, Dr. Mahir Gülşen, Dr.
Mehmet Çakmak, Dr. Maurizio Angelo Catagni, Dr. Mehmet Kocaoğlu)
9. Ilizarov GA. In: Green SA, editor. Historical back-

References ground of transosseous osteosynthesis. Transosseous
osteosynthesis. Berlin: Springer-Verlag; 1991.
1. Adams F. Hippocrates. In: The genuine works of hip- 10. Ilizarov GA. Clinical Application of the tension stress effect
pocrates. London: Sydenham Society; 1849. for limb lengthening. Clin Orthop. 1990;250:8–26. Review
2. Asami.org. 2015. ASAMI web site – STORY. (online) 11. Ilızarov GA, Irianov M. The characteristics of osteo-
Available at: http://www.asami.org/asami_story/. genesis under conditions of stretch tension. Biull
Accessed 16 Nov 2015. Eksp Biol Med. 1991;111(2):196. Russian Article
3. Cakmak M, Kocaoğlu M. External fixators. In: 12. Ilizarov GA, Frankel VH. The Ilizarov External

Turkish orthopedics and traumatology association. Fixator, a physiologic method of orthopedic recon-
Damla Printing House; 1995. struction and skeletal correction. A conversation with
4. Cakmak M, Arıtamur A, Domaniç Ü, Taşer Ö. Limb Prof. G. A. Ilizarov and Victor H. Frankel. Orthop
Lengthening with the method of distraction osteogen- Rev. 1988 Nov;17(11):1141–54.
esis, Experimental Study. Acta Ortoped Traumatologica. 13. Ilizarov S.. The Ilizarov method: history and scope.
1985;19(2):167–176. In: Robert Rozbruch S, Svetlana Ilizarov. Limb
5. Girgin O. Tibia Lengthening with special designed lengthening and reconstruction surgery. CRC Press;
instruments, XII Meeting of Turkish Orthopedics and Miami, Florida. 2006. p. 1–18.
Traumatology Book s441; 1991. 14. Maiocchi AB, Aronson J. Operative principles of Ilizarov,
6. Frankel V.H. Golyakovsky. In: Operative manual of ASAMI. Baltimore: Williams & Wilkins; 1991. p. 4.
Ilizarov’s techniques, Mosby; St. Louis. 1993. 15. Malgaigne JF. Manuel de medecine operatoire. Germer
p. 2. Baillière, Libraire-Editeur, Paris; 1834.
7. Golyakhovsky V, Frankel VH. Textbook of Ilizarov 16. Moseley CF. Leg Lengthening, the historical perspec-
surgical techniques: bone correction and lengthening. tive. Orthop Clin North Am. 1991;22(4):555.
New Delhi: Jaypee Brothers Publishers; 2010. 17. Sisk TD. External fixator, historical review, advan-
8. Hall JN. Clayton parkhill, anatomist and surgeon tages, disadvantages, complications and indications.
editorial article. Ann Surg. 1902;35(5):503–4. Clin Orthop. 1983;180:15–22.
The Histology and Biology
of Distraction Osteogenesis 2
Vecihi Kırdemir
Prof. Dr. Gavril Abramovich Ilizarov, who had plate. On the contrary, the growing bone origi-
begun to design an external fixator in 1945, nates from the bone tissue itself – the osteo-
started his first fracture treatment with this equip- progenitor cells – in contact with the growth
ment and had published his first results in 1950. plate from above and below.
Ilizarov had been using the external fixator for 3. The significance of vascularization for frac-
fracture treatment, and while he was treating a ture healing and bone growth.
patient, instead of tightening the screws on the
rods, he loosened them by mistake. With this First, external fixator devices are applied to
mistake, he observed that there were also signs of the bone in the operating room. Thereafter, a low-
union on the fracture line and callus formation in energy osteotomy is performed to make a frac-
the distracted fracture line. In 1969, Ilizarov pub- ture line during the same session with stable
lished results of his 10 years of work which was fixation as Ilizarov described. After the opera-
entitled “The course of compact bone reparative tion, a 5-day waiting period for children and
regeneration in distraction osteosynthesis under 7 days for adults, the osteotomy line is moved
different conditions of bone fragment fixation 1 mm/day via unscrewing the rods. This 1-mm
(experimental study).” In his studies, he investi- elongation is achieved through four applications
gated distraction osteogenesis on 65 dogs and per day. Following osteotomy, new trabecular
published his first conclusions [1–4]. bone tissue develops between both bone surfaces
After Ilizarov’s mistake, orthopedic surgeons based on this distraction. This process continues
understood the following facts: until the planned distraction distance is achieved
(e.g., 10 days for 10 mm).
1. For fracture healing, compressive forces
Newly formed tissue, rich in type I collagen, is
applied to the fracture line are not always a fibrous tissue that cannot be seen radiologically.
needed. The new repair tissue develops on the collagenous
2. The longitudinal bone growth does not origi- bridge formed between the two osteotomy sur-
nate from the cartilage cells in the growth faces. Collagen fibers and blood vessels are aligned
parallel to the forces of distraction. Following full
distraction, bone cells intensify as microcolonies
V. Kırdemir, MD and immediately become bone- like formations.
Suleyman Demirel University, Faculty of Medicine,
This phase is called the consolidation phase.
Orthopedics and Traumatology Department,
Isparta, Turkey The 10 % lengthening of muscle tissue due to
e-mail: vkirdemir@gmail.com the distraction of bone can be well tolerated;

https://doi.org/10.1007/978-3-319-45675-1_2
12 V. Kırdemir
however, lengthening more than 30 % of the muscle However, during its existence, the features of the
length causes significant histopathological changes. zygote to proliferate will be kept on, but the abil-
Temporary histopathological changes are also seen ity to differentiate will be restricted by the time.
in neurovascular structures due to distraction. Two Stem cells have two distinct features:
months after the distraction, these temporary
changes disappear. Tibial lengthening performed on 1. Proliferation
rabbits also showed histopathological changes on (a) Clonality (embryonic stem cell (ESC),
the surface of the knee joint cartilage following a malignant cells, microorganism)
short period. It was observed that the growth of car- (b) Self-renewal (adult stem cell (ASC))
tilage showed a decrease in the hypertrophic and 2. Differentiation or potency
proliferative zone thickness [2, 3].
Ilizarov explained the guidelines for bone Proliferation and differentiation processes
lengthening between 1990 and 1995, according show some differences in embryonic cells and
to the principles of histology and physiology in adult cells. For this reason, we divide stem cells
this manner [2]. into two groups: (1) embryonic stem cells (ESC)
E. Donnall Thomas received the Nobel Prize and (2) adult stem cells (ASC). In the embryo,
in the field of medicine for hematopoietic stem each of the daughter cells formed by mitosis gen-
cell transplantation in 1990 [5]. In 2001, after erally (clonality) contains both genetic and epi-
discovery of key regulators in the cell cycle by genetic characteristics of the principal stem cell
Tim Hunt and Paul Nurse, information pertaining (symmetric division) [if daughter cells have same
to the healing of fractures was again reevaluated epigenetic features between each other but differ-
[6]. In 2012, the Nobel Prize in the field of medi- ent from mother cell, this is also called symmet-
cine was given to Sir John Bertrand Gurdon from ric division] (Fig. 2.1). Sometimes one of the
England and Shinya Yamanaka from Japan for daughter cells contains the same genetic and epi-
demonstrating that fully differentiated skin fibro- genetic characteristic – as expected – but the
blasts could be transformed into stem cells by other sibling has the same genetics but different
reprogramming [7]. epigenetic characteristics (asymmetric division).
With these studies of D. Thomas, T. Hunt, As a result of asymmetric division, this epigene-
P. Nurse, J. Gurdon, and S. Yamanaka, a new per- tic difference reflects either as phenotypic differ-
spective has been brought in the field of histology ence or apoptosis.
and physiology. In today’s practice, the clinical In adults, stem cells want to keep their counts in
success in the healing of a fracture or an osteot- constant to prevent becoming cancerous. For this
omy is related to the integrity of the surrounding reason, one of the daughter cells protects the same
tissue and proper mechanical features of the bone genetic and epigenetic characteristics (self-renewal),
that will be able to support possible weights. whereas the other daughter cell encompasses the
Stem cells are also needed for tissue healing. The genetic but different epigenetic characteristics. In
cells that comprise bone tissue are called osteo- asymmetric division, the daughter cell with the
genic progenitor cells. The formation of bone tis- epigenetic differences preserves the ability to
sue, fracture healing, and the principles of become a stem cell. However, in adults, the
distraction should be evaluated in enlightenment purpose is to prevent becoming cancerous and

of the new literature which is about stem cells. maintain constant counts, and the daughter cell
with the different epigenetics g enerally loses the
ability to become a stem cell and stays differenti-
2.1 Definition of the Stem Cells ated until the end of the differentiation process
(Fig. 2.2, left column). Embryonic stem cells do
An organism develops by the proliferation and not use self-renewal; they use symmetric or asym-
differentiation of the zygote, which is actually a metric division (apoptosis, inner cells, outer cells,
stem cell. The zygote is a totipotent stem cell that endo-meso-ectodermal stem cells) (Fig. 2.2 right
has the ability to differentiate to any type of cell. column).
2 The Histology and Biology of Distraction Osteogenesis 13
Symmetrical Cell Division Asymmetrical Cell Division
1st Division
2nd Division
3rd Division
4th Division
5th Division
Fig. 2.1 Illustration of the symmetrical and asymmetrical division
Adult Stem Cell Embrionic Stem Cell
First Division
2 2 2 1 2
1
Second Division
Differantiation
SELF RENEVAL
CLONALITY
Differantiation
1 3 3 3 1 3 2 4
Differantiation
Differantiation
Third Division
1 5 3 6 2 7 4 8
Apoptosis
1 4 4 4
Apoptosis
Fig. 2.2 Illustration of the proliferation and differentiation of the adult and embryonic stem cells
In adults and fetus following organogenesis 2.1.1 E

mbryonic Stem Cell (ESC)
phase, stem cells are found in microenviron- and Bone Formation
ments called “niches,” e.g., bone marrow, peri- in the Embryo
cytes in surrounding tissue of the vessels, hair
follicles, intestinal epithelium, gonads, lymph Proliferation in the embryo is achieved by clonal-
nodes, satellite cells of the muscles, and periph- ity. The principal cell transforms into two daugh-
eral blood. ter cells by mitosis. It is believed that both of
14 V. Kırdemir
TOTIPOTENT
2-cell Zygote Oocyte
4-cell
Morula 8-cell
Primitive Endoderm
Delamination Epiblast
Trophectoderm Late Blastocyst 2 disc shape

Inner Cell Mass Primordial
Hypoblast
PLURIPOT
Amniotic Cavity
Early Blastocyst
Endodermal
Cells of Yolc Sac
Primitive Streak
Mesoderm 3 disc shape
Fig. 2.3 Illustration of early embryonic differentiation
these daughter cells are capable of carrying the d eveloping the embryo (pluripotent = multipotent).
same characteristics (stem cell and same External cell groups multiply asymmetrically and
potency). The daughter cells can differ according form the amniotic sac via apoptosis. Inner cell
to their potency (Fig. 2.2). This division can be mass forms clusters and continues asymmetric
symmetrical in which both of the cells carry the division on the 7th day and differentiates into epi-
same characteristics or asymmetrical in which blasts and hypoblasts. The epiblasts form the ecto-
one of the daughter cells carries different epigen- dermal cell layers, whereas hypoblasts form the
etic characteristics, while the other one does not endodermal cell layers (Fig. 2.3) [8].
(e.g., inner cell, outer cell, hypoblast, and epi- On the 9th day, some epiblasts are divided
blast formation). asymmetrically in order to differentiate into
Epigenetic transformation can result in three amnioblasts and extraembryonic mesoderm
ways: along with external cell layers [8].
Between the 9th and 16th days, epiblasts and
1. Change of potency, transformation into a new hypoblasts continue to increase in number via
type of stem cell (hypoblast, epiblast) symmetric and asymmetric divisions and produce
(totipotent-pluripotent) two empty globes that consist of e pithelial cells.
2. Apoptosis – controlled cell death The globe created by epiblasts (green globe)
3. Differentiation resulting in the final state [8] grows faster than the globe created by hypoblasts
(orange globe). The orange globe will be sur-
In the embryo, the zygote proliferates by rounded by the green globe in order to create the
c lonality until the 5th day (totipotent). On the 5th hypoblastic cavity eventually (Fig. 2.3) [8].
day, epigenetic differentiation takes place, and The empty globe of the hypoblasts (orange
competency differs for developing inner cell mass circle in Fig. 2.3) first develops the temporary
(green-orange) and external cell (blue) trophecto- vitellus sac, and then the temporary vitellus sac
derm layers. External cell groups are now only transforms to the yolk sac. The amniotic sac is
capable of producing cells for external tissues of formed by epiblasts (green circle in Fig. 2.3). When
the embryo, and inner cell mass is capable of the two globes are back to back, the interface
Endodermal
Cells of Yolc Sac
Primitive Streak
3 disc shape
Primitive Streak
Ectoderm
16th Day Primary

mesoderm
EMT
Endoderm
Fig. 2.4 Illustration of the embryonic development in the 16th day (epithelial-mesenchymal transition or EMT)
between the two globes forms an elliptical shape features. Three discs referring to embryonic germ
(fusion of both orange and green globes in Fig. layers are called ectoderm-mesoderm-endoderm.
2.3). Epithelial contact areas of the globes are (Stem cells in these three layers are (1) embryonic
just like two discs on top of each other [8]. ectodermal stem cells [EEcSCs], (2) embryonic
For surrounding the hypoblastic cavity, the endodermal stem cells [EEnSCs], and (3) embry-
disc belongs to the bigger globe cracks from the onic mesenchymal stem cells [EMSCs]). These
center toward the periphery at the 16th day (prim- stem cells gain multipotency (9).
itive streak) (Figs. 2.4 and 2.6). Around the 16th During the 16th day of the intrauterine phase,
day, Wnt genes’ signal pathway helps the streak to the formation of the mesenchyme tissue occurs
be formed in the ectodermal disc. By the help of by the migration of the stem cells whose pheno-
this cleft, some epithelial cells from the upper disc types have changed based on the epigenetic
migrate to the space between two discs. changes of the stem cells in the ectoderm. The
Migration of these epithelial cells is called process of EMT and production of the
“epithelial-mesenchymal transition” (EMT). mesenchymal stem cells (EMT type I) during the
Theoretically this period can be referred by three intrauterine phase are observed in adults during
discs as illustrated in Figs. 2.2 and 2.3 (ectoderm- the repair of damaged tissue (EMT type II) and
mesoderm-endoderm). In order to form the mes- tumor metastases (EMT type III) [8].
enchymal disc, epithelial cells have to gain On day 18, the edges of the neural plate start
characteristics of mesenchymal cells by losing to thicken and lift upward forming the neural
the ability of adhesion to each other and to the folds. The center of the neural plates remains
basal membrane. Along with the capability of grounded, allowing U-shaped neural groove to
migration, mesenchymal cells also have the abil- form. The neural groove gradually deepens as the
ity to synthesize the surrounding extracellular neural folds become elevated, and ultimately the
matrix which cannot be created by epithelial cell folds meet and coalesce in the middle line and
layers [8, 9]. convert the groove into a closed neural tube. This
The stem cells which form two-disc shape neural groove sets the boundary between the
resemble each other in epithelial features. However, right and left sides of the embryo. The ectoder-
in three-disc shape, stem cell differentiation begins. mal wall forms the rudiment of the nervous sys-
Stem cells in the middle disc have mesenchymal tem (Fig. 2.5).
16 V. Kırdemir
Amnioc ube
ral T
Sac
Mesoderm Neu
erm
sod
Me
Notochord
a rta
a Cav Ao
Neural Plate Border Endoderm Ven
Ectoderm
Neural Fold
Neural Groove
Notochord
Fig. 2.5 Illustration of the neural tube development
The mesenchymal layer grows sideways and sels in the embryo c annot penetrate into the mes-
forward between the ectodermal and endodermal enchymal tissue because the cartilage matrix does
layers. Migrated cells which are positioned under not allow this action. However, cartilage cells con-
the neural tube form the chordal process which tinue to differentiate with the molecules produced
transforms the “notochord” which is a primitive by the Chordin and Noggin genes. This differanti-
carina of the embryo between 19th and 21st days ation is not only due to the chemical effect
(Fig. 2.6). In the next stages of the fetal develop- (Chordin and Noggin), but by helping with the
ment, all germ layers will be supported by this appropriate mechanical stimulation. The cartilage
structure. This rod is the skeleton holding the tissue at the tip of the anlage becomes dense and
three layers stable and the first cartilage structure hypertrofic in midsecitons and might enter apopto-
of the human embryo [8]. sis. At the same time, apoptosis which takes place
Because of the separate formation of the at the same structure keeps the tissues apart ana-
mesenchymal cells, unlike the epithelial cells, a tomically. The matrix has to be disintegrated enzy-
matrix fills the intercellular space. This matrix matically during this phase because phagocytic
facilitates the interaction with signal molecules. cells have not developed to disintegrate the matrix
Signal molecules do not affect the epithelial and of cells yet. Metalloproteinase (MMPs) enzymes
mesenchymal cells in the same way, and they can are used in this disintegration. Following comple-
even change their own effect mechanism. The tion of their purposes (segmentation and formation
impact of the bone morphogenetic protein (BMP) of joint gaps), their impact is stopped by other
is suppressed by the effect of Chordin and Noggin enzymes (tissue-inhibiting metalloproteinase
genes, and ESC differentiation leads toward the [TIMPs]). Vascularization begins at the cavities
cartilage tissue. Vascular endothelial growth factor formed after segmentation. Blood vessels in the
(VEGF) differentiates ectoderm and endoderm embryo are created in two ways. The first way is
stem cells into vessel endothelium. These new ves- differentiation of epithelial cells from endodermal
a b
Ectoderm
Amnion
Endoderm
lG
roo
ve Neural Ridge
ura
Ne
Paraxial mesoderm
Intermediate mesoderm
Notochord Somatopleural (mesoderm
Lateral mesoderm
and ectoderm)
Interaamnionic Coelom
(mesoderm and endoderm)
21st Day
16th Day
c
Neural Tube
Intermediate Chorda- Paraxial Lateral Mesoderm

Mesoderm Mesoderm Mesoderm
Notochord Splanchnic Somatic Extra-

embryonic
Kidney Gonads Head Somite
Sclerotome Myotome Dermatome
Fig. 2.6 Illustration of the embryonic development in the 21st day (first supporting structure (notochord) of the
embryo)
18 V. Kırdemir
Fig. 2.7 Illustration of the mesenchyme segmentation and somite formation
Fig. 2.8 Blood vessels that originate from tubal struc- for the tube formation, for example, the brain and spinal
tures in the embryo are created from epithelial cells which cord. (b) Condensation of the mesenchymal cells for the
differentiate from endoderm or ectoderm stem cells, from tube formation, for example, blood vessels and some kid-
mesenchymal cell clusters whose core underwent apopto- ney tubules (MET). (c) Cavitation of the condensed mes-
sis, or from the gaps formed following migration to the enchyme clusters to form a lumen (MET)
periphery. (a) Rolling or bending of the epithelial sheets
or ectodermal stem cells to form tubal s tructures. apoptosis or migrate to the periphery and form a
The second way is that the cells in the middle part gap in the middle part. This is called mesodermal-
of the mesenchymal cell mass disappear with epithelial transition (MET) (Figs. 2.7 and 2.8).
The embryo is a tube-shaped structure like a the 20th day c oncomitantly, and this happens
worm, and there is not any sign of appendicular perpendicularly to the axial midline (in dorso-
skeleton formation until the 21st day. First embry- ventral direction). Three somites per day for-
onic signs of appendicular skeleton development mation provides 42–44 somites at the end. At
will be seen in the 32nd–33rd day, because the this period, a rod-shaped primitive cartilage
worm-like embryo does not have any limb buds. named notochord which is a part of unseg-
After this day, signal molecules and local environ- mented mesenchyme blocks the folding of the
ment affect the epigenetic mechanisms for deter- embryo [9].
mination of the stem cell differentiation. These
signal molecules will affect the axial skeleton When segmentation occurs in the worm-
development in the 21st–33rd day; after the 33rd shaped embryo, this process only takes place in
day, these signal molecules will determine both mesenchyme tissue in a direction from midline
axial and appendicular skeleton development. toward laterally and dorsoventrally. But neural
tube and precordial rod (notochord) and also
1. Bone morphogenetic protein (BMP) stimulates ectoderm and endoderm do not have segmenta-
the pluripotent stem cells [EEcSC and EEnSC] tion during this period. A cross section of
(Fig. 2.3) to differentiate into epithelial cells or somite transfer would show that the ectoderm is
bone cells [9]. However, presenting suppress- sinking toward the midline and has started to
ing signal molecules which are the products of form the spinal cord; the mesoderm between
Noggin or Chordin genes in local environment the bottom of this sunken area and notochord
inhibits the effects of BMP which is: lays below and will form the primitive verte-
(a) Before formation of mesoderm, differen- brae. The segmented mesenchyme divides into
tiation of stem cells into ectoderm and three parts at both sides of notochord. These
hereby formation of the neural structures parts are called paraxial- intermediate-lateral
(b) After formation of mesoderm, differentia- mesoderm, respectively, from midline to
tion of stem cells into the bone [9] periphery (Fig. 2.6b, c).
2. Transforming growth factor (TGF) and BMP At the 28th day, cell clusters lose their com-
stimulate the differentiation of the EMSCs bined structures and start the formation of the
into the bone and differentiation of the EEcSC sclerotomes, myotomes, and dermatomes (Fig.
and EEnSC into vessel epithelium. Products 2.6c) [9]. At this time, EMSCs are being exposed
of the Noggin and Chordin genes in the local to fibroblast growth factor (FGF), products of
environment inhibit effect of the BMP to the Hedgehog gene family (Indian and Sonic
EMSCs and thus provide: Hedgehog (Shh)), and products of Wnt gene fam-
(a) Differentiation of the stem cells into carti- ily. These signals inhibit the angiogenesis and
lage cells. obstruct further anastomosis. At the same period,
(b) Maturation of the cartilage cells. umbilical artery migrates toward the embryo
(c) Formation of cartilage cells in chains. anteriorly to the notochords at ventral side. The
(d) Becoming hypertrophic in further. dorsal aorta forms into segmental branches at the
(e) Some hypertrophic cartilage cells lead to 20th day. The vena cava and the aorta develop
apoptosis, but the angiogenesis is never from endodermal disc which originates from
seen in these cartilage tissues [9]. EEnSC.
3. Proteins more of which are products of Sonic Suppressing molecules such as the products
Hedgehog (Shh) Genes and less are Wnt of Noggin and Chordin genes inhibits the BMP
Genes affect at 19th day and provide the and hereby differentiates the mesenchymal stem
somite formation by splitting. Splitting by cells into chondrocytes. This continues with fur-
apoptosis is seen in ectodermal tissue in the ther differentiation of the cartilage tissue and
center line toward the periphery (in caudocra- apoptosis. Chondrocytes line parallel to the bone
nial direction) and causes the primitive streak. outline, and the diaphyseal part of these chon-
In mesenchyme tissue, this splitting starts at drocytes becomes hypertrophic. At both ends,
20 V. Kırdemir
chondrocytes form clusters, and the rest of them cells named osteoclasts which have brush mem-
go into apoptosis. With all these procedures, branes that help immune defense.
joint formation becomes visible between the EMSCs have the ability to differentiate into
segments [9]. both cartilage and bone tissue stem cells along
At the 30th day, epithelial progenitor cells with all mesenchymal tissues (multipotency).
which are positioned dorsoventrally to C3-Th3 Differentiation is the only process for building
and L1-Coc4 [cervical (C), thoracic (Th), lumbar this mesenchymal or cartilage scaffold. However,
(L), coccygeal (Coc)] somites form four apical for building the bone skeleton (or scaffold), epi-
ectodermal ridges (AERs) and proliferate to form thelial cells which are going to transform into
upper and lower extremities toward distally. In bone periost, endosteum, and vessel system epi-
this epithelial extension, mesenchymal stem cells thelium are required. These cells are provided by
which will produce sclerotome, myotome, and embryonic endodermal or ectodermal stem cells
dermatome migrate. At the 32nd day, mesenchy- (EEnSCs, EEcSCs) or epithelial-mesenchymal
mal stem cells in the upper extremity transform transition (EMT).
into mesenchymal tissue. Condensation of the Osteoid matrix does not allow diffusion or
mesenchymal cells leads to the formation of the osmosis for nutrition as mesenchymal or carti-
scapula and first mesenchymal structures of lage matrix. For the nutritional support, a vessel
upper extremity bones. At the 35th day, the system is required which this system can only be
humerus and, at the 38–40th day, ulna radius structured by angiogenesis or vasculogenesis.
structures are beginning to form. At the 49th day, Cartilage tissue does not allow angiogenesis,
first skeleton structures of phalanx and carpal neurogenesis, or hematopoiesis in spite of being
bones are seen. At the 35th day, only the subcla- originated by mesenchymal tissues because this
vian artery can reach to extremities from the dor- cartilage tissue is composed of well-differentiated
sal aorta. At the 42nd–44th day, the nutritional cells with slow metabolism. These cells are hard
branch and, at the 44–48th day, ulnar and radial to become malignant, regenerate, or be repaired.
artery branches are provided. At these bones, pri- In embryonic state or later, cartilage tissue
mary ossification centers become visible at this forms joint surfaces, growth plates, or special
moment. structures such as fontanels. These structures
Appendicular skeleton which originates from are located among bones which prevents vessel
mesenchymal cells continues to maturate with anastomosis or unions between these bones.
cartilage and bone formation. Bone tissue lives The extremities are formed by EEcSCs in
with a cycle which starts from intrauterine life to apical ectodermal ridge (AER). However, mesen-
death of the organism. This cycle contains bone chymal and cartilage cells can only fill this
regeneration and formation at the same time and tubercle by the inhibition of Chordin or Noggin
keeps sustainability (mesenchymal – cartilage under BMP effect. This prevents the influence of
bone skeleton). VEGF toward the cells inside this tubercle. When
Mesenchymal and cartilage tissues do not cartilage formation is begun at the distal end of
contain vessels and hematopoietic tissue. On the the tubercle, angiogenesis is not started yet or has
contrary, bone tissue does contain hematopoietic just begun.
tissue and vessel web (Haversian and Volkmann). Stem cells primarily do not differentiate to the
While cartilage tissue is surrounded by epithelial mesenchyme in repair tissue. Epithelial stem
tissue (perichondrium), bones are surrounded by cells (pericytes) primarily form the vessel tubes,
periosteum at the outside surface and endosteum and the area between these tubes is filled with
at the inside surface. Mesenchymal and cartilage stem cells from EMG type II. Mesenchymal stem
tissues do not contain immune cells. However, cells are differentiated based on signal molecules
bone tissue has primary multinuclear immune in the matter (Fig. 2.8).
Summary 2.2.2 Inflammation Phase

1st and Formation of the epithelium layers
2nd weeks The fracture line distal to the plugs and the closest
3rd week Transformation into mesenchymal layer, area forms ischemia. Ischemic region cells secrete
(trilaminar germ disc)
a lot of cytokines. Although plasma proteins are
Formation of the dorsal aorta and vena
cavas inactive in blood vessels, they become active when
4th week Formation of the first cartilage tissue they are outside of the vessels. Changing of the per-
Initiation of the segmentation via meability of the blood vessels in the fracture area
angiogenesis (segmentation of the axial increases the escape of the blood elements and liq-
skeleton)
uid to the outside of the vessels (extravasation).
5th week Initiation of appendicular skeleton (the
This creates the edema at the injury site. Counter
formation of the upper and lower limbs)
Formation of the subclavian and femoral transaction from extravascular area to the lumen
vessel system also happens at the same time [9].
Starting matrix ossification in the axial Pre-kallikrein synthesized from the liver and
skeleton
some exocrine tissues (especially kidneys) trans-
6th week Formation of the hand and foot plates
First hyaline cartilage tissue in
form into kallikrein with the help of various
extremities chemical and physical factors. Kallikrein stimu-
8th week Separation of the fingers of the hand lates kinin synthesis from kininogens. Kinin
inhibits the smooth muscle contraction at the ves-
sels and increases the permeability (edema) and
causes pain from the nerve endings [9].
2.2 dult Stem Cells
A Kinin-bradykinin system is interactively associ-
and Fracture Healing ated with coagulation-fibrinolytic-complement sys-
tems and influences the release of prostaglandins,
2.2.1 Hematoma Phase prostacyclins, and histamines that cause inflamma-
tion and increase in the mitosis of T-lymphocytes,
Fracture lines caused by osteotomy or those that which makes them efficient in tissue repair [9].
occur spontaneously first fill with blood from The coagulation system is activated when
open vessels in this line. The blood vessel tips are coagulatory factors in circulating blood meet
plugged with fibrin that results from fibrinogen in with foreign surfaces. As a result, coagulation
the liquid matrix of the blood tissue and thrombo- occurs by the transformation of the fibrinogen to
cytes, thus forming masses. The fibrinogen in the fibrin. This process is the blood matrix transfor-
hematoma transforms into fibrin so that the first mation from liquid form to colloid form [9].
scaffold between the fracture tips is made of There are other cells and molecules in the
fibrin. The strength of the fibrin scaffold is hematoma formation:
dependent upon the stability of the fracture tips. 1 . Secretory molecules originated from
Even though the transformation of the blood leukocytes
matrix from liquid to colloid is chemically depen- (a) Interleukins secreted in time
dent on the conversion of fibrinogen to fibrin, the 2. Secretory molecules originated from platelets
distance between the fracture tips being small (a) Platelet-derived growth factor (PDGF)
and steady provides stability for the fibrin mole- (b) Thromboxane A2
cules. It is easier to attach newly created cells to 3. Secretory molecules originated from plasma
the long fibers, which then form colonies. The (a) Acute-phase reactants
external or internal distraction system should not (b) Clotting factors
allow for any movement of the fracture tips dur- (c) Complement system
ing this phase. (d) Molecules of the kinin-bradykinin system
22 V. Kırdemir
4 . Antigen Presenting Cells (APC) 2.

In the alternative pathway, pathogen-
5. Phagocytic cells circulating in the blood associated molecular patterns (PAMPs) which
are another form of immune complexes acti-
With the molecules of 1a, 2, and 3 in list vate the complement in the host complex with
above, free nerve endings are stimulated and ves- the help of detection of bacterial membrane
sel permeability are changed. With these mole- molecules (in infection and open fractures).
cules and cells, the fractures and biological 3. Occasionally, the complement system can be
changes are noticed by the central nervous sys- activated by the lectin pathway with the help
tem via the circulation system and peripheric of sugar molecules [9].
nervous system. The first local inflammatory
response begins with these molecules. And also If the immune system is normal, and local
these molecules trigger the central nervous sys- inflammation is small, then so is the systematic
tem and circulatory system, thus causing sys- response. The severity and size of the inflamma-
temic inflammatory response [9]. tion are related to the following:
Acute-phase proteins (AFPs) are the easiest
indicators to track inflammation biochemically. (a) The amplitude of the local damage (type of
They support clinical findings. AFPs can be the fracture and osteotomy)
divided in two groups in which one of them has (b) Infectious agents
positive effects (anti-inflammatory effects), while (c) The type of the material used at the fracture
the other group has negative (proinflammatory) site and the correlation with the line of
effects (Table 2.1). fracture
The complementary system is generally inac-
tive (Ca) when there is no stimulator. The system Osteotomy should be performed with lower
can be activated in three pathways: (1) classic energy. Damage to the surrounding soft tissue
pathway, (2) alternative pathway, and (3) lectin along with the periosteum and endosteum should
pathway [9]. be minimal. Damage in the periosteum, endos-
teum, and soft tissue caused by the replacements
1. In the classic pathway, formation of the of the implants increases the inflammatory

immune complexes, in other words damage- response as well as performing the osteotomy
associated molecular patterns (DAMPs), is the itself [9].
main feature which forms as a result of trauma If implant material is used in the fracture site
when the shattered host detects its own cells or passes through the fracture line, the reaction of
and matrix molecules as foreign substances. the immune system to this foreign object will
have humoral (inflammation) and cellular com-
Table 2.1 Positive and negative effects of acute-phase ponents [9].
proteins If an increase in local response is not observed,
Positive and negative acute-phase proteins
it does not mean that a systemic response is not
Positive Negative increasing either. Cytokines that moved from the
(anti-inflammatory) (proinflammatory) affected tissue to the distant areas can initiate
C-reactive protein Albumin various problems in distant organs (e.g., chang-
Alpha 1 antitrypsin HDL ing blood-brain barrier permeability to produce
Alpha 1 macroglobulin Protein C brain edema, changing the alveolar membrane
Ceruloplasmin Protein S permeability to cause acute respiratory distress
Lipopolysaccharides Antithrombin III syndrome [ARDS]) [9].
(LPS) In the osteotomies, local damage affects the
LPS-binding proteins Fibrinogen bone cells and bone matrix, as well as the perios-
Prothrombin teal and endosteum blood vessels. Molecules from
C4BP damage-associated molecular patterns (DAMPs)
trigger the local immune response in the area. row niches are not the only source for this repair.
Triggered immune cells either produce new chem- Other niches are listed below:
ical molecules (humoral immunity) or execute
phagocytosis (cellular immunity) [9]. 1 . Pericytes in the vessel endothelium
Immune cells alert the local immune cells 2. Muscle satellite cells
(osteoclasts and phagocytes in the hematoma) in 3. Stem cells in blood circulation
the bone tissue with chemical secretions as well (a) Entrapped ones in the fracture hematoma
as increase the permeability of the surrounding (b) Free stem cells in circulation
undamaged blood vessels [9].
For local immune responses, the hematopoi-
etic stem cells in the nearby bone marrow are 2.2.3 Cartilage Callus Phase
desired to increase and differentiate to immune
system cells. However, for the fracture repair, we In adult differentiation, the mesenchymal stem
want the hematopoietic stem cells to differenti- cells are controlled by the cytokines and growth
ate to mesenchymal stem cells rather than factors. In tissue repair, cytokines affect the stem
immune cells. If the osteotomy is performed cells to differentiate into immune cells which
with lesser energy, the environment is not have the ability to phagocyte the necrotic cells
infected, and there is no implant in the osteot- and eliminate the unnecessary matrix compo-
omy region to create foreign object reaction; nents. The newly formed immune cells also
stem cells will differentiate along fibroblasts to secrete another cytokines which delay the origi-
produce connective tissue. Otherwise, stem cells nal cell formation in tissue repair [9].
tend to differentiate to cells related to phagocytic After the osteotomy, periosteal, Haversian,
and humoral immunity [8]. Volkmann, and endosteal vessel systems shatter.
Fibroblasts settle on the scaffold formed by With the influence of VEGF and hypoxia, peri-
fibrin from the previous phase. The differentiation cytes next to the vessels and endothelium cells
of stem cells to the fibroblasts is determined by start to reproduce. This lengthens the vessel lumen
the cytokines and growth factors in the environ- in linear form. Angiogenesis provides new vessels
ment. Increased amounts of platelet-derived about 1–2 mm per day. If the distance is short
growth factor (PDGF) and fibroblast growth fac- between the fracture ends, anastomosis occurs
tor (FGF) in the environment provide for the dif- and restores the vessel integrity (Fig. 2.9a, b).
ferentiation of the fibroblasts, and a few of the Hematoma between the blood vessels is phagocy-
stem cells change to osteoblasts with the effects of tized and filled by the mesenchymal stem cells. If
bone morphogenetic protein (BMP). At the same the Haversian and Volkmann system are restored,
time, some of the stem cells differentiate to the stem cells in the bone marrow and pericytes near
chondroblasts as a result of Chordin and Noggin the vessels differentiate to the osteoblasts.
genes, which produce signal molecules that If the distance between fracture ends is
inhibit the effects of BMP. Environmental matrix extremely wide or there is a movement on axial
is richer in elastin than the fibronectin because plane, the blood vessels cannot reach each other,
fibroblasts are present in large numbers in the and anastomosis fails eventually. Vessel lumens
matrix. Differentiated stem cells with the phago- curve and make a budding formation (Fig. 2.9c).
cytosis capability and other phagocytic cells in the This formation inhibits the transformation of the
environment destroy the necrotic leukocytes, stem cells originated from pericytes and bone
erythrocytes, and platelets within the fracture marrow to osteoblasts. These stem cells trans-
hematoma and nonviable bone and soft tissue form to fibroblasts and chondroblasts. Irregular
cells in the area adjacent to the fracture line [8]. angiogenesis (budding) and granulation tissue
The most important source for mesenchymal composed of fibroblasts stimulate the stem cells
stem cells for tissue repair is the bone marrow to transform into phagocytes. Moreover these
“niches” at the fracture site. However, bone mar- stem cells could even transform into synovial
24 V. Kırdemir
a b c d e
Fig. 2.9 (a) Angiogenesis in callus. (b) When proper dis- between the fracture ends, angiogenesis happens with
traction is applied, linear anastomosis connects the frac- budding without linear anastomosis. But also synovial tis-
ture ends. (c) If the distraction is much more than normal sue cells have been seen in the fracture line. This will
between fracture ends, budding will take place the linear eventually compromise the union. (e) If compressive
angiogenesis and this will cause nonunion. (d) If the mul- forces are applied in the fracture line, “compression”
tiaxial movement such as rotation and angulation, other destroys the budding formation and synovial tissue
than vertical movements such as distraction, happens
type A-B cells. At this moment, the fracture line collagen type 1 molecules synthesized in their
has to be compressed vertically to each other matrix cannot be organized to respond mechani-
(compression). Compression destroys the bud- cal forces. Matrix mineralization will not occur
ding formation and gives another chance to linear because there will be no suitable spaces among
anastomosis (Fig. 2.9e). the unorganized collagen fibers. Bone tissue
(woven bone), which looks like cotton candy,
develops in the osteotomy line.
2.2.4 Bone Callus Phase The desired length can be obtained by distrac-
tion of 1 mm per day until the distraction is discon-
After the osteotomy, if the fracture ends are sta- tinued. The nerves restrict the distraction. In fast
ble and the distance is short, the Haversian and distraction, the nerves can be lengthened by 5 %
Volkmann system will be reestablished by anas- and up to 20 % in slow distraction. Once 20 % of
tomosis. Within 5–7 days following osteotomy, the original nerve length is achieved in the distrac-
anastomosis of the blood vessel occurs Fig. 2.9b tion area, the procedure cannot be continued [10].
(latency period). Formation and organization of the osteoblast
Following this period, by applying a distrac- colonies and collagen fibers in the original bone
tion of 1 mm/day, we can also lengthen the endo- could only be obtained under physiologic loads
thelium of the blood vessels 1 mm/day. The space at the osteotomy line. To gain these loads,
between the blood vessels is filled with mesen- K-wires must be applied perpendicularly to each
chymal cells or fibroblasts that differentiated other with the tension of 110–130 kg in the lower
from stem cells. We need a fixation system which extremity and 70–90 kg in the upper extremity.
will only provide at the fracture ends on the oste- Thus, the opportunity for the physiologic loads to
otomy line to move vertically but rigid for the be applied to the osteotomy line could be pro-
axial-transverse plane movements. If the fixation vided. Collagen type I fibers align consistently
system allows this vertical movement in the oste- with the physiologic loads. The spaces between
otomy line, the stem cells could differentiate to the fibers are filled with calcium in various forms.
the osteoblasts. Osteoblasts line up as parallel Physiologic loads must be applied to the osteot-
colonies in the direction of the distraction, but omy line after lengthening [11].
References 6. Nurse P. Cyclin dependent kinases and cell cycle

control (nobel lecture). Chembiochem. 2002;3(7):

596–603.
1. Ilizarov GA. The tension–stress effect on the genesis
7. Yamanaka S, Blau HM. Nuclear reprogramming to a
and growth of tissues: part I. The influence of stability
pluripotent state by three approaches. Nature.
of fixation and sort tissue preservation. Clin Orthop.
2010;465(7299):704–12.
1989;238:249–81.
8. Alp C. Chapter 2-3-4-5-6-7-8: Kök Hücre Biyolojisi
2. Spiegelberg B, Parratt T, Dheerendra SK, Khan WS,
Türleri ve Tedavide Kullanımları, (in Turkish).
Jennings R, Marsh DR. Ilizarov principles of deformity
Biology of stem cell species and medical applications.
correction review. Ann R Coll Surg Engl. 2010;92:
1st ed. ANKARA Akademisyen Medical Publishing;
101–10. doi:10.1308/003588410X12518836439326.
2014. p. 50–288.
3. Kaljumae U, Martson A, Haviko T, Hanninen O. The
9. Martjin G. Chapter 3: Pathogenetic changes damage.
effect of lengthening of the Femur on the extensors of
In: Pape HC, editor. Control management in the poly-
the knee. An electromyographic study. J Bone Joint
trauma patient. Springer Science+Busines Media.
Surg Am. 1995;77:247–50.
ISBN 978-0-387-89507-9; 2010. p. 45–52.
4. lizarov GA, Lediaev VI, Shitin VP. The course of
10. Rickett T, Connell S, Bastijanic J, Hegde S, Shi R.
compact bone reparative regeneration in distraction
Functional and mechanical evaluation of nerve stretch
osteosynthesis under different conditions of bone
injury. J Med Syst. 2011;35:787–93. doi:10.1007/
fragment fixation (experimental study). Eksp Khir
s10916-010-9468-1.
Anesteziol. 1968;14(6):3–12.
11. Ayas M. İlizarov tekniği ve uygulama Pratikleri. (in
5. Appelbaum FR, Forman SJ, Negrin RS, Blume KG,
Turkish), Ilizarov Techniques and clinical applica-
editors. Thomas' hematopoietic cell transplantation:
tions 3. Chapter; Fundementals. p. 10–57. ANKARA.
stem cell transplantation. 4th ed. Malden: Blackwell
ISBN:978-605-63965-0-2; 2013.
Publishing Ltd ; 2004.isbn: 978-1-405-15348-5
Parts of Ilizarov-Type External
Fixators 3
Melih Cıvan
3.1 Rings 3.1.3 5/8 Rings
3.1.1 Full Rings These partial rings are used to obtain a space for
dressing or surgery and even for more joint move-
Because of the difficulties in the application, ment (Fig. 3.4). For example, in the knee joint,
whole rings were removed from standard Ilizarov these rings allow full flexion when positioned
sets (Fig. 3.1). Today, two half rings are used to anteriorly.
make a whole ring.
3.1.4 Omega Rings

3.1.2 Half Rings
These rings are especially used in the shoulder to
Half rings are the main components of the allow patient’s joint movement (Fig. 3.5).
Ilizarov system (Fig. 3.2). The internal diameter
of the rings varies between 80 and 240 mm. The
holes were rare in the early years. Today we use 3.1.5 Arches
half rings with 8 mm-wide holes, 4 mm apart.
The rods that cross the rings are 6 mm wide, The original Ilizarov set contained 290 and
which allows 15° of angulation between the per- 300 mm arches; today we have 80 to 260 mm
pendicular line to the ring and rods. Besides arches. These arches are wider and thicker than
using a whole ring, half rings can be used to make normal rings and have grooves with holes. These
alternative structures. Today, radiolucent “carbon are especially used in the pelvic region with
fiber” rings that visualize joints more clearly in Schanz screws. The combination of Schanz
X-rays are used (Fig. 3.3). screws with the system was originally used by
R. Cattaneo et al. who reduced the risk of vessel
and nerve injury because of the K-wires. Arches
also make patients more comfortable while rest-
ing in the supine position (Figs. 3.6, 3.7, and 3.8).
M. Cıvan, MD
Orthopedic and Traumatology Department,
34190 Istanbul, Turkey
e-mail: melihcivan@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_3
28 M. Cıvan
Fig. 3.4 5/8 ring
Fig. 3.1 A whole ring
Fig. 3.5 Omega rings
Fig. 3.2 Half ring
Fig. 3.6 Italian femoral arch
Fig. 3.3 Carbon fiber half ring
Fig. 3.7 Carbon fiber Italian femoral arches in different

sizes
3 Parts of Ilizarov-Type External Fixators 29
Fig. 3.9 Top-to-bottom threaded, cannulated, and slotted

rods
Fig. 3.8 Foot half rings are easy to apply to the hindfoot
Fig. 3.10 Graduated type telescopic rod

3.2 Connection Parts
3.2.1 Rods
As mentioned before, rods are threaded bar-type

connection parts, 6 mm in diameter. Length of
the rods varied from 60 to 400 mm in the original
Ilizarov set. Every thread is 1 mm long.
Rods are not only for connection but also they
can allow compression or distraction. If three
rods are going to be used, there must be 120° of
angle between them. If four rods are to be used,
there must be 90° of angle between them.
Especially when proper rods are selected with
wide rings, four rods must be used. Thus, resis- Fig. 3.11 Top-to-bottom flat, long connection plate, con-
tance for stretching can be strengthened. Rods nection plate with threaded end, and twisted plate
can be threaded, cannulated, or slotted (Fig. 3.9).
For slotted rods, thin K-wires can be crossed These graduated types of telescopic rods are
inside for distraction of the bones in various added to the set by ASAMI. In the original Ilizarov
directions. set, there were 130, 170, and 210 mm-long tele-
scopic rods.
Plates are used for the connection of different-
3.2.2 Telescopic Rods sized rings, which increases the stability of the sys-
tem, making intervention rings or foot components.
Telescopic rods are used for increasing the endur- Holes in the plates differ between 2 and 10 mm.
ance of the system during lengthening. A new These connection plates have three types: flat,
type of telescopic rod has allowed us to deter- twisted, and curved plates (Figs. 3.11 and 3.12).
mine lengthening speed and amount (Fig. 3.10). Flat connection plates are used for the connection
30 M. Cıvan
Fig. 3.12 Curved plate
Fig. 3.14 Thinner female (left) and male (right) hinges
Fig. 3.13 A male (top) and a female post
Fig. 3.15 U-type hinges

in the same plane, whereas twisted plates are used
for connections in the perpendicular plane. Curved
plates are used to extend half-ring connections. 3.2.5 Wire Fixation Bolts
3.2.3 Posts There are two types of wire fixation bolt with
centered or lateral positioned holes. Bolts with
Posts are used for crossing additional wires close lateral positioned holes are used for fixation of
to the rings for improving the stability of the sys- the wire to the ring without displacement and
tem. There are two subtypes of posts with either obtaining the tension. In the Ilizarov set, these
a threaded end or threaded hole. The lengths of apparatus allow 200–300 kg tension to the wires.
the posts vary between single and four holes Besides these, there are more types of pin fixa-
(Figs. 3.13 and 3.14). tion bolts (Figs. 3.16, 3.17, and 3.18).
For more easily hinged movement, there are
also thinner posts.
3.2.6 Connection Bolts and Nuts
3.2.4 U
niversal Socket (U-Type These apparatus are used for fixation of the rings
Hinges) with rods or fixation of the threaded sockets and
making whole rings from half rings. These are
These recently invented hinges add hinge move- 6 mm in width and 10, 16, or 30 mm in length
ment for an additional plane (Fig. 3.15). (Figs. 3.19, 3.20, 3.21, and 3.22).
Fig. 3.19 Different sizes of bolts
Fig. 3.16 Wire fixation bolts with centered (left) and

lateral-positioned (right) holes
Fig. 3.20 A nut
Fig. 3.17 Single and multiple-pin fixation bolts
Fig. 3.21 Square nut
Fig. 3.18 Open-frame (or solid-frame) clamps Fig. 3.22 Nylon-insert nut (nyloc nut)
32 M. Cıvan
Fig. 3.25 Sleeves and set screws for Schanz screw

fixation
Fig. 3.23 Threaded socket
Fig. 3.26 Square sockets used for Schanz screw fixation
Fig. 3.24 Different size of square sockets
3.2.7 Threaded Socket
These apparatus were used to connect rings

instead of short rods (Fig. 3.23). We are now Fig. 3.27 Straight and 90° screwdrivers for set screws
using square sockets.
3.2.9 Bushes and Washers

3.2.8 Square Sockets
(Wrenchoqube) These parts adjust the surfaces of fixation. There
are flat-sided, oval, conical, star, and slotted
Today we use these square sockets instead of the washers. Slotted washers are used for fixation of
classic threaded socket (Fig. 3.24). They can trans- wires. Conical washers are used to obtain angula-
form into pin clamps with additional sleeves. There tions with the frame and rods and can tolerate 7.5°
are four alternative sizes with holes. Schanz screws of angulation. Oval washers allow for two holes to
are fixated to the Wrenchoqubes with sleeves and set be used at the same time (Figs. 3.28 and 3.29).
screws (Figs. 3.25 and 3.26). We use straight and 90° Bushes are used for spacers in hinges (Fig.
screwdrivers for this procedure (Fig. 3.27). 3.30).
3.2.10 L-Type Connectors
These connectors are also called oblique support

connectors. They are used for connecting the
circular system to the semicircular or unilateral
system (Fig. 3.31).
Fig. 3.28 From left to right; flat-sided washer, star 3.3 Wires and Screws
washer, and slotted washer
3.3.1 Kirschner Wire
K-wires are used for trans-osseous fixation. The

thickness of the wires varies between 0.5 and
2 mm. The 0.5 and 1 mm wires are used in short
bones. Trocar-pointed and bayonet-pointed wires
are the two types of wires available. Trocar-
pointed wires are used in cancellous bone and
Fig. 3.29 Male (left) and female (middle) conical wash-
pass the metaphysis more safely. Bayonet-
ers and an oval washer
pointed wires prevent the abrasion of the cortical
bone and osteonecrosis.
There are also K-wires with olives, which are
used for traction or fixation of bone fragments.
These wires prevent the system from sliding on
the bone. Furthermore, compression or reduc-
tion of the fragments is possible with these
wires. Stop wires can be constructed with cross
formation of standard K-wires. The other end of
the wires must be blunt for safe use (Fig. 3.32).
Fig. 3.30 A bush
Fig. 3.32 Top-to-bottom, trocar-pointed, bayonet-

Fig. 3.31 Oblique support connectors pointed, and olive K-wires
34 M. Cıvan
Fig. 3.33 Schanz screw
Fig. 3.35 Translation rotation device
Fig. 3.34 Plastic caps
3.3.2 Schanz Screws
These screws were added to the system later for

safe unilateral or semicircular use in proximal
regions, especially when there is a risk for vessel
and nerve damage. There are various types of Fig. 3.36 Top-to-bottom wrench with two open ends,
wrench with open-circular end and adjustable wrench
Schanz wires regarding thickness and length.
These screws are self-tapping and do not require
drilling. Deeper threads are used for cancellous
bone. There are two cut types for Schanz screws:
cylindrical and conical. For pediatric use, there are
shorter and thinner screws, 4.5 mm in diameter.
After the application of the Schanz screws, sur-
plus length must be shortened with scissors. After
cutting, plastic caps are used (Figs. 3.33 and 3.34).
Fig. 3.37 Double-ended offset socket wrench

3.4 Other Parts
3.4.1 Translation Rotation Device 3.4.2 Wrenches
These devices allow translation or rotation No. 10–14 wrenches are used for the whole sys-
between two frames and were invented by Dr. tem. There are various types of wrenches (Figs.
Dror Paley (Fig. 3.35). 3.36 and 3.37).
Fig. 3.38 Old wire tensioners
Fig. 3.40 Gigli wire
Bibliography
Fig. 3.39 New wire tensioners
1. Ilizarov GA, Green SA (ed.) Transosseous
Osteosynthesis. Theoretical and clinical aspects of the
3.4.3 Wire Tensioner regeneration and growth of tissue. Berlin: Springer-
Verlag; 1992
2. Maiocchi AB, Aronson J. Operative principles of
Various types of wire tensioners have been ilizarov. Baltimore: Williams & Wilkins; 1991
invented over time (Fig. 3.38). In practice, the 3. Golyakhovsky V, Frankel VH. Operative manual of
sound of the wire is used because the original ilizarov techniques. St. Louis: Mosby; 1993
wire tensioner does not have the capability to 4. Çakmak M, Kocaoğlu M. Surgery and Principles of
Ilizarov (In: Turkish ) Istanbul: Doruk Graphics; 1999
measure the amount of tension. New tensioners 5. Rozbruch SR, Ilizarov S. Limb lengthening and
have the capability to measure tension (Fig. 3.39). reconstruction surgery, 1st ed. Miami FL: CRC Press;
2006
3.4.4 Gigli Wire
This wire is used in procedures of mini-open corti-

cotomy or for cutting carbon fiber rings (Fig. 3.40).
K-Wire and Schanz Screw
Application Techniques 4
4.1 Kirschner Wires wire passes through the bone far from the frame,
connection parts must be used for the fixation
K-wires have two kinds. such as nuts, washers, and clamps. Otherwise, the
imbalance of the system affects the soft tissue,
which leads to pain and infection.
4.1.1 Transfixation Wires Transfixation wires can be reshaped as olive
wires through twisting or rotating (Fig. 4.2).
They are 1.5- and 1.8-mm-diameter wires. The
hardness is proportional to the fourth power of
diameter. Two-millimeter-diameter wires have 4.1.2 Olive K-Wires
also been put into use in recent years. The small
1.5-mm wire is used especially in pediatric and These wires have integrated sphere-shaped olives
upper extremity cases. K-wires can be tipped tro- in the middle section that allow the stabilization
car or bayonet (Fig. 4.1). or traction of the bone segments (Fig. 4.2). Their
Thick diaphyseal cortex can be drilled without diameters are the same as transfixation wires.
heating with the bayonet-tipped wires. Trocar- The purposes of these olive wires are:
tipped wire is used in metaphyseal or epiphyseal
region for cancellous bone. (a) Suppression of bone movement on K-wires
Wires must be straight and perfect to use. Any during deformity correction
deformed section can lead to failure after appli- (b)
Form an anchor for the correction
cation of the wires. movements
After transfixation, wire passes through the (c) Use as a transfixation wire for traction of the
bone, and one end of the wire must be connected bone segments or fragments (Fig. 4.3)
to the fixator. The other end must be tensioned
before fixation. While tensioning, caution must Before use, a small incision must be made
be exercised in terms of bending the frame. If the with a no. 11 scalpel for the thick olive part to
pass through the skin. The olive must withstand
the cortex. For the stabilization purposes after the
M. Çakmak, Prof. MD (*) • M. Cıvan, MD fixation of the stopped end to the ring, counter-
Istanbul University, Istanbul Faculty of Medicine, side must be tensioned before fixation. For trac-
Orthopaedic and Traumatology Department,
tion of the bone fragments with the released
e-mail: profcakmak@gmail.com; stopped end, the counterside must be tensioned
melihcivan@gmail.com and fixated. Conical-shaped stopping wires are

https://doi.org/10.1007/978-3-319-45675-1_4
38 M. Çakmak and M. Cıvan
Fig. 4.3 Using the wire tensioner to apply traction to

bone fragments
Fig. 4.1 Trocar (left) and bayonet-tipped (right) K-wires
Fig. 4.4 Displaying a 90° angle with K-wires crossing

under and over the ring
Fig. 4.2 Rotated or twisted K-wires can be used instead
of olive K-wires wires, tension, and distance between wires and
frames are very important. The primary target is
used for the same purposes. They can be used to obtain the maximum stability with the mini-
safely in osteoporotic bones because of the wide mum number of wires and rings.
diameters.
4.3 Application of the K-Wires

4.2 Wire Tensioners
The number of wires and application positions
Standard wire tensioners were made from two tele- must be considered for each patient within spe-
scoping metal tubes with a spring mechanism or cific principles. To obtain maximum stability for
threads (Fig. 4.3). The outer tube is consistent with each patient, two or more transfixation wires that
the ring at the fixation point. Inner tube is used for cross each other at 60–90-degree angles must be
straining the wire through rotation of the clamping used. While one of the wires must cross under
lever. A tensioner with an automated spring mecha- the 5-mm ring, the other wire must cross over it
nism that allows the determination of the tension (Fig. 4.4).
magnitude has been introduced in recent years. If stability is compromised because of lim-
In the Ilizarov’s circular external fixator sys- ited angulation and pathologic movement occurs,
tem, mechanical factors such as the number of additional oblique positioned wires can be applied.
4 K-Wire and Schanz Screw Application Techniques 39
Transfixation wires must be used while con- If the wire is overheated or smoke can be seen
sidering anatomy; otherwise, vascular and nerve coming from the bone, the wire must be changed
damage may occur. Wire inlets and outlets should for a cold one from a different passage.
be 1.2–2 cm away from important vascular and For surfaces where subcutaneous tissue is thin
nerve structures. such as the anteromedial tibial surface, wire must
Wires of the main ring must cross at the be positioned from the contralateral surface so as
metaphyseal region to protect periosteum and to reduce soft tissue damage.
bone marrow. Also, the nutritional arteries should When the fixator is completely applied, related
be protected. joints must be evaluated for movement. Wires
Malpositioned transfixation wires can pene- can limit movement because of the tension on the
trate or push aside vascular or nerve structures. skin. In these situations, wires must be changed.
Massive bleeding at the entry or exit points of the For maintaining joint movement and extrem-
wires refers to vascular injury, which requires ity function:
vascular repair after the removal of the wire.
Intraoperative nerve damage detection is dif- (a) Tendon penetrations must be avoided.
ficult. Fasciculation at the related muscles indi- (b) Muscles must be at optimal functional length
cates nerve damage. Nerve function usually during K-wire applications.
returns after removal of the wire. (c) Synovium must be protected.
Necrosis at the soft tissue is also an important
consideration. Surrounding tissue destruction For example, in the distal femur while cross-
caused by crossing the wire, over-tension, and ing the wire from the anterolateral to posterome-
thermal tissue damage can lead to necrosis. dial, the quadriceps muscle must be perforated at
Before use, the perforator wires must be able 90 degrees of knee flexion, and the wire must be
to withstand the cortex perpendicularly without advanced perpendicularly to the femur. After the
any rotational movement. Bone penetration must bone has been crossed, the knee must be fully
be as midline as possible. extended before crossing from the other side
K-wires sometimes bend while crossing the (Fig. 4.5).
bone, which extends the passageway. In these In cruris, while crossing the wire from the
situations, fixation stability compromises and anterior compartment, the foot must be at plantar
soft tissue damage occurs. Risk for pin tract flexion. After the bone is crossed, for the pero-
infections and loosening increases. The solution neal muscles, the foot must be at inversion. When
is in using an alcohol- or antiseptic solution- the triceps surae is being crossed, the foot must
soaked gauze to hold the wire while using the be at dorsiflexion position (Fig. 4.6). Use of cor-
perforator. rect positions for K-wire application is essential
Hand perforators are more suitable for bone for joint movement.
drilling. Electrical perforators have risk for ther- Tendon perforations can be prevented using a
mal tissue damage, especially in the cortex. simple method. First the whole tendon tracing
Thermal necrosis increases the resistance for must be palpated. After crossing the anterior
drilling. When using an electrical perforator in soft tissue, the drill must be stopped. When the
bone tissue, it must be used in short intervals and bone is not penetrated, if the related joint is
at low speed. (hammer drilling). The wet gauze maneuvered, the K-wires will also move at the
also facilitates cooling of the wire. same time. This means the wire has penetrated
The drill must be stopped after the bone has the tendon. If it is the entry point, it must be
been crossed because the rotating tip of the changed.
wire can cause soft tissue damage. Pliers can For using the Ilizarov’s circular external fix-
be used for nailing the wire for crossing the ator at the proximal femoral region, 4–6-mm-
soft tissue. diameter threaded half-pins must be used for
Fig. 4.5 Joint positions for applications of K-wires at the proximal and distal femur
safety (Fig. 4.7). Soft tissue damage and obstruc- Transfixation of the anterior skin of the thigh at
tions can be prevented with guides for these this position limits extension, which leads flexion
applications. Half-threaded pins must be used contracture.
with T-handles after the bone is contacted to pre- To prevent skin positioning problems and skin
vent thermal tissue damage. Before tapping the necrosis:
half-pins, the tract must be drilled.
Especially in specific locations, transfixation (a) During the limb lengthening, extensive skin
wires can thread vascular and nerve structures. tension in corticotomy site must be consid-
Infection and thermal injury are other disadvan- ered, and more skin tissue must be provided
tages. Nonetheless, the half-pins introduced by during transfixation. If compression is
Cattaneo and Catagni are easy to use and safer planned, skin must be pushed against the
than transfixation wires. However, the applica- compression direction.
tion of these half-pins contradicts the main idea (b) While correcting angular deformities with

and Ilizarov’s doctrine of stability and elasticity; open-wedge osteotomy, skin and subcutane-
they are much safer, and some authors, along ous tissue must be loose at the concave side,
with our department, use half-pins instead of and more soft tissue must be provided.
transfixation wires in these specific conditions. (c) Entry and exit points of the wires must be
positioned at sites that have limited skin
movement during joint motion.
4.3.1 Skin Positions
Skin positions are important in K-wire crossing 4.4 Tensioning of K-Wires

because of the excessive and prolonged pain and
pin tract infections. For example, while crossing While circular external fixators provide maxi-
a K-wire from anterior to posterior in the distal mum stability, K-wires spread the forces equally
femur at knee 90° of flexion, anterior skin moves and obstruct bone movement. Without adequate
distally and posterior skin moves proximally. tension and proper fixation, the small diameter of
Fig. 4.6 K-wire application at the ankle region
the K-wires compromises the stability of long Wire tension is also an important factor on
bones. For optimal stability and to overcome induction of osteogenesis. Too tight or loose
intrinsic tissue resistance, K-wires must be ten- wires inhibit osteogenesis. When half-pins are
sioned like tightrope. Cyclic micromovements on loaded from the non-crossed end, it moves but
axial loading are acquired with the movement of the stiffness remains the same. If transfixation
the K-wires, like a springboard effect. If the wires wires take a centered load, it effects stiffness.
are tensioned at optimal strength, the risk for More loading leads too greater stiffness on wires.
bone and soft tissue damage reduces to a mini- When K-wires deviate by 4 mm, their stiffness
mum. If the tension on wires is not enough, con- reaches the half-pin level.
tinuous vibration irritates the patient and The main factor that reduces wire tension is
increases the risk for infections. An improperly minimal deviation at the wire fixation. Therefore,
prepared Ilizarov’s circular fixator device is a the adequate tightening of the nuts is important
constant source of torment. (20 Nm).
Table 4.1 Recommended wire tension in different

situations
Recommended wire
Situation tension
One wire with half ring or arch 50 kg
One wire with one whole ring 70 kg
Two wires with one whole ring 110 kg
(adolescent)
(adult)
(overweight patients)
4.4.2.2 Inclination Technique

Fig. 4.7 Fixation at the proximal femoral region with
threaded half-pins After fixation of the tip of the wire, the other end
must be fixated with an obliquely positioned
clamp. For maximum tension, bilateral clamps
Heat and the axial cyclic loading are non-
can be used.
controllable factors.
Larger rings at the wider areas of limbs
4.4.2.3 Standard Tension Device
improve forces for adequate wire tensions.
We use standard tension devices for adequate
tension. Not knowing the amount of the tension
is a disadvantage.
4.4.1 Recommended Wire
Tensioning
4.4.2.4 Dynamometric Tension Device
These parts are calibrated for use in range of
Different amount of tensions for different situa-
50–130-kg forces. Tension can be adjusted
tions are listed below (Table 4.1):
manually.
The wires must be cut until 4 mm is left from
4.4.1.1 Transfixation Wire Tension
the ring and bent.
In some cases, the number of wires can be
increased for more stability.
Bibliography
4.4.1.2 Olive Wire Tension
If the stop is at the counterside of the bone, opti- 1. A.S.A.M.I Group. Chapter 7: Basic principles of oper-
mal tension is 120 kg. If the stop is used for ative technique. In: Maiocchi AB, Aronson J, editors.
interfragmenter compression, optimal tension is Operative principles of ilizarov; Milan, Medi Surgical,
30 kg. 1991. p. 65–71.
2. Aronson J. Proper wire tensioning techniques for ilizarov
type external fixators. Tech Orthop. 1990;5(4):27–32.
3. Aronson J, Harp JH. Mechanical considerations in
4.4.2 Wire Tensioning Techniques using tensioned wire in a transosseous external fixa-
tion systems. Clin Orthop. 1990;280:23–9.
4. Aronson J, Harrison B, Boyd CM, Cannon DJ,
4.4.2.1 Rotating the Bolts Lubansky HJ. Mechanical induction of osteogenesis:
If the bolts are rotated, wire tension increases. It importance of pin rigidity. J Pediatr Orthop. 1988;8(4):
is a simple technique that requires no devices. 396–401.
The disadvantage is the malpositioning of wires 5. Green SA. Components of the ilizarov system. Tech
Orthop. 1990;5:1–11.
during rotation, which leads to tension in the soft 6. Green SA. The use of wires and pins. Tech Orthop.
tissue and pain. 1990;5:19–25.
7. Green SA, Harris NL, Wall DM, Ishanian J, Marinow G, editor. Transosseous osteosyntesis. Heidelberg:
M. The rancho mounting technique for the ılizarov Springer; 1992. p. 63–136.
method, a preliminery report. Clin Orthop. 1992;280: 9. Maiocchi AB Chapter 2: Instruments and their use.
104–16. In: Maiocchi AB, Aronson J, editors. Operative
8. Ilizarov GA. Chapter 1: The apparatus : components principles of Ilizarov; Milan, Medi Surgical, 1991.
and biomechanical principles of application. In: S.A p. 9–32.
Hinge Types and Positioning
5
The difference and advantage of the Ilizarov The angle between the proximal and distal
external fixator (IEF) is the ability to be modified fragments axes is the deformity angle. Proximal
during the operation until the device is removed. and distal blocks are formed with K-wires and
The motion of the fragments has some technical two rings for each block. After the blocks are
terms listed below: built, hinges must be positioned between them
according to the CORA. Then the deformity can
(a) Bone fragments can be approximated to each be corrected.
other: compression.
(b) Bone fragments can be removed from each
other: distraction. 5.1 Benefits of Hinges
(c) One fragment can be twisted in the long axis
toward each other: rotation. 1. Hinges allow uniaxial movement, which can
(d) One fragment’s long axis can be repositioned also be limited by the tightened nuts.
to the other fragment’s axis: translation. 2. Hinges are supporting points for the correc-
(e) One fragment can be repositioned in a differ- tion of angulation and fracture site displace-
ent direction in all axes to the other fragment: ment at the same time.
angulation. 3. Hinges make soft tissue adapt biologically to
the device. Gradual tension facilitates the soft
In addition to fixation procedures, because of tissue adaptation.
the ability of the particular movements, the 4. Hinges allow joint movements.
device can also be used for correction of angular
deformities, pseudoarthrosis, fracture reduction,
joint contractures, or treatment of bone defects. 5.2 Building the Hinges
Hinges in particular are used for the correction of
angular deformities, and they must be positioned Hinges are easily built with two components.
to the center of rotation of angulation (CORA). Each has the same mechanism at the rotation cen-
ter and allows movement in just one axis. In the
Ilizarov’s original set, there are posts that can be
M. Çakmak, Prof. MD (*) • M. Cıvan, MD female or male and threaded or not.
Istanbul University, Istanbul Faculty of Medicine, At the bottom of the hinge, there is a standard
Orthopedic and Traumatology Department, thread. This threaded part connects the hinge to
e-mail: profcakmak@gmail.com; the other parts. Female hinges do not have
melihcivan@gmail.com threaded rods. Instead they have threaded holes.

https://doi.org/10.1007/978-3-319-45675-1_5
Fig. 5.1 A hinge built with two male half hinges

Fig. 5.4 A hinge built with two male posts
Fig. 5.2 A hinge built with two female half hinges Fig. 5.5 A hinge built with two female posts
Fig. 5.3 A hinge built with a male and a female hinges Fig. 5.6 A hinge built with a male and a female post
posts can be used for building hinges (Figs. 5.4,

5.2.1 Half Hinges
5.5, and 5.6).
When two half hinges are used for building for
Hinges are originally built with a female half
one hinge, the threaded end or hole is aligned on
hinge, a male half hinge, a bolt, and a nut. Two
the same line. When two posts are used for build-
male or two female half hinges can also be used
ing one hinge, threaded end or hole cannot be
for building a hinge (Figs. 5.1, 5.2, and 5.3).
aligned on the same line. These two hinge types
There are also many alternatives for building
can be used if there is only angulation as a defor-
hinges in Ilizarov’s sets with other parts.
mity. But if rotation is to be corrected, hinges
must be built with half hinges in order to prevent
unnecessary translations.
5.2.2 Posts
These parts are like half hinges. They have female 5.2.3 Plates
and male types with threaded holes or ends. They
are distinguished from the half hinges by addi- Another hinge type can be built with two plates,
tional holes and thickness. Like half hinges, two a nut and a bolt (Fig. 5.7). Plates can also be con-
female, two male, or one male and one female nected with previously described parts.
5 Hinge Types and Positioning 47
Fig. 5.9 Custom-made hinges with two perpendicular

Fig. 5.7 A hinge built with two plates axes
Fig. 5.10 Modification of the custom-made double-axis

hinge to the polyaxial hinge
Fig. 5.8 A polyaxial hinge made of three half hinges
5.2.4 Polyaxial Hinges
We have mentioned uniaxial hinges with a single

motion plane, but it is possible to build multiaxial
Fig. 5.11 Universal joint
hinges with multiple rotational centers if neces-
sary. To do that, three or more half hinges must
be assembled together (Fig. 5.8).
5.2.5 Custom-Made Double-Axis

Hinge
Custom-made hinges are built specifically for the

use of two perpendicular motion axes in a single
system (Fig. 5.9). It can also be modified with
additional hinges and transformed into a polyax-
ial hinge (Fig. 5.10).
Because the two axes need to be able to move
in all directions, a “U-hinge” (universal joint)
was created. These hinges are used in axial defor-
mities or in the joints to allow movement.
U-hinges are connected with threaded rods to the Fig. 5.12 The U-hinge in the foot system is marked with
system (Figs. 5.11 and 5.12). white arrow
5.3 Positioning of Hinges deformity. A malpositioned hinge for opening a

joint contracture can cause luxation in the joint
It is extremely important to insert hinges at the and even create a cartilage defect, which leads to
right positions. The exact positions must be cal- joint ankyloses later.
culated with mathematic formulas. For the calcu-
lation, AP and sagittal view X-rays are required.
The projections of the X-rays must be sketched 5.3.1 P
rinciples of Hinge
onto the papers, and calculations can be made. Positioning
The most important advantage of the IEF is to
adjust the system after application to allow any 1. The rings connected to the hinge must be

movement using the hinges, acutely or gradually. placed perpendicularly to the bones.
With malpositioned hinges, additional deformi- 2. The rotational center of the hinge must be at
ties can occur. For instance, malpositioned hinges the apex of the deformity (Fig. 5.13).
in an angulation deformity create a secondary 3. The correction plane of the deformity must be
in the same plane with the hinges.
4. The hinges must be at the same horizontal
level (Fig. 5.13).
5. For stability, at least two hinges must be

placed facing each other (Fig. 5.14).
Fig. 5.13 The rotational center of the hinge must be at Fig. 5.14 For stability, at least two hinges must be placed
the apex of the deformity facing each other
6. Through the positions of adjustable hinges, recting deformities. The further the hinge is
different types of corrections can be obtained. positioned from the convex cortex, the more
These corrections are open wedge, closed the increase in the lengthening amount.
wedge, neutral wedge, compression, distrac- Distraction hinges are used in situations in
tion, translation, and rotation. The hinge posi- which deformities or hypertrophic pseudoar-
tions for these different correction models are throsis is associated with shortness or bone
explained below. loss. The amount of shortness determines the
distance of the hinge to the convex side.
Hinges serve different purposes depending on
their positions and sides.
Hinge positioning is explained in three main
subjects:
5.3.2 Hinges on the Bisector Line

Bisector Line
Hinges on the bisector line can be positioned on
the convex side, on the concave side, or at the A B C
bone outline (Fig. 5.15).
(a) Convex Side: When the hinge is positioned on

point A in Fig. 5.15 (outside of the convex cor-
tex), distraction occurs while deformity is cor-
rected. Distraction of the concave side is more
than the convex side (Fig. 5.16). Hinges posi-
tioned like this are called “distraction hinges.”
Distraction hinges lengthen bone while cor- Fig. 5.15 Hinge positioning on bisector line
a b
Fig. 5.16 (a, b) The distraction hinge at the top and situ- correction. Points A and B move in a circle that is cen-
ation after the correction at the bottom. Pay attention to tered by the hinge. The distance between points A and B
the distance between points A and B before and after the and the hinge is the diameter of the circle
(b) Bone Outline: Hinges on the bone outlines bone, these hinges are called “open-wedge
play different roles (Fig. 5.17). hinges.” These hinges lengthen bones
1. Convex Cortex: When the hinge is posi- moderately while correcting deformities
tioned on point B1 in Fig. 5.17 (on the con- and are used at deformities and pseudoar-
vex cortex), the contact at the convex cortex throsis with mild shortness and sclerotic
remains while the deformity is corrected. pseudoarthrosis.
Distraction of the concave side creates a 2. Middiaphyseal Line: When the hinge is
triangle-shaped bone defect (Fig. 5.18). positioned on the B2 point in Fig. 5.17
Because the bone defect is triangle-shaped (on the middiaphyseal line), contact at
the convex cortex remains while a
triangle-shaped bone defect occurs at the
concave side. Distraction of the concave
side creates a triangle-shaped bone
defect that is smaller than the open-
wedge hinge (Fig. 5.18). At the same
time, similar triangle-shaped bone com-
Bisector Line presses the convex side.” This hinge type
B1 B2 does not change the length of the bone
B3
while correcting the deformity and is
used at the deformities and in non-scle-
rotic pseudoarthrosis, which needs bio-
logical stimulation without lengthening.
These hinges use compression and
distraction and at the same time are
called “neutral hinges.”
3 . Concave Cortex: When the hinge is posi-
tioned at the B3 point in Fig. 5.17 (on the
Fig. 5.17 Hinges on the bone outline, B1 convex cortex,
B2 middiaphyseal line, B3 concave cortex concave cortex), compression occurs on
a b
Fig. 5.18 (a, b) Illustration of the correction of a deformity in a circle, centered by the hinge. Increasing distance
with an open-wedge hinge. Before (top) and after (bottom) between points A and B refers to the bone lengthening
the correction; pay attention to points A and B, which move
the convex side while the concave side pseudoarthrosis without shortness and
remains the same. Compression of the atrophic pseudoarthrosis.
convex side creates a shortening on the (c) Concave Side: When these hinges are posi-
bone (Fig. 5.20). This hinges are called tioned in point C (Fig. 5.15) (outside of the
“closed-wedge hinges.” This hinge type concave cortex), compression occurs while
shortens bone while correcting deformi- deformity is corrected. Compression of the
ties and is used at the deformities and convex side is more than the concave side
a b
Fig. 5.19 (a, b) Before (top) and after (bottom) correction with a neutral hinge. The distance between the points A and
B remains exactly the same
a b
Fig. 5.20 (a, b) Before (top) and after (bottom) correction with a closed-wedge hinge. The distance between points
A and B reduces
(Fig. 5.21). These hinges can also be used 5.3.3 Proximal Hinges
for reduction at the fracture site (Fig. 5.22).
The further the hinge is positioned from the As mentioned before, hinges can also be used for
concave cortex, the amount of the compres- fracture reduction. If there is a translation with an
sion increases and is called a “compression angular deformity on a fracture, both deformities
hinge.” Compression hinges shorten bones. can be corrected with same hinges. This can also be
However, these hinges are not commonly used in pseudoarthrosis. If the hinge is positioned
used; they can be selected in osteoporotic distally or proximally to the bisector line, it is
bones and deformities with bone defects. called a “translation hinge.” Proximal hinges can
a b
Fig. 5.21 (a, b) Illustration of the compression hinge and its working principle
a b
Fig. 5.22 (a, b) Before (top) and after (bottom) the use of compression hinges for reduction. Pay attention to the con-
vergence of points A and B
be positioned on the concave side, on the convex At the same time, distraction occurs more at
side, or on the bone outline (Fig. 5.23). the concave side, which refers to the bone
lengthening. These hinges are called
(a) Convex Side: When proximal hinge are posi- “translation-distraction hinges.”
tioned in point A (Fig. 5.23) (outside of the (b) Bone Outline: When the proximal hinge is
convex cortex), the distal fragment moves to positioned at point B in Fig. 5.23 (on the
the convex side and the proximal fragment bone outline), the distal fragment moves to
moves to the concave side while the defor- the convex side and the proximal fragment
mity is corrected. Translation occurs between moves to the concave side while the defor-
distal and proximal fragments (Fig. 5.24). mity is corrected. Translation occurs
between the distal and proximal fragments.
However, distraction and compression
occur at the same time, and the bone length
remains the same, like the effect of neutral
hinges (Fig. 5.25). These hinges are called
“translation hinges.” The difference with
neutral hinges is the translation of the
fragments.
(c) Concave Side: When the proximal hinge is
positioned at point C in Fig. 5.23 (outside
of the concave cortex), the distal fragment
moves to the convex side and proximal
fragment moves to the concave side while
the deformity is corrected. Translation
occurs between the distal and proximal
fragments (Fig. 5.26). At the same time,
compression occurs more at the convex
side, which refers to the bone shortening.
These hinges are called “translation-com-
Fig. 5.23 Proximal hinge positioning pression hinges.”
a b
Fig. 5.24 (a, b) Illustration of the translation-distraction hinge and its effect. Pay attention to the divergence of the A
and B points
a b
Fig. 5.25 (a, b) Illustration of the translation hinge and its effect. Pay attention to the constant distance between points
A and B
a b
Fig. 5.26 (a, b) Illustration of the translation-compression hinge and working principle
a b
Fig. 5.27 (a, b): Before (top) and after (bottom) the use of the translation-compression hinges for reduction. Pay atten-
tion to the convergence of points A and B
5.3.4 Distal Hinges (a) Convex Side: When the distal hinge is posi-
tioned at point A in Fig. 5.28 (outside of the
Translation hinges can also be positioned distally convex cortex), the distal fragment moves to
from the bisector line. Distal hinges translate the the concave side and the proximal fragment
distal fragment to the counter-side, which is done moves to the convex side while the deformity
by the proximal hinge. While the deformity is is corrected. Translation occurs between the
corrected, the proximal fragment moves to the distal and proximal fragments (Fig. 5.29). At
convex side and distal fragment moves to the the same time, distraction occurs more at the
concave side. Distal hinges can be positioned in concave side which refers to the bone length-
three different ways (Fig. 5.28). ening. These hinges are called “translation-
distraction hinges.”
(b) Bone Outline: When the distal hinges are
positioned at point B point (Fig. 5.28) (on
the bone outline), the distal fragment moves
to the concave side and the proximal frag-
ment moves to the convex side while the
deformity is corrected. Translation occurs
between the distal and proximal fragments.
Distraction and compression occur at the
same time, and the bone length remains the
same, like with the effect of neutral hinges
(Fig. 5.30). These hinges are called “transla-
tion hinges.” The difference between these
and neutral hinges is the translation of the
fragments.
(c) Concave Side: When the distal hinge is posi-
tioned at point C (Fig. 5.28) (outside of the
concave cortex), the distal fragments move
to the concave side and the proximal frag-
Fig. 5.28 Distal hinge positioning ment moves to the convex side while the
a b
Fig. 5.29 (a, b) Before (top) and after (bottom) the use of the translation-distraction hinges for reduction. Pay attention
to the divergence of points A and B
a b
Fig. 5.30 (a, b) Illustration of the translation hinge and its effect. Pay attention to the constant distance between points
A and B
a b
Fig. 5.31 (a, b) Illustration of a translation-compression hinge and its working principle
deformity is corrected. Translation occurs are called “translation-compression hinges.”

between the distal and proximal fragments The distance between the hinge and the
(Fig. 5.31). At the same time, compression bisector line increases with the amount of
occurs more on the concave side, which the translation. These hinges can also be used
refers to the bone shortening. These hinges for reduction at fracture sites (Fig. 5.32).
Fig. 5.32 (a, b) Before (top) and after (bottom) translation-compression hinge reduction. Pay attention to the conver-
gence of points A and B
5.4 Dual-Axis Hinges
A dual-axis hinge (double-axis hinge) corrects

two deformities at the same time. For example, a
frontal-plane deformity can be accompanied by a
sagittal-plane deformity in a tibia. If these two
deformities are to be corrected at the same time,
a dual-axis hinge must be used.
As mentioned before, custom-made dual-
axis hinges can be used for correction, espe-
cially in foot and hand deformities. A dual-axis
hinge can also be built with three half hinges
(Figs. 5.9 and 5.10).
5.5 Correction Speed

with Hinges
If the hinges are positioned as in Fig. 5.33, the Fig. 5.33 Application of the similar triangle law for posi-
amount of compression or distraction can be calcu- tioning the hinges
lated because of the similar triangle law (ab/ad =
bc/de = 1/2). The correction speed between b and c tions, this speed needs to be adjusted. For a healthy
points must be 1 mm/per day. Speed must be child, 1.5 mm/day speed concludes with good
adjusted according to the distance bc because it is regeneration. For an osteoporotic bone of a 70-
the most distracted area. Fast distraction compro- year-old patient, the optimum speed is 0.5 mm/day.
mises the quality of regeneration. If distraction is However, the distraction forces on the convex
too slow, early consolidation occurs. In some situa- cortex are not as strong as on the concave side; in
Fig. 5.34 Concentric rings theorem for hinge positioning

Fig. 5.35 Calculation of correction time
practice, this does not create a problem. The c orrection can be calculated with the formula:
distraction forces on the soft tissue are not the time = length/speed. Length can be calculated
same at every point either. The main restrictive with the formula when the concentric rings are
factors are nerves and tendons while correcting drawn: 2πRα/360 (ab = R = radius), 2πR =
soft tissue deformities. For example, while cor- length of the circle’s circumference. α is the
recting an equinus deformity, the Achilles tendon deformity angle. Speed is usually 1 mm/day
is the main restrictive factor. While correcting a (Fig. 5.35).
knee contracture deformity, the sciatic nerve is To explain the total correction time to the
the main restricting factor. patient, correction and consolidation times must
In complex systems, instead of the similar tri- be considered and mentioned.
angle law, concentric rings theorem can be used
(Fig. 5.34). Because of the circular motion around
the hinges, this theorem is much more accurate Bibliography
than the similar triangle law.
Two concentric rings must be drawn that are 1. Golyakhovsky V, Frankel VH. Operative manual of
ilizarov techniques. St. Louis: Mosby; 1992. p. 2.
tangential to the concave cortex and motor unit. 2. Herzenberg JE, Waanders NA. Calculating rate
Daily distraction amount = ac/ab × 1 mm/day. and duration of distraction for deformity correc-
Both calculation methods must be checked tion with ilizarov technique. Orthop Clin North Am.
with new X-rays every 2 weeks. 1991;22(4):601–11.
3. Lavelle DG. Chapter 52: Delayed union and pseudo-
arthrosis of fractures. In: Campbell’s operative ortho-
pedics, 9th ed; CV. Mosby. Co Publishing, St. Louis
5.6 Correction Time with Hinges 1998. p. 2595–9.
4. Maiocchi AB, Aronson J. Operative principles of ilizarov,
ASAMI. Baltimore: Williams & Wilkins; 1991. p. 4.
Patients treated with Ilizarov’s external fixator 5. Paley D. The principles of deformity correction by the
usually ask surgeons about the external fixator Ilizarov technique : techincal aspects. Tech Orthop.
time. For angular deformities, the time of 1989;4(1):P15–29.
Techniques for Building the Frame
6
6.1 General Principles and at least on two different directions. Distal sys-
tem of the frame is formed by fixation of K-wires to
Frames must have the features indicated below: the bone at least on two different levels and direc-
tions. The frame has three main components. These
1 . Rigid fixation to the bone are proximal system, distal system, and conjunction
2. Prevent major movements of bone fragments apparatus, which connect those two systems.
3. Enable bone fragments to move for distrac-
tion, compression, rotation, and translation
6.1.1 Proximal System
Any desired movement of the bone fragments
can be achieved with the frame established with The proximal system holds the proximal frag-
those principles. ment of the bone and enables external control.
The most important components of frames in This system consists of at least of two rings.
Ilizarov’s external fixator are the rings. Rings
have three important roles: 6.1.1.1 Proximal Main Support Ring
This is located on the basis of the frame and acts
1 . Enable frame building as the center, which guides the other components.
2. Support K-wires At first, the place of the main proximal support
3. Support the extended sections of the frame. ring must be determined (Fig. 6.1).
The most proximal and steady part of the bone
At least two levels and two different directions is preferred for application, as this ring will carry
for adequate fixation of each fragment are needed the frame’s entire load. The most proximal part
after a fracture or osteotomy. Proximal system of of the bone is chosen because the longer the dis-
the frame is formed with the fixation of the proxi- tance between the proximal and distal rings in
mal fragment with two rings on two different levels each section (proximal and distal block) makes
the frame more stable. It is not possible to apply
a full ring on the proximal region of the femur
M. Çakmak, Prof. MD (*) • M. Cıvan, MD and humerus because of their anatomic structure
Istanbul University, Istanbul Faculty of Medicine, and relationship with joints. Ilizarov preferred
Orthopedic and Traumatology Department, half rings for proximal regions of femur and
e-mail: profcakmak@gmail.com; humerus. We prefer the “Italian femoral arch”
melihcivan@gmail.com developed by Catagni and Cattaneo on proximal

https://doi.org/10.1007/978-3-319-45675-1_6
Fig. 6.3 Italian femoral arches designed by Catagni and

Cattaneo
be measured on the patient. The largest part of the

extremity region is measured where the other rings
will be fixed, because we prefer rings of the same
diameter. There must be at least 2 cm distance
between the inner edge of the ring and the skin.
(Or there must be enough space for two fingers.)
Because we obtain rings with the same diameter,
we will also determine the diameter of proximal
support ring. The distance between the proximal
support ring and the skin can be larger but not
Fig. 6.1 An illustration of a pseudoarthrosis on the right
tibia and identification of the location of the proximal smaller. The ring is generally fixed with two
main support frame K-wires to the bone in the proximal tibia. One
K-wire and one or two Schanz screws may be used
for fixation. We prefer two Schanz screws for fixa-
tion of rings to proximal humeri and femurs.
6.1.1.2 Pushing/Pulling Ring

Secondly, the position of the pushing/pulling ring
must be determined. This ring is a dynamic com-
ponent used for applying compression and distrac-
tion forces on the fracture or at the pseudoarthrosis
region. The most appropriate place that enables a
steady fixation is the distal end of the proximal
Fig. 6.2 Proximal pelvic ring used by Dr. Ilizarov at fragment. In cases of o steotomies and fractures,
proximal regions of femur additional microfractures may occur on the distal
point of the proximal fragment (Fig. 6.4).
femurs and omega-shaped rings on proximal Fixation of rings to bone will be inappropriate
humeri (Figs. 6.2 and 6.3). if K-wires are located on microfractures or osteo-
Ilizarov used K-wires for fixation in proximal porotic bone endings and compression – distrac-
regions, but we prefer Schanz screws in this region tion mechanism can be unable to be used.
due to difficulty of the fixation and complications Besides, inappropriate fixation of the distal
of K-wires. The location of the proximal ring must region of the proximal fragment leads to insuffi-
be identified on X-rays. The ring is positioned per- cient fixation of the whole ring. Hence, a 4 cm
pendicularly to the anatomical axis of the bone. inner point from the distal region must be pre-
Afterwards, the size and diameter of the ring must ferred for application.
6 Techniques for Building the Frame 61
Fig. 6.4 Position of the proximal pushing/pulling ring Fig. 6.5 Building the proximal system by connecting two
rings with threaded rods
6.1.1.3 Connections of the Proximal

Block
When the proximal main support ring and push-
ing/pulling ring are connected with four
threaded rods, the proximal system is now cre-
ated (Fig. 6.5).
Generally three or four threaded rods are used
for that purpose. Rods are fixed to anteromedial,
posteromedial, and posterolateral regions when
three threaded rods are used. We prefer four
threaded rods fixed to the anteromedial, anterolat-
eral, posteromedial, and posterolateral regions.
Threaded rods must be placed on frontal and sag-
ittal axes parallel to the bone. Practically, this fea-
ture is obtained by fixing the threaded rods parallel
to tibial crista; otherwise, the array of fragments
will be destroyed when the wires are fixed. Fig. 6.6 Telescopic rods and wrench cubes can be used
Threaded rods must be parallel to one another, for creating more stable connections or step cuts
and the distance between the rods must be as
equal as possible. To accomplish this, rods must Telescopic rods must be preferred in such cases.
be fixed to the holes in equal distances from the For creating more stable connections, rods may
center line. If the distance extends or if the patient be used by passing them through wrench cubes
is overweight, threaded rods may remain weak. (Fig. 6.6).
Fig. 6.7 Completion of the proximal block with the addi- Fig. 6.8 An illustration of a pseudoarthrosis on the right
tion of K-wires to the bone tibia and identification of the location of the distal support
frame with the completed proximal block
Proximal block is completed with the addition

of the transosseous K-wires to the proximal sys-
tem (Fig. 6.7). used for knee and elbow joints. When “carbon
fiber” rings are used, they are nipped with a
Gigli wire saw to enable free joint
6.1.2 Distal System movements.
This ring can be fixed or dynamic. It is always
The distal system fixes the distal fragment of the fixed vertically to the anatomic axis of the distal
bone and enables manipulation of the system. fragment. We prefer to fix this ring with two
Basically, this system consists of at least two K-wires. The ring can be fixed with one K-wire
rings. and one Schanz screw depending on the sur-
geon’s choice.
6.1.2.1 Distal Support Ring
This is the main component that fixes the distal 6.1.2.2 Distal Guide Ring
fragment. Therefore, it is fixed to the most distal This ring is fixed to the most steady and most
and steady part of the bone (Fig. 6.8). proximal part of the distal fragment (Fig. 6.9).
The wires must be fixed 3–5 cm behind the It must be fixed vertically to the anatomic axis
joint line so as not to prevent the joint move- and must not be closer than 3–4 cm to the end of
ments. Rings with 5/8 dimensions must be the fragment.
Fig. 6.9 Position of the distal guide ring Fig. 6.10 Completion of the distal system by connecting
two distal rings with threaded rods
6.1.2.3 Connections of the Distal Block

The distal system is created by connecting the
distal support ring and distal guide ring with
threaded rods (Fig. 6.10). The distal block is cre-
ated by fixing the distal system with transosseous
K-wires (Fig. 6.11).
6.1.3 System Connections
After building the proximal and distal blocks, the

fragments can easily be manually controlled. The
main purpose of creating the proximal and distal
blocks is to enable the external and manual control
of the bone fragments. Manipulations of the frag-
ments will be possible with the augmented con-
nections between the proximal and distal blocks.
Compression, distraction, and deformity cor-
rections (translation, rotation, and angulation)
and reductions will be possible with the correct
arrangements and system connections on the
bone; chondrolysis and even dislocation may
occur at the close joints such as the knee joint as Fig. 6.11 Creating distal block by connecting the rings to
a consequence of incorrect implementations. the bones with K-wires
Fig. 6.12 A case of

pseudoarthrosis on tibia
(left) and identification of
the location of the rings
(right)
Deformity corrections are generally per- Let’s explain the building of the frame step by
formed with hinges and will be discussed in a step using a tibia illustration as follows:
specific chapter.
(a) First, the location of the rings must be identi-
fied on X-ray and/or on the patient (Fig. 6.12).
6.2 Building the Frame (b) A K-wire must be inserted into the anterior
aspect of tibia positioned parallel to the joint
Ilizarov frame can be built either during the oper- with 3 to 4 cm distance (Fig. 6.13).
ation or before the surgery. In both ways, the (c) Rings are used in appropriate sizes, and cor-
resulting frames are identical. We prefer to create rect fixation holes are chosen for the K-wires
the frame 1 day before the operation so as to (Fig. 6.13 – right). During this process, the
shorten the duration of the operation. tibia must be centralized, and there must be
at least 2 cm circular distance between the
ring and the skin. If inappropriate holes are
6.2.1 B
uilding the Frame chosen, undesired translation and rotational
During the Operation movements may develop with a wire stretch-
ing p rocess. This feature may rarely be used
A sterile Ilizarov set must be provided ready to for desired various translation and rotation
build the frame during the operation. The frame is movements.
built using the required pieces consecutively and (d) A K-wire is fixed to one of the appropriate
step by step. If the frame is to be created during holes on the ring and wire stretching is per-
the operation, K-wires are inserted into the bone formed with wire stretching apparatus and
and the rings are then tied to the K-wires. After the other end of the K-wire is also fixed
that, the rest of the pieces are tied to the ring. (Fig. 6.14 – left).
Fig. 6.13 Deter
mination of the
appropriate fixation
holes on the ring by
inserting K-wires on
proximal support ring
level
Fig. 6.14 The proximal

support ring is fixed to the
bone (left), and a K-wire is
inserted at the level of
wire-tensioner ring (right)
Fig. 6.15 Deter
mination of the correct
holes on the ring with
the appropriate size
(left) and fixation of
K-wires to the holes
(e) One K-wire is inserted vertically to the tibia

from the level determined for the wire-
tensioner ring (Fig. 6.14 on the right).
(f) The correct fixation holes are chosen using
the rings in appropriate size as described ear-
lier (Fig. 6.15 – left), and a K-wire is fixed to
the holes by stretching (Fig. 6.15 – right).
Finally, the proximal base support ring and
wire-tensioner ring are fixed to the bone.
(g) After that, the proximal block must be built
using the interconnection structures.
Threaded rods are generally used in this pro-
cess (Fig. 6.16).
Telescopic rods and cubes may also be used

when more stabilization is desired, particularly
when there is a long distance between the two rings.
(h) For building the distal system, a ring must be

fixed to the pushing/pulling ring perpendicu-
larly to the axis of the distal fragment in a
predetermined level without fixation to the
Fig. 6.16 Building the proximal block by combining the
bone (Fig. 6.17) because the location of this proximal support ring and wire-tensioner ring with
ring may need to be modified. threaded rods
Fig. 6.17 Fixation of the guide

ring to the bone on the
predetermined level (left) and
connection with the pushing/
pulling ring (right)
(i) The distal fragment’s first K-wire must be (j) The distal support ring is fixed to the bone
inserted perpendicularly to the axis of the dis- using a K-wire (Fig. 6.19 – left) and tied to
tal fragment and parallel to the ankle joint (Fig. the guide ring with threaded rods (Fig.
6.18 on the left), and the correct holes are cho- 6.19 – right).
sen for fixation to the distal base support ring (k) Finally, the guide ring is fixed to the bone
(Fig. 6.18 – right). The K-wire must hold gen- using K-wires, and the distal block is created
tly to prevent bending; otherwise, the fragment (Fig. 6.20).
will be displaced when the wire is stretched.
Fig. 6.18 Position
ing of the distal
K-wire of distal
support ring, which
must be parallel to
the ankle joint and
perpendicular to
the mechanical axis
of the distal
fragment at a
predetermined
level (left), and
determination of
the holes on distal
support ring for
fixation (right)
Fig. 6.19 Fixation
of the distal support
ring (left) and
connection of the
distal support ring
with the guide ring
with the help of the
rods (right)
6.2.2 Frame Building

Before Surgery
The frame can be built 1 day prior to surgery

appropriate with the scheduled treatment after
the evaluation of the patient and the X-rays.
Required final corrections are performed using
radiography imaging on the patient to avoid
loss of time during the operation (Fig. 6.22).
The frame must be sterilized as a whole, so the
sterile device can be fixed to the patient’s
extremity at the beginning of the operation
(Figs. 6.21 and 6.22).
The rings must be placed perpendicularly to
the bone axes and rods must be parallel to the
bone (both in frontal and sagittal plane), and the
hinge must be placed on the CORA (Fig. 6.23
left). Deformities will be fixed when all the rings
are set parallel to each other with the help of the Fig. 6.20 The distal block is completed with the
fixation of the guide ring to the bone using K-wires.
hinge and the motor unit, if the frame is placed Any desired movement can be performed on distal and
appropriately (Fig. 6.23 – right). proximal fragments using this frame
Fig. 6.21 Locations of the rings are marked on the radiography image and/or on the patient (left), and the frame is cre-
ated in accordance with the frame (right)
Fig. 6.22 An X-ray of a pre-built frame before

surgery for the ultimate modifications of the frame
Fig. 6.23 The frame is

placed perpendicularly and
rods parallel to the long
axis of the frame, and the
hinge is placed on the
CORA (left). Deformities
can be corrected with the
help of the hinge and
motor unit (right). At the
end of the correction, all
the rings will be parallel to
the others
6.3 Frame Applications to Femur 6.3.1 Building the Proximal System
We will explain the application of the frame to 6.3.1.1 Proximal Base Support Ring
the femur step by step on a case genu valgum As a start position, the main support ring of the
deformity (Fig. 6.24 – left). A malalignment test frame must be determined. The most proximal
was performed, and the deformity was found to and steady part of the femur is preferred for
originate from the distal part of the femur. application. The ring will carry all loading of the
Proximal and distal anatomic axes of femur were frame, so it has to be at a rigid position. We pre-
drawn (yellow lines), and the CORA point was fer Italian femoral arches with a 90° angle on
identified (green circle); a 25° angle was mea- femurs for proximal support rings. The femoral
sured (Fig. 6.24 – right). Location and direction arch must be fixed to the anterolateral side, not to
of the osteotomy were determined by drawing an the lateral to enable physiologic functions such
bisector angle passing through the CORA point as sitting. By doing so, the gluteal region of the
(green line). patient will be free. Location of the crescent
Fig. 6.24 A patient with

genu valgum deformity:
clinical photo (left) and
X-ray (right)
Fig. 6.25 Location of the main support

ring (on the left) and the pushing-pulling
ring (on the right) on radiography
imaging
must be determined on radiography imaging and 4 cm behind the osteotomy region (from the
must be positioned at the level of minor trochan- CORA point) must be preferred. We prefer full
ter of the femur. The ring must be fixed perpen- rings while positioning the pushing-pulling ring
dicularly to the anatomic axis of the femur. to the distal region of the femur, whereas for
The size and diameter of the ring must then be proximal positioning, we use crescent rings with
determined according to the patient’s limb 120° angle. The diameter of the pushing-pulling
(Fig. 6.25 – left). ring must preferably be the same as the diameter
of the proximal support ring in both full and cres-
6.3.1.2 Pushing-Pulling Ring cent rings; otherwise, complications such as
The location of the pushing-pulling ring must be translations may occur in the process.
identified. This ring is a dynamic ring to where
compression and distraction forces are applied. 6.3.1.3 Proximal Ring Connections
The most appropriate place is the most steady Proximal system can be built by connecting two
and the most distal point of the proximal frag- proximal rings with threaded rods and cubes or
ment (Fig. 6.25 on the right). A location about L-connections (Figs. 6.26 and 6.27).
Fig. 6.26 Connection of the rings with generated medial

support with the help of L-connectors
Fig. 6.27 Creating a proximal system by connecting the

proximal main support ring and pushing-pulling ring with
6.3.2 Building the Distal System the help of threaded rods
6.3.2.1 Distal Support Ring line), and there is an 81° angle between them
The distal support ring is the main component (aLDFA), so it has a 6° angle with the mechan-
that ultimately fixes the distal fragment, so it ical axis. Therefore, this ring, which is posi-
must be positioned at the distal and the most tioned perpendicularly to the anatomic axis,
steady region of the femur (Fig. 6.28 on the will have a 6° angle with the knee joint orienta-
left). This position refers to the epicondyle tion line. If a full ring is used, it will prevent
line. Wires must be fixed to 3 to 5 cm proximal flexor movement of the knee. So the ring with
of the joint line. This ring can be rigid or mov- 5/8 dimension must be chosen for fixation by
able. However, it must always be positioned replacing the open region to the popliteal
vertically to the anatomic axis of the distal region, or the posterior 3/8 part of the ring is
fragment. The anatomic axis of the femur is nipped with a Gigli saw while using a “carbon
not vertical to the joint orientation line (red fiber” ring.
Fig. 6.28 The position of the distal

support ring (left) and the guide
ring (right)
6.3.2.2 Guide Ring the crescent rings or Italian femoral arches

The guide ring must be fixed to the most steady (Fig. 6.29). Telescopic rods and cubes can be
and proximal part of the distal fragment (Fig. 6.28 used instead of threaded rods to improve the sta-
on the right). It must be positioned perpendicu- bility of the system.
larly to the anatomic axis and no closer than
3–4 cm to the end of the fragment. In proximal
regions, half or crescent-shaped rings can be used 6.3.3 Checking
instead of whole rings, which are used at more
distal regions of the femur. After the frame is prepared, it must be checked
on the patient clinically and with radiography
6.3.2.3 Distal Ring Connections images. It is a simple but useful method for
The distal block can be built by connecting two shortening the duration of operations. If a
rings using threaded rods or L-connections for nonconformity is identified, it can be fixed
Fig. 6.30 Radiography image of the frame after

osteotomy
before the operation, and time loss can be

prevented.
As described on the above example, after
the application of the appropriate frame, oste-
otomy was performed (Fig. 6.30) on the level
of angle bisector, and valgus deformity on
Fig. 6.29 Distal block built by connection of the distal femur was fixed clinically and radiologically
support and guide rings with threaded rods (Fig. 6.31).
Fig. 6.32 Clinical appearance of a patient with genu

varus deformity on the right lower extremity (left) and
X-ray (right)
Therefore, there has to be 3 systems (proxi-

mal, intermediate, and distal systems) instead of
2 because the tibia will comprise 3 separate
Fig. 6.31 Post-op radiography image fragments after performing 2 osteotomy

applications.
The proximal system holds the proximal frag-
6.4 Frame Application to Tibia ment, the intermediate system holds the interme-
diate fragment, and the distal system holds the
We will explain the steps of building a frame on a distal fragment. The three systems are connected
case with varus deformity on the right tibia with intermediate connections.
(Fig. 6.32).
The required planning was made, mechanical
axis of femur and tibia were drawn (red lines), 6.4.1 Building the Proximal System
and the CORAs (black dots) were identified
(Fig. 6.33). 6.4.1.1 Proximal Base Support Ring
There were two CORAs: one on the proximal The position of the main support ring of the
and the other on the distal part. Osteotomy was frame must be determined first. The location of
planned in a 2-level correction. the main support ring must be 3–5 cm below the
Fig. 6.34 Application of the proximal support ring (left)

and fixation from a second level because it will also be
used as pushing-pulling ring (right)
must be fixed in two different levels and two dif-

ferent directions with transosseous K-wires. Two
consoles are added to the base support ring, and
fixation is applied from the second level [4] (Fig.
6.34 – right).
Fig. 6.33 Radiography image of a patient with genu

varum deformity on the right lower extremity 6.4.2 B
uilding the Intermediate
System
joint surface of the tibia. A ring with 5/8 open 6.4.2.1 Base Support Ring
posterior must be chosen to enable the flexor This ring must be positioned at the distal and
movement of knee. The ring (green lines) must steady part of the medium segment. It is fixed
be positioned perpendicularly to the mechanical 3–5 cm proximal from the distal osteotomy level
axis and parallel to the joint orientation line (yel- and vertical to the mechanic axis [3] (Fig.
low line) (Fig. 6.34 – left). 6.35 – left).
6.4.1.2 Pushing-Pulling Ring 6.4.2.2 Guide Ring

As the proximal fragment is very short, it is not The guide ring must be positioned perpendicu-
possible to replace two rings there. For that rea- larly to the anatomic axis of the tibia 3–4 cm dis-
son, the base support ring is also used as pushing- tal of the proximal osteotomy line (Fig. 6.35 on
pulling ring. To enable that, the base support ring the right).
Fig. 6.36 Fixation of the distal support (left) and the

Fig. 6.35 Fixation of the support ring of the medium sys- guide rings (right)
tem (left) and the guide ring (right)
6.4.2.3 Medium System Connections

The rings are tied to one another with threaded rods.
6.4.3 Building the Distal System
6.4.3.1 Distal Support Ring

The distal support ring must be positioned at the
distal and steady part of tibia. The best position is
the level of the distal metaphysis of tibia. It must
be positioned perpendicularly to the mechanical
axis and parallel to the joint line and 3–5 cm
proximal of the joint line [1, 2] (Fig. 6.36 – left).
6.4.3.2 Guide Ring

This ring must be positioned at the 3–4 cm distal
of the osteotomy line [3] (Fig. 6.36 – right).
6.4.3.3 Distal Ring Connections

The distal support ring and guide ring are Fig. 6.37 Building the proximal, segmenter, and distal
connected with three or four threaded rods systems (left) and fixation of the hinges in appropriate
(Fig. 6.37 – left). This enables the required locations
Fig. 6.38 Radiologic check of the frame on the patient Fig. 6.39 Radiography image of the proximal and distal
osteotomies
stability. All fragments can be held by creat-

c orrections are performed, and thus the duration
ing the distal system. With this method,
of the operation is shortened.
hinges can be fixed to appropriate locations
After applying all these processes, the proxi-
(Fig. 6.37 – right).
mal and distal osteotomies are performed at the
level of the angle bisectors of the CORAs that
were determined with malalignment tests earlier
6.4.4 Checking (Fig. 6.39).
The radiologic (Fig. 6.40) and clinical (Fig.
Clinical and radiologic (Fig. 6.38) checks of the 6.41) appearances of the patient are shown
frame are performed on patient, required below.
Fig. 6.40 Comparison of the first

(left) and the final (right) positions on
radiology images
Fig. 6.41 Preop and

post-op clinical appearance
of the patients
Ilizarov method. In: Robert E. Eilert (ed.). Instructional

References course lectures, vol. XLI; AAOS publishing. 1992.
3. Golyakhovsky V, Frankel VH. Operative manual of
1. Bagnoli G, Paley D. Application of apparatus, Basic Ilizarov techniques. St. Louis: Mosby; 1993. p. 2.
Components and Technical Aspects, in the Ilizarov 4. Maiocchi AB, Aronson J. Operative principles of
Method; B.C. Decker, 1990. p. 19–48. ilizarov, ASAMI. Baltimore: Williams & Wilkins;
2. Catagni MA. Chapter 47: Trends in the treatment of 1991. p. 4.
simple and complex bone deformities using the
Ten Basıc Rules for Ilizarov
Applications 7
Cengiz Şen
7.1 eing Careful for Anatomic

B 7.2 Biomechanical Features
Structures of Kirschner Wires
and Schanz Screws
The first rule for the circular external fixator
(CEF) application is being careful for the ana- Trocar tip K-wire for spongious bone and bayonet
tomic structures while placing wire and screws. tip K-wire for cortical bone should be used. K-wires
The anatomy atlas must be studied before sur- can be tensioned up to 120 Nw/m at distal femur
gery, or the patient can even be brought to the and proximal tibia. The biomechanically strongest
operation room [1–5]. Thus, neurovascular combination can be obtained by using K-wires and
injury rates can be decreased to as low as possible Schanz screws together. Wires and screws should
(Fig. 7.1). be placed at 60° angle while caring for anatomic
structures. The use of one K-wire and two Schanz
A screws for distal femur and proximal tibia (delta
Femoral Artery,
shape) is the strongest combination (Fig. 7.2).
Vein and Nerve
60º Schanz screws can be placed directly at
Safe metaphyseal site, but it should be drilled first
Zone
while placing at diaphyseal site to protect the
L M
30º
Sciatic Nerve
Fig. 7.1 Positioning of Schanz screws properly to the

anatomic structure
C. Şen, MD
34190 Istanbul, Turkey Fig. 7.2 One K-wire and two Schanz screw application
e-mail: senc64@gmail.com in delta shape

https://doi.org/10.1007/978-3-319-45675-1_7
84 C. Şen
bone. Because of the fracture risk, the diameter 7.4 Building the Frame
of Schanz screws should not extend more than
one third of the diameter of the bone. Also, Circular external fixator (CEF) should be pre-
hydroxyapatite coating screws should be used in pared before the procedures for both fractures
lengthening procedures because of better adher- and deformities. In this way, a lot of time is
ence [1]. saved compared with preparing it during sur-
gery. However, the surgeon should keep in mind
that the connection parts of the carbon ring
7.3 eatures of Application
F frames can loosen during sterilization process
of Kirschner Wires and must be tightened. Bone fragments should
and Schanz Screws be fixed at two different levels. The rings must
be positioned at least 3 cm off the fracture site
K-wires and Schanz screws should be cleaned and perpendicular to the axis of fracture frag-
with alcohol before application and held with ments [1, 3, 5]. The rods must be parallel to the
sterile material soaked with alcohol for helping bone axis. If two rings for one fragment are not
proper angulation while placing. A low-speed possible, fixation must be augmented with off-
drill (30–40 rpm) should be used to prevent bone set fixation (Fig. 7.4).
necrosis. After crossing the second cortex, wire L-connectors can be used for medial support,
should be pushed forward using a hammer or a especially for CEF for the femur, to achieve ade-
drill with lower turnover. In this way, neurovas- quate stability (Fig. 7.5).
cular tissues will not twist around the wire at the
exit site [2, 3, 5]. To prevent tissue necrosis at the
wire and screws entry site, the tissue should be
widened using a lancet, and if necessary, an off-
set construction can be built with additional tools
(Fig. 7.3).
Fig. 7.3 Fixation of the wire to the system with offset

construction Fig. 7.4 A proper Ilizarov frame
7 Ten Basıc Rules for Ilizarov Applications 85
Fig. 7.6 Correction of a deformity of a femur using hinges
Fig. 7.5 Building a stable frame around the femur and

use of L-connectors
7.5 Positioning of the Hinges

Fig. 7.7 Two-finger rule in circular external fixator
Hinges are widely used in deformity surgery application on tibia
although they can also be used in some fractures
to obtain anatomic reduction (Fig. 7.6). When
hinges are positioned on the fracture site, they 7.6 ixation of Circular External
F
enable frame movements for angulation. When Fixators (CEF) to the Bone
they are positioned more proximally or distally,
they can be used for correcting both angulations The adequacy of space between the skin and
and translations [1]. For lengthening, hinges rings should be checked before fixation of the
should be positioned at the convex side. For cor- CEF (two-finger rule) (Fig. 7.7).
recting rotational deformities, translation devices For this, a ring with an appropriate diameter
should be used. should be selected before surgery. Screws and wires
86 C. Şen
must be positioned perpendicularly to the bone axis; 7.7 afety of the Soft Tissue
S
first proximal and then the distal wires and nuts and the Surgeon
should be fixed for tibia, and first distal and then
proximal wires and nuts must be fixed to the femur To prevent necrosis in the soft tissue, all entry
taking care that the rods are parallel to the axis of and exit sites of wires and screws should be wid-
the bone. All procedures should be performed under ened using a lancet. Especially if a K-wire’s exit
fluoroscopy, and it should be checked with AP and site is far from the ring, it must not bend over the
lateral X-rays if there is suspicion about orientation ring; instead it should be fixed using posts.
and alignment [4] (Fig. 7.8). After the alignment K-wires and screws should be covered with plas-
is obtained, the frame should be completely fixed tic caps after cutting to protect both the patient
using sufficient K-wires and Schanz screws. and the surgeon (Fig. 7.9).
Fig. 7.8 Positioning of reference wires
Fig. 7.9 Covering
screw ends with plastic
caps
7 Ten Basıc Rules for Ilizarov Applications 87
Fig. 7.11 Osteotomy made with using the multiple-

drilling method
regeneration, principles of distraction should be

carefully observed such as protecting periosteum,
waiting for the latent period (7 days), and 1 mm
Fig. 7.10 Including the foot in the frame elongation per day (0.25 mm per 6 hours) [3].
7.10 Rehabilitation
7.8 I ncluding Adjacent Joint
to Fixation One of the best advantages of the circular exter-
nal fixator and Ilizarov’s philosophy is providing
For fractures close to the joint at the distal tibia early movement and weightbearing of the patient,
(closer than 4 cm), and when lengthening is or as much as can be tolerated. Along with pro-
planned, especially at the metaphyseal site, the tecting joint contractures in the early period, also
foot should be included in fixation to prevent an early return to work is possible for these
equinus contracture [3, 4] (Fig. 7.10). For frac- patients. As a result, patient’s compliance for the
tures at the knee, if the fracture is closer than treatment increases and high motivation brings
4 cm or the tibial plateau is broken, the knee joint more successful results.
should be included in fixation using a ring at the Even though higher success rates and fewer
distal femur. complications are possible when these ten basic
rules are followed, sometimes successful results
cannot be achieved, notably with open fractures,
7.9 Osteotomy fractures with multiple fragments or bone loss,
and one third distal tibia fractures that have higher
Most of the time, osteotomy is unnecessary for pri- rates of pseudoarthrosis. However, by following
mary bone osteosynthesis at fractures, but it should the ten rules in this chapter, osteosynthesis is
be done on the proper level to equalize extremity more possible even in the fractures mentioned
length in fractures with bone loss. Osteotomy can above, and by allowing adjustments on the frame,
be achieved through multiple drilling or using a adding Schanz screws and K-wires, consecutive
Gigli wire (Fig. 7.11). To obtain high-quality distraction-compression applications (accordion
88 C. Şen
technique), and grafting could bring success to 2. Catagni MA. Materials and method. In: Catagni
the treatment. For this reason, even in difficult MA, Maiocchi, editors. Treatment of fractures, non-
unions and bone loss of the tibia with the Ilizarov’s
fractures, these “ten basic rules” will bring better method. Milan: Medi Surgical Video; 1998.
success rates and fewer complication risks. p. 1–21.
3. Ilizarov GA. Transosseous osteosynthesis. Heidelberg:
Springer; 1992. p. 63–137.
4. Paley D, Herzenberg JE. Translation and angulation-
References translation deformities. Heidelberg: Springer; 2002.
p. 195–234.
1. Cakmak M, Bilen FE. Principles of building a frame. 5. Pietrogrande V, Bagnoli G, Paley D. Building the
In: Çakmak M, Kocaoğlu M, editors (in Turkish). frame, basic components and technical aspects. In:
Principles of Ilizarov surgery. Istanbul: Doruk Graphics; The Ilizarov’s method. Milan: Medr Surgical Video;
1992. p. 47–62. 1986. p. 19–49.
Hardware and Osteotomy
Considerations 8
Dror Paley
This chapter was originally published in my book Availability of hardware may be the determining
Principles of Deformity Correction in 2002. I factor in developing countries and in situations in
was asked to publish this chapter for this new which cost is a key concern.
book of my colleagues from Istanbul University. Most deformity corrections can be performed
Because of the limited page numbers and images, with various methods of fixation. The importance
this time I had to extract some of the topics which of the CORA method of planning is that the prin-
are originally mentioned in this chapter. However, ciples can be applied with most hardware sys-
you will be able to find more information about tems. The biggest failings are associated not with
extracted topics on related chapters all along the the type of hardware chosen but rather with the
book, and you can also look for Principles of way it is applied. Often, the osteotomy level and
Deformity Correction in Chap. 11 (Paley D: type of correction are determined by the limita-
Principles of Deformity Correction. Berlin: tions of the chosen hardware rather than the hard-
Springer-Verlag, 2002). ware’s being chosen based on the level and type
of correction.
8.1 Choice of Hardware

8.2 Patient Age
The choice of hardware depends on several fac-
tors: patient age, level of osteotomy, number of With pediatric patients, size and physes must be
osteotomies, type of osteotomy (percutaneous taken into consideration. Bone diameter and
versus open), acute versus gradual correction, length limit the size of the implants that can be
bone factors (diameter, patency of medullary used. Holes in the bone greater than one third of
canal, vascularity, etc.), soft tissue factors (cover- the diameter of the bone significantly weaken the
age, vascularity, etc.), joint factors (stiffness, bone and result in a high risk of fracture through
intra-articular hardware, irritation from hard- the hole, either during fixation or after removal.
ware, etc.), and familiarity of the surgeon with Removal of internal fixation after healing is fre-
the hardware and techniques of application. quently recommended for children and young
adults because of the theoretical risks of carcino-
genesis, stress shielding, and stress risers as well
D. Paley as the difficulties of late removal and future sur-
Paley Orthopedic and Spine Institude,
West Palm Beach, FL, USA gery. Children also heal quickly, and the time for
e-mail: inquiry@paleyinstitute.org fixation is therefore short. Accordingly, external

https://doi.org/10.1007/978-3-319-45675-1_8
90 D. Paley
fixation may be preferable for children in many

situations because the fixator is left in place for a
limited period of time, and no hardware is
retained. External fixation can easily avoid the
physis and can even bridge across joints. The
rapid healing ability of children often obviates
the need for rigid fixation. In some cases, fixation
may be accomplished with crossed K-wires and
plaster. The presence of open physes contraindi-
cates the use of intramedullary nailing (IMN) in
most cases. The risk of avascular necrosis after
femoral nailing through the piriformis fossa cau-
tions against the use of IMN in adolescents with
open physes [1].
Fig. 8.1 To mark a closing wedge, two K-wires are

8.3 Closing Wedge Osteotomy driven perpendicular to each segment, proximal and distal
to the osteotomy
Closing wedge osteotomy is perhaps the most
common method of osteotomy because it pro-
duces excellent bone-to-bone contact and stabil- between the K-wires is measured and should cor-
ity. Closing wedge osteotomies are most respond to the magnitude of angulation. If oste-
commonly stabilized using internal fixation, espe- otomy rule 1 is followed, the concave cortex is
cially with screws and plates. Because bone must left intact and cracked at the time of the closure
be removed, this osteotomy is usually performed of the wedge. If the osteotomy line needs to be
open, under direct vision, rather than percutane- translated (osteotomy rule 2), the concave cortex
ously. The most important step is to identify the needs to displace.
closing wedge CORA to avoid creating secondary The bone can be cut freehand or by using a
translation deformities. When the CORA is at the guide. The most common difficulty is preventing
apex of the closing wedge (osteotomy rule 1), the deformity in another plane. This occurs from cut-
bone is realigned without secondary translation ting the two sides of the closing wedge in a nonpar-
deformity. If the CORA is proximal or distal to allel fashion. This will create an angular deformity
the osteotomy line, secondary translation will in another plane to maintain bone contact.
result if translation of the bone ends is not per- Alternatively, if correction is constrained to a plane
formed (osteotomy rule 3). Therefore, when the different from that of the cut, the bone ends will
CORA is intentionally distant from the osteot- not be in contact except at one point. Another com-
omy, the bone ends should be angulated and trans- mon shortcoming of the closing wedge technique
lated according to osteotomy rule 2. is accuracy. Despite preoperative planning, and
K-wires can be used as guides to mark the even the use of templates or guides, inaccuracy can
level and direction of the planned closing wedge occur in making a closing wedge osteotomy
osteotomy (Fig. 8.1). The K-wires should con- because of the thickness of the osteotome or saw
verge on the closing wedge CORA. They should blade, templating error, and the amount of com-
also be in the true plane of angulation. The bone pression of the bone ends by the hardware [2, 8].
can be cut using a saw or an osteotome. It is pref- Templating can be performed by using metal
erable and easier to make each side of the oste- wedges or by inserting Steinmann pins with an
otomy perpendicular to the long axis of each angle-measuring guide. When using an Ilizarov
respective side of the long bone. To ensure that external fixation device, a saw guide can be con-
the correct amount of bone is resected, the angle structed using metal plates (Fig. 8.2).
8 Hardware and Osteotomy Consideratıons 91
Fig. 8.3 When translation is planned, a hemiclosing

wedge (neutral wedge) with translation may be preferable
to a full width closing wedge. The wedge removed can be
used as bone graft on the side of the bone that has the step
due to translation. a angulation, t translation
rection for acute closing wedge with translation is

translation first and then angulation. If angulation
is performed first, the soft tissue and bone hinge
Fig. 8.2 The Ilizarov apparatus can be applied using a may lock, making it technically difficult to dis-
closing wedge hinge (hinge on the concave cortex).
Because the rings on the other side of the hinge are per- place the bone ends. If translation is performed
pendicular to their respective bone segments, the rings can first, the bone ends are shifted when there is little
be used as a saw guide. A plate is suspended from each of bone contact and before there is any soft tissue
the middle rings, and the saw blade rests on the plate tension. When a closing wedge technique is com-
bined with translation, the width of the wedge
The fixator is applied with the proximal rings resected can be reduced, creating a neutral wedge
parallel to the proximal part of the bone and the with translation (Fig. 8.3). The width of the wedge
distal ring parallel to the distal part of the bone, resection corresponds to the area of bone contact
with the hinge centered on the CORA. The plates after the closing wedge is translated. With a neu-
are applied parallel to the proximal and distal tral wedge correction with translation, the half
rings to make the proximal and distal cuts of the wedge resected can be used to fill the space on the
closing wedge osteotomy. translated concave side. A closing wedge correc-
The bone substance removed by closing tion can also be performed, leaving the convex
wedge osteotomy can be morcelized and used as cortex as an instant hinge. If the concave cortex is
bone graft around the osteotomy site. Dissection left intact, the osteotomy can be stabilized with
around a closing wedge osteotomy can usually be staples or a tension band wire.
performed with preservation of the periosteum.
Limited soft tissue dissection is required proxi-
mally and distally on the convex side, with little 8.4 Opening Wedge Osteotomy
if any dissection on the concave side.
When translation is required with closing With opening wedge osteotomy, as with closing
wedge correction, additional soft tissue dissection wedge osteotomy, the appropriate CORA must
is required to permit the bone ends to displace be identified and marked. If the osteotomy is at
relative to each other. If the periosteum is freed up the level of the CORA, the convex cortex acts as
on the concave side, the bone ends will be able to the ACA. The osteotomy is simpler because it is
shift without tearing the concave periosteum. The a single straight cut extending from the concave
advantage of a bone and soft tissue hinge is lost in cortex toward the opening wedge CORA. The
this situation, requiring increased stability from periosteum on the concave side can be elevated
the internal or external fixation. The order of cor- proximally and distally to prevent disruption at
92 D. Paley
the time of opening wedge correction. This

technique is more successful with small opening
wedge corrections. Periosteal integrity on the
concave side is difficult to preserve in most
instances. In contrast, both the periosteum and
the cortex can often be preserved on the convex
side. Opening wedge osteotomies can be per-
formed percutaneously or open. With the former
method, there is minimal soft tissue stripping;
therefore, despite the loss of bone contact, there
is a strong propensity for healing, especially Fig. 8.4 To improve the bone contact at the opening
wedge osteotomy site, the osteotomy can be made at a
with children. When the osteotomy is performed
level different from that of the CORA, and the bone ends
open, it is preferable to minimize soft tissue can be translated so that the corner of one segment is in
dissection. the canal of the other segment
Opening wedge osteotomy is associated with
the risk of bone healing problems because of the Opening wedge correction can be performed
limited bone contact. Nonunion or a low cross- acutely or gradually, depending on the hardware
sectional area of union may result. To prevent used and the severity of the deformity. The larger
this, bone grafting should be considered, espe- the deformity is, the more stretch will result from
cially in diaphyseal regions and in adults. an acute correction. Neurovascular structures are
Morcelled autogenous cancellous bone graft is at the highest risk, especially if they are located on
preferred when internal or external fixation is the convex side. The magnitude of angular defor-
used. Tricortical iliac crest or fibula is preferred if mity that can be corrected acutely when neurovas-
bone grafting is required to provide structural cular structures are on the concave side is larger
support. In the future, bone graft substitutes will than when they are on the convex side (e.g., acute
play an important role, avoiding the need for correction of proximal tibia vara is safer than
bone grafting. Intramedullary “reamings” are acute correction of proximal tibia valga). Opening
another excellent source of bone graft. If IMN is wedge correction stretches the soft tissues more
used for fixation, the reamings will exit into the than does closing wedge correction.
opening wedge defect if the opening wedge oste- Gradual correction currently requires an exter-
otomy is performed before reaming. nal fixator; it is possible that in the future, gradual
To reduce the loss of bone contact with open- correction will be performed with innovative
ing wedge corrections, an a-t correction may be internal devices. Acute correction is amenable to
preferred. With the a-t method, one bone end is both internal and external fixation. Gradual correc-
inserted into the medullary canal of the other tion is more accurate than acute correction [3, 14].
bone end. There is less risk of bone healing prob- This is because of the external fixator and not
lems. The a-t type of opening wedge osteotomy is because of the method of correction. Acute correc-
chosen when the osteotomy is made at a level dif- tion can be as accurate, especially if it is performed
ferent from that of the CORA. If it is performed with fixator assistance. Templating wedges are
at the level of the CORA, a secondary translation available to increase the accuracy of opening
deformity will result. The osteotomy may be wedge corrections [11, 13].
intentionally chosen at a level different from that
of the CORA to improve bone contact (Fig. 8.4).
Other advantages include less stretch of soft tis- 8.5 a-t Osteotomy
sues, no need for bone graft, increased stability,
and amenability to either a percutaneous or open The a-t osteotomy is performed either as a closing
osteotomy technique. If a saw is used, care needs or opening wedge procedure, as described above.
to be taken not to burn the bone ends. It is very useful and should be used at a level differ-
ent from that of the CORA, following osteotomy in a circular pattern and connected with an osteo-
rule 2. If it is performed at the level of the CORA, tome. With the multiple drill hole method, any
a secondary translation deformity will result. radius of curvature can be made. Although tem-
plates can be used for different radii, it is prefer-
able to use a central pivot point to guide the drill
8.6 Dome Osteotomy holes, similar to the way a compass is used to
draw concentric circles. If the central pivot point
The so-called dome osteotomy is not shaped like is matched to the CORA, the axis of the cylindri-
a dome at all but rather like an arch (a dome has cal cut is centered on the CORA. This is called
a spherical surface, whereas an arch has a cylin- focal dome osteotomy.
drical surface). This cylindrical bone cut is cor- Dome osteotomies can be used to correct
rected by rotating around the central axis of the angulation around the axis of the cylindrical
cylinder. If the axis of the cylindrical bone cut is cut and translation parallel to the walls of the
not matched to the CORA, a secondary transla- cylinder (Fig. 8.5). The dome cannot be used to
tion deformity will result. If the axis of the cylin- correct axial rotation. This is one of the limit-
drical osteotomy and the CORA correspond, the ing factors of the dome osteotomy. There are
correction will follow osteotomy rule 2, with no two modifications to the dome osteotomy that
secondary translation of the axis lines but with can be made to allow it to correct angulation
angulation and translation of the bone ends. The and rotation at the same time. The first is to
dome osteotomy is an a-t osteotomy with better incline the dome cut so that the axis of correc-
bone contact than that provided by the straight tion is also inclined. An inclined axis will cor-
cut variant. It is much more difficult to produce a rect both angulation and rotation. The other
dome osteotomy than a straight cut. There are way is to make a spiral dome osteotomy. This
many ways to make dome osteotomies. Special allows the bone surfaces to conform to each
curved saws and osteotomes are available for other as angulation and rotation corrections
domes of a small radius, such as in the metatar- occur together.
sals. In larger bones, multiple drill holes are made
a b
Fig. 8.5 (a) Focal dome osteotomy allows simultaneous radiographs show lateral translation and recurvatum mal-
correction of recurvatum and lateral translation of the union deformities, respectively. There is also medial com-
tibia (i, ii, and iii). The dome osteotomy does not allow partment osteoarthritis
correction of axial rotation. (b) AP (i) and LAT (ii) view
94 D. Paley
8.7 Hardware and distally. This is unstable in the plane perpen-

dicular to the fixator. Using an external fixator with
8.7.1 Plate Fixation two pins proximally and two distally provides bet-
ter biplanar control during the correction. All four
The plating technique depends on the type and
level of the osteotomy performed. For opening
wedge correction, the plate should be located on
the concave or convex side. Biomechanically, the
best location for a plate is on the side of the base of
the opening wedge correction (Figs. 8.6 and 8.7).
The intact cortex acts as one intact column and
the plate as the other. Axial loading places signifi-
cant shear stresses on the screws. Bone grafting, if
used, can be performed under the plate. The intact
periosteum on the convex side should be preserved.
If the plate is placed on the convex side, it is
exposed to significant bending forces, and unless a
solid graft is interposed into the opening wedge
space to share the load, it will likely fail. If, instead
Fig. 8.6 (a) Varus deformity at the tibia diaphysis. (b)
of a graft, a step is incorporated into the plate, axial
Osteotomy at the mid-diaphyseal section to have the con-
loading will pass from the bone through the plate vex hinge point. Opening wedge correction with a lateral
because that becomes the path of least resistance. plate. This plate may fail because of the large axial gener-
Therefore, the screws are protected by the step. ated bending forces. (c) Same osteotomy as that shown in
b, with the plate on the concave side. Axial forces exert
Reduction before fixation can be facilitated by
high shear forces on the screws. (d) Step plate used to
using an external fixator as a distractor. The distrac- allow transmission of the axial forces in a direct line. The
tor used can have a single fixation pin proximally screws are protected from loading by the step in the plate
a b c d
Fig. 8.7 (a) Varus deformity of the proximal tibia. (b) the large axial generated bending forces. (c) Same osteotomy
Osteotomy of the proximal tibia to have the convex hinge as that shown in b, with the plate on the concave side. Axial
point on the tBL of the CORA. Opening wedge correction forces exert high shear forces on the screws. (d) Step plate
with a lateral plate. Because of the large bending forces, a used to allow transmission of the axial forces in a direct line.
blade plate is chosen. Even so, this plate may fail because of The screws are protected from loading by the step in the plate
pins can be in the same plane, or two separate dis- designed anatomically. Knowing this, one can
tractors, each with one pair of pins in planes that modify the application of plates for use in juxta-
are perpendicular to each other, can be used. With articular deformity correction (e.g., using the 95°
only one pin above and one below in a single plane, angled blade plate from the medial side for valgus
there can be difficulty controlling or preventing to varus distal femoral osteotomy correction) (Fig.
deformity in the plane perpendicular to the pins. 8.8). Another alternative is to accept some second-
We call this technique fixator-assisted plating. ary deformity in cases in which the amount of
Deformities at the ends of bones (CORA in translation is small and of little clinical signifi-
metaphysis or epiphysis) have limited space for cance. If one does accept this, it is better to do so
fixation between the osteotomy level and the physis knowing that a mild secondary deformity of little
or joint. The farther the osteotomy level is away consequence will arise rather than not recognizing
from the CORA, the more translation is required at this effect, which in larger deformities may be very
the osteotomy site to avoid creating secondary clinically significant. Understanding the principles
deformities. Traditionally, plates have been the pre- of deformity correction does not mean that every
ferred hardware in metaphyseal regions. Some plate correction must be absolutely geometrically cor-
designs incorporate translation into the correction rect. It means that for every deformity correction,
(e.g., hip varus osteotomy plate). Most other plates one should understand the geometric ramifications
do not intentionally incorporate the translation into and assess them for their clinical significance.
the plate; therefore, secondary deformities are cre- Special opening wedge plates that have steps
ated unless special care is taken to compensate. The of different widths incorporated into their walls
plate for supracondylar osteotomy of the distal can be used in the metaphyseal regions. To avoid
femur is an example of a plate design that attempts secondary translation deformity, the hinge point
to incorporate translation. It usually produces a of the opening wedge osteotomy is chosen to be
medial translation deformity when used for varus as near as possible to the level of the CORA. The
osteotomy of the distal femur (Fig. 8.8). osteotomy is often inclined so that it can be
This plate is designed for fracture reduction and started at a convenient level distant to the CORA
fixation and not for reconstructive osteotomies. In but ended at the hinge point, which is at the
fracture treatment, the aim of treatment is restora- CORA. Furthermore, the cortex near the CORA
tion of the normal anatomy. Most plates are is left intact and can thus serve as a hinge axis. In
metaphyseal regions, opening wedges smaller
than 10 mm usually do not require bone grafting.
The typical plate has screws that are not phys-
ically linked to the plate. The plate and screw are
connected only by friction from compression of
the screw head onto the plate and bone. Another
type of plate system has the screws attached to
the plate. This converts the plate into an internal
fixator. This system may become more popular
in the future. It may prove useful for stabilizing
opening wedge osteotomies and limb lengthen-
ing distraction gaps. Its increased stability may
also make it more useful in the treatment of non-
unions and diaphyseal osteotomies. When the
screws are connected to the plate, the system acts
like an implantable external fixator (Fig. 8.9).
Because of the less invasive nature and the supe-
rior fixation afforded by nails in diaphyseal regions,
Fig. 8.8 The standard condylar screw plate for the distal there is little indication for the use of plates in
femur will lead to medial translation deformity when a
varus osteotomy is performed. It does not allow for neces- diaphyseal deformities of the femur and tibia.
sary lateral translation at the osteotomy site Exceptions to this are cases in which it is techni-
96 D. Paley
for lengthy periods of time. Even removal does not

a b
require extensive surgical exposure. Diaphyseal
angular deformities, especially around the isthmus,
are easily realigned using IMN. The isthmus of the
bone directs the nail path so that a diaphyseal angu-
lar deformity automatically realigns as the nail
passes. For more proximal or distal diaphyseal
deformities and for metaphyseal deformities, the
path of the nail is not as constrained, and the nail
may deviate from the center of the bone once it
crosses the osteotomy site. Therefore, it is essential
to choose the correct starting and ending points. It
is not sufficient to obtain just one of these two
points correctly (Figs. 8.10 and 8.11).
Accuracy can be improved using the FAN
technique (Figs. 8.12) [10, 12]. The accuracy
comes from the adjustability of the external
fixator and the check radiograph(s) that is
Fig. 8.9 (a, b) Internal fixation with plates relies on fric-
obtained before inserting the definitive internal
tion between the screws, plate, and bone from the com-
pression generated by the screws (left). The internal fixation.
fixator is a plate with connected screws (right). This type Correction of length with or without defor-
of plate functions like an external fixator in which the can- mity correction can also be achieved using IMN
tilever forces on the screws are minimized
fixation by the lengthening over nail (LON) tech-
nique (Fig. 8.13) [4, 5, 10].
cally too difficult or risky to insert a nail (e.g., Limb lengthening techniques will be explained
sclerotic medullary canal, discontinuity of the
particularly in related chapters of this book.
canal due to translation deformities, open physis).
Active or latent infection is usually a contraindica-
tion to both plating and nailing. Previous infection 8.7.3 External Fixation
is not necessarily a contraindication to plating or
nailing if the infection is thought to have been suc- External fixators can be used at any level in a
cessfully eradicated by previous treatment. bone. They offer excellent fixation for juxta-
Plating requires more surgical exposure than do articular regions. Circular fixators using ten-
other methods. Current techniques using indirect sioned wires require the least amount of bone
traction with a distractor minimize the exposure length for fixation of any of the hardware meth-
needed. The accuracy of plating in metaphyseal ods. External fixators can be used with gradual
regions varies greatly with different operators. or acute deformity correction. Gradual defor-
Even very skilled surgeons have an accuracy of mity correction is especially useful for large
only approximately 5°. This accuracy can be fur- deformities or when there is a neurovascular or
ther improved if the MAT is used intraoperatively other soft tissue structure at risk (SAR) from
(intraoperative radiograph) after temporary or lim- acute correction. Bone at risk of poor healing
ited fixation is achieved. The osteotomy can still be (congenital pseudarthrosis of the tibia, rickets,
adjusted after the MAT. The final fixation is applied adult diaphyseal bone) should usually be cor-
only after the desired joint orientation is achieved. rected gradually to minimize injury to the peri-
osteum. Acute correction can be used in
8.7.2 Intramedullary Nailing (IMN) deformities of lesser magnitude, especially in
the metaphyseal regions of the tibia or both
IMN offers the advantages of a limited open proce- metaphyseal and diaphyseal regions of the
dure, remote insertion site, and percutaneous oste- femur. There is a greater risk of bone healing
otomy. The hardware is buried and well tolerated problems with acute corrections, especially in
Fig. 8.10 (a) An IMN follows the medullary canal and, deformity (i). If the starting point is too lateral, such as in
therefore, the anatomic axis of the femur. The correct the greater trochanter, the varus will be only partially cor-
starting point for the proximal femur is the piriformis rected despite the correct ending point (ii). (c) Similarly,
fossa. The correct ending point should be at the center of for infra-isthmic deformities, not only is the correct start-
the femoral condyles, with the nail pointing toward the ing point important but also the correct ending point (i).
medial tibial spine. (b) With correct starting and ending Insufficient correction with excessive varus or valgus is
points, an IMN can be used to fully correct a femoral associated with a noncentralized ending point (ii)
98 D. Paley
Fig. 8.10 (continued)
a b
Fig. 8.11 (a) In the non-deformed tibia, the mid-diaphy- before starting the nailing. (b) With a focal dome osteot-
seal line usually passes through the medial tibial spine. omy, the starting point must be correct (i). If the nail start-
Therefore, the correct starting point is at the medial tibial ing point is too lateral, a varus deformity will result,
spine. In some non-deformed tibiae, the mid-diaphyseal whereas if it is too medial, a valgus deformity will occur (ii)
line passes more laterally. It is important to know this
adults. Acute correction is also more likely to Angular deformity correction with circular
cause stretch injury to neurovascular structures external fixation uses hinges. The imaginary line
and lead to increased compartment pressure. passing through the axis of rotation of two col-
External fixation osteotomies can often be per- linear circular fixation hinges is the ACA. If the
formed with minimal invasiveness using percu- axis of the hinges is matched to the level of a
taneous techniques, usually of the opening CORA on the bisector line and is perpendicular
wedge type, with or without translation. to the plane of angulation, the proximal and distal
a b
Fig. 8.12 Illustration of FAN technique after osteotomy

with the implant and fixator applied. The nail is inserted
and locked proximally and distally. The distal screws are Fig. 8.13 (a, b) Illustration of the LON technique. The
easier to insert from the medial side to avoid collision nail must be locked from the medial side to avoid con-
between the locking guide and the fixator. The fixator tamination from the half-pin sites. The fixator can then be
body is anterior to the femur so that it does not obstruct removed. The nail maintains the length of the femur while
visualization of the femur by the image intensifier the regenerate bone consolidates
axis lines will realign with correction of angula- The other general rule is that the distance
tion around the hinges. If the osteotomy is at the between the pair of rings on opposite sides of the
level of the CORA, the hinge correction will fol- hinges is one hand’s breadth (10 cm). The reason
low osteotomy rule 1. If the osteotomy is at a for this is to maximize the leverage of the device.
level different from that of the hinge, correction The limiting factor for bending strength is the diam-
will follow osteotomy rule 2. eter of the threaded rods (usually 6 mm) (Fig. 8.17).
The circular fixator can be constructed before Therefore, keeping the distance between the
surgery to the diameter, length, and deformity rings that hold the hinges to 10 cm maximizes
parameters of the limb. After measuring the the bending strength of the device (Fig. 8.15).
patient for the correct ring diameter (large The other rings are spread out maximally in the
enough to allow for two finger’s breadth circum- bone to maximize the lever arms of fixation on
ferentially around the limb segment) (Fig. 8.14), either side of the osteotomy. The two hinges are
the rest of the preconstruction is based on the made collinear with each other by first making
preoperative planning from two orthogonal sure that they are at the same level and that they
radiographs. are oriented the same way. To do this, bend the
The levels of all the rings are marked on the hinges to 90° and tighten the connections of the
radiographs. In general, the full length of the threaded rods to the proximal and distal rings. It
bone is used for fixation. In the tibia, the is very important to place the hinges in the cor-
proximal-most ring is usually placed at the level rect o rientation to the plane of angulation. For
of the flare of the bone (Fig. 8.15). The distal- example, for a frontal plane angulation, the
most ring is placed within 1 or 2 cm of the pla- hinges should be oriented anteroposterior (per-
fond. In the femur, the distal-most ring is at the pendicular to the plane of angulation). Because
level of the adductor tuberosity. In the proximal the correction is almost always an opening wedge
femur, it is at the level of the lesser trochanter correction, the hinges are located one hole con-
(Fig. 8.16). vex to the central bolts that connect the two half
100 D. Paley
Fig. 8.14 For circular external fixators, such as the Fig. 8.16 Femoral apparatus for varus deformity. The
Ilizarov device, the ring size chosen should allow approxi- upper femoral arch is at the level of the lesser trochanter,
mately two finger’s breadth of space between the ring and and the lower femoral ring is at the level of the adductor
the widest part of the limb segment tuberosity. The space between the rings on either side of
the CORA is one hand’s breadth
Fig. 8.15 Four-ring apparatus with middle rings one

hand’s breadth apart. The rods do not bend, and full cor-
rection is easily achieved because of sufficient leverage Fig. 8.17 Two-ring apparatus with rings far apart. If the
on both sides of the osteotomy. The upper tibial ring is at entire fixation is at these two levels, the leverage on the
the level of the flare of the tibia, and the lower tibial ring bone is limited. The 6-mm threaded rods will likely bend
is 1–2 cm proximal to the ankle joint while the apparatus is trying to straighten the bone.
Incomplete angular correction may result
rings together. The two central bolts represent

the sagittal plane. On our oblique plane analysis orly and, if possible, confirm by using the image
graph, these bolts also represent the y-axis. To intensifier that they overlap. We then fix the
center the apparatus accurately on the limb, we apparatus to a reference wire that is in the frontal
rotate the limb until the patella is forward. We plane. The next step is to make sure that the hinge
then orient the two central bolts anteroposteri- is at the level of the CORA. This can be accom-
plished by measuring the level of the CORA rela- one needs to know the rate of correction of the
tive to the knee on the radiograph and reproducing bone. Because the bone is opening as a wedge
this measurement using the image intensifier shape in a circular direction, the duration of cor-
intraoperatively after compensating for magnifi- rection will be the length of the arc divided by
cation. The hinge level is adjusted to the level of the rate of correction along that arc. The length
the CORA, and a distal reference wire is then of the arc is the fraction of the circumference of
inserted to fix the distal part of the apparatus. If the circle at the radius of the bone edge from the
the hinge level is not correctly adjusted to the hinge (r) and of magnitude a (2pra/360). If the
level of the CORA and the osteotomy is made at rate of correction is set to 1 mm per day, the
the CORA, the bone osteotomy will translate. It duration of correction is 2pra/360 days (where r
is important to ensure that the hinges are at the is measured in millimeters). If one is perform-
correct level along the longitudinal axis, and it is ing lengthening and deformity correction simul-
important to make sure that the hinge is located taneously, to calculate the rate of distraction at
correctly on the bisector line. If the hinge loca- the distraction rod, we need to know the overall
tion is at the lateral cortex, an opening wedge rate of lengthening and the ratio of deformity
correction will occur. If the hinge is located at the correction based on the rule of triangles or con-
concave cortex, the bone ends will be compressed centric circles described above. For example, if
together, unless a wedge is resected, because the the rate of lengthening is 0.5 mm per day, this
net effect is a closing wedge osteotomy. The leaves 0.5 mm of distraction of the bone avail-
apparatus should be correctly oriented and fixed able (assuming we do not want to distract the
on the limb with the ACA of the hinges perpen- bone faster than 1 mm per day at any point on
dicular to the plane of deformity and at the cor- the osteotomy line). If the rate ratio of the dis-
rect level of the CORA, usually on the opening traction rod to the hinge versus the bone edge to
wedge side of the bone. If the apparatus is being the hinge is 4:1, we want to c alculate how many
used for an oblique plane correction, the only dif- millimeters per day we can lengthen at the dis-
ference is the location of the hinges on the ring. traction rod to produce 0.5 mm of distraction of
To find the correct location, we use the graphic the osteotomy bone ends. This will be 4 ¥
method of oblique plane p lanning to locate the 0.5 mm per day, or 2 mm per day. Because the
correct holes for the hinges. The centering of the overall lengthening rate is 0.5 mm per day of all
apparatus is performed in the same way as for a the rods, the rate for the distraction rod is 0.5+2
frontal plane deformity. After the apparatus is in = 2.5 mm per day. The hinge rods will be length-
place with two pins (wires or half pins), the rest ened only 0.5 mm per day.
of the pins are placed to achieve stable fixation. Rotation and translation can also be corrected
The pattern of safe wire and half-pin fixation was acutely or gradually with various mechanisms
illustrated for the femur and the tibia on previous and modifications of the apparatus (Fig. 8.19).
chapters. If only wires are used for fixation, it is For rotation correction with circular frames,
important to incorporate olive wires in strategic one must consider that because the apparatus is
locations. This follows the “rule of thumbs” as usually centered on the limb, it is not usually cen-
mentioned in previous chapters. For juxta-articu- tered on the bone. Therefore, if rotation correc-
lar angular deformities, a juxta-articular hinge is tion is performed around the center of the ring,
used instead (Fig. 8.18). the off-center bone ends will translate relative to
The rate of correction for angular deformities each other. Because translation may be a product
must follow the biological principles of rate and of gradual rotation correction, it is preferable to
rhythm of bone regeneration. Therefore, it is correct translation deformity last. The amount of
important to calculate the rate of correction translation deformity that will occur from rota-
according to simple mathematical rules [7, 9]. tion can be calculated. To avoid secondary trans-
The duration of correction can also be calculation deformity, the ring-within-a-ring construct
lated [6]. To calculate the duration of correction, can be used (Fig. 8.19).
102 D. Paley
When combinations of lengthening and grad- length of the regenerate bone if rotation and
ual deformity correction are planned, the order of translation are performed last.
correction is important. It is preferable to correct Readers can find more information about
length and angular deformity together and then advanced deformity correction techniques with
rotation and translation. Both rotation and trans- monolateral fixators and recently developed non-
lation produce shear on the newly regenerated circular external fixators in Principles of Deformity
bone. This shear can be distributed over the entire Correction from Springer.
Fig. 8.18 (a) Varus deformity of the tibia with the CORA opposed olive wires are required, as shown in the insets. If
near the joint line. To match the hinge of the fixator to the half pins are used, they constrain the bone, and olive wires
level of the CORA, the hinge must be above the level of are not required. (b) After correction, the axis lines are
the ring. The hinge is therefore constructed in the manner realigned. The osteotomy site bone ends are translated to
shown. This is called a juxta-articular hinge assembly. To each other according to osteotomy rule 2
affect the translation with an all-wire frame, counter-
Fig. 8.19 (a) Acute rotation using offset threaded rods. construct. This construct is the only one that centers the
This construct is good for one- or two-hole rotation cor- rotation around the center of the bone instead of the center
rections. It is fast to assemble and to use. (b) Gradual rota- of the ring. One ring is connected to the upper block of
tion correction using original Ilizarov parts. The transverse rings, and the other is connected to the lower block of
threaded rods are tangential to the ring. (c) Gradual rota- rings. Only one transverse rod is required. Parallel plates
tion correction using Paley’s rotation-translation boxes. sandwich the ring-within-a-ring construct. This construct
The translation boxes are tangential to the ring. (d) is difficult and time consuming to assemble
Gradual rotation correction using the ring-within-a-ring
104 D. Paley
8.8 Order of Correction an osteotome between the bone ends and twist it
so as to separate the bone ends (disimpaction)
With acute correction, it is preferable to correct and “walk” one end relative to the other.
rotation first, because rotation of an undisplaced The order for gradual correction of deformities
bone usually maintains alignment and does not starts with angulation and length together. If angu-
lead to displacement of the bone ends. In cases in lation is corrected alone and lengthening is then
which the bone ends were already translated, performed, there is a high risk that the convex cor-
there is a strong likelihood for the ends to slip off tex will prematurely consolidate before lengthen-
each other, leading to marked instability. Acute ing is performed. Because rotation correction is
angular correction leads to asymmetric tension in often performed around an axis that does not per-
the soft tissues. This locks the bone ends together, fectly correspond to the central axis of the bone,
preventing translation. Therefore, translation unwanted secondary translation may arise.
should always precede angulation for acute cor- Therefore, translation is corrected after rotation.
rection. One technical trick to translate the bone The order of correction of deformities with
ends in the face of soft tissue tension is to insert acute correction is rotation before translation or
angulation and then translation before angulation. neutralized with an extension stop to a brace. In
The order of correction of deformities with grad- the frontal plane, the path of least resistance is
ual correction is angulation and length together, not the knee because there is no knee range of
then rotation, and then translation. motion in the frontal plane. The path of least
Simultaneous six-axis correction using exter- resistance, therefore, may be the internally fixed
nal fixation is the latest concept. This theoreti- osteotomy site, and a long leg brace may be use-
cally allows simultaneous correction of length, ful to neutralize the frontal plane lever arm forces.
rotation, angulation, and translation. Practically, It is not necessary to lock the brace for flexion
even with such devices, correction of translation except to prevent HE forces. When there is a stiff
cannot be achieved until the bone ends are out to joint adjacent to an osteotomy, the lever arm on
length and clear of each other. This is further dis- the stiff joint side is very long. Neutralization of
cussed in subsequent chapters. the lever arm may be required to prevent non-
union or hardware failure. Neutralization can be
achieved either by external bracing or external
8.9 Lever Arm Principle fixation across the stiff joint. Rarely, neutraliza-
tion is achieved by extending internal fixation
Perhaps the most common mistake made with temporarily across a joint.
any form of fixation is not achieving stability.
The length of bone fixed on either side of an oste-
otomy is critical to stability. Therefore, the lever 8.10 Method of Osteotomy
arms should be considered. The lever arms are
the lengths of the bone segments on either side of Although osteotomy types will be discussed in
the osteotomies. If the joint at the end of a lever subsequent chapters, it is important to emphasize
arm is stiff or fused, the lever arm extends to the that all osteotomies that are performed via exten-
next mobile joint. The femur in the case of sile exposure cause some devascularization of the
proximal tibial osteotomies and the tibia in the bone. Dissection of the periosteum should be
case of distal femoral osteotomies can be counted minimized to limit damage to this fragile tissue.
as part of the frontal plane lever arm. In the sagit- Power instruments can cause thermal necrosis of
tal plane, because the knee moves freely, the bone. To prevent this, the saw blade should be
adjacent bone is not part of the lever arm. Ideally, irrigated with cold saline during the bone-cutting
it is desirable to have equal lengths of fixation on process. A start-stop technique is also important
both sides of the osteotomy. This is possible only to prevent thermal injury.
in middiaphyseal osteotomies. For metaphyseal
osteotomies, the length of fixation on one side of
the osteotomy is limited. Therefore, the type and References
amount of fixation is increased to balance the
lever arms. Auxiliary devices such as orthoses 1. Astion DJ, Wilber JH, Scoles PV. Avascular necrosis
and splints can be used to help balance the lever of the capital femoral epiphysis after intramedullary
nailing for a fracture of the femoral shaft: A case
arms (e.g., knee brace or cast brace in conjunc- report. J Bone Joint Surg Am. 1995;77:1092–4.
tion with plate or IMN). An osteotomy near the 2. Collinge CA, Sanders RW. Percutaneous plating in
knee, for example, experiences very low lever the lower extremity. J Am Acad Orthop Surg.
arm forces in the sagittal plane as long as the 2000;8:211–6.
3. Gladbach B, Pfeil J, Heijens E. Deformitätenkorrektur
knee is mobile. Lever arm forces will act through des Beins: Definition, Quantifizierung, Korrektur der
the path of least resistance, which in the sagittal Translationsfehlstellung und Durchführung von
plane is the knee throughout the range of knee Translationsvor- gaben. Orthopäde. 1999;28:1023–33.
motion. At the extremes of motion, the osteot- 4. Herzenberg JE, Paley D. Femoral lengthening over
nails (LON). Tech Orthop. 1997;12:240–9.
omy will experience lever arm forces. Therefore, 5. Herzenberg JE, Paley D. Tibial lengthening over nails
HE forces and exercises should be avoided and (LON). Tech Orthop. 1997;12:250–9.
106 D. Paley
6. Herzenberg JE, Waanders NA. Calculating rate and matched-case comparison with Ilizarov femoral length-
duration of distraction for deformity correction with ening. J Bone Joint Surg Am. 1997;79:1464–80.
the Ilizarov technique. Orthop Clin North Am. 11. Paley D, Tetsworth K. Percutaneous osteotomies:

1991;22:601–61. Osteotome and Gigli saw techniques. Orthop Clin
7. Herzenberg JE, Smith JD, Paley D. Correcting tor- North Am. 1991;22:613–24.
sional deformities with Ilizarov’s apparatus. Clin 12. Paley D, Tetsworth K. Deformity correction by the
Orthop. 1994;302:36–41. Ilizarov technique. In: Chapman MW, editor.
8. Krackow KA. Approaches to planning lower extremity Operative orthopaedics, vol. 1. 2nd ed. Philadelphia:
alignment for total knee arthroplasty and osteotomy J.B. Lippincott; 1993. p. 883–948.
about the knee. Adv Orthop Surg. 1983;7:69–88. 13. Scheffer MM, Peterson HA. Opening-wedge osteot-
9. Paley D. The principles of deformity correction by the omy for angular deformities of long bones in children.
Ilizarov technique: technical aspects. Tech Orthop. J Bone Joint Surg Am. 1994;76:325–34.
1989;4:15–29. 14. Tetsworth KT, Paley D. Accuracy of correction of

10. Paley D, Herzenberg JE, Paremain G, Bhave complex lower extremity deformities by the Ilizarov
A. Femoral lengthening over an intramedullary nail: a method. Clin Orthop. 1994;301:102–10.
Definitive Surgery for Open
Fractures of the Long Bones 9
with External Fixatıon
Cengiz Şen, Halil Ibrahim Balci, Mustafa Celiktaş,

Cenk Ozkan, and Mahir Gulsen
9.1 Reconstruction Methods vascular, and soft tissue repair have allowed more
for Fractures with Bone severely injured limbs to be salvaged over the last
Defects, Vascular Injury, two decades [5]. At the time of emergency pre-
and Salvage Procedures sentation, an immediate decision is required
regarding limb salvage versus amputation.
Cengiz Şen and Halil Ibrahim Balci Various scoring systems using a variety of com-
ponents have been developed to assist surgeons in
Management of severely injured extremities making a decision [6–10]. Open long bone frac-
remains challenging for orthopedic surgeons. tures with vascular injury that need vascular
They are associated with higher rates of limb loss reconstruction are classified as Grade 3C open
in addition to high mortality, secondary amputa- fractures according to the Gustilo-Anderson clas-
tion, nonunion, infection, multiple surgical inter- sification system [11, 12].
ventions, occupational changes, and psychological Diagnosis of vascular injury can be difficult,
problems [1–4]. Patients with high-energy open but early diagnosis is vital [13]. The ankle bra-
extremity fractures and massive soft tissue dam- chial index (ABI) is one of the most effective
age pose a demanding clinical challenge that and reliable tools to screen for vascular problems
requires a complex interdisciplinary approach and [14–16]. When ABI is less than 0.9, the sensitiv-
multiple orthopedic, vascular, and reconstructive ity is 95 % and specificity is 97 % for a major
procedures. Developments in orthopedic fixation, arterial injury [15, 16]. The ABI is not easy to
perform in fractures under the proximal one
third of the tibia; therefore, arteriography should
be considered. Although arteriography increases
the ischemic time, Glass et al. reported that this
C. Şen, MD • H.I. Balci, MD, FEBOT (*) increase did not affect amputation rates [17]. We
Istanbul University, Istanbul Faculty of Medicine, do not routinely use conventional preoperative
Orthopaedic and Traumatology Department, arteriography in our practice because of the time
e-mail: senc64@gmail.com; balcihalili@hotmail.com delay and increased ischemic time [15, 16]; CT
angiography is preferred because it is faster
M. Celiktaş, MD • M. Gulsen, MD
Ortopedia Hospital, Adana, Turkey (Figs. 9.1 and 9.2).
After the diagnosis of vascular injury, the deci-
C. Ozkan, MD
Cukurova University, Orthopaedic and Traumatology sion regarding whether to perform an amputation
Department, Adana, Turkey or limb salvage must be taken by the surgeon.

https://doi.org/10.1007/978-3-319-45675-1_9
108 C. Şen et al.
Multiple injury scores have been published to

assist in making this decision [6–8]. Fodor et al.
reviewed the injury scores in the literature and
showed that the Mangled Extremity Severity Score
(MESS) was the injury score most commonly
used. The MESS showed a good correlation with
amputation rates in children and in combat inju-
ries. Such scoring systems could be beneficial, but
they have been shown not to be good predictors of
limb salvage or amputation [17–20]. We also use
the MESS to determine the appropriate treatment,
but it is not the only predictor used to make this
decision because we have attempted limb salvage
in cases even when MESS was greater than 7;
however, the MESS is the simplest and seems to
be the most applicable. Differences in injury sever-
ity and cultural beliefs make the scoring systems
difficult to use. Scoring systems should not be a
guide for the decision between an amputation and
a salvage procedure [41].
With regard to the concept of “damage control
orthopedics,” external fixation plays an important
role in the management of patients with multiple
traumas [33]. Management with an external fix-
ator is more appropriate in cases where the frac-
Fig. 9.1 Distal femur intraarticular, plato tibia and distal ture is open, grossly contaminated, unstable, and
tibia fractures with vascular injury in the popliteal area associated with vascular injury.
Fig. 9.2 Conventional and CT angiographic view of the vascular injury

9 Definitive Surgery for Open Fractures of the Long Bones with External Fixatıon 109
Amputation has a great impact, especially in Associated crush-type injuries and neural inju-
countries with low socioeconomic levels. The ries were found to be predictors of amputation
Lower Extremity Assessment Project (LEAP) following vascular compromise [23]. Poorer
showed that outcomes were often more affected functional outcomes in patients with neural injury,
by a patient’s economic, social, and personal especially sciatic or tibial nerve, have been
resources than by the initial treatment choice. reported [23, 24]. Current studies show
Only 34 % of LEAP patients achieved normal satisfactory results with the application of exter-
physical scores of the general population, and nal fixators for open femur fractures with exten-
58 % were working at the same place as before sive soft tissue injury [35, 36]. Prophylactic
the injury [4]. At 2- and 7-year follow-ups, the fasciotomy is recommended by multiple surgeons
LEAP study showed no differences in functional [37, 38]. The requirement for fasciotomy has been
outcomes between patients who underwent significantly reduced in literature reports because
either limb salvage surgery or amputation [4]. shunts have become widely used (Fig. 9.4) [22].
The authors also concluded that spending exces- We perform crural fasciotomy in all cases that
sive effort to preserve the knee joint was manda- require vascular repair. Early application of
tory in cases that require amputation.
Young patients have higher elasticity and bet-
ter survival rates in high-energy traumas [18].
The use of a shunt prior to skeletal fixation
followed by a vascular repair can significantly
reduce ischemia time compared with approaches
that favor skeletal fixation first [22–29]. In
addition, salvage rates have been found to be
higher with the use of a vascular shunt [22, 34].
Shunting permits time to evaluate soft tissue
viability and time without stress for orthopedic
surgeons to perform satisfactory bone fixation.
Although the idea is a temporary bone fixation
on the first day, sometimes first-day stabiliza-
tion can become a permanent fixation [41]
(Fig. 9.3).
Fig. 9.4 Primary external fixation of the femur with vas-

Fig. 9.3 Emergency application of the vascular shunt to cular injury because of gunshot injury. Note that circular
provide blood supply to the extremity during the fixation fixation is applied to the distal condylar region. The area
of the fractures of vascular repair is kept open for the vascular surgeon
110 C. Şen et al.
systemic anticoagulant therapy prevents further

thrombosis in the microcirculation and reduces
amputation rates [37, 39].
If the decision is for a salvage procedure, one
should know that secondary operations are
needed for soft tissue coverage, graft thrombosis,
infection, joint stiffness, nonunion, malunion, or
amputation.
In cases of vascular injury, we prefer to fix
the fracture with multiplanar external fixators or
a monoplanar external fixator according to the Fig. 9.5 Grade 3C open tibial fracture with severe soft
soft tissue and bone defect. In cases of soft tis- tissue defect. Vascular injury was between popliteal and
trifurcation. Knee joint is fixed to prevent motion and
sue defect, we place external fixators away from
increase the vascular reconstruction success
the defect area to care for the soft tissue.
Negative-pressure wound therapy, used in the
form of the vacuum-assisted closure – VAC sys-
tem (KCI, USA) – improves healing of exces-
sive soft tissue damage [21, 30]. VAC increases
blood flow, decreases soft tissue edema, and
supports cleaning infected wounds [31, 32].
Some surgeons have doubts about using vacuum
dressings with these compound fractures
because of fears of inducing a sudden hemor-
rhage. Despite its multiple advantages, however,
vascular surgeons should be consulted before
using a VAC system in areas of vascular anasto-
mosis. After the extremity viability becomes
more evident, which can take up to 3 weeks to
Fig. 9.6 Vascular repair at the femoral Hunter’s canal
decide, soft tissue procedures such as free flaps
can be considered.
In cases of vascular reconstruction around ries occur. In this way, the vascular surgeon
the knee, it is possible to prevent the knee move- can make the end-to-end anastomosis over the
ment with extension of the external fixator over arteries without the need of a vascular graft
the knee region for up to 3 weeks to prevent (Fig. 9.6). Gradual lengthening of the extrem-
movement at the anastomosis region (Fig. 9.5). ity is possible with an osteotomy at the intact
Flexion and extension at the knee joint makes metaphysic of the region where the bone is not
the vascular anastomosis more fragile. We think affected by injury. This technique is called
that prevention of knee movement increases the acute shortening and relengthening (Fig. 9.7).
success rate of vascular reconstruction. Thirty Its use is mostly described for bone defects that
degrees of knee flexion is preferred to decrease occur after the trauma and postinfections [40].
the stress on the anastomosis side. Distraction osteogenesis solves many technical
In cases of bone defect with vascular injury, problems related to traumatic bone defect and
orthopedic surgeons can assist vascular sur- its consequences such as nonunion, deformity,
geons by shortening the extremity acutely at LLD, and soft tissue contracture. Another dis-
the defect area where most of the vascular inju- traction osteogenesis technique that should be
Free vascularized fibula grafts can also be

used for segmental defect reconstructions; how-
ever, it causes significant morbidity because of
the resection of the patient’s own fibula with vas-
cular supply. Moreover, vascularized free fibula
use at the repaired vascular extremity can be
technically demanding.
The Masquelet technique is also suitable for
the reconstruction of posttraumatic bone defects.
The technique consists of staged protocol for
obtaining a clean viable soft tissue bed, place-
ment of an antibiotic-impregnated polymethyl-
methacrylate (PMMA) spacer to induce
neovasculature, and a bioactive membrane fol-
lowed by autogenous bone graft [41, 42].
Although this technique is popular worldwide,
there are insufficient studies from different cen-
ters showing the success of the procedure.
We prefer acute compression in cases of bone
defect and vascular injury; end-to-end arterial
anastomosis is more successful, and soft tissue
coverage is maintained without any other soft tis-
sue reconstructive technique. Up to 4 cm acute
shortening is safe in most cases where there is
intact arterial circulation. If there is arterial
injury, we reconstruct the arterial circulation.
After that we supervise the venous status of the
extremity to decide about the shortening. Our
experience is that more than 7 cm shortening is
well tolerated. We can also shorten the extremity
gradually over a few days (0.5 cm 4 times/day).
Direct contact of the bone end gives more stabil-
Fig. 9.7 Acute shortening of the defect area with vascu- ity to the construction. If we can obtain trans-
lar injury verse ends on both sides of the bone, we can
compress the bone ends, which results in a shorter
period of bone h ealing. In cases where there is
kept in mind is segment transport. Segment greater vascular defect than bone, which is seen
transport technique can be appropriate for pure in cases of crush and traction injuries where the
bone defects. We mostly use this technique for intima layer of arteries is injured over a longer
cases in which we obtain successful vascular segment, we do not cut the bone ends but put one
and soft tissue reconstruction with defects of bone end into the other. It works mostly in
more than 7 cm. It is important to know the metaphyseal and diaphyseal injuries. Lengthening
position of the new reconstructed vascular from a noninjured region of the bone segment is
before applying the external fixator, half pins, started after 3 weeks when we can safely elon-
and Kirschner wires. gate the vascular structure. The disadvantage of
112 C. Şen et al.
the method is that the bone from areas of muscu- lengthening from another level in the treatment of
lar or tendinous structure shortens but lengthens the bone defect, different interventions are
on the other side, which can change the required for soft tissue. Local and distant flaps
biomechanics of soft tissue. However, we should have been designed to overcome difficulties in
not forget that this is a salvage procedure of the achieving wound closure. Fracture fixation with
extremity. Early consolidation for a more suc- subsequent flap coverage is widely used. Although
cessful vascular repair and early soft tissue clo- combined use of external fixators with free flaps
sure are the main success points with the acute is possible, it has been reported to be associated
shortening technique. with practical difficulties [46]. It is known that the
size of soft tissue defects can be diminished with
acute shortening [43, 48]. Other methods used for
9.2 Reconstruction Methods bone defects include vascularized or non-vascu-
for Fractures with Soft Tıssue larized fibula transfer or reconstruction with auto-
Defects: Acute Angulation graft or allograft following osteosynthesis with
Technique screw plate or external fixator [50]. However,
internal fixation is associated with major
Mustafa Celiktaş, Cenk Ozkan, and Mahir Gulsen complications and increases the risk of infection
[43, 46, 53]. Further disadvantages of long treat-
High-energy traumas are always a challenging ment process are limb length inequality, non-
orthopedic problem. Besides the multi-union, deformities, and infection, which are
fragmentation of the bone in high-energy trauma, complications often encountered and are partially
disruption of the soft tissue coverage makes treat- independent of the treatment method [51, 54].
ment difficult. The Ilizarov external fixator, A method often used for soft tissue defects is
which is often used in the treatment of these inju- acute shortening. Although a greater amount of
ries, is a successful method [44, 45]. skin can be obtained in acute shortening, how the
In cases where bone resection is applied for rea- incision is made is important. A conventional
sons such as tumors, osteomyelitis, and defective longitudinal incision will become diagonal after
fractures and comminuted fractures that result from shortening, and coverage of the skin defect can
high-energy trauma, segment transport is a fre- become more difficult. A transverse incision can
quently used method. Normal skin is always an be made over the area where bone excision or
advantage for segment transport, as when the skin osteomyelitis debridement is to be made. Skin
is damaged in the trauma, the skin loss in addition coverage after shortening is easier with a trans-
to the bone loss creates a bigger problem. Early soft verse incision, but it may be difficult to obtain the
tissue coverage is an important factor that influ- required exposure for sufficient bone interven-
ences fracture healing. Delayed coverage has been tion during the operation. In our clinic, it is pre-
reported to be associated with most problems [46]. ferred to make a transverse incision when
In addition, when there is osteomyelitis, if there is possible in acute shortening cases. It has been
a sinus opening in the skin, the debridement applied reported that acute shortening can be made with a
will result in both a greater bone defect and soft Z-plasty incision [52]. In a classic Z-plasty, the
tissue defect. When there is also chronic inflamma- long and central limb of the “Z” is usually placed
tion, the loss of skin elasticity makes it difficult to along the line of the scar to be lengthened or
achieve integrity of the skin [49]. reoriented. The two lateral limbs extend from this
In traumas like this, while methods are used line at varying angles which determine the per-
such as segment transport, acute shortening and centage lengthening of the central section. Once
Figs. 9.8 and 9.9 Tibia fracture due to high energy trauma with skin defect and bone loss
these flaps have been raised, they are transposed, applied, it is necessary for segment loss of the
resulting in reorientation of the scar and its effec- bone and skin defect of the soft tissue to be at the
tive lengthening. With the method of Simpson same level (Figs. 9.8 and 9.9). First, debridement
et al., the long, central limb of the Z is made of the bone and necessary soft tissue is made;
transverse to the long axis of the bone, and thus then all osteomyelitis, if there is any, together
when the flaps are closed, the skin is shortened. with infected bone is excised. At the end of the
At the same time, the Z-plasty provides the procedure, viable bone and skin defect are

required exposure for intervention to bones. It reached. Ilizarov rings are placed in a manner to
has been reported that especially if the soft tissue hold the two bone segments stable. Hinges are
defect is equal to or smaller than the bone defect, placed at the level of the bone and skin defect. At
Z-plasty will be able to be used successfully [52]. this point the aim is to apply compression and
Another method for segment loss of the bone angulation to the bone from the fracture or defec-
plus skin defect is angular compression. This tive segment. Angulation is applied to the bone
method is described by Gulsen et al. and made by until primary closure of the skin can be made
an external fixator [47]. For this method to be (Figs. 9.10, 9.11, 9.12 and 9.13) and primary
114 C. Şen et al.
Figs. 9.10–9.13 Angulation is applied to the bone with ilizarov EF until primary closure of the skin can be made and
primary closure of the skin is applied
Figs. 9.14 and 9.15 Angulations are correcting by the hinges. Osteotomy are made from the distant metaphysis for
residual leg length discrepancy
closure of the skin is applied. No type of flap or The treatment stages of a patient with proxi-
skin graft can be applied. If leg length discrep- mal metaphyseal bone defect and skin defect in
ancy is anticipated at the end of the treatment, the cruris proximal are shown in Figs. 9.23, 9.24,
the system is set on the defective area in such a 9.25, 9.26, 9.27, 9.28, 9.29, 9.30, 9.31, 9.32,
way that osteotomy can be made from the dis- 9.33, 9.34, 9.35, and 9.36.
tant metaphysis. The system is left like this for Acute angular shortening does not require a
3 weeks and skin recovery is awaited. At the flap for coverage over open bone tissue, and
end of 3 weeks, correction of the bone defor- thus there is no donor site morbidity. Maximal
mity starts by the hinges (Figs. 9.14 and 9.15). bone contact can be achieved through adapta-
The deformity is corrected in accordance with tion of bone edges by angulation without the
the principles of deformity correction. Bone need for bone debridement or grafting in case of
union is expected after deformity correction failure of docking site union. Even if there is pin
and equalization of the leg lengths (Figs. 9.16, tract infection, which is a frequently encoun-
9.17, 9.18, 9.19, 9.20, 9.21, and 9.22). If nec- tered complication because of the long period of
essary, union accelerating interventions can be fixator use, there are no significant complica-
made such as compression distraction and bone tions. It is possible to treat all components of a
grafting. complex injury with a circular fixator.
116 C. Şen et al.
Figs. 9.16 and 9.17 Bone union is expected after deformity correction and equalisation of the leg lengths
Fig. 9.18 Patient with frame

Figs. 9.19–9.22 Postop xrays and functional photos after treatment

118 C. Şen et al.
Figs. 9.23 and 9.24 A

man aged 44 years with an
open tibia fracture as a
result of being struck by a
vehicle; AP and lateral
radiographs
Fig. 9.25 The defect after debridement and the Ilizarov

system setup
Figs. 9.26 and 9.27 Application of angular compres-

sion by the hinges and skin defect was closed
120 C. Şen et al.
Figs. 9.28 and 9.29 Early postoperative AP and lateral radiographs
Fig. 9.30 Angulation correction and wound closure. At

the same time lengthening was started in the system by
making osteotomy from the distal
Figs. 9.31 and 9.32 When union started in the proximal defective fracture line, lengthening continued from the distal
Figs. 9.33 and 9.34 AP and lateral radiographs

following removal of the Ilizarov EF system at the end of
lengthening and union
122 C. Şen et al.
Figs. 9.35 and 9.36 Postoperative clinical status of the patient
9.3 I M Nailing with Cage numerous and increase with the time spent in the
Technique external fixator [55, 63, 68]. Vascularized bone
transfers, massive allografts, and metallic
Cenk Ozkan, Mahir Gulsen, and Mustafa Celiktas implants are other alternative methods of recon-
struction, but each method has its own l imitations,
and orthopedic surgeons still seek new approaches
9.3.1 Introduction with less patient morbidity [57, 58, 61, 66].
Cylindrical titanium mesh cages for bone
Bone defects are frequently encountered in rou- defects of the appendicular skeleton have been
tine orthopedic practice. Surgery, in cases of adopted from postvertebrectomy reconstruction.
open fractures, infection, and nonunion, may be Hollow titanium mesh cages have been used with
complicated by bone loss. Segment transport success for reconstruction of the corpectomy
with external fixators is still the gold standard. defects of the vertebra [60]. The first report on
Regenerating the bone by distraction osteogene- the use of titanium mesh cages for the treatment
sis provides biologic healing of the bone while of defective, open fractures of the tibia was pub-
preserving its original architecture. However, the lished by Cobos et al. in 2002 [59]. Since then
average time to obtain new load-bearing bone is there have been few additional case reports, and
one and a half months for each centimeter, and the literature lacks case series with long-term
the treatment may take quite a long time because follow-up [55, 56, 67]. The indications, surgical
the size of the defect increases. Complications technique, and possible complications will be
encountered throughout the treatment period are discussed in this chapter.
9.3.1.1 Indications, Timing of Surgery,

and Prereconstruction Care
Patients who present with bone defects caused
by open fractures due to high-energy trauma or
gunshot injuries, infection, and pseudarthrosis
are candidates for reconstruction with titanium
mesh cages. The technique involves the use of
allografts to fill inside and incorporation of an
intramedullary nail to the titanium mesh cage.
Both the allograft and metallic implants are sus-
ceptible to infection, so the prerequisite is an
aseptic wound at the time of reconstruction.
Meticulous debridement of open fractures, and
especially gunshot injuries, should be done with
administration of broad spectrum antibiotics at
emergency admission. The surgeon should be
generous in excision of any bone fragment with-
out soft tissue attachment from the surgical site.
Even large fragments that may be referred to as
keystone parts for reduction during conven-
tional fracture surgery may be excised, but via-
ble bone at the fracture site should be preserved
for further reconstruction. Preparation of bone
ends to adopt the mesh cages should not be done
at initial debridement, and it should be remem-
bered that titanium mesh cages can be manufac-
tured as custom made or cut easily into the
desired shape to fit the bone defect. Repeat
debridements may be necessary to assure com-
plete wound healing.
Another group of patients that requires wound Fig. 9.37 Custom-made temporary spacer of antibiotic-
care is patients treated with external fixators. The loaded bone cement with intramedullary rod
current authors avoid the use of temporary exter-
nal fixation if possible. In patients previously
treated with external fixators, delaying definitive
(Fig. 9.37). Multiple specimens for culturing
reconstruction for at least 2 weeks after removal microorganism and biopsy should be obtained.
of the external fixators is recommended until Medical treatment should be initiated and contin-
complete healing of the pin tracks is achieved. ued until the serum markers of infection, WBC
count, ESR, and CRP levels, return to normal.
Treatment of Infected Patients The length of the defect and diameters of the
Patients with active infection can also be treated proximal and distal bone ends are noted.
in a staged procedure that involves placement of Orthoroentgenograms and computed tomogra-
a temporary spacer. The technique was defined phy are valuable in the determination of the exact
by Masquelet et al. [65]. The first stage involves nail length and the cage for definitive reconstruc-
radical debridement, followed by placement of a tion. In the second stage of reconstruction, biopsy
temporary custom-made spacer with antibiotic- specimens are sent to frozen section, and implan-
loaded bone cement. Bone cement is wrapped tation is continued after verifying eradication of
around an intramedullary placed central rod infection.
124 C. Şen et al.
Surgical Technique
The patient is placed in the supine position on the
operating table. The lateral decubitus position is
reserved for femoral reconstruction when intraop-
erative distraction is planned. The fracture site is
exposed through a longitudinal incision wide
enough to gain access to both ends of the bone,
which will act as load-bearing platforms. The
diameter of the cage limits the nail size. A nail that
easily passes through the cage with both
reinforcement rings attached on the cage is pre-
ferred. The medullary canals of the distal and prox-
imal parts are reamed separately to the appropriate Fig. 9.38 Proximal reduction of the impacted cage
diameter. If there is no limb length discrepancy, a
trial nail can be inserted to the construct before fill-
ing the cage. The cage is then filled with a compos-
ite of cancellous allograft mixed with autogenous
graft harvested from the ipsilateral ilium. Tight
packing of the cage should be provided by inser-
tion of a rod during impaction of the grafts so that
the grafts are forced out through the fenestrations,
rather than the center of the cage, and do not scatter
easily during passage of the nail. A trial passage
should be performed prior to insertion of the nail.
Reinforcement rings should be attached to both
ends if possible. The nail is passed through the
Fig. 9.39 Intraoperative distraction over the nail
medullary canal of the proximal fragment, and the
prefilled cage is attached on the nail tip with com-
pression while the distal fragment is kept away. inserted without the cage in the proximal and dis-
Using bone-holding clamps and applying adequate tal fragments. A monolateral external fixator is
traction, the distal fragment is reduced to the proxi- applied without contact to the nail with a similar
mal bone-cage construct. This kind of reduction technique to lengthening-over-nail procedure.
technique decreases the chance of graft scattering Distraction is applied until 10 mm more than the
and also overcomes minor limb length discrepancy desired length is achieved (Fig. 9.39). At this
(Fig. 9.38). Compressive contact at the host bone- stage the nail is taken back, and the prefilled cage
cage junction should be provided. The length of the is reduced to reconstruct the intercalary segmental
cage should always be longer than the length of the defect. The nail is inserted distally and compres-
defect. The cage can be shortened intraoperatively sion is applied by the external fixator. The fixator
if needed, and compressive contact can only be is removed confirming that the desired length and
achieved by restoring leg length. reduction of the cage at both ends are appropriate
With major limb length discrepancy, the tech- (Fig. 9.40). The remaining grafts are placed
nique can be modified by addition of simultane- around the cage for future bridging. Vascular sta-
ous intraoperative lengthening of the femur with tus of the extremity should be closely monitored
cage reconstruction. Acute lengthening of the during and after the lengthening procedure. Distal
tibia is not recommended because of possible soft locking of the nail is performed with maximum
tissue complications. Lengthening should also not compression (Fig. 9.41). Dynamic locking should
be done in case of vascular repair. The patient is be preferred because of possible shortening at
positioned to lateral decubitus, and the nail is follow-up.
Follow-Up and Possible Complications

The patient is allowed to weight bear as tolerated
in the early postoperative period. Active and pas-
sive ranges of motion exercises are started. Care
should be taken for possible wound problems
because the use of allograft and internal fixation in
open fractures brings the risk of infection which
may end up with catastrophic results for the
patient. The clinical results in a limited number of
Fig. 9.40 Compression of the cage with removal of the cases are encouraging for the use of titanium mesh
external fixator
cages. IM nail-cage reconstruction has certain
advantages over alternative methods. Patient com-
fort is provided with minimal morbidity.
Experimental studies showed short-term success
with partial healing of bone defects in animals [62,
64]. Complete bridging of the defect has not yet
been shown, and fracture healing is a dynamic pro-
cess that involves remodeling with creeping sub-
stitution that takes place over years. Long-term
implant failure is still an important consequence.
The surgical technique is easy and readily avail-
able implants are used. Although the early results
are promising, more clinical and basic science
studies are needed.
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Latta LL. The efficacy of cylindrical titanium mesh Clin Orthop Relat Res. 1989;243:65–70.
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segmental femoral diaphyseal defect. J Orthop Res. Ekkernkamp A. Management of a long segmental
2006;24(7):1438–53. defect at the proximal meta-diaphyseal junction of the
65. Masquelet AC, Fitoussi F, Begue T, Muller GP.
tibia using a cylindrical titanium mesh cage. J Orthop
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autogreffe spongieuse. Ann Chir Plast Esthet. 2000; 68. Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M. Bifocal
45:346. compression-distraction in the acute treatment of grade III
66. Nusbickel FR, Dell PC, McAndrew MP, Moore MM. open tibia fractures with bone and soft-tissue loss: a report
Vascularized autografts for reconstruction of skeletal of 24 cases. J Orthop Trauma. 2004;18(3):150–7.
Treatment of Intraarticular Joint
Fractures of the Lower Extremity 10
with External Fixators
Mehmet Erdem, Deniz Gulabi, Ibrahim Tuncay,

Gokcer Uzer, Mehmet Erdil, Ersin Kuyucu,
and Gokhan Karademir
10.1 T
reatment of Distal Femur extending to the metaphysis. These fractures may
Intra-articular Fractures be the result of high-energy trauma or a simple
with Ilizarov Circular fall from a standing height. The amount of frag-
External Fixator mentation is determined by the energy causing the
fracture and by the individual’s bone quality. The
Mehmet Erdem and Deniz Gulabi age groups which have peak frequency of these
injuries are elderly females and young males. In
elderly patients, fractures more commonly occur
10.1.1 General Background as a result of indirect forces and result in a multi-
fragmentary metaphyseal fracture and possible
Distal femoral fractures constitute 3–7% of all intra-articular extension. High- energy mecha-
femoral fractures. The degree of intra-articular nisms may have quite complex articular involve-
fractures varies from simple split fractures to ment. These high-energy fractures may be seen
wide intra-articular and fragmented fractures together with fractures in other areas.
Following fracture, shortening, and varus and
extension deformity occur due to the unopposed pull
M. Erdem, MD (*)
of the gastrocnemius and adductor muscles [1]. As
Sakarya University, Department of Orthopedic
Surgery and Traumatology, Sakarya, Turkey distal femur intra-articular fractures are often frag-
e-mail: drmehmeterdem@gmail.com mented, treatment is difficult and good planning is
D. Gulabi, MD required. If the joint surface is not well restored, this
Kartal Dr. Lütfü Kırdar Education and Research may result in post-traumatic osteoarthritis in the
Hospital, Istanbul, Turkey knee in the future [2–6]. Mortality rates have been
e-mail: dgulabi@yahoo.com
reported previously as 6–48% after distal femur
I. Tuncay, MD • G. Uzer, MD fractures [7]. These results are similar to the mortal-
Bezmialem University, Department of Orthopaedic &
ity rates published for proximal femur fractures [7].
M. Erdil, MD • E. Kuyucu, MD
Istanbul Medipol University, Orthopedic &
Traumatology Department, Istanbul, Turkey 10.1.2 Anatomy
e-mail: drmehmeterdil@gmail.com
G. Karademir, MD The distal femur includes the supracondylar and
Istanbul University, Istanbul Medicine Faculty, intercondylar areas extending from the metaphy-
Orthopaedic & Traumatology Department, sis–diaphysis junction to the knee joint surface.
Istanbul, Turkey

https://doi.org/10.1007/978-3-319-45675-1_10
130 M. Erdem et al.
10.1.3 Classification
For the purposes of reliable communication, the

development of treatment algorithms, and the
interpretation of results, it is important that a
common language is used when discussing
fracture types. The Orthopaedic Trauma

Association (OTA) comprehensive fracture clas-
sification system expanded the attempts of the
Arbeitsgemeinschaft für Osteosynthesefragen
(AO) to classify all fractures using an alphanu-
meric system. According to the AO/OTA fracture
classification system, type B fractures are partial
intra-articular fractures, B1, lateral condyle frac-
ture; B2, medial condyle fracture; and B3, partial
coronal plane intra-articular fracture (Fig. 10.2a).
Type C fractures are intra-articular bicondylar
fractures and subgroups are characterized by
metaphyseal and intra-articular fragmentation,
C1, simple intra-articular split fracture (T or Y
shaped); C2, simple intra-articular split and frag-
mented metaphyseal fracture; and C3, frag-
mented intra-articular and metaphyseal fractures
(Fig. 10.2b) [2, 9].
10.1.4 Clinical Evaluation
Generally there is deformity, swelling, and pain.

Adequate radiographic evaluation is extremely
Fig. 10.1 Between the mechanical and anatomical axes important for classification of the fracture and
of the femur, valgus angulation of 7° ± 2° and distal development of an operative strategy.
femur-oriented angles. Angular values: aLDFA anatomic Anteroposterior (AP) and lateral views of the
lateral distal femoral angle, mLDFA mechanical lateral
knee and femur are required. Placing the limb in
distal femoral angle
manual traction while obtaining the views will
enhance understanding of the fracture pattern. If
Between the mechanical and anatomical axes intra-articular extension is present, the use of
of the femur, valgus angulation of 7° ± 2° and the oblique views is helpful to define the extent of
angular values (anatomic lateral distal femoral involvement.
angle (aLDFA) = 81° ± 2°; mechanical lateral Computed tomography (CT) is important in
distal femoral angle (mLDFA) = 87° ± 2°) made the definition of fragmentation in intra-articular
laterally with the femoral distal joint line form fractures and in fractures in the coronal plane. Of
the femoral alignment (Fig. 10.1). Achieving this all distal femur fractures, 38.1% are coronal plane
alignment and regaining knee functions are fractures and a third cannot be differentiated on
extremely important in the surgical treatment of plain radiographs. When ligament, tendon, or
intra-articular fractures with metaphyseal frag- meniscus injury is suspected, magnetic resonance
mentation of the distal femur [8]. imaging (MRI) can be applied [2, 5, 10].
10 Treatment of Intraarticular Joint Fractures of the Lower Extremity with External Fixators 131
Fig. 10.2 (a)
Classification of AO/OTA a
type B fractures. (b)
Classification of AO/OTA
type C fractures
B1 B2 B3
C1 C2 C3
Neuromuscular examination of the affected 10.1.5 Treatment

extremity is necessary before and after reduc-
tion. Skeletal traction or a knee-bridging tempo- The goals of treatment include anatomical
rary, unilateral, external fixator may be useful in reconstruction of the articular surface with com-
unstable fractures, where early surgical inter- pressive fixation, followed by restoration of
vention cannot be made or in polytrauma length, rotation, and angulations in the metaph-
patients [2]. yseal and diaphyseal extension of the fracture so
132 M. Erdem et al.
that early mobilization and excellent recovery fixation material, the Ilizarov circular external
can be gained. fixator (CEF) is used in the treatment of AO/
Disruption of the coronal plane alignment OTA type C2–C3 fractures showing intra-
causes varus or valgus deformity of the knee. articular metaphyseal fragmentation and/or open
Post-traumatic arthritis is known to develop in fractures.
fractures recovering with the knee at >15° val- Internal fixation implants include support
gus (the angular value between the tibial and plates, wedge plates, dynamic condylar plates,
femoral anatomic axes) or at any degree varus. locking plates, and LISS plates [18–24]. There is
Disruption of the alignment in the sagittal plane widespread use of these plates for intra-articular
(procurvatum or recurvatum) has fewer negative fractures with minimal or moderate fragmenta-
effects on knee kinematics and joint range of tion (AO/OTA type C1, C2) and fragmented frac-
movement (ROM) compared to coronal plane tures (AO/OTA type C3) [2, 18, 19].
deformity. The early initiation of postoperative Intramedullary (IM) nailing can be used for
knee movements is extremely important in the simple or minimally fragmented intra-articular
treatment of intra-articular fractures. Long-term fractures (AO/OTA type C1, C2), but the indica-
immobility of the knee joint causes stiffness of tions are limited [5].
the knee, loss of ROM, and poor functional Support plates and screws are used as fixation
results [11–13]. material in a stable fracture configuration and
In the early 1900s, open reduction and internal partial intra-articular fractures (AO/OTA type B).
fixation (ORIF) methods were developed, and Total knee arthroplasty may be a choice in
many different methods were applied to the distal cases with pre-fracture osteoarthritis, those with
femur (makale 0). In a comparison of the results osteoporotic and highly fragmented C3 fractures,
of ORIF and nonoperative treatment, Stewart or those of advanced age [25].
reported that the results of the nonoperative treat- In distal femur intra-articular fractures, fixa-
ment were as acceptable as those of the surgically tion of the femoral shaft is necessary together
treated group. The authors concluded that the with reduction of the joint segment. In intra-
additional trauma of surgery may have affected articular type C fractures, restoration of the joint
the results and stated that “Conservatism should surface should be achieved first. By making fixa-
be taught and practiced more universally” [14]. tion with reduction clamps, K-wires, or inter-
The AO group published its first review of supra- fragmentary screws, the joint block is stabilized,
condylar femoral fractures treated according to and care must be taken that these do not hinder
their principles of anatomic reduction, stable the placement of implants which are to be
internal fixation, and early motion. Good or applied later.
excellent results were reported from the use of Following reconstruction of the joint block,
this method [15]. Subsequently, many authors reduction of the extra-articular large bone frac-
published similar results and confirmed the effi- ture fragments of the joint block with the femoral
cacy of these methods [15–17]. shaft is applied with an external fixator or inter-
nal fixation materials. The length of the extrem-
ity, correct alignment, and rotation are checked
10.1.6 Surgical Treatment clinically and fluoroscopically after reduction
and before implant fixation.
10.1.6.1 S urgical Fixation Methods In metaphyseal bone losses, in the application
and Principles of internal implants, acute grafting is made with
There are several surgical methods for the fixa- primary iliac wing bone autograft–allograft. If
tion of distal femur intra-articular fractures. The fixation is made with an Ilizarov CEF system,
method to be used depends on the fracture char- bone loss can be reconstructed with bone segment
acteristics and the patient status. As external shift.
Distal Femur Wedge Plates and Dynamic and show great resistance to pull-out force.
Condylar Plates Biomechanically, locking plates have been
Wedge plates provide controlled alignment and shown to be superior to wedge plates with both
stable fixation in multiple planes in the surgical the frequency of loading and maximum resis-
treatment of distal femur fractures. These rigid tance [2, 22].
condylar plates which contain a blade are applied LISS plates have two major benefits over tra-
to the lateral condyle side of the distal femur. ditional fixed-angle plates: (1) screws can be
Dynamic condylar plates with lag screws are angled away from the articular surface and (2)
technically easier. The advantage of these screws can be angled away from prostheses and
implants is that as they are formed of two parts, toward areas of bone cement or remaining can-
there is a less invasive entry site and application is cellous bone when addressing periprosthetic
easy. These two devices have the similar benefit fractures [26]. Supplementary medial fixation
of being a fixed-angle device, thereby preventing can be considered to prevent the anticipated
varus collapse. Long-term clinical studies have varus collapse in fractures at a higher risk of
reported good and excellent results in 82% of failure.
fractures treated with condylar plate and in 81% In a prospective, randomized, multicenter
of those treated with dynamic condylar plate [2, study on 126 patients with distal femur fractures
20, 21]. The disadvantages of these two implants by Tornetta et al. [27], it was reported that
are the difficulties of achieving stable fixation in malalignment was more common with the use
osteoporotic bones and in coronal plane fractures. of plating, and the functional outcomes were
In lateral condylar fragmented fractures, the entry worse than those of cases that had been treated
region of the lag screw or the wedge (blade) is not with nailing.
technically suitable. Another disadvantage of In a biomechanical cadaver study by
dynamic condylar plates is that the lag screw can- Zlowodzki et al., LISS plating was shown to have
not be held by a large part of the femoral condyle less resistance to torsional loading compared to
because of reduced bone stock. In addition, with lateral wedge plating and IM nailing. In clinical
these types of implants, reconstruction of length studies, rates of union related to LISS plating
and bone losses is difficult in fractures with have been reported as 93–100% and the mean
advanced metaphyseal fragmentation [2]. time to union as 12–13 weeks [23, 24, 28, 29].
Locking and LISS Plates Ilizarov Circular External Fixator Fixation

Modern plating techniques continue to be devel- EF is the least often used fixation method but is
oped on the basis of osteosynthesis: absolute sta- used in specific situations. The advantages are
bility for articular fractures and relative stability that vascularity is protected with minimal peri-
of metaphyseal comminution with soft tissue osteal stripping of the fracture fragments, soft
care are recommended [26]. tissue integrity is protected, blood loss is
Locking plates and LISS (less invasive surgi- reduced, and length is provided [2]. Another
cal stabilization) plating systems, which have significant advantage is that it is a successful
emerged as a result of technological developments, surgical treatment choice in fractures with
are used much more in osteoporotic fractures and many fragments and bone defects which cannot
intra-articular distal femur fractures. be reconstructed with open reduction and inter-
Laterally based anatomic pre-contoured plates nal fixation and in advanced stage osteoporotic
are best indicated for A- and C-type fracture pat- fractures with poor skin coverage. In the con-
terns only. ventional plating system and the locked plating
Locking screws increase implant stability by system, early weight-bearing cannot be applied
holding the plate tightly at multiple points, to the extremity. Due to the dynamic structure
eliminate movement in the plate bone interface, in the Ilizarov CEF system, weight-bearing is
134 M. Erdem et al.
permitted in the early postoperative period [2, Rehabilitation starting in the early postopera-
18, 30, 31]. tive period is extremely important to preserve
Currently, locking plates and LISS plates are knee flexion. In studies of C2 andC3 fractures
much more widely used in the treatment of distal treated with Ilizarov CEF, mean knee flexion has
femur fractures. However, problems may be been reported as 92–105° [18, 19]. Generally,
encountered such as nonunion, medial varus col- after removal of the fixator, a significant increase
lapse, plate–screw breakage, pseudarthrosis, and is observed in knee flexion together with reha-
infection. These types of complications can be bilitation. In a study by Marsh et al. [9] of 13
reduced with the Ilizarov CEF system. Prior to supracondylar femur fractures, knee flexion was
the application of the CEF system, reconstruc- reported as mean 62° while the fixator was in
tion of the distal joint block can be achieved by place, and this increased to mean 111° after
internal fixation with very few screws and removal of the fixator.
K-wires. Then stabilization of the fracture can be In C3 fractures with internal implants, non-
achieved at the same time with the Ilizarov union rates have been reported as 3.4% with wedge
CEF. By shifting the bone segment in the plate, 16% with locking plate, and 11% with
metaphyseal defect area, union is facilitated and LISS. The nonunion rates in C3 fractures treated
femoral length is regained. When necessary, with Ilizarov CEF vary between 0 and 11%, and it
grafting can be applied to the fracture region has been shown to be a surgical method which can
with autologous iliac wing graft in the follow-up be selected for suitable patients [18, 19, 30, 31].
period [2, 18, 19, 30–33]. In conclusion, in the treatment of C2 and
In a study by Hutson et al. [19], 16 distal especially C3 distal femur intra-articular frac-
femur intra-articular AO/OTA C3 fractures were tures, the current technique is locking plates or
treated with Ilizarov CEF, and in 15 cases joint the LISS plating system. However, the CEF sys-
surface restoration was applied using minimal tem is an extremely important dynamic stabili-
implants (screw and wire). Acute grafting was zation system in multi-fragmented, osteoporotic
applied to 1/3 of the cases because of metaphy- GIII open fractures with bone loss which extend
seal bone defect. All the fractures recovered and to the proximal diaphysis, as a reconstructive
no marked alignment problems were observed surgical technique allowing the process of union
[2, 18, 19]. to be facilitated with compression in the defect
The disadvantages of the Ilizarov system are area, and with simultaneous bone lengthening,
that the application requires experience, the limb length discrepancy is removed (Fig.
patient compliance problems, the risk of infec- 10.18a, b).
tion developing from the pins, and the risk of
knee stiffness due to fixation through the quad-
riceps muscle. These effects are associated with 10.1.7 Surgical Technique
the “bridle effect” of the wire and Schanz for the Application
screws on the quadriceps muscle. To reduce this of the Ilizarov CEF Fixation
effect, it is necessary to apply the Schanz System
screws under traction while the knee is in a
moderate degree of flexion (while the extensor 10.1.7.1 Patient Position
mechanism is stretched), not from the anterior The patient is placed supine on the fluoroscopy
of the thigh (in the rectus femoris and vastus table with a support placed to raise the hip on the
intermedius) but from the lateral (in the vastus affected side. Thus it is possible to place the
lateralis). Other significant factors causing loss semicircular ring on the proximal femur trochan-
of movement are the anatomic type of fracture teric area and the full ring on the femur mid and
and the degree of related soft tissue damage distal areas. By placing a rolled compress under
[18, 19, 34–36]. the knee in the distal femur fracture localization,
the knee is brought into 30–45° flexion. This eratively while traction is applied to the patient,
position helps to relax the gastrocnemius muscle according to the AP radiograph taken at a dis-
and facilitate the reduction of the fractured femur tance of 1 m. The unit formed by the first distal
posterior condyle. Traction of the extremity is and the second ring provides compression to the
applied with manual skeletal traction from the defect area in m ulti-fragmented fractures. The
ankle or the proximal tibia [18, 37]. unit formed by the second and third rings, after
making compression on the metaphyseal area,
10.1.7.2 Setting Up the Frame allows lengthening with distraction by applying
The first distal ring is placed on the distal femo- an osteotomy (Figs. 10.16 and 10.17). In the
ral condylar area. The second ring is placed determination of the size of the rings (180–
4–5 cm proximal to the proximal fracture frag- 220 mm) which form the frame, adjustment can
ment, and 10 cm further proximal to this ring, be made according to the width of at least two
the third ring is placed. Finally, by adding a fingers between the inner edge of the rings and
semicircular pelvic arc at the level of the tro- the skin on the contralateral thigh. If the circle is
chanter minor, the frame system is completed too narrow, soft tissue will be constricted and if
(Fig. 10.3). This frame system is applied preop- too wide the stability of the Ilizarov CEF system
can be reduced [18, 37, 38].
If sufficient stability is not provided by mini-
mally invasive internal fixation together with
the Ilizarov CEF in the distal femur intra-articu-
lar fracture area, the external frame can be
extended by fixing two full rings to the proximal
tibia. Knee joint movement is provided with two
hinges. Thus, controlled distraction at the joint
level increases the stability of the system by
allowing more weight-bearing and protecting
the joint from the pressure of excessive weight
[18, 37].
10.1.7.3 F orming the Distal Femoral

Condylar Block
In displaced, multi-fragmented, distal femur
intra-articular fractures extending to the metaph-
ysis (AO/OTA type C2–C3), firstly without sepa-
ration of the soft tissue and periosteum from the
fracture fragments (not to disrupt the blood
flow), internal fixation is applied with a minimal
surgical incision and as few screws (spongeous-
cortical screw, standard cannulated screw, fully
grooved headless conical cannulated screw, etc.)
and/or K-wires as possible. Thus, by providing
integrity with the reduction of the distal femur
joint surface, the distal femur condylar block is
formed (Fig. 10.4). Then the Ilizarov CEF sys-
Fig. 10.3 Frame system which can be applied in the sur- tem is applied, which will simultaneously pro-
gical treatment of AO/OTA type C2 and C3 fractures.
Compression between the distal first and second rings and vide reconstruction and primary stability of the
distraction between the second and third rings fracture.
136 M. Erdem et al.
Trochanter major
Section 1
Section 2
Section 3
Section 4
Fig. 10.4 In an AO/OTA type C2 fracture model, mini-
mally invasive joint surface restoration with the least
number of screws and formation of the distal condylar
block
Section 6
10.1.8 Ilizarov CEF System Surgical

Technique Stages
10.1.8.1 A pplication of the Ilizarov

CEF Fixation System
Fig. 10.5 Schematic image of the anatomic sections of
To form the distal femoral block, the previously the thigh where the rings of the frame are to be placed [37]
made frame, which is generally formed of three
full rings and one semicircular pelvic arc, is
applied to the femur. The localization of the 10.1.8.2 First Stage
frame rings is placed at the levels of the second, The distal first ring is fixed by advancing a
third, fourth and fifth sections of the thigh (Figs. 2-mm stoppered K-wire as a reference wire,
10.5, 10.6, 10.7, 10.8, and 10.9). Before com- from lateral to medial to the major fracture line
mencing Ilizarov surgery, under fluoroscopy, a as far as possible and perpendicular to the ana-
K-wire or a Schanz screw is attached with a ster- tomic axis (Figs. 10.9, 10.10, and 10.11). By
ile band to the anterior thigh to show the ana- visualization under fluoroscopy that the two
tomic axis of the femur. A distal reference K-wire pins in the midline joining the two half rings are
and a proximal reference Schanz screw sent per- above each other in the center of the femoral
pendicular to this K-wire facilitate the advance- condyle, the reference K-wire is aligned with
ment perpendicular to the femur anatomical axis the distal ring and fixed to the ring (Figs. 10.10,
[37] (Figs. 10.10 and 10.11). 10.11, and 10.14).
Anterior
R.F. S. Femoral
artery vein
V.I.
A.L.
V.M. Deep femoral
A.B. artery vein
Femur
Lateral V.L.
A.M. G
Schanz
screw
S. S.M.
Siatic nerve B.F.
T
Fig. 10.6 Section 2: Diagrammatic image of the section of vastus lateralis, RF rectus femoris, VI vastus intermedius,
the thigh showing the anatomic structures and Schanz VM vastus medialis, S sartorius, AL adductor longus, AB
screws at 45–60° to each other advanced from posterolateral adductor brevis, AM adductor magnus, G gracilis, SM semi-
to anteromedial and from anterolateral to posteromedial (VL membranosus, ST semitendinosus, BF biceps femoris)
Anterior Anterior
R.F. Femur R.F.

V.I.
V.I.
V.L. S.
Femur Femoral
V.M.
artery V.L.
Lateral
A.B. vein Lateral
Schanz V.M.
G. Deep
screw A.M. femoral Schanz
B.F. artery screw S.
vein B.F.
Tibial and S. S.M.
common T. S.M.
Tibial and G
peroneal
nerve common
peronal
nerve S.T.
Fig. 10.7 Section 3: Diagrammatic image of the section of
the thigh showing the anatomic structures and Schanz screws
at 45–60° to each other advanced from posterolateral to
anteromedial and from anterolateral to posteromedial Fig. 10.8 Section 4: Diagrammatic image of the section
of the thigh showing the anatomic structures and Schanz
10.1.8.3 Second Stage screws at 45–60° to each other advanced from
posterolateral to anteromedial and from anterolateral to
The semicircular arc at the most proximal of posteromedial
the frame is located immediately distal to the
trochanter minor, and after making a hole with
a 4-mm drill (if the Schanz screw is sent are placed perpendicular to the femur anatomic
directly, the femoral second cortex may be bro- axis. Under fluoroscopy, on both the anterior–
ken), a 6-mm hydroxyapatite (HA)-covered posterior image and the lateral image, the
Schanz screw is advanced from posterolateral frame-connecting rods should be seen to be
to anteromedial perpendicular to the anatomic parallel to the femur anatomic axis (Figs. 10.10
axis and fixed to the semicircular ring (Figs. and 10.11). Thus, the first application of the
10.6, 10.10, and 10.11). The rings of the frame frame is implemented.
138 M. Erdem et al.
Fig. 10.9 Section 5: Diagrammatic Anterior

image of the K-wires advanced and the
Schanz screws advanced from
posteromedial to anterolateral and from
posterolateral to anteromedial of the K wire
femur medial and lateral epicondyles,
perpendicular to the anatomic axis Lateral
epicondyle Medial
epicondyle
Schanz
screw
B.F. P.L.
G.N. G.N. S.M. S.
S.T.
Common Popliteal
peroneal N.A.V.
nerve
Fig. 10.10 Schematic image showing the femur ana-

tomic axis in the frontal plane with the guide K-wire, the Fig. 10.11 Schematic image of the femur anatomic axis
distal reference K-wire, and the proximal Schanz screw in the sagittal plane showing the distal reference K-wire
advanced perpendicular to the femur anatomic axis and and proximal Schanz screw after sending the guide K-wire
that the rod axes are parallel to the femur anatomic axis perpendicular to the femur anatomic axis and the rod axes
parallel to the femur lateral anatomic axis
Fig. 10.12 Schematic image after fixation of the frame to

the femur, showing in the frontal plane that the rods are
parallel to the femur anatomic axis, the K-wires and
Schanz screws are perpendicular to the anatomic axis, and
the rings are perpendicular to the anatomic axis
10.1.8.4 Third Stage Fig. 10.13 Schematic image after fixation of the frame to
the femur, showing that in the sagittal plane the rods are
One or two stoppered K-wires are advanced per-
parallel to the femur lateral anatomic axis, and the Schanz
pendicular to the anatomic axis to the distal first screws have been advanced from anterolateral to postero-
ring to stabilize the fracture fragments (Figs. medial and from posterolateral to anteromedial at an angle
10.9, 10.12, 10.13, 10.14, and 10.15). of 45–60°
10.1.8.5 Fourth Stage 10.1.8.6 Fifth Stage

HA Schanz screws are advanced from posterolat- One Schanz screw from posteromedial to antero-
eral to anteromedial to the distal second and third lateral and one from posterolateral to anterome-
rings perpendicular to the anatomic axis (Figs. dial of the femur medial and lateral epicondyles
10.7, 10.8, 10.12, 10.13, and 10.14). are advanced perpendicular to the anatomic axis
140 M. Erdem et al.
to the distal condylar block (Figs. 10.9, 10.12,

10.13, 10.14, and 10.15).
10.1.8.7 Sixth Stage

Schanz screws are advanced perpendicular to the
anatomic axis from anterolateral to posteromedial
to be at an angle of approximately 45°–60° with
the Schanz screws which were first placed to the
proximal pelvic semicircular arc and the second
and third rings (Figs. 10.6, 10.7, 10.8,10.12,
10.13, and 10.14).
10.1.8.8 Seventh Stage

In distal femur intra-articular fractures extending to
the metaphysis–diaphysis, in cases with metaphy-
seal multi-fragmented fractures and bone loss (AO/
OTA C3), the Ilizarov CEF system both facilitates
union by closing the defect and allows bone length-
ening to compensate for shortness (Fig. 10.3). In
fractures such as these, there may be bone loss
because of fragmentation or open fracture, and to
Fig. 10.14 Schematic image showing the alignment of
the pins of all three rings of the combined half rings reconstruct this, either acute compression can be
along the femur anatomic axis and the position of the applied between the distal first and second rings
K-wires and Schanz screws advanced to the distal con- during surgery, or gradual compression can be
dylar block applied postoperatively. In this way, union prob-
lems can be reduced to a minimum. Finally, if there
is reconstruction of shortness which has developed
in these fractures, bone lengthening procedures can
be applied with a distraction osteogenesis method
by making an osteotomy with percutaneous drill-
ing between the second and third rings (Figs. 10.16,
10.17, and 10.18).
Fig. 10.15 Schematic image of the lateral distal femoral

condylar block
Fig. 10.16 Schematic image showing lengthening of

femoral shortness with closure of the defect with com-
pression of the system between the distal first and second
rings and distraction between the second and third rings in
fractures with metaphyseal fragmentation and bone defect Fig. 10.17 Schematic image showing distal compression
and proximal distraction of the Ilizarov CEF system in the
sagittal plane
a b
Fig. 10.18 (a) (32-year-old male) Preoperative radio- was made with multiple K-wires with a minimally inva-
graphs of AO/OTA type C3 fracture. Noticeable metaphy- sive entry, and then with the Ilızarov CEF system, union
seal fragmentation following high-energy trauma (Istanbul was achieved with compression in the distal and lengthen-
Med Fac archives). (b) First, distal femoral reconstruction ing from the proximal (Istanbul Med Fac archives)
142 M. Erdem et al.
10.2 Proximal Tibia Fractures lateral meniscus covers approximately 50% of the
and Treatment lateral tibial plateau, and as the lateral tibial pla-
with an External Fixator teau is convex in shape, the concavity of the lateral
meniscus has an important role in providing stabil-
Ibrahim Tuncay and Gokcer Uzer ity of the femoral condyle. The medial meniscus
structure is smaller than the l ateral meniscus and is
Proximal tibial fractures are fractures that occur oval in shape. It makes a greater contribution to the
in the joint surface and within the adjacent posterior stability of the medial femoral condyle.
metaphysis and diaphysis. They are generally The ACL, PCL, and posterolateral and pos-
caused by high-energy trauma and are typically teromedial corner ligament complex constitute
accompanied by soft tissue injuries (MCL, LCL, another important part of the knee joint, and
ACL, PCL, meniscal structures, cutaneous and these are the structures that are responsible for
subcutaneous tissue) and neurovascular injuries. the primary stabilization of the knee joint (Fig.
At the same time, as there is a risk of future post- 10.19).
traumatic arthritis developing in intra-articular
fractures and a high risk of deformity due to mal-
union, the diagnosis and treatment strategies of 10.2.2 The Mechanism of Injury
proximal tibia fractures, as one of the significant
load-bearing joints of the body, are important. The mechanism of injury of the intra-articular
cartilage is generally the varus stress, the valgus
stress, and the result of axial loading or varus-
10.2.1 Anatomy axial, valgus-axial loading. Proximal metaphyso-
diaphyseal injuries are generally caused by direct
The proximal tibia is formed from the joint sur- trauma or bending (Fig. 10.20).
face made of hyaline cartilage and the metaphy- As a result of osteoporosis forming in the
sis. The joint surface is formed from the medial bones with aging, fractures may occur with
and lateral tibial plateau and the medial and lat- low-energy trauma. These are generally in the
eral tibial eminence where the anterior cruciate form of intra-articular split-depression fractures.
ligament (ACL) and posterior cruciate ligament
(PCL) are attached.
The medial tibial plateau is larger than the lat- 10.2.3 Classification
eral tibial plateau. The lateral plateau is a convex
medial plateau concave structure. The articular The most commonly used classifications of prox-
cartilage of the lateral plateau is thicker than that imal tibial fractures are the Schatzker and AO/
of the medial, and the lateral plateau is approxi- OTA classification systems.
mately 2–3 mm superior to the medial plateau.
There is approximately 3° varus angulation
between the proximal tibial plateau and the tibia 10.2.4 Schatzker Classification
long axis, and a posterior slope of approximately (Fig. 10.21)
9°. Due to this anatomic varus angulation, the
trabecular bone beneath the medial tibial plateau Type 1: Cleavage type fracture
is thicker and more sclerotic than the lateral tib- A single wedge-shaped fracture fragment dis-
ial plateau. placed laterally and inferiorly in the sagittal plane
The medial and lateral meniscus structures are of the lateral tibial plateau. This fracture type is
fibrocartilage structures that absorb the load borne generally seen in young patients and together
by the cartilage surface of the knee joint. The with lateral meniscal injury.
Fig. 10.19 Proximal
tibia anatomy
L A M P L
C C C C C
L L L L L
Lat. Med. Lat. Med.

meniscus meniscus meniscus meniscus
Femoral
adduction
Dynamic
Knee
valgus
abduction
Ankle
Midline
eversion
Fig. 10.20 Position of

neighboring joints during injury
144 M. Erdem et al.
Type 1 Type 2 Type 3
Fig. 10.21 Schatzker classification
Type 2: Split and depressed type fracture Type 4: Medial condyle fracture
The lateral part has split collapsed toward the This fracture type does not generally involve
metaphysis together with the lateral plateau joint the medial articular surface and is separated
surface. This form of injury generally occurs from the tibial eminence or from the lateral
with lateral bending force together with axial tibia. As the medial plateau is thicker and more
loading. sclerotic, this kind of injury requires higher
energy. There is a risk of ligamentous injury,
Type 3: Central depressed type peroneal nerve injury, arterial injury, and soft
The lateral tibial plateau is depressed to the tissue injury. These fractures tend to be unstable
metaphysis and the lateral cortex is intact. This is and varus.
the most commonly seen type in the Schatzker
classification and generally occurs in elderly Type 5: Bicondylar fractures
patients with osteoporosis. When there is insta- This type of fracture occurs as a result of
bility and severe collapse, surgery is necessary. axial loading while the knee is in full extension.
It is an unstable fracture where both plateaus 10.2.6 Posterior Shearing Fracture

are separated from the intercondylar area and
the metaphysis. Load-bearing surfaces may This type of fracture includes the posterior part of
remain intact. Evaluation must be made in the medial tibia plateau. Typically, the anterior
respect of neurovascular injury and compart- tibia together with the tibial metaphysis is
ment syndrome. displaced anteriorly and the fractured posterior
fragment is displaced to the distal and posterior
together with the femur (Fig. 10.23).
Type 6: Bicondylar plateau tibial fracture with
metaphysodiaphyseal separation
This may be an open or closed fracture with 10.2.7 Open Tibia Fracture
severe soft tissue injury which occurs as a result Classification
of high-energy trauma. Evaluation must be made
of the neurovascular status and in respect of com- 10.2.7.1 G ustilo–Anderson
partment syndrome. Classification
Gustilo type 1:
Injuries on the skin <1 cm
10.2.5 AO/OTA Classification (Fig. 10.22)
Gustilo type 2:
The AO (Arbeitsgemeinschaft für Osteosyn Injuries >1 cm. No serious tissue loss in the
thesefragen)/OTA (Orthopaedic Trauma Asso surrounding soft tissue. Primary closure can be
ciation) classification is often used in scientific made of the wound.
studies. In this classification, the proximal tibia is
numbered as 41. (4, tibia; 1, proximal segment; the Gustilo type 3:
joint length includes the joint and the metaphysodi- Gustilo type 3 A:
aphyseal part extending distally from the joint). In These generally occur as a result of high-
the AO/OTA classification, there are three subgroups energy trauma and there is enough soft tissue
of ABC for the articular section: A, extra-articular; coverage over the bone.
B, partially articular; and C, fragmented articular.
Gustilo type 3 B:
Within these three types, a further separation into
Accompanied by injuries of soft tissue defects
three types is made as 1, 2, and 3, and these are
and periosteal loss over the bone
finally classified within themselves (e.g., 41 A1.1).
41 A1: Avulsion fracture Gustilo type 3 C:

41 A2: Simple metaphyseal fracture(2 parts) All fracture types accompanied by arterial
41 A3: Metaphyseal multi-fragmented fracture injuries requiring vascular repair.
41 B1: Split fracture
41 B2: Collapsed type fracture
41 B3: Split and collapsed type fracture 10.2.8 T
scherne Classification
41 C1: Intra-articular and metaphyseal simple (Fig. 10.24)
fracture
41 C2: Intra-articular simple metaphyseal frag- The fracture may be open or closed and classifi-
mented fracture cation is made according to the size of the
41 C3: Intra-articular fragmented fracture injury.
146 M. Erdem et al.
A1 A2 A3
B1 B2 B3
C1 C2 C3
Fig. 10.22 AO classification
Grade 1 open fracture: Grade 2 open fracture:

A group of simple fractures with the bone This group is the equivalent of AO type B
fragment making a small hole in the skin. No and C fractures. The skin or soft tissue is
compression or abrasion on the skin injured by compression and the fracture frag-
ment has made contact with the external envi-
ronment. No nerve or vascular damage is
seen.
Grade 3 open fracture:

Severe soft tissue injuries accompanied by
vascular and nerve damage. Vascular injuries can
be repaired. There is a high risk of infection in
these fractures.
Grade 4 open fracture:

Injuries requiring total or subtotal amputa-
tion with no possibility of vascular repair
10.2.9 Tscherne Closed Fracture

Classification
Grade 0 closed fracture:

Simple fracture type with minimal soft tissue
damage

Fracture accompanied by superficial abrasions
and moderate compression
Fig. 10.23 Tibia posteromedial shearing fracture
Fig. 10.24 Tscherne open fracture classification

148 M. Erdem et al.

This group is examined as fragmented frac-
tures as a result of blunt trauma. Injuries are
seen with significant muscle contusion and
abrasions with deep contamination. Attention
must be paid in respect of compartment
syndrome.

Injury in the form of subcutaneous abrasion
with large muscle tissue loss and arterial dam-
age. There is a high risk of compartment
syndrome.
10.2.10 Diagnosis
In these types of injuries, it is important to

understand the mechanism of trauma that
caused the fracture, to define the type of frac-
ture and additional injuries such as soft tissue
damage, and to evaluate the risk of neurovascu-
lar damage. It is important that the necessary
evaluation is made in respect of compartment
syndrome.
After identification of the fracture, the plan-
ning of treatment must be applied according to
the age and functional status of the patient. Fig. 10.25 Direct radiograph taken at 10° caudal for
imaging of the tibial plateau
10.2.11 Physical Examination

ation in respect of any hypoesthesia, pain, or
In the evaluation of patients with polytrauma, motor function loss in the leg must be made on
first, an evaluation of vital functions must be the 1st and 2nd days. If the ABI is <0.9, angio-
made (A, airway; B, breathing; C, circulation). graphic evaluation should be applied (Fig.
After the first evaluation, skin injuries on the 10.25).
body must be evaluated by inspection.
Hemarthrosis or effusion evaluation offers clues
as to the severity of the trauma. Then distal cir- 10.2.12 Imaging Methods
culation is evaluated. When no pulse can be
obtained in the distal circulation, the ankle-bra- As the knee joint has a posterior slope of approxi-
chial index is examined (ABI = systolic pressure mately 10°, better evaluation of the tibial plateau
of the injured extremity/systolic pressure of the is provided by taking craniocaudal radiographs at
uninjured extremity). When the value is >0.9, 10°–15°(Fig. 10.27). Standard AP–lateral and
close monitoring must be applied, and against oblique radiographs and CT are the gold standard
the possibility of compartment syndrome, evalu- (Figs. 10.26 and 10.27).
Fig. 10.26 Standard AP

and lateral radiograph
Fig. 10.27 CT image

150 M. Erdem et al.
In the evaluation of the meniscus and liga-

ments within the joint, CT is not sufficient and
MRI is superior (Fig. 10.28). However, this is not
an imaging method used routinely in these
injuries.
10.2.13 Treatment
10.2.13.1 Conservative Treatment

Treatment is planned with the aim of obtaining
joint movement, joint stability, joint surface con-
formity, and lower extremity alignment, which is
pain-free and prevents osteoarthritis.
The most important factors in the development
of osteoarthritis have been reported to be joint
malalignment, instability, and concomitant liga-
ment injuries [43].
Generally, <3 mm step-off, up to 5 mm col-
lapse, >5 mm separation from the fracture line,
up to 5° valgus, up to 10° valgus malalignment,
up to 10° malalignment in the sagittal plane,
and <10° angulation in the frontal plane cre-
ated by stress are evaluated as the acceptable
Fig. 10.28 PCL tibial avulsion on MRI limits.
Age alone is not a contraindication for sur-
CT is useful in the evaluation of occult intra- gery, but patients with functional expectations,
articular fractures not seen on direct radiographs accompanying systemic diseases, and problems
and the evaluation of the amount of intra-articular that are contraindications for surgery are suitable
collapse in three planes. candidates for conservative treatment.
Traction and/or plaster casting is used as

conservative treatment [40]. Early movement is
important in respect of future knee function.
The desired results are full extension and 120°
flexion. Therefore, after plaster casting, a func-
tional brace should be used for an appropriate
period of time.
10.2.13.2 Surgical Treatment
Indications for Surgical Treatment

1. Open fractures
2. Fractures together with vascular damage
3. Displaced medial condylar fractures
4. Lateral tibial plateau fractures causing joint
instability
5. Fragmented unstable fractures
6. Displaced bicondylar fractures
7. Polytrauma Fig. 10.29 It is necessary to fix the bone in the center of
the fixator [47]
The surgical method most favored in tibial
plateau fractures, proximal tibial fractures, and incision and clamps, fixation of the fracture frag-
especially Schatzker type 1, 2, and 3 fractures is ments must be made percutaneously. If the joint
open reduction and internal fixation. However, surface has collapsed, this can be raised and, after
in cases where there is insufficient soft tissue grafting, an external fixator of three or four rings
coverage and in multi-fragmented fractures such should be used (Figs. 10.30, 10.31, and 10.32).
as Schatzker types 4, 5, and 6, external fixation With the proximal entry point of the wires at
is the first treatment choice [49, 44, 52, 45]. The least 14 mm from the subchondral bone and the
aim of treatment must be to obtain the best pos- extracapsular entry of the pins, the risk of septic
sible reduction and stable fixation [47]. arthritis is reduced to a minimum [41, 46].
The preferred fixators for external fixation are Compression should be provided by calculating
hybrid types or circular-type external fixators. An the wires to be advanced according to CT and
appropriate circular type fixator should have at advancing them vertically to the fracture line
least one ring in the epiphyseal region and two (Fig. 10.33).
rings on the diaphyseal bone. The fixator position When joint surface reduction is achieved and
should be adjusted to one finger width anterior after placement of the proximal ring, for final
and two fingers width posterior. osteosynthesis, appropriate alignment of the
The fixator must be positioned so that the bone is rings of the external fixator is obtained on the AP
in the center (Fig. 10.29). K-wires of 1.8 mm set at and lateral plan and they should then be fixed to
an angle of at least 30° between each ring and the bone with the assistance of Schanz pins and
Schanz pins in the diaphyseal region provide better K-wires. If a hybrid-type external fixator is to be
fixation. With this system, the K-wires and Schanz used, fixation should be provided with Schanz
pins used in bone fixation have a minimum effect on screws to the diaphysis (Fig. 10.34).
bone nutrition. Devitalization reduces the risk of To prevent pin tract infection in the skin entry
tumors and increases the chance of fracture union. points of the wires, it is necessary to loosen tight
Appropriate articular surface reduction may not skin at the wire ends during the operation.
be possible with an external fixator. When a chieving With this treatment, knee joint movement is pro-
joint reduction with the assistance of a small vided at the earliest stage possible, and this reduces
152 M. Erdem et al.
to a minimum any restrictions in joint movements

that may develop in the late stage [51] (Fig. 10.35).
When bone consolidation can be seen on
direct radiographs, full weight-bearing is permit-
ted. After seeing findings of loosening of the
Schanz pins or wires in the bone entry holes,
dynamization is applied to the fixator and the
patient is permitted to make movements without
restriction. In this process, if the patient reports
pain, it indicates that full union of the bone has
not been achieved. In those cases the application
of compression distraction osteogenesis or graft-
ing achieves bone union.
After consolidation has been observed on
direct radiographs, dynamization is applied.
Approximately 10–14 days later, if no deformity
has developed and there is no pain, the fixator is
removed (Fig. 10.36).
In a study by Ramos et al., 11 patients with
Schatzker type 1–4 proximal tibial fracture and 19
patients with Schatzker type 5–6 proximal tibial
fracture were treated with an Ilizarov external
fixator. In 25 patients, range of knee movement
was better than 10–110°. Pin entry site infection
was determined in 4% of the pin areas and
debridement was necessary in only two patients.
Compartment syndrome developed in two
patients and fasciotomy was applied. No func-
Fig. 10.30 Joint surface restoration with an elevator and tional knee instability was determined in any
a Weber fixation clamp [46]
Fig. 10.31 Intra-articular fracture reduction with elevator assistance

Fig. 10.32 External fixator

application following joint surface
restoration [46]
patient. Total knee prostheses were applied to

two patients due to the continuation of pain. As a
result, pleasing results were obtained in 27 of the
30 patients [48].
In a prospective randomized study by Hall
et al., a comparison was made of the treatment of
Schatzker type 5 and 6 bicondylar displaced frac-
tures with circular external fixator in 43 fractures
and open reduction with internal fixation in 40
fractures. No difference was determined in the
2-year results in respect of function, pain, and
joint stiffness. In those treated with a circular-type
external fixator, the return to pre-fracture activi-
ties was earlier, hospital stay was shorter, and
Fig. 10.33 Planning of the wires to be advanced on the
CT image blood loss during surgery was found to be less. In
154 M. Erdem et al.
Fig. 10.34 Patient with circular external fixator
the open reduction and internal fixation group, the

number and severity of deep tissue infections and
need for repeated operations were found to be
greater [42].
Catagni et al. treated 59 patients with Schatzker
type 5–6 fractures with a circular-type external
fixator, and as a result of the treatment, excellent
results were obtained in 30 patients, good results
in 27, fair results in 1, and poor in 1 [39].
In a biomechanical study by Yilmaz et al., a
comparison was made of the standard circular
external fixator and four different hybrid external
fixators. From the results, it was seen that the
Fig. 10.35 Knee flexion can be made as far as the frame circular-type external fixator was much more
allows
Fig. 10.36 Radiographic images preoperatively, postoperatively, and after removal of the Ilizarov fixator of a patient
with a Schatzker type 6 fracture
156 M. Erdem et al.
resistant to axial and bending forces than the imaging at multiple plans, fragmentation and dis-
hybrid-type external fixators [50, 53]. placement of the fracture can be evaluated in
In conclusion, in proximal tibia fractures, details (Figs. 10.37c–e). Planning of the Ilizarov-
there may be poor soft tissue coverage, high risk type circular external fixator can be better per-
of deep tissue infection, and functional results formed with CT imaging (Fig. 10.38) [57].
may not always be pleasing, which are all signifi- Various classifications have been defined for
cant orthopedic problems. Therefore, external identification of the fractures and the choice of
fixators remain as one of the leading treatment proper treatment. During tibial pilon fracture
choices because functional results are good, there classification, considering the soft tissue condi-
is a low risk of infection, and stable osteosynthe- tion and further classification of open fracture is
sis is obtained. crucial in selection of the accurate treatment and
communication between the surgeons. The
Tscherne classification system is the most
10.3 Intra-articular Fractures common and best-known classification for
of Long Bones: Tibial Pilon assessment of soft tissue conditions. According
Fractures to this classification, Grade 0 describes low-
energy injuries seen with simple fracture pat-
Mehmet Erdil, Ersin Kuyucu, and Gokhan terns without any clinical manifestations. Grade
Karademir I refers to moderate-energy injuries such as soft
tissue contusions caused by compression exerted
Tibial pilon fractures are complex intra-articular on the skin by the fractured bone ends. Grade II
fractures. They account for about 1% of the lower represents high-energy injuries that include
extremity fractures and about 5–10% of tibial comminuted or segmentary fracture patterns
fractures. These fractures usually occur after with substantial contusions. These injuries may
high-energy traumas with 20% of open fractures. be accompanied by compartment syndrome, and
Tibial pilon fractures are often accompanied by hemorrhagic bullae may present in the skin.
severe soft tissue injuries and impaction-form car- Grade III includes skin and muscle tendon inju-
tilage injuries from the supra-articular metaphy- ries in the forms of severe crush, vascular injury,
seal region [54]. and denudation, accompanied by decompen-
The orthopedic examination that is performed sated compartment syndrome. The Gustilo–
after the systemic examination of a patient should Anderson classification of open fractures is the
include a detailed assessment of circulation and most commonly used classification based on the
neurologic examination of the extremity. The size of soft tissue injury related to the fracture
condition of the soft tissue around the fracture line, persistence of neurovascular injury, con-
site should definitely be noted in comparison tamination of the wound, damage to the soft
with the soft tissue of the healthy extremity. tissue, and fracture configuration [58]. The dis-
Diagnostic imaging should be performed after advantage of this classification is its subjective
temporary fixation of the extremity. Other injuries nature, which often leads to different interpreta-
and fractures that may coexist should certainly be tions among clinicians. In this classification,
sought in these high-energy fractures [55]. severe contamination, gunshot injuries, seg-
In general, anteroposterior (AP) and lateral mentary fractures, multiple comminuted frac-
radiographs are sufficient to establish diagnosis tures, and those with bone loss and injuries that
(Figs. 10.37a, b). When obtaining these radio- last longer than 8–12 h were considered as type
graphs, views of the adjacent joints (tibiofemoral III regardless of their size [59].
and tibiotalar joints) are crucial [56]. In most Ruedi–Allgower (Table 10.1) and AO/OTA
cases, CT imaging is needed for better visualiza- (Orthopaedic Trauma Association) are the most
tion and understanding of the fracture configura- common classification systems used in the defi-
tion and for treatment planning. With spiral CT nition of tibial pilon fractures. The AO/OTA
a b d e
Fig. 10.37 A 47-year-old man admitted to hospital after falling from a height. Imaging before operation; (a) AP view;
(b) lateral view; (c–e) 3D CT views
a b c d
Fig. 10.38 After treatment with an Ilizarov-type circular view, (c) postoperative 8th month AP view, (d) postopera-
external fixator of the patient in Fig. 10.37; (a) postoperative 8th month lateral view
tive first week AP view, (b) postoperative first week l ateral
158 M. Erdem et al.
Table 10.1 Ruedi–Allgower classification satisfactory results owing to indirect reduction

Type I No comminution or displacement of joint and ligamentotaxis. Absence of soft tissue dis-
fragments section, provision of reduction and fixation of
Type II Some displacement but no comminution or the fracture fragments in a safe way, patient’s
impaction ability to walk with full weight-bearing in the
Type III Comminution and/or impaction of the joint early postoperative period, and early mobiliza-
surface
tion are the advantages of the Ilizarov-type cir-
cular external fixator method. Furthermore, this
classification enables a more detailed evaluation technique also has advantages of ability to be
of pilon fractures in the preoperative planning. concurrently performed with soft tissue closure
The code of pilon fractures is 43 in this classifi- operations such as grafting, rotation flap, and
cation system, which has 27 subtypes. AO/OTA free flap with a lower risk of infection in the
43-A-type fractures include extra-articular frac- treatment of open fractures that require soft tis-
ture pattern and should not be considered as sue coverage [62].
pilon fractures. AO/OTA 43-B-type fractures The condition of soft tissues around the frac-
are partial articular fractures, 43-B1 represents ture site is very important in surgical timing. In
pure split fractures, 43-B2 is split-depression cases of tibial pilon fractures with bullous lesions,
fractures, and 43-B3 refers to pilon fractures over swelling, and erythema, early definitive
with multi-fragmentary depression. 43-C-type treatment with internal fixation can be problem-
fractures are complete articular fractures, 43-C1 atic. Immobilization with splint or calcaneal skel-
represents complete articular pilon fractures etal traction in addition to elevation of the
that expand to simple metaphysis, 43-C2 are extremity and cold application accelerate skin
complete articular pilon fractures that expand to and soft tissue healing and make patients ready
simple metaphysis with multi-fragmentation, for a successful, comfortable operation. Another
and 43-C3 refers to complete articular pilon option for tibial pilon fractures with poor soft tis-
fractures that expand to complicated metaphy- sue conditions is two-stage surgery: early tempo-
sis. In addition, each fracture type is further rary fixation of the fracture with monolateral or
divided into three subtypes according to the AO-type external fixator for improvement of soft
fracture configuration [60]. tissue conditions and the second stage of late
Complete anatomic reduction trials and inter- open reduction and internal fixation (Fig. 10.39)
nal implants for joint restoration may impair the (REF). Early definitive treatment can be obtained
environment needed for fracture healing. Due to with external fixators if the soft tissue and skin
the infection and bleeding risk caused by the devi- are not in good condition (Fig. 10.40) [63].
talized bone and soft tissues with open reduction In order to deliver the transfixation wires and
and internal fixation, less invasive techniques have Schanz screws in a safe way without any dam-
become popular in the treatment of these high- age to the neurovascular structures, the tibia is
energy fractures in the last two decades. Several roughly examined in 5 sections (Fig. 10.41).
studies have demonstrated the superiority of per- Section I is 1–2 cm distal to the tibia plateau and
cutaneous plating with indirect reduction com- can be readily marked in fluoroscopy as about
pared with the conventional plating in terms of the one finger beneath the plateau. The first refer-
wound site complication and the complications ence K-wire should be delivered from this level
such as nonunion. In prospective studies, the in the circular-type external fixation surgery.
Ilizarov circular external fixator has been reported Section II is at proximal ¼, section III mid ½,
to present outcomes similar to plating with a and section IV distal ¾ of the length between
shorter healing time [61]. the tibial plateau and the most distal end of the
Treatment of tibial pilon fractures with exter- lateral malleolus. The middle of the section IV
nal fixators offers biologically and mechanically and the most distal end of the lateral malleolus is
a b c
d e f
Fig. 10.39 A 34-year-old male patient with a tibial pilon (d–f), an AO-type external fixator was applied and soft
fracture; (a–c) soft tissue conditions of swelling, ery- tissue healing was obtained in preparation for the defini-
thema, and bullous lesions were obvious. In Fig. 10.3 tive surgery with open reduction and internal fixation
distal 7/8 of the length between the tibial plateau, to medial, from anterolateral to posteromedial,
and the most distal end of lateral malleolus is and from anteromedial to posterolateral (with
defined as section V. Safe wire delivery directions care because of the peroneal nerve). For level II
for the levels between these sections have been (between sections II and III), the lateral oblique
described. At level I (between sections I and II, plane from the anterolateral toward the postero-
about one finger beneath the tibial plateau), wire medial and mediolateral planes are safe. At level
and screws can be safely delivered from lateral III (between sections III and IV), the medial
160 M. Erdem et al.
oblique plane from a nteromedial to posterolat-

eral, lateral oblique plane from anterolateral to
posteromedial, and mediolateral planes are safe.
Although at level IV the medial oblique plane
from anteromedial to posterolateral, and the lat-
eral oblique plane from anterolateral to postero-
medial are safe, the mediolateral plane is risky in
terms of neurovascular structures and should not
be preferred. At level V, wires and screws can be
delivered at various planes; the medial oblique
plane from anteromedial to posterolateral, the
lateral oblique plane from anterolateral toward
posteromedial, and mediolateral planes are safe.
In order to perform osteosynthesis in coronal
plane tibial pilon fractures with percutaneous
cannulated screws, the screws should be applied
from anterior to posterior [64].
10.3.1 Surgical Technique
The patient should be prepared on a radiolucent

fluoroscopy table in the supine position with a pil-
low inserted under the hip under general or
regional anesthesia. Use of a tourniquet is not rec-
ommended. Fluoroscopy device and monitor
should be placed at the side of the healthy
extremity, facing the surgeon. Following pro-
phylactic antibiotherapy, fluoroscopy-guided
closed reduction should be attempted. Anatomic
Fig. 10.40 A man aged 48 years following an occupational reduction of the articular surface, alignment of the
accident. Definitive treatment with Ilizarov-type circular articulation to the axis of lower extremity, and its
external fixator was applied because the soft tissue and skin orientation in the sagittal and rotational planes
in the site of planned open surgery were in poor condition,
together with the existent tibial lower end fracture should be checked using fluoroscopy at every
stage of the operation. In the event of fracture,
Section I Section II Section III Section Section
fixation of the fibula by providing its reduction
IV V
and length should be the first step of the surgery. If
there are no problems in the soft tissue over the
fibula, its length is maintained by providing open
reduction of the fibula with a 4- or 6-hole plate
through a mini-open incision. If the skin or soft
tissue over the fibula is in poor condition that
will not allow open reduction, the fibula should
0 1/4 1/2 3/4 7/8 1 be reduced using a rugine and fixed to the tibia
with K-wires in a percutaneous fashion [65].
Fig. 10.41 Sections and levels of the tibia and fibula used A circular external fixator should consist of
for transfixation wires and Schanz screws
three or four rings. Frames with four rings should
be preferred in fractures with wide expansion in Proximal rings should be fixed to each other
the metaphysodiaphyseal region (Fig. 10.42). using rods and the fixation of the rings should be
The frame should be inserted such that the ring at started from the most proximal ring, so the most
the most proximal point is parallel to the joint, distal ring is loose [66].
2–3 cm distal to the knee joint and to the midst, The ring is then fixed with the K-wire, which
and the ring at the most distal to center the ankle is sent from lateral to medial at the level of fibula
articulation parallel to the tibial plafond from head, parallel to the tibial plateau, such that the
1–2 cm proximal to the tibial plafond. The ring in most proximal ring is in the exact center of the
the middle should immediately be proximal to extremity and perpendicular to the proximal
expansion of the fracture line to the shaft. tibia. A minimum 3-cm space (approximately
two fingers thickness) between the ring and the
soft tissue at every region of the ring must be
obtained. Stability of the ring is increased with
Schanz screws and/or additional transfixation
wires delivered to the most proximal ring antero-
medial of the tibia. Fixation of the rings proxi-
mal to the fracture line is completed following
the same principles so as to be in the exact center
of the extremity and to leave about 3-cm space
between the skin and rings with transfixation
wires or Schanz screws from at least two levels
as perpendicular to the steady proximal tibia. It
is not necessary to use olive K-wires up to this
stage [67].
If indirect reduction with ligamentotaxis is suf-
ficient at the articular fixation stage, the fracture is
reduced and stabilized with olive K-wires that are
delivered according to the large bone fragments.
Olive K-wires are delivered to provide reduction
and compression of the fragments based on the
fracture configuration. Orientation of the transfix-
ation wires is provided considering anatomy of
the neurologic structures according to the fracture
fragments. Beads in the olive K-wires are sent up
to the bone fracture; the beaded side is first
adapted to the ring and then the wire is tensioned
from the opposite side, which provides reduction
and compression. In coronal fracture patterns,
fixation of wires can be facilitated by percutane-
ous screwing. After the distal ring is localized
with transfixation wires, connection of the distal
ring with other rings is provided with rod tighten-
ing. When performing these stages, reduction of
the fracture, congruence of the articular surface,
and orientation of the articulation and tibial pla-
Fig. 10.42 Levels of the rings of circular external fixator fond should be checked with fluoroscopy both at
consist of four rings on the artificial bone AP and lateral plane at each time [68].
162 M. Erdem et al.
a b d e f
Fig. 10.43 A 33-year-old male, Gustilo–Anderson type II open tibial pilon fracture detected following an road traffic
accident. Preoperative (a) AP view; (b) lateral view; (c) wounds sutured after debridement; (d–f) 3D CT
In case of failure to provide sufficient reduc- should be kept distracted for 6 weeks. It has
tion with ligamentotaxis or sufficient stability at been shown that the use of foot rings may nega-
the dynamic fluoroscopy control, reduction and tively affect ankle function. Stable fracture
screw fixation can be performed through mini- reduction should be tried to obtain without add-
open incisions together with external fixator. With ing foot ring as much as possible (Figs. 10.43
the incisions made over the fracture line, not only and 10.44) [73, 74].
reduction is achieved, but also impacted bone During the surgery, the olive wires should
fragments are reduced and grafting can be applied be tensioned with tensiometer at the stage of
if deemed necessary. Following these processes, adaptation to the rings, and reduction should
fixation can be provided with olive K-wires or be checked under fluoroscopy.
cannulated screws [69, 70]. When checking that the rings are at the tibial axis
Fixation with at least three or four olive K-wires centering the extremity, we can control whether
is required in the restoration of articular surface. If screws and nuts that connect the semirings are in
there is a syndesmosis injury and d iastasis of tibia alignment along the tibial midline. In addition, all
fibula, syndesmosis fixation can be achieved with the rods must be parallel to the tibial anatomic axis.
olive K-wire from lateral to medial, from 1 cm This provides rotational control. Furthermore, all
proximal to the articular line [71, 72]. the rods must be parallel and all the rings must be
After osteosynthesis of the tibial pilon frac- perpendicular to the tibial anatomic axis [75].
ture, dynamic examination should be performed For the postoperative period, rehabilitation
under fluoroscopic control in order to make a with partial weight-bearing should start in the
decision about whether a foot ring will be first 8 weeks, and full weight-bearing is possible
added. Furthermore, in order to increase the only after callus formation in radio imaging at
stability in cases with very small distal bone 12–16 weeks. If a foot ring is added on frame, it
fragments, a foot ring can be added to the should be removed after callus formation, and
frame. If a foot ring is added, the articulation ankle range of motion must be ensured [76].
a b c d
Fig. 10.44 Postoperative view of the patient in Fig. 10.43 postoperative first week AP view; (d) postoperative first
who underwent surgery with Ilizarov-type circular exter- week lateral view
nal fixator; (a, b) clinical appearance after the surgery; (c)
8. Paley D. Principles of deformity correction. 1st ed.

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External Fixation for Upper
Extremity Trauma 11
Ata Can Atalar and Ali Erşen
11.1 E
xternal Fixator Use in Distal 11.2 R
adius Distal Functional
Radius Fractures Anatomy
Distal radius fractures are the most common frac- A healthy wrist joint has the capacity of almost
tures, accounting for 17% of fractures in the 90° flexion, 80° extension, 20° radial devia-
elderly population. Its treatment is challenging tion, and 30° ulnar deviation. The anatomy of
because of accompanying osteoporosis in this bones plays an important role in obtaining that
population. After the advantages of locking range of motion. The lateral view of the radius
plates in osteoporotic bone stabilization were distal tip has an angle of 11° between the long
recognized, they became widely used as the treat- axis of the bone and the line connecting joint
ment of choice in distal fractures of the radius. In surfaces; this angle is called the volar tilt. Any
low-energy fractures with no comminution, volar change of this angle during fracture treatment
locking plate osteosynthesis is the current gold may lead to loss of motion. Similarly, another
standard because it enables stable osteosynthesis angle (22°) is formed between the line con-
and early joint mobilization. However, in high- necting the joint surfaces and the line of the
energy fractures with many fragments, it is long axis in the AP plane. This angle is called
almost impossible to provide anatomic reposi- radial inclination and should be maintained
tioning using open approaches. In such cases, close to anatomic values during treatment in
fixation without opening the fracture and reposi- order to achieve optimal functional outcomes.
tioning of fracture fragments by ligamentotaxis The tip of the styloid process of the radius
make the external fixator a feasible option. In this bone extends 12 mm from the crossing point of
chapter, techniques and functional outcomes of the radius joint surface and ulna to distally.
external fixators in fragmented intra-articular Protection of the radial length is important to
radius distal fractures will be discussed in view prevent possible arthrosis of radiocarpal and
of the current literature. radioulnar joints (Fig. 11.1).
Perugia et al. conducted a retrospective study
on 51 surgically treated distal radius fractures.
A.C. Atalar, MD (*) • A. Erşen, MD The authors found that volar tilt was the most
Istanbul University, Istanbul Faculty of Medicine, effective radiologic parameter on functional out-
Orthopedic & Traumatology Department,
Istanbul, Turkey comes, and small changes in other parameters
e-mail: atalar@istanbul.edu.tr were not significant.

https://doi.org/10.1007/978-3-319-45675-1_11
168 A.C. Atalar and A. Erşen
21° 11°
Volar Dorsal
Radius Ulna
Fig. 11.1 Illustration of radial inclination and volar tilt
11.3 Classification Among the surgical treatments, volar plate

osteosynthesis has come to the fore through the
The most widely used classifications of radius development of locking plate technology. In a
distal tip fractures are Frykman, Fernandez, and meta-analysis that included randomized con-
AO classifications (Fig. 11.2). trolled studies comparing internal and external
The basic factor that determines treatment is fixation, it was shown that anatomy could be
involvement of the articular surface; if the frac- better restored with internal fixation [1].
ture extends to the articular surface, the damage However, some other studies reported no dif-
of this surface is the most important factor for the ference between treatment methods. McQueen
functional outcome of the treatment. et al. [2] compared four treatment methods in a
The main goal of treatment is to protect the randomized controlled study and found no
anatomic features and to keep the joint surface functional difference between external and
compliant. internal fixations [2]. The same authors com-
pared bridging versus non-bridging wrist exter-
nal fixators and found that both radiologic and
11.4 Treatment Options functional outcomes were in favor of non-
bridging external fixators. They also suggested
• Closed reduction and circular plaster cast that non-bridging external fixation was the
• Closed reduction and percutaneous treatment of choice for unstable fractures of the
pinning distal radius that have sufficient space for the
• Open reduction and plate-screw osteosynthe- placement of pins in the distal fragment [3]. It
sis (volar-dorsal plate) should be known that fixation is impossible
• Osteosynthesis by using a non-bridging exter- without bridging in intra-articular fractures,
nal fixator but external fixation may be performed without
• Osteosynthesis by using a bridging external bridging in fractures that do not extend to the
fixator articular surface, such as the Colles fracture.
11 External Fixation for Upper Extremity Trauma 169
Fig. 11.2 Application of the Schanz screws for external fixation in distal radius fractures
11.5 E
xternal Fixation in Distal horizontal plane. They may be delivered to the shaft
Radius Fractures of radius between the brachialis and extensor carpi
radialis longus muscles (Fig. 11.3).
11.5.1 Wrist Bridging Fixator The joint part of the fixator enables reduction
and distraction at desired levels. After adequate
Bridging fixation is used especially in distal radius reduction, the joint part is tightened. In order to
unstable fractures. It provides reduction of fracture increase the stability of fixation, multiple K-wires
fragments by ligamentotaxis of distractive forces may be delivered percutaneously (Fig. 11.4).
and protects the length of the radius. Ligamentotaxis
is obtained by the stretching of radioscapholunate
and radiolunate ligaments. Thus, forearm muscle 11.5.2 Non-bridging Fixator
force that depresses distal fragments is balanced,
but excess or long-term (>3 weeks) stretching may In the treatment of distal radius fractures, non-
lead to joint stiffness and reflex sympathetic dys- bridging external fixators were reported to achieve
trophy [3]. Again with this method, it should be better functional outcomes, but indications are lim-
kept in mind that medial die-punch fragment can- ited when compared with bridging fixators. In frac-
not be reduced by ligamentotaxis [4]. tures with sufficient space for the placement of pins
Although there are many bridging external fixator in distal fragment such as Colles-like fractures,
systems, in our clinic we commonly use the Penning better functional outcomes may be obtained [5].
fixator, in addition to percutaneous pinning.
11.5.1.1 W rist Bridging External 11.6 E

xternal Fixators in Elbow
Fixator Application Technique Fracture-Dislocations
At application, four Schanz screws are delivered
(two of them to the second metacarpal bone and two The elbow joint is the second most common site
of them to the radius proximal diaphysis). Schanz for dislocation, following the shoulder joint. If
screws are sent to the second metacarpal in parallel there is no accompanying fracture, it is called sim-
to each other and at an angle of 45° to vertical the ple elbow dislocation, whereas it is called complex
elbow dislocation when there is accompanying most common form of such a complex condition is
fracture. The radial head (36%), coronoid process called the terrible triad, which comprises posterior
(13%), capitellum, trochlea, or olecranon fractures elbow dislocation, radius head fracture, and coro-
may accompany elbow dislocation [6]. These ana- noid process fracture. In this section, external fixa-
tomic structures may be fractured together. The tion of these unstable elbow dislocations with
fracture will be discussed.
The terrible triad is quite a complex condition
that requires a systematic approach. The treat-
ment aims at providing a stable and functional
elbow. In the treatment of such injuries, surgery
is required to recover stability. Osteosynthesis or
repair of all anatomic structures may not be nec-
essary. Structures that need repair or fixation may
be determined based on stability at the operation.
Starting from lateral structures, lateral column
stabilization is obtained through osteosynthesis
or radial head prosthesis together with lateral col-
lateral ligament (LCL) repair. The coronoid pro-
cess is fixed by sutures, screw, or anatomic plate
according to the type of fracture and instability.
Medial collateral ligament (MCL) repair is per-
formed if necessary.
At this stage of the operation, all anatomic
structures are repaired or fixed. External fixator
may be applied in the presence of instability or in
order to maintain the achieved stability. The big-
gest advantage of the external fixator is to support
early joint mobility when protecting stability.
Thus, stiffness due to long-term immobilization
may be prevented. There are several retrospective
studies with controversial results in small patient
Fig. 11.3 Distal radius fracture operated with external groups [7–9]. As it is a rare injury, randomized
fixator, postoperative AP X-Ray
a b
Fig. 11.4 (a, b) Distal radius fracture operated with external fixator, clinical view
controlled studies with a high level of evidence fixator is delivered through the K-wire; from the
are not easy obtainable. lateral side, two Schanz screws are sent to the
Iordens et al. [10], in their multicenter study, ulna and two screws are sent to the distal humerus.
reported good functional outcomes and stable When delivering Schanz screws to the distal
elbow joints with open reduction and internal humerus, a 4–5-cm incision should be made, the
fixation in 27 unstable elbow dislocations with radial nerve should be found without exploration,
fracture. They applied hinged external fixator to and screws should be visualized on the bone.
prevent instability [10]. After mounting the fixator using Schanz screws,
joint movement should be controlled for any
change in the range of motion. If joint movement
11.7 H
inged External Fixator is adequate, the K-wire should be removed to fin-
Application Technique ish the procedure.
in Elbow Joint Complication rates are not low even in reports
with successful outcomes [10]. It should be kept in
In our clinical practice, if stability is not achieved mind that redo surgery may be necessary if the
with open reduction and internal fixation in com- rotation centers are not correct. Complications with
plex elbow dislocation, the joint is stabilized this method include radial and ulnar nerve damage
using a MAYO-type hinged unilateral external or pin bottom infection as in all external fixators.
fixator.
In order to place the fixator properly, the joint
rotation axis should be defined. To do this, the 11.8 E
xternal Fixator for Salvage
trochlea and capitellum should be superposed, Procedures in the Upper
and a perfect circle should be obtained on lateral Extremity
fluoroscopic image when the elbow is at 90°
flexion. Rotation centers of the joint and fixator 11.8.1 Distraction Interposition
are superposed by delivering a K-wire through Arthroplasty
the midpoint of this circle parallel to the joint
(Fig. 11.5a, b). In a patient with limited elbow motion due to pain or
If this is not achieved, concentric joint move- intrinsic reasons, elbow prosthesis may be a treat-
ment cannot be obtained. The central hole of the ment option, but it is not preferred in a young, active
a b
Fig. 11.5 (a, b) Application of the hinged external fixator in elbow joint

patient with the potential use of the elbow in heavy increasing. Nonunion rate varies between 2 and
activities. In such cases, distraction interposition 30% following conservative treatments, whereas
arthroplasty is one of the salvage methods that can it varies between 2.5 and 13% following surgery
be preferred [11]. In our clinic, Achilles tendon (Fig. 11.7a, b) [15–17].
allograft is preferred for interposition. Following There are various alternatives for treatment of
interposition, a hinged elbow fixator is used for dis- nonunion, but each method has its own advan-
traction to protect interposition during healing for tages and disadvantages [18]. The goal of treat-
6 weeks. There are studies with reported long-term ment is to establish a structure that is firm enough
successful results with this method [12, 13]. We per- to allow the adequate range of motion of shoulder
formed this method on five patients, the mean range and elbow joints. Plate–screw and internal fixa-
of motion was increased from 24 to 81°, and no tion is a proven treatment method for nonunions
revision or prosthesis operation was necessary dur- after conservative treatment, but it is not a choice
ing a 7-year follow-up period (Fig. 11.6a–c) [14]. with infection or bone defects after surgical treat-
ment. Thus, external fixation comes forward in
such cases [19]. Circular external fixation seems
11.8.2 Diaphyseal Humeral to be a successful treatment in diaphyseal humeral
Nonunion nonunions, because it corrects surgical deformi-
ties and it enables bone transport after segment
Even if conservative methods are frequently used resection in infected patients. However, circular
in the treatment of diaphyseal humeral fractures, fixation of the humerus is not easy in terms of
the frequency of surgical treatment has been application, and patient comfort is low. Thus, it is
a b
Fig. 11.6 (a–c) Intraoperative pictures of the external fixator application to the elbow joint with the hinge positioning
a b c
Fig. 11.7 (a, b) Pseudoarthrosis at the elbow joint and implant failure, mechanical instability is the main reason for
this nonunion. (c, d) Circular external fixator application to the patient of humerus pseudoarthrosis at figures a, b
preferred in patients who have undergone many cessful union without loss of functional elbow
operations and/or infected (Fig. 11.7c, d) [20]. range of motion (Fig. 11.8a, b ) [22].
Unilateral external fixator application can be
preferred as it is easier to apply than circular fixa-
tion with a higher patient comfort. It provides 11.9 H
umeral External Fixator
sufficient stabilization and enables compression- Application Technique
distraction [21]. In our clinic, 80 patients with
diaphyseal humeral nonunion underwent further Safe planes should be known during humeral
treatment. Of these, 35 had a circular external external fixator applications because there are neu-
fixator and 24 had a unilateral external fixator. rovascular structures close to the bone; the surgeon
Both external fixation methods resulted in suc- should stick to these planes when delivering pins.
Again, in order to protect neurovascular structures, The radial nerve turns from posterior to anterior
a Schanz screw is preferred rather than a K-wire. in the distal diaphyseal and metaphyseal regions;
In general, the pinning of the proximal humerus therefore, a small incision should be made, and the
is accepted as safe. A pin can be delivered from radial nerve should be exposed before delivering a
anterolateral to posteromedial by staying lateral to pin in this region (Fig. 11.9a, b).
the bicipital groove in the 5-cm area from the Pinning should be performed after protecting
acromial lateral rim, which is safe for the axillary the nerve. In the distal supracondylar region, a
nerve. When going to the distal, the anterolateral Schanz screw should be delivered from lateral to
region in the proximal metaphyseal region is fea- medial, whereas a K-wire should be delivered
sible for pinning. Around the middiaphyseal from medial to lateral to protect the ulnar nerve.
region, the radial nerve extends through the poste- It is also possible to deliver 2 K-wires from the
rior part of the bone; therefore, lateral and anteromedial side (Fig. 11.10a, b).
lateral application is accepted as safe.
Fig. 11.8 (a, b) Postoperative clinical photos of the patient in Fig. 11.7
a b
Fig. 11.9 (a, b) Radial nerve exploration at the circular external fixator application because of a nonunion
Fig. 11.10 (a, b) Union a b

after 2 months
6. Josefsson PO, Nilsson BE. Incidence of elbow disloca-

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19. Hierholzer C, Sama D, Toro JB, Peterson M, Helfet
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S. Outcome after closed functional treatment of
Forearm Fractures
12
Levent Eralp
The management of forearm fractures using the care. All rings close to the joint should be
Ilizarov technique has many technical difficulties radiolucent.
because of regional anatomic and biomechanical The main indications to use a circular external
characteristics. Many tendons, nerves, and ves- fixator in forearm trauma are compound frac-
sels are at risk during pin or wire insertion. tures, fractures with bone loss, and patients who
Therefore, conventional surgical techniques are are candidates for bone transport.
promoted for beginners in external fixation sur-
gery. The complex anatomic structure of the fore-
arm also causes many difficulties during 12.1 Proximal Fractures
preoperative frame mounting. The protection of
supination and pronation range is of great impor- 12.1.1 Olecranon Fractures
tance. This is accomplished by fixing only the
appropriate bone segment. In selected cases, the Olecranon fractures are classified according to
uninjured bone segment is included in the fixa- the site of injury on the joint surface, in three
tion to increase the frame stability. Frame mount- stages (Figs. 12.1, 12.2, and 12.3).
ing in early cases included only K-wire fixation;
today frame instability has been increased by the Type 1 Fracture The joint surface is injured in
addition of Schanz screws. The Schanz screws the proximal one third. The injury is caused by
utilized in forearm fractures are of 4 mm diame- the pull of triceps tendon on the olecranon. There
ter and cause less morbidity than K-wires. The two types of this injury:
transosseous wires or screws are inserted on the
ventral aspect of the forearm, the wrist joint held • Type1A: The joint cartilage is not included.
in 40° of palmar flexion. As a rule, all rings • Type1B: The joint surface is in the zone of
applied in forearm frames should have the same injury.
diameter and consist of full rings. In open frac-
tures, 2/3 rings can be utilized to facilitate wound Type 2 Fracture The joint surface is injured in
the middle one third. There two types of this
injury:
L. Eralp, MD
Istanbul University, Istanbul Medicine Faculty, • Type 2A: Single fracture
Orthopedic & Traumatology Department, • Type 2B: Compound fracture
e-mail: drleventeralp@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_12
178 L. Eralp
Fig. 12.1 Type 1

olecranon fracture 1A 1B
Fig. 12.2 Type 2

olecranon fracture
2A 2B
1A
Fig. 12.3 Type 3 olecranon fracture
Type 3 Fracture The joint surface is injured in

the distal one third.
Fig. 12.4 Illustration of proximal full ring for olecranon
Type 1 fracture
Surgical Technique (Type 1 Olecranon
Fracture)
These types of fractures are treated using a single movement of the bone fragments on dynamic
half ring. Therefore, there is no need to preas- radiologic examination, early rehabilitation is
semble a frame. The fracture is repositioned and allowed.
placed using a towel clamp under fluoroscopic Tips for mounting a frame for olecranon
control, while the elbow joint is held in exten- fractures:
sion. One or two olive K-wires are inserted per-
pendicular to the fracture line. The olive should 1 . One full ring (Fig. 12.4)
sit firmly on the proximal cortex. Alternatively, a 2. Two rings (Fig. 12.5)
fully threaded Schanz screw can be used. The
reposition is controlled in extension and 90° flex- The type of frame to be utilized is determined
ion of the elbow. The olive wires are tightened by by the fracture type. Only Type 2 frames neces-
their fixing holes on the half ring. If there is no sitate preassembling. If two rings are taken, they
12 Forearm Fractures 179
Fig. 12.5 Illustration of the

frame built with one full ring at
distal region and one half ring in
proximal region
Fig. 12.6 Different
combinations of full and half
rings
are connected by three fully threaded rods. The third wire is inserted through the ulna with a
distal ring is fixed by three K-wires applied on 25–35° inclination to the coronal plane. The
the proximal metaphysis of the radius and ulna. point of insertion is on a line that combines the
The first wire should have a 35° angle to the cor- coronoid process and the humeral medial
onal plane, which transfixes both bones (Fig. epicondyle.
12.6). The second wire fixes only the radius and On the proximal forearm, transfixing K-wires
has a 10° inclination to the sagittal plane. The have a small motion restraining effect, due to
180 L. Eralp
Fig. 12.7 Illustration
of a frame which
enables flexion and
extension movement of
the joint
1 A. Radialis
2 V. Radialis
Volar A. Ulnaris
3
4 V. Ulnaris
5 N. Medianus
6 N. Ulnaris
7
8 B
A
N. Radialis
R Forearm (r. superficialis & r. profundus)
anatomical position
(supination) c
Medial Lateral
K-wire
ew
scr
Sc
nz
ha
ha
Sc
nz
sc
Safe zone
re
w
Dorsal
Fig. 12.8 Illustration of K-wire and Schanz screw application to ulna in proximal forearm and important anatomical
structures (first level)
close proximity of muscle insertions in this mally in their direction of motion. During wire
region. Flexion can be minimally diminished by insertion from the flexor site, the wrist should be
transfixing the brachioradialis muscle (Fig. 12.7). dorsiflexed and the fingers extended maximally.
During wire insertion from the extensor site, the
wrist should be flexed and the fingers flexed max-
12.1.2 Proximal 1/3 Radius Fractures imally. Two K-wires inserted into the proximal
radius should be perpendicular to its long axis.
Surgical Technique To protect wrist joint range The wires should fix only the radius (Fig. 12.8).
of motion, muscles should be tensioned maxi- Two K-wires inserted into the distal metaphyseal
A. Ulnaris
1 V. Ulnaris
Volar
2 N. Medianus
3 A. Radialis
4 V. Radialis
5 N. Radialis
6
N. Ulnaris
(r. superficialis)
7
8
Sc
ha
nz
R Forearm sc
rew
anatomical position
(supination)
Medial Lateral
Safe zone Schanz screw

N. Radialis
(r. profundus)
K-
wi
re
Dorsal
structures (second level)
radius should be perpendicular to its long axis. K-wires should fix the radius and the ulna sepa-
One of the K-wires should be fixed to the rately (Figs. 12.8 and 12.9).
proximal and the other to the distal aspect of the
ring. If the stability of the frame is not sufficient,
a fifth K-wire should be inserted into the diaphy-
sis close to the fracture line.
12.2 Middiaphyseal Fractures
12.2.1 Anatomic Considerations

12.1.3 Proximal 1/3 Radius and Ulna
Fractures This anatomic region is mostly affected by
oblique fracture lines. The proximal fragment is
Surgical Technique The proximal and distal pulled by three muscles: biceps, brachialis, and
metaphyses of the radius and ulna are fixed by pronator teres. On the middiaphysis, K-wires
three K-wires on each site. The K-wires should should fix both bones in the sagittal plane. The
cross each other and should be fixed on both insertion point is medial to the radial artery on
aspects of their according rings. Of the three the radius. The ulnar insertion point is dorsal and
K-wires, one should transfix both the radius and can be easily palpated. Reference points at this
the ulna, the other two only the radius and the level are radial artery pulsation and tendon of
ulna. On the middiaphyseal region, two parallel flexor carpi radialis (Figs. 12.10 and 12.11). This
182 L. Eralp
A. Ulnaris
1
2
V. Ulnaris
Volar
3
N. Medianus
4
5 A. Radialis
6
N. Ulnaris V. Radialis
7
8 N. Radialis
(r. superficialis)
R Forearm
anatomical position
(supination)
K-wire
Medial Lateral
ew
z scr
an
Sc
h ne
ew
zo
fe
scr
Sa
K-wire K-
K-w
wir
e
anz
ire
Sch
Dorsal
structures (third level)
1
A. Ulnaris Volar N. Medianus
2
V. Ulnaris A. Radialis
3 V. Radialis
4 N. Ulnaris N. Radialis
5
(r. superficialis)
6
7
8
Sc
ha
nz
scr
ew
R Forearm
anatomical position
(supination) Lateral
Medial
Safe zone
Schanz screw
K-
wi
re
Dorsal
structures (fourth level)
insertion technique protects the tendons, thus fin- 12.2.3 Middle 1/3 Radius and Ulna
ger movements. Fractures
This anatomic region is mostly affected by

12.2.2 Middle 1/3 Radius Fractures oblique fracture lines. Anatomic reposition needs
the forearm to be held in a neutral rotation. A
Surgical Technique The proximal fragment is stable Ilizarov frame consists of four full rings.
pulled both by pronator teres and the supinator
muscles. Therefore, the position should be in a Surgical Technique The proximal and distal
neutral rotation. The frame has to consist of three metaphysis of the radius and ulna are fixed by
rings. Proximally and distally, two K-wires three K-wires on each site. The K-wires should
perpendicular to the long axis of the bone and cross each other and should be fixed on both
crossing each other, on both aspects of the ring, aspects of their according rings. Of the three
should be inserted (Fig. 12.12). Inter-fragmentary K-wires, one should transfix both the radius and
compression is provided by compression of two the ulna, the other two only the radius and the
olived K-wires. ulna. Additional K-wires are inserted into the
diaphyseal bone segment if needed (Fig. 12.13).
1 N. Medianus
2 A. Radialis
A. Ulnaris Volar V. Radialis
3
V. Ulnaris N. Radialis
4
5 N. Ulnaris (r. superficialis)
6
7
8
R Forearm
anatomical position Lateral
(supination) Medial
K-wire
rew
sc
anz
Sch
Sc
ha
Safe zone
nz
K-
scr
wi
Dorsal
re
ew
Fig. 12.12 Illustration of K-wire and Schanz screw application to ulna in middle forearm and important anatomical
structures (fifth level)
184 L. Eralp
1
N. Medianus
2
A. Ulnaris Volar A. Radialis
3 V. Radialis
4 V. Ulnaris
N. Ulnaris N. Radialis
5
(r. superficialis)
6
7
8
R Forearm
anatomical position
(supination)
Medial Lateral
K-wire
ew
z scr
h an
Sc
Sc
ha
Safe zone K-
nz
wir
e
sc
rew
Dorsal
Fig. 12.13 Illustration of K-wire and Schanz screw application to ulna in middle forearm and important anatomical
structures (sixth level)
12.3 Distal Forearm Fractures 12.3.1 Distal 1/3 Radius Fractures
Anatomical Considerations The proximal Surgical Technique The proximal and distal
fragment is pulled by six muscles: supinator metaphyses of the radius and ulna are fixed by
muscle, biceps, brachialis, extensor pollicis bre- two K-wires perpendicular to the long axis of
vis, abductor pollicis longus, and pronator teres. the bone, on each site. The K-wires should
For anatomic reposition, the distal fragment must cross each other and should be fixed on both
be held in supination. aspects of their according rings. Interfragmantery
compression is accomplished by two olived
Surgical Technique The distal metaphysis must K-wires.
be fixed using three K-wires. The transfixation wire
has to be inserted by 5° inclination to the frontal
plane, from the radius to ulna. The K-wire inserted 12.3.2 Middle-Distal 1/3 Ulna
into the ulna has to be in 105–110° inclination to Fractures
the frontal plane, ulnar to the flexor carpi ulnaris
tendon. The tendon should be drifted to the radial The proximal and distal metaphysis of the radius
side before wire insertion. The radial wire should and ulna are fixed by two K-wires perpendicular
be inserted from the volar aspect with a 5° inclina- to the long axis of the bone, on each site. The
tion to the sagittal plane; the radial artery and flexor K-wires should cross each other and should be
carpi radialis tendons drifted to the ulnar side fixed on both aspects of their according rings.
before wire insertion. The wire should come out of Inter-fragmentary compression is accomplished
the distal cortex between the extensor tendons on using two olived K-wires.
the dorsal aspect (Figs. 12.14 and 12.15).
1
2
A. Ulnaris Volar
3 V. Ulnaris N. Medianus
4 N. Ulnaris
5
6
7 A. Radialis
8 V. Radialis
R Forearm
anatomical position
(supination)
Medial Lateral
K-wire
ew
z scr
h an
Sc
Sc
h
an
K-
Safe zone wir
zs
e
cre
Dorsal
w
Fig. 12.14 Illustration of K-wire and Schanz screw application to ulna in distal forearm and important anatomical
structures (seventh level)
Volar
1
N. Medianus
2
A. Ulnaris
3 V. Ulnaris
N. Ulnaris A. Radialis
4
V. Radialis
5
6
C B
7 A
8
Medial Lateral
R Forearm K-wire
anatomical position
(supination)
w
re
Sc
sc
ha
z
an
nz
h
Sc
sc
re
w
Safe zone
Dorsal
Fig. 12.15 Illustration of K-wire and Schanz screw application to ulna in distal forearm and important anatomical
structures (eighth level)
186 L. Eralp
12.3.3 Distal 1/3 Radius and Ulna Surgical Technique A proximal K-wire

Fractures accomplishes radioulnar transfixation. Distally,
only the radial metaphysis is fixed by K-wires.
Surgical Technique The proximal and distal All K-wires are fixed to their corresponding full
metaphysis of the radius and ulna are fixed using rings, and distraction is applied, thus the radius
two K-wires perpendicular to the long axis of the fracture is repositioned and radial length restored.
bone, on each side. The K-wires should cross each Subsequently, one olived K-wire is inserted through
other and should be fixed on both aspects of their the distal radioulnar joint, thereby achieving reduc-
according rings. Additional K-wires are inserted tion of the dislocation. Additional K-wires are
into the diaphyseal bone segment if needed. inserted when necessary.
12.3.4 Monteggia Fracture: 12.3.6 Postoperative Follow-Up

Dislocations
An ideal Ilizarov frame achieves perfect stability,
12.3.4.1 Anatomic Considerations and early postoperative range of motion exercises
The injury consists of a proximal ulnar fracture can be started. Passive stretching exercises are
and a concomitant radial head dislocation. The recommended. Frame removal should be per-
first step is reduction of the dislocation. The fore- formed by removal of K-wires one by one on
arm should be kept in neutral rotation. separate days. Soft tissue swelling is expected in
the first postoperative week hence elevation is
Surgical Technique One K-wire each is inserted recommended.
into the proximal radius and ulna, separately. The
radial wire must be olived to accomplish radial head
reduction. Thereafter, one K-wire each is separately 12.3.7 Possible Mistakes
inserted into the distal radial and ulnar metaphysis. and Complications
All K-wires, except the proximal radial, are fixed to
the frame and immediate distraction is applied. The most common mistake is a rotational malpo-
Following reposition of the fracture, the olived sition of the bone fragments before fixation.
K-wire is fixed to its corresponding ring, which Another common mistake is fixation without
helps to maintain radial head reduction. completing anatomic distal radioulnar reposition.
If reposition is to be achieved by K-wires, the
order of their insertion is essential. Inter-
12.3.5 Galeazzi Fracture: fragmentary fixation should not cause angulation
Dislocations at the fracture site.
12.3.5.1 Anatomic Considerations

The injury consists of a radius fracture and a con- 12.4 C
ase of Example (Figs. 12.16,
comitant distal radioulnar dislocation. 12.17, 12.18, 12.19, and 12.20)
Fig. 12.16 Clinical
photo of 37-year-old male
patient who has Galeazzi
fracture dislocation
because of a traffic
accident
Fig. 12.17 Preoperative
AP and LAT x-ray of the
patient
Fig. 12.18 X-rays after

application of Ilizarov
external fixator for
longitudinal distraction
188 L. Eralp
Bibliography
1. ASAMI Group. Fractures of the forearm. Chapter 12.
In: Maiocchi AB, Aronson J, editors. Operative princi-
ples of Ilizarov. Milan: Williams and Wilkins; 1991.
2. Catagni MA, Malzev V, Kirienko A. Fractures of the
radius-ulna. In: Maiocchi AB, editor. Advances in
Ilizarov apparatus assembly. Milan: Medicalplastic;
1994.
3. Solomin LN. Fractures of the forearm. In: The basic
principles of external fixation using the Ilizarov device.
Milan/New York: Springer; 2008.
Fig. 12.19 Clinical photo of the patient with Ilizarov

frame
Fig. 12.20 X-ray of the

patient after treatment
Treatment of Pediatric Fractures
with Ilizarov’s Method 13
Fuat Bilgili
Pediatric long bones have some different char- 13.1 I ndications for Ilizarov’s
acteristics including thicker periosteum, better Method
blood supply, shorter healing time, and higher
remodeling capacity than the adult bone. • Fractures located in the distal or proximal
Therefore, most fractures are treated conserva- metadiaphyseal region that are difficult for
tively with traction or casting. However, the both reduction and fixation. Both short
prolongation of the treatment can cause “cast- metaphyseal fragment and adjacent growth
ing disease,” which manifests as joint stiffness, plates may complicate fixation of the fracture
muscle weakness, and disuse osteopenia. with other methods.
Prolonged treatment also prevents parents from • Recurrent fractures with underlying
working and children from going to school. The osteopenia.
cost of treatment with external fixation is lower • Refractures after elastic nailing.
than treatment with traction in hospital and • Fractures where remodeling capacity is low,
hospital/home. such as in supracondylar humeral fractures.
Surgical treatment can be primary treatment • Fractures in the bone with previous
for suitable long bone fracture to avoid the men- defomity.
tioned disadvantages or secondary treatment if • Pathologic fractures with benign metaphyseal
conservative treatment fails. Elastic intramedul- lesions.
lary nailing, rigid intramedullary nailing, plate
fixation, and unilateral or circular external fixa-
tion are the surgical management options. 13.2 A
dvantages of Ilizarov’s
The indication, advantages, and surgical tech- Method
niques of circular-type external fixator treatment
for pediatric long bone fractures will be discussed • Lower blood loss due to the lack of surgical
in this chapter. exposure.
• Allows weight bearing immediately after sur-
gery without cast or supporting device.
• No need for major surgical procedure for the
F. Bilgili, MD removal an internal implant.
Istanbul University, Istanbul Faculty of Medicine, • Low potential for deep infection.
Orthopedic & Traumatology Department, Istanbul, • Unlike the other external fixator systems,
Turkey Ilizarov system apply great force to prevent
e-mail: profcakmak@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_13
190 F. Bilgili
Fig. 13.1 Ilizarov fixation in open tibia fracture with soft tissue injury
the shortening and angulation of fractures that fixation in supracondylar fractures are necessary
could not be treated with closed methods. for best results because of the lower remodeling
• Modular design of Ilizarov fixator allows pin capacity in supracondylar fractures. Closed
fixation in different directions. reduction with percutaneous pinning is the gold
• Preoperative preparation of the frame shortens standard treatment in Gartland type III supracon-
the operation time. dylar fractures When this method fails to provide
• The Ilizarov fixator allows the fixation of sufficient reduction and stable fixation, other
metaphyseal fractures close and for growth of methods must be applied. The use of an Ilizarov
cartilage without damaging the physis and fixator in the treatment of supracondylar humerus
epiphysis. fractures was first described by Ilizarov himself.
• Giving a chance to correct the residual defor- Ilizarov frames should be prepared before the
mity noticed immediately after the operation operation. The size of the rings must be selected
(Fig. 13.1). such that there is a two-finger space between the
ring and the largest- diameter soft tissue. The
frame consists of three rings: a half-ring or com-
13.3 Surgical Techniques posite ring at the level of surgical neck, a total
ring at the level of the diaphysis, and a total ring
13.3.1 Humerus or five-eighth ring at the level of the olecranon
fossa. Total ring in the middiaphysis is used to
Humeral shaft fractures, supracondylar region transmit the force and usually contains no pin or
fractures, and comminuted fractures that contain wire.
intra-articular components can be treated with The patient is placed in the supine position on
Ilizarov’s method. Anatomic reduction and stable a radiolucent surgical table. The fracture, the
13 Treatment of Pediatric Fractures with Ilizarov’s Method 191
elbow, and the humerus are viewed under fluo- tion of the femur must be corrected for a balanced
roscopy for proper frame placement. First, a ref- load distribution. Moreover, early joint motion
erenced implant (a 4-mm half-pin) is driven should be started to prevent stiffness in the knee
lateral to medial through the surgical neck of the and hip joint. The frame should be prepared
humerus approximately 5 mm distal to the phy- according to the location of the fracture before
seal line. The half-pin is connected to the proxi- the operation. It is recommended that each frac-
mal ring directly or with a Rancho swivel. The ture segment should be stabilized with two rings
Rancho swivel apparatus provides better reduc- connected to each other with four rods. While
tion of fracture although it is less stable than a two half-arches are used in proximal fractures,
direct connection of half-pin to ring. one-half and one distal full arch is used in distal
Second reference implant (1.8-mm plain wire) fractures. Two half-rings or femoral arc for proxi-
is driven medial to lateral just above the olecra- mal fractures and one-half and one distal full ring
non fossa. While gentle axial traction is applied for distal fractures comprise the frame. Additional
to provide length, rotation, and alignment of the rings, including femoral arc or full ring, can be
humerus, a distal wire is fixed to the ring. The attached distally or proximally to improve
humerus must be in the middle of the frame. Two stability.
opposing 1.8-mm olive wires are used to reduce The patient is placed in a supine position on a
the fracture in the distal part of the humerus by radiolucent surgical table. A pad is placed under
tensioning simultaneously. The proximal refer- the ipsilateral pelvis. For proximal metadiaphy-
ence implant is then fixed to the crescent (poste- seal fractures, half-pins are inserted at right
rior) and the bolts are screwed. Two more angles to the mechanical axis of the femur. A
half-pins are added to the proximal ring at differ- Kirchner wire inserted from the tip of trochanter
ent levels and different planes. major to the center of femoral head can be used
Different methods can be used for reduction. as a guide. The first reference half-pin proximal
If more traction is required for reduction, threaded to the fracture is placed parallel to the guidewire
rods are turned for distraction. Conical washers at the level of the trochanter minor. It is con-
can be used for angular correction. The disadvan- nected to the ring directly or with a Rancho
tage of the conical washers is that they make the swivel assembly. The second reference half-pin
frame unstable. distal to the fracture is angled 7° distal to the
Reduction of the intra-articular component of middiaphyseal axis because of the difference
the fracture can be achieved by simultaneously between the anatomic and mechanical axes.
tensioning the crossed olive wires under fluoros- Another half-pin may be driven from the trochan-
copy. Cross-sectional anatomy should be known ter major to the trochanter minor to increase the
in order to place half-pin or wire without damag- stability.
ing the surrounding neurovascular structures. For distal metadiaphyseal fractures, refer-
Furthermore, pins and wires should not restrict enced half-pins located at the proximal and distal
the movements of joint. to the fracture are inserted at right angles to the
anatomic axis of the femur. There are some
important points to consider in the treatment of
13.3.2 Femur distal femoral metaphyseal fractures with exter-
nal fixation. The distal pin must be placed at least
There is 7° ± 2° valgus angulation between the 1 cm away from the physis to avoid thermal
anatomic and mechanical axis of the femur. injury or possible pin tract infection. End-to-end
Ilizarov external fixation is applied according to reduction is recommended in transverse frac-
these axes or the contralateral femur if it is nor- tures. However, side-to-side fracture reduction is
mal. More stable fixation is required in femur recommended with about 5 mm in oblique frac-
fracture compared with humerus fracture due to tures to avoid overgrowth in children aged under
weight bearing. The alignment, length, and rota- 10 years. A reference Kirschner wire (1.8 mm)
192 F. Bilgili
may be used parallel to the axis of the knee to There should be no tension at Schanz screw
attach the distal full ring. Two opposite olive and K-wire sites to avoid limitation of movement
wires are passed through the condyles to reduce of the knee, pain, and inflammation.
the fracture or if there is angular or translational
deformity. Each ring should be connected to the
bone with 2–3 5-mm or 6-mm half-pins at differ- 13.3.3 Tibia
ent levels and planes). If the angle between the
half-pin is 90 °, it will increase the stability in all Tibia fractures are most common in children.
planes. As a rule, to avoid fracture, the diameter of Unilateral and circular external fixation can be
the half-pin should be less than one-third of the used successfully to treat these fractures. It is
bone diameter. Oblique half-pins should be placed advised to consider using a circular fixation system
to avoid damage the quadriceps muscle. All rings in children’s tibial fractures with comminution or
must be orthogonal to each fracture segments in oblique fracture patterns, or, if treated with mono-
all planes. The arches should not be placed too lateral fixation, frequent follow-up is required to
anterior or posterolateral in order not to prevent pay attention to the fracture alignment.
daily activities. In the original Russian technique, the Ilizarov
After placing the device, it should be checked frame is reconstructed during the operation.
with intraoperative X-ray and reduced later. However, it is advised to prepare the frame before
Closed reduction is achieved after connecting the the operation to save time. The frame consists of
proximal and distal ring blocks. If there is resid- one or two rings proximally and distally depend-
ual deformity, conical washers or plates may be ing on the location of the fracture (Fig. 13.2).
used to angulate or translate for correction. A five-eighth ring can be used to allow full
Electrocautery cable can be used to check knee motion if the fracture is not located in the
mechanical axis deviation of the lower extremity. proximal third of the tibia.
The cable extended from the center of the femo- Muscle relaxants such as curare are not rec-
ral head to the center of the ankle should pass ommended to see muscle contraction due to pos-
10 mm (range, 3–17 mm) medial to the midpoint sible nerve damage during anesthesia. In this
of the knee joint. situation, the wire must be replaced.
Fig. 13.2 Planning the frame according to the location of the fracture (Taken from http://www.ilizarov.com/en/
traumatology-ilizarov-surgery)
The K-wire is driven parallel to the joint 13.3.4 Complications

line, proximally and distally. The diameter of
the wire is decided according to the weight of There are some complications including refrac-
the children: 1.5 mm wires for small children ture, pin tract infection, and malunion associated
and 1.8 mm for heavier children. During the with external fixation. However, there are some
fixation of wires to the frame, tibial anatomic recommendations to minimize these complica-
axis must be perpendicular to the ring on the AP tions (Hedin 2004;):
image and parallel to the rods on the lateral
image under fluoroscopy. Furthermore, the • Use hydroxyapatite-coated half-pins to
bone should be centralized in the frame. Olived increase stability.
wires applied proximal and distal of the frac- • Use a sharp drill to avoid thermal necrosis.
ture are used for fracture reduction and inter- • Choose a suitable diameter of half-pin accord-
fragmentary compression. The tibia and fibula ing to the diameter of the bone and soft tissue
(fibular head proximally and lateral malleolus thickness.
distally) should be fixed proximally and dis- • Prescribe oral antibiotics to use as soon as the
tally with a smooth wire. Only K-wires are used patient sees any pin site drainage.
in the original Russian technique with two • Dynamize the fixator before removing. Both
olived wires and two smooth wires in each frac- clinical and radiologic examinations are
ture segment according to the direction of the required before deciding to remove the fixator.
deformity. However, both K-wires and Schanz The patient should walk without any pain on a
screws can be used in the Italian modification. fully dynamized fixator. On two side X-rays,
The distal and proximal pin and wire must be three of the four cortexes must be healed at the
placed at least 1 cm away from the physis to fracture site.
avoid thermal injury or possible pin tract infec-
tion. During the tensioning of the distal
K-wires, the ankle should be in maximum dor- 13.3.5 Postop Care
siflexion (Fig. 13.3).
Before ending the operation, an AP and lateral On the first day after the operation, partial weight
X-ray (ankle and knee joint should be seen) bearing should be started. As long as the patient
should be taken, and the alignment should be tolerates the pain, full weight bearing should be
confirmed. started to prevent osteoporosis and to improve
Fig. 13.3 Different hybrid

application techniques
(Taken from http://www.
ilizarov.com/en/
traumatology-ilizarov-
surgery)
194 F. Bilgili
bone healing. Adjacent joint movements and 7. Paley D, Herzenberg JE, Tetsworth K, et al. Deformity
planning for frontal and sagittal plane corrective oste-
muscle strengthening exercise also should be
otomies. Orthop Clin North Am. 1994;25:425–65.
added to rehabilitation program. 8. Sabharwal S. Role of Ilizarov external fixator in the
Both parent and patient should be trained management of proximal/distal metadiaphyseal pedi-
about the daily pin care for hygiene. Alcohol- atric femur fractures. J Orthop Trauma.
2005;19(8):563–9.
chlorhexidine solutions should be used to clean
9. Gordon JE, Schoenecker PL, Oda JE, et al. A com-
the pin and wire tract. Oral antibiotics (usually a parison of monolateral and circular external fixation
first-generation cephalosporin) are recommended of unstable diaphyseal tibial fractures in children.
for use as soon as there is increasing erythema or J Pediatr Orthop B. 2003;12:338–45.
10. Al-Sayyad MJ. Taylor spatial frame in the treatment
purulent drainage around the pin site(s).
of pediatric and adolescent tibial shaft fractures.
The time to remove the fixator is decided after J Pediatr Orthop. 2006;26:164–70.
clinical and radiologic examination. If there is no 11. Blondel B, Launay F, Glard Y, et al. Hexapodal exter-
healing, dynamization should be applied. nal fixation in the management of children tibial frac-
tures. J Pediatr Orthop B. 2010;19:487–91.
Loosening the rods, removing wire or pin, and
12. Eidelman M, Katzman A. Treatment of complex tibial
acute compression comprise of dynamization fractures in children with the taylor spatial frame.
techniques. In radiologic examination, three of Orthopedics. 2008;31:161–72.
the four cortexes must be healed at the fracture 13. Miner T, Carroll K. Outcomes of external fixation of
pediatric femoral shaft fractures. J Pediatr Orthop.
site on two side X-rays. In the clinical examina-
2000;20:405–10.
tion, the patient should walk without any pain on 14. Hedin H, Hjorth K, Rehnberg L, Larsson S. External
a fully dynamized fixator. fixation of displaced femoral shaft fractures in chil-
There are some advantages to removing the dren: a consecutive study of 98 fractures. J Orthop
Trauma. 2003;17:250–6.
external fixator in the operating room under gen-
15. Kong H, Sabharwal S. External fixation for closed
eral anesthesia. Evaluating the fracture healing pediatric femoral shaft fractures: where are we now?
under fluoroscopy by stress test, debridement of Clin Orthop Relat Res. 2014;472(12):3814–22.
pin and wire tract, and applying cast or brace are doi:10.1007/s11999-014-3554-5.
16. Gugenheim JJ. The Ilizarov fixator for pediatric and
easily performed.
adolescent supracondylar fracture variants. J Pediatr
After removal of the frame, it should be for- Orthop. 2000;20(2):177–82.
bidden to partake in athletic activities to avoid 17. Hedin H, Borgquist L, Larsson S. Cost analysis of
new fractures at pin hole sites or original fracture three methods of treating femoral shaft fractures in
children: a comparison of traction in hospital, traction
site for 8 weeks.
in hospital/home and external fixation. Acta Orthop
Scand. 2004;75:241–8.
18. Sanders JO, Browne RH, Mooney JF, et al. Treatment
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dists: results of a 1998 survey. J Pediatr Orthop.
1. Gugenheim JJ. The Ilizarov fixator and pediatric frac- 2001;21:436–41.
tures. Tech Orthop. 1996;11(2):201–7. 19. Miner T, Carroll KL. Outcomes of external fixation of
2. Kettelkamp DB, Hillbery BM, Murrish DW, Heck
pediatric femoral shaft fractures. J Pediatr Orthop.
DA. Degenerative arthritis of the knee secondary to 2000;20:405–10.
fracture malunion. Clin Orthop. 1988;234:159–69. 20. Moroni A, Vannini F, Mosca M, Giannini S. State of
3. Green SA. The use of wires and pins. Tech Orthop. the art review: techniques to avoid pin loosening and
1990;5:19–25. infection in external fixation. J Orthop Trauma.
4. Green SA, Harris NL, Wall DM, Ishkanian J, Marinow 2002;16:189–95.
H. The Rancho mounting technique for the ilizarov 21. Sabharwal S, Kishan S, Behrens F. Principles of

method: a preliminary report. Clin Orthop. external fixation of the femur. Am J Orthop.
1992;280:104–16. 2005;34:218–23.
5. Bagnoli G, Paley D. Methods in reduction. In: Bagnoli 22. Hedin H, Larsson S. Technique and considerations
G, Paley D, editors. The Ilizarov method. Philadelphia: when using external fixation as a standard treatment
Decker; 1990. p. 49–123. of femoral fractures in children. Injury.
6. Schwartsman V, Schwartsman R. Techniques in frac- 2004;35:1255–63.
ture reduction. The Ilızarov method. Orthop Clin North 23. France J, Strong M. Deformity and function in supra-
Am. 1990;21:639–53. condylar fractures of the humerus variously treated by
closed reduction and splinting, traction and percuta- 28. Skaggs DL, Leet AI, Money MD, Shaw BA, Hale JM,
neous pinning. J Pediatr Orthop. 1992;12:494–8. Tolo VT. Secondary fractures associated with external
24. Otsuka NY, Kasser JR. Supracondylar fractures of the fixation in pediatric femur fractures. J Pediatr Orthop.
humerus in children. J Am Acad Orthop Surg. 1999;19:582–6.
1997;5:19–26. 29. Robertson P, Karol LA, Rab GT. Open fractures of the tibia
25. Wilkins KE. Supracondylar fractures: what’s new? and femur in children. J Pediatr Orthop. 1996;16:621–6.
J Pediatr Orthop Part B. 1997;6:110–6. 30. Gordona JE, Schoeneckera PL, Odaa JE, Ortmanb
26. Ilizarov GA, Znamenskij GB. Bloodless transosseous MR, Szymanskic DA, Dobbsa MB, Luhmanna SJ. A
osteosynthesis in intra-and periarticular fractures of comparison of monolateral and circular external fixa-
the distal humerus in children, Kurgan, 1985. Cited tion of unstable diaphyseal tibial fractures in children.
in: Bianchi-Maiocchi A, Aronson J, editors. Operative J Pediatr Orthop B. 2003;12:338–45.
principles of Ilizarov. Baltimore: Williams & Wilkins, 31. Hamdy RC, Stanitski DF. A visual presentation of
1991. p. 173. Ilizarov tibial lengthening. J Orthop Tech. 1995;3:55.
27. Fragomen AT, Rozbruch SR. The mechanics of exter- 32. Maiocchi AB, Aronson J. Operative principles of

nal fixation. HSS J. 2007;3(1):13–29. doi:10.1007/ Ilizarov, ASAMI. Baltimore: Williams&Wilkins;
s11420-006-9025-0. 1991. p. 91–188.
Role of External Fixators in Pelvic
Fracture Treatment 14
Cengiz Sen
14.1 Introduction 14.2 Anatomy
Pelvic ring fractures constitute 2% of all frac- Pelvic anatomy consists of sacroiliac joints pos-
tures, although the incidence increases. The mor- teriorly, and two innominate bones joined by
tality rate associated with these types of fractures symphysis pubis anteriorly and sacrum.
is reported as 1–2%, depending on the severity of Innominate bone further consists of ilium,
the trauma. However, the mortality rate in closed ischium, and pubis in the triradiate cartilage.
pelvic ring fracture cases with polytrauma can be Weight bearing in the pelvic ring, which is the
up to 10–15%. When pelvic fractures are con- most important structure in conducting the
comitant with intracranial bleeding and abdomi- weight of the upper part of the body to the lower
nal injuries, the mortality rate is increased to extremites, is through the sacroiliac joints and
50%. In open pelvic fractures, the mortality rate femoral neck, whereby symphysis pubis provides
is reported to be 30–50%. The determining fac- support and in some cases (e.g., pregnancy)
tors for mortality is age, injury severity, and the stretching.
amount of bleeding [1–7]. Other structures that comprise the pelvic ring
The treatment of pelvic fractures was first and maintain the stability include the interosse-
defined by Gibson in 1841 as “bed rest.” ous ligament, posterior and anterior sacroiliac
Afterwards Watson-Jones proposed hammocks ligaments, sacrotuberous ligament, sacrospinous
and pelvipedal casting. In time, Levine, Letournel, ligament, iliolomber ligament, lateral lumbosa-
and Jevett used external fixators in the treatment cral ligaments, and symphysis pubis ligaments
of these fractures. Nevertheless, the modern (Fig. 14.1).
approaches for the treatment of pelvic fractures The pelvic ring is divided into two compart-
was specified by Tile [3, 4]. ments by the pelvic ridge created by the promon-
torium, iliopectineal line, pubic crest, and
symphysis pubis. The upper space, created by the
ala of sacrum and iliac fossa, is called the false
pelvis and contains abdominal organs. The lower
part of the pelvic ring is called the true pelvis.
C. Sen The obturator foramen, which separates the
Istanbul University , Istanbul Faculty of Medicine, ischium from the pubis, is covered with a mem-
Department of Orthopedic Surgery and brane and the obturator nerve and vessels exit
Traumatology, Istanbul, Turkey through here (Fig. 14.2).
e-mail: senc64@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_14
198 C. Sen
Anterior longitudinal
ligament
Iliolumbar ligament
Anterior sacroiliac
Promontory ligament
Sacrum Sacrospinous ligament
Sacrotuberous Anterior superficial

ligament iliac spine
Anterior inferior
Ischial spine
iliac spine
Inguinal ligament
Coccyx
Obturator Pubic tubercle

membrane
Pubic
symphysis
Fig. 14.1 Pelvic ring anatomy
M.gluteus
maximus
Post.sup.
iliac crest
A.V Gluteus
Sacrum vessels
M.Gluteus
A.V medius
internal iliac
M.Gluteus
minimus
A.V
external iliac
N. femoral M.Tensor
fascia lata
Ant.sup.
iliac spine
Fig. 14.2 Soft tissue anatomy of pelvis
The most important neurovascular structures In addition, other urogenital structures, in par-
at risk in pelvic fractures are the median sacral ticular the urethra and the bladder, can be injured
artery, superior rectal artery, internal iliac artery, in 12–20% of cases.
and sacral plexus.
14 Role of External Fixators in Pelvic Fracture Treatment 199
14.3 Biomechanics Especially in pelvic ring fractures caused by

external rotation crisscross forces, internal organ
The foremost forces that result in pelvic ring injuries may be concomitantly present. Organ
fractures are external rotation, lateral compres- injuries are caused directly by bone in lateral
sion, and shearing forces [1–6]. Crashes from compression injuries.
behind cause direct loading on the ASIS, and
external rotation of the femur causes splitting of
the symphysis pubis and in cases of continuing 14.4 Clinical Evaluation
loading, rupture of sacrospinous and anterior sac-
roiliac ligaments. The pelvis opens like a book A good clinical evaluation contains good history
(external rotation injury); when forces are directly taking. Questioning the type of trauma is impor-
on the iliac crest, the injury occurs solely in pel- tant in making a diagnosis and planning the treat-
vis; when directly on the trochanter, pelvic injury ment. In older patients, due to the loss in bone
accompanies acetabular fracture. The stability of volume, even low energy traumas can cause
the pelvis is usually maintained (lateral compres- severe pelvic injury. In younger patients, soft tis-
sion injury). In another type of injury, significant sue injuries are more frequent due to higher qual-
displacement in bones with large tears in soft tis- ity of the bone. Furthermore, urethral injuries
sues occur. A prominent instability occur in pel- could be detected in men, while vaginal injuries
vic ring (shearing forces) (Fig. 14.3). could be detected in women [2–4].
a b
Fig. 14.3 Pelvic injury types

200 C. Sen
Clinical evaluation starts with inspection (obser- femur, the presence of instability must be noted.
vation). During the examination, patient must be Widening of the pubic area or external rotation in
completely naked. A sign of an open fracture or both legs points to symphysis pubis diastasis
urethral/vaginal bleeding can be a sign of a pelvic (Fig. 14.4). During pelvic examination, the sac-
fracture. Even in the absence of other fractures in roiliac complex is evaluated with traction. In
the lower extremity, shortening and external rota- addition, the pelvic ring must be fully evaluated
tion may be the sign of a vertical pelvic fracture. with rectal and vaginal examination.
After inspection, the presence of pathologic Besides these examinations, one of the most
movements must be evaluated through meticu- important issues that must be addressed is the
lous palpation. Through pressing over the iliac presence of hypovolemic shock due to signifia-
crest or testing rotational movements of the cant bleeding. Because of this factor, the exami-
nation must be swift and not repeated. At the
same time, vital signs of the patient must be noted
and fluid replacement must be initiated.
14.5 Radiologic Evaluation
All high-energy and polytrauma patients must first

have their X-ray examination. A good AP X-ray
can reveal the majority of pelvic ring lesions. In
addition to AP X-ray, patients who are thought to
have pelvic injuries should have inlet and outlet
X-ray examinations (Figs. 14.5 and 14.6).
In these X-rays, especially the sacroiliac com-
plex, the symphysis, the sacrum, and the foram-
ina, iliopubic and iliopectineal lines must be
carefully evaluated. After a careful clinical exam-
Fig. 14.4 External rotation in both two legs indicates a ination, this radiologic evaluation can diagnose
pubic diastasis pelvic instability 90% of the time [2–4].
a b
Fig. 14.5 (a, b) Inlet X-ray of pelvis

a b
Fig. 14.6 (a, b) Outlet X-ray of pelvis
ponading the bleeding is decreased. Second, due

to the proximity of the pelvic area to perianal
region, infection and sepsis are frequent compli-
cations. Therefore, mortality and morbidity are
higher in these types of fractures [1–7].
Treatment of these fractures must be faster and
more effective. First, the hemodynamic status of the
patient must be fixed, and then the open wound
should be closed with sterile drapes to reconstitute
the tamponade effect. Afterward, through repeated
debridement and irrigation, infecting the open
wound and septicemia should be prevented. Later,
when the general condition of the patient is stable,
the wound should be closed and the fracture should
be stabilized, preferentially with an external fixator.
Fig. 14.7 Three-dimentional CT of a patient with sacro-
iliac joint fracture dislocation
When in doubt, due to its benefit in observing

bone and soft tissue planes of the pelvis in axial 14.6 Classification
slices and treatment planning, a CT scan should
be added to the work-up. Sacroiliac complex, The classification of pelvic fractures takes many
sacrum fractures, and foramina are particularly criteria into account, such as the position of the
well observed in CT scans (Fig. 14.7). fracture, whether it is stable, whether it concerns
weight-bearing areas, the mechanism of injury,
and whether it is an open or closed fracture [1–6].
14.5.1 Open Pelvic Fractures In Tile classification, minimally displaced and
stable fractures are classified as type A, fractures
There are two important consequences of open with rotational instability as type B, and fractures
pelvic fractures. First, because the normally with vertical instabilities with or without rotation
closed pelvic space is open, its effect in tam- instability as type C (Fig. 14.8).
202 C. Sen
Fig. 14.8 Tile Classification
14.6.1 Tile Classification sacroiliac ligaments, sacrospinous and

sacrotuberous ligaments, and the pelvic floor
Type A: Stable pelvic ring injuries is also torn.
B2: Lateral compression fractures. These are
A1: Avulsion fractures without disruption of pel- classified as B2-1 when the acting force
vic ring (ASIS and AIIS avulsion fractures) causes injury at the ipsilateral side and as
A2: Stable but minimally displaced iliac wing frac- B2-2 when at the contralateral side. These
tures (iliac wing, pubis, and ischion fractures) are stable fractures owing to the integrity of
A3: Transverse fracture of the coccyx and sacrum. the posterior sacroiliac complex. In B2-2
Neurologic deficit is particularly frequent in lesions, the hemipelvis is rotated superior
displaced fractures of the sacrum. and medially and looks like a bucket handle.
On clinical examination, the leg is short and
Type B: Rotationally instable, vertical stable internally rotated. There may be concomitant
pelvic fractures internal organ and neurovascular injuries
B1: Open book fractures. The injuring force acts (Fig. 14.9).
on ASIS as compression or on the femur as B3: Two-sided B1 fractures, stable. The stability
external rotation. Thus, the symphysis pubis is due to the integrity of the posterior sacroil-
splits. The sacroiliac complex is intact. iac liagements; however, organ injury is com-
When there is more than 2.5 cm of opening, mon due to the opening of the pelvic floor.
C3: Two-sided type C injury. This type of injury

is associated with the greatest instability and
the worst prognosis. The pelvic floor is torn
completely on both sides. Neurovascular and
internal organ injuries accompany.
14.7 Treatment of Pelvic Fractures
Twenty percent of patients with instable pelvic

fractures have their hemodynamics disrupted.
Therefore, securing a patent airway, obtaining IV
Fig. 14.9 Tile B2 injury
access, and controlling bleeding are top priorities.
After the patient’s vital signs are stable, medical
antishock trousers may be used to decrease bleed-
ing. The patient must be transferred to the first aid
center as quickly as possible. If that is not possi-
ble, a large sheath should be tied around the pelvis
and trochanteric area so as to decrease the pelvic
volume. Neither the antishock trousers nor the
pelvic sheath should be tied very tightly consider-
ing the possibility of internal organ injuries. If the
patient is thought to have vertical instability, mea-
sures should be taken after slight traction of the
leg. Afterward, the patient should be transferred
swiftly to the ER.
Fig. 14.10 Tile C-type injury After the patient is admitted to the ER and his
vital signs are stable, X-ray and—if needed—CT
Type C: Instable pelvic fractures (rotationally scans should be obtained to fully evaluate the pel-
and vertically instable) vic ring fracture and plan treatment. However,
In these injuries, due to the forces acting on these studies should be done quickly and in a way
the vertical plane and crisscross forces, the such that the patient’s life is not endangered.
sacroiliac complex is completely disintegrated,
and the affected hemipelvis is completely insta-
ble. Sacrospinous, sacrotuberal ligaments and 14.8 T
he Role of External Fixator
pelvic fracture is also completely torn and split. in Pelvic Fractures
Internal organ injuries and neurovascular damage
may accompany the pelvic injury (Fig. 14.10). Severe injuries that compromise the integrity of
the pelvic ring often damage the sacral plexus and
C1-1: Fractured ilium, intact sacroiliac joint. rarely the internal iliac artery and its branches.
C1-2: SI joint dislocation or SI joint dislocation Hypovolemic shock is present in the majority of
with iliac fracture. these pelvic fractures due to bleeding. Stabilization
C1-3: The most common type is fracture of the of unstable pelvic fractures provides a rapid
sacrum. They are usually located at the improvement of the patient’s hemodynamics. With
level of the foramina and accompanied by the pelvic ring integrity restored, the pelvic diam-
neurologic deficit. eter is decreased causing a decrease in bleeding
C2: Two-sided injuries with one side being B1, due to the tamponading effect; movement between
the other being C. the fragments is restricted so that rebleeding is
204 C. Sen
prevented, the patient’s pain is relieved, and care and embolized to stop bleeding. If that does not
and transfer of the patient is eased [2–4, 8, 9]. work, the bleeding vessel is held or tamponaded
For hemodynamically compromised patients with an open surgical approach [2–4, 9].
who are thought to have bleeding into the pelvic Since their first use in pelvic fractures in the
space, the foremost and most effective surgical 1970s, external fixators have been subject to
procedure is narrowing the pelvic ring with an change. As the applications of these fixators
external fixator to achieve the tamponade increased, the properties, locations, and applica-
effect(Fig. 14.11a, b) [8–10]. tion techniques of the screws have also changed.
However, despite these measures, the hemo- In the first application technique as described by
dynamics of the patient may not be normalized. Slatis [11], the screws were sent vertically to the
In this situation, injury of a large caliber artery iliac crest in a superoinferior direction; nowadays,
inside the pelvis must be considered. The bleed- the screws can be applied in three different places
ing vessel should be detected using angiography (Fig. 14.12) [12].
a b
Fig. 14.11 (a, b) External fixator applications in pelvic fractures
Fig. 14.12 Schanz screw application techniques

In addition, the body of literature shows that

the fixators themselves have also changed. In
hemodynamically compromised patients, single-
bar single joint fixators are preferred due to faster
reanimation. Afterward, when the patient is sta-
ble, both tubular and circular-type fixators are
used. In a biomechanics study by Ponsen et al.,
the resistance to weight bearing of certain fix-
ators was measured, and the most stable fixator
was found to be Iowa-type single-bar external
fixator, providing more stability than frame-type Fig. 14.13 Anterior external fixator application
fixators [13].
larly of subcristally should be preferred (Fig.

14.8.1 Tubular Fixators 14.13) [14–18].
If it is desired to apply a fixator very quickly and
Owing to the fact that resuscitative measures to fix a severe hemodynamic instability, C-clamped
should be very quick, it is important to be famil- fixators—especially at the resuscitation phase—
iar with the technique. If the patient has a dis- should be applied. Although Ganz-type fixators
rupted SI complex and SI joint dislocation, the are more commonly used, neurovascular com-
SI joint must be reduced first. If reduction can- plications due to the screw entering the pelvis
not be achieved with manual traction, 5–10 kg have been reported, and thus trochanteric
of skeletal traction applied at supracondylar part C-clamped fixators are being more commonly
of femur (tuberositas if there is fracture of employed.
femur) will achieve reduction. After reduction,
fixator is applied. Most commonly used applica-
tion site is on the iliac crest. Schanz screws with 14.8.2 Circular Fixators
5 mm of diameter are used in the anterior half of
the iliac crest because this is the thickest part of Circular fixators are usually applied when a
the iliac crest. Besides biomechanical stability, patient is in good general condition and their
it was shown that fixator can be most stably hemodynamics have been stabilized. The reason
applied here. During the procedure, the anteri- is that their application takes more time than a
ormost screw must be 2 cm posterior to ASIS to tubular fixators. Therefore, in the case of acute
avoid lateral femoral cutaneous nerve damage. shock, tubular fixators should be preferred and
With this in mind, nowadays supraacetabular later changed to circular fixators.
and subcristal applications are also preferred. At The most common site of application is the
least two screws, parallel to each other at a dis- iliac crest. The screws are placed with the
tance of 1 cm, must be applied in a 45° oblique technique previously explained in tubular fix-
angle. A third screw may be sent if the patient’s ators section. In addition, when the screws on
general condition can tolerate it. The reason both sides are placed, they must be tied to the
being is that if one of the screws becomes arcs with posts or fixed to the arc cleavage
infected or slips out, the remaining screws [19, 20].
should provide enough stability. The threaded In our clinic, we use Çakmak guides to facili-
part of the screws must be completely sub- tate screwdriving. This way, it is possible to send
merged in the iliac crest. After the screws are screws more safely (Fig. 14.14a, b).
placed on both sides, fixation is achieved with a After the screws are fixed to the arcs, depend-
single-bar external fixator. If an abdominal pro- ing on the location of the fracture on symphysis
cedure is planned, an anterior external fixator or sacroiliac joints, reduction is achieved using
with one or two screws is placed supraacetabu- telescopic rods and offsets (Fig. 14.15a, b).
206 C. Sen
a b
Fig. 14.14 (a, b) Çakmak guide and its usage
a b
Fig. 14.15 (a, b) Reduction with a circular external fixator
14.9 A
reas of Application 14.9.1 Applications in the
of External Fixators Resuscitation Phase
It is possible to classify the clinical use of exter- Because pelvic fractures are commonly accom-
nal fixators in three different groups: (1) applica- panied by internal organ injuries, the rate of mor-
tions in the emergency room during the tality ranges between 10 and 50%. This rate is
resuscitation phase, (2) temporary applications accepted to be higher in unstable pelvic fractures.
in vertical unstable injuries with internal fixa- In these fractures, hemorrhagic shock is the most
tion, and (3) permanent applications in vertically important cause of mortality. In some studies,
stable and rotationally unstable fractures [8–10, significant drops in mortality rate were achieved
12–14]. with early application of an external fixator. Early
application of fixators has many effects such as 14.9.2 Combined Applications

stopping bleeding with the tamponade effect and in Vertically Unstable Injuries
stabilizing the hematoma achieved by decreasing
the pelvic diameterand inhibiting movement of In Tile C-type pelvic ring fractures, the SI com-
fracture fragments, thereby preventing new plex is completely disintegrated due to vertical
bleeding and preventing the opening of formed and scissoring forces. The sacrospinous, sacrotu-
venous clots [8–10, 12–18]. beral ligaments and pelvic floor are also com-
Open surgery to hold the bleeding vessel or pletely torn; thus, the affected hemipelvis is
stop bleeding with compression bandages, espe- unstable. In these types of pelvic fractures, inter-
cially in the early period when the hemodynamic nal organ injury, neurovascular damage, and most
status is most disrupted, increases mortality. importantly, severe hemodynamic instability due
External fixators must be primarily preferred to pelvic space bleeding frequently accompany.
because they can be applied very quickly and Therefore, the first step in treating these fractures
minimally invasively and thus have lifesaving is to decrease pelvic volume to stop the bleeding
potential. and fix the hemodynamics of the patient. A
In the resuscitation phase, the external fix- reconstruction of the posterior pelvic ring is
ators come in three types: Ganz-type fixators, required 3–10 days after the patient’s hemody-
anterior external fixator, and C-clamped external namics have been stabilized with anterior exter-
fixator. All these fixators can be applied in nal fixator. This is due to the fact that many
25–30 min and thus must be primarily preferred studies have reported inadequate repair of the SI
in patients with unstable pelvic fractures and dis- complex with anteriorly applied external fixators
rupted hemodynamics. These fixators contribute (Fig. 14.16a, b) [5, 6, 8, 9, 14–16].
to the hemostasis by decreasing the pelvic vol- In the second step in the treatment after the
ume and their tamponading effect. Also, they repair of SI complex, commonly with a percuta-
inhibit the movement of the fracture fragments neous screw, if for any reason the anterior exter-
and as such prevent new bleeding [1–6, 10, 12, nal fixator has to be removed, the stability of the
13, 15, 17, 18]. symphysis pubis must be continued with single
With the application of these fixators, screw or double plate. If that is not the case, the anterior
slipping, screw pathway infection, screw loosen- external fixator must be preserved for the repair
ing, and neurovascular damage due to the screw of the anterior portion of the pelvic ring [2, 8, 9,
have been reported. However, additional care is 12, 15, 16].
recommended, particularly in patients with sacral In addition, as the experience in Ilizarov sur-
fractures or posterior sacral instability [9]. gery increases, circular fixators can also be used.
a b
Fig. 14.16 (a, b) Symphisis diastasis and anterior application of external fixator

208 C. Sen
a b
Fig. 14.17 (a, b) Reduction using circular external fixator in a fracture model
a b
Fig. 14.18 (a, b) Tile B2-2 (bucket handle)-type injury and external fixator application
After placing Schanz screws on the iliac wing, a ity. They are especially preferred in Tile B2-2-
frame is built with post, hinge, and telescopic type injuries known as bucket handle injuries [1,
rods. In this way, a safe and stable fixation is 5, 6, 8–18]. In B1-type fractures described as
achieved (Fig. 14.17a, b) [19, 20]. open book, the amount of splitting in the sym-
physis is important. When the split is less than
2.5 cm, the pelvic floor is usually uninjured, and
14.9.3 Sole External Fixator as such symptomatic treatment is preferred. If the
Applications in Vertically opening of the symphysis is greater than 2.5 cm,
Stable Injuries pelvic floor and anterior SI ligaments are torn and
surgical treatment is indicated (Fig. 14.18a, b) [8,
In the treatment of Tile B1-, B2-, and B3-type 9, 14–18].
pelvic ring injuries, anterior external fixators In B2-type injuries of the pelvic ring, which
alone are adequate due to provide enough stabil- are lateral compression injuries, there is internal
a b
Fig. 14.19 (a, b) Tile B2-2-type injury and external fixator application in a fracture model
rotation deformity in the pelvic. For that reason, lesion and 70 with Tile C lesions, using only
measures that further decrease the pelvic diame- anterior external fixators to achieve osteosynthe-
ter such as the “hammock” are contraindicated. sis and reported that this method was quite suc-
Furthermore, patients should not lie on their side; cessful and could provide adequate stability
if their general condition is such that they are alone [16].
unfit for surgery, then they must be laid on a hard In contrast, in open book fractures, circular fix-
surface. Sometimes, spontaneous reduction is ators formed with telescopic rods fixed with arcs are
achieved in this position (Fig. 14.19a, b) [1, 2, 5, preferred. After reduction is achieved using posts
6, 8, 9, 14–16]. and hinges, the pelvis is stabilized and permanent
In a study by Belhan et al., 27 patients with treatment is achieved (Fig. 14.20a, b) [19, 20].
Tile B-type fractures were treated with anterior External fixators should be primarily pre-
external fixators, and pelvic external fixators ferred in open fractures close to the perianal
were found to be a safe and effective way of region, in patients who are grossly overweight,
achieving hemodynamic stability in the acute and those for whom an abdominal procedure is
stage and treating the fracture in later stages [8]. planned. The fact that they can be rapidly
Bellabarba et al. treated 13 patients with 61-B2 applied, have low morbidity, and benefit the
pelvic ring fractures in accordance with the OTA treatment of patient’s hemodynamic status com-
classification and one patient with 61-B3.2 frac- prises their other indications (Fig. 14.20c, d)
ture with single-bar anterior external fixator and [1–6].
supraacetabular screw and found that this method In treating these types of pelvic fractures, the
alone achieved adequate stability, was quite primary advantages of external fixators are early
effective, provided the patient early mobilization mobilization and weight bearing of the patient,
opportunity, and had a low morbidity and com- not obstructing treatment of other fractures or
plication rate [14]. Rommens et al. treated 222 intra-abdominal procedures and allowing patients
patients with pelvic ring injuries, 56 with Tile B to go on with their daily activities.
210 C. Sen
a b
c d
Fig. 14.20 (a, b) Circular external fixator application in an open book injury. (c, d) The same patient after treatment
Conclusion As experience increases and with careful

Pelvic ring fractures, although rare, have a high application of this method, complication rates
mortality and morbidity, and thus proper treat- will decrease and so will the need to use flou-
ment is important. Hemorrhagic shock due to roscopy, thereby making it easily applied in all
bleeding into the pelvic space is the most kinds of operating rooms.
important factor that increases mortality. In the
early period called the resuscitation phase,
anterior external fixator and C-clamped tro-
References
chanteric fixators are lifesaving with their effect
on decreasing pelvic volume with tamponade 1. Canale ST, Beaty JH. Fractures of the pelvis. In: JH
effect and thus stopping bleeding. For that rea- B, Kasser JR, editors. Fractures in adults. 5th ed.
son, they must be considered as the first-line Philadelphia: LWW; 2001. p. 883–912.
2. Şar C. Fractures of pelvis and acetabulum. In: Ertekin C,
treatment option in these type of injuries. In
Taviloğlu K, Güloğlu R, Kurtoğlu M, editors. Trauma.
addition, external fixators play an important Istanbul: Istanbul Medical Publishing: 2005. p 1001–14.
role in treating pelvic ring fractures as part of 3. Olson SA, Burgess A. Classification and initial man-
the combined treatment of Tile C-type pelvic agement of patients with unstable pelvic ring injuries.
Instr Course Lect. 2005;54:383–93.
ring fractures and as the sole treatment of Tile
4. Templeman DC, Simpson T, Matta JM. Surgical man-
B1-, B2-, and B3-type fractures by providing agement of pelvic ring injuries. Instr Course Lect.
enough stability on their own. 2005;54:395–400.
5. Kellam JF, Mayo K. Pelvic ring disruption. In: Browder 14. Gardner MJ, Nork SE. Stabilization of unstable pelvic
BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal fractures with supraacetabular compression external
trauma. Edinburgh: Saunders; 2003. p. 1052–108. fixation. J Orthop Trauma. 2007;21(4):269–73.
6. Guyton JL, Perez EA. Fractures of acetabulum and 15. Rommens PM, Hessmann MH. Staged reconstruction
pelvis. In: Canale T, Beaty JH, editors. Campbell’s of pelvic ring disruption: differences in morbidity,
operative orthopeadics. 11th ed. Mosby Elsevier, St. mortality, radiologic results and functional outcomes
Louis; 2008. p. 3309–70. between B1, B2/B3 and C type lesions. J Orthop
7. Papakostidis C, Kanakaris NK, Kontakis G, Gianondis Trauma. 2002;16(2):92–8.
PV. Pelvic ring disruptions: treatment modalities and 16. Lafaivre KA, Starr AJ, Barker BP, Overturf S,

analysis of outcomes. Int Orthop. 2009;33:329–38. Reinert CM. Early experience with recution of dis-
8. Belhan O, Karakurt L, Yılmaz E, Serin E, Kaya M, placed disruption of the pelvic ring using a pelvic
Kargın D. Our external fixator applications in Tile B reduction frame. J Bone Joint Surg Br. 2009;91(9):
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9. Mohanty K, Mussa D, Powel JN, Kortbeck JB, 17. Ponsen KJ, van Dijke GAH, Joose P, Snijders

Kirkpatric AW. Emergent mamangement of pelvic ring CJ. External fixators for pelvic fractures. Acta Orthop
injuries: an update. Can J Surg. 2005;48(1):49–56. Scand. 2003;74(2):166–71.
10. Archdeacon MJ, Hiratza J. The trochanteric C-clamps 18. Lafaivre KA, Starr AJ, Barker BP, Overturf S, Reinert
for provisional pelvic stability. J Orthop Trauma. CM. Reduction of displaced pelvic ring distruptions
2006;20(1):47–51. using a pelvic reduction frame. J Orthop Trauma.
11. Slatis P, Karaharju EU. External fixation of the pel- 2009;23(4):299–308.
vic girdle with a trapezoid compression frame. Injury. 19. Runkov AV, Solomin LN. Pelvic injuries. In: Solomin
1975;7:53–6. LN, editor. The basic principles of external fixation
12. Solomon LB, Pohl AP, Sukthankar A, Chehade
using the ilizarov’s divice. Springer, Milan; 2008.
MJ. The subcristal pelvic external fixator. Technique, p. 256–74.
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365–9. RA, Heddings AA. Anterior pelvic external fixator
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External Fixator Use in Femur
Diaphysis Fractures 15
15.1 Femoral Fixation Levels Two half rings could also be used instead of two
Italian femoral arches (Fig. 15.3).
The horizontal cross sections are more impor- Sometimes fixation may be applied with a
tant than sagittal and frontal cross sections femoral arch at proximal femur with a half ring at
because osteosynthesis with Ilizarov is a type of more distal position [3] (Fig. 15.4).
transosseous osteosynthesis method. Particular The half rings or the femoral arches must be
levels are required in order to identify the frac- positioned at the anterolateral section of the hip;
ture locations, safe routes for the K-wires and otherwise the posterior part of the ring causes
Schanz screws, and locations of the rings. discomfort for the patient in the supine position.
Solomin analyzed the femur in eight different
levels [1]. The first cross section is at the tro-
chanter major level, and the second cross sec- 15.2 F
ixation Types According
tion is at the trochanter minor level, and the to the Levels
eighth cross section is at the level of femoral
condyles (Fig. 15.1). Fixation at the First Level The trochanteric
Generally, two Italian femoral arches are used level is a dangerous region because of the neuro-
to fix the proximal femur (to build proximal block) vascular bundle positioned at the anteromedial
when transosseous osteosynthesis is planning in side and the sciatic nerve positioned at the pos-
treatment of femur fractures [2] (Fig. 15.2). teromedial side. Ilizarov used K-wires on that
One femoral arch must be positioned at the level, but we do not prefer to use K-wires. We
level of trochanter major, and the other femoral use Schanz screws to fix the proximal rings to
arch must be positioned at the level of trochanter the bone. Fixation at least at two different levels
minor. The femoral arches must be fixated per- and on two different planes is necessary for each
pendicularly to the anatomic axis of the femur. segment fixations. Schanz screws must be posi-
tioned perpendicularly to the anatomic axis of
the femur [1].
The first Schanz screw must be applied
M. Çakmak, Prof. MD (*) • M. Cıvan, MD through posterolateral to anteromedial direction
Orthopedic & Traumatology Department, Istanbul so as to provide a 30° angle with the frontal
University, Istanbul Faculty of Medicine,
plane and perpendicular to the anatomic axis of
e-mail: profcakmak@gmail.com; the femur. The second Schanz screw is threaded
melihcivan@gmail.com through the anterolateral to posteromedial direc-

https://doi.org/10.1007/978-3-319-45675-1_15
Fig. 15.3 Two half rings may also be used for fixation of
the proximal femur
Fig. 15.1 The femur levels described by Solomin
Fig. 15.4 A half ring and an Italian femoral arch are used
for fixation of the proximal femur
Fig. 15.2 Generally two Italian femoral arches are used

for fixation of the proximal femur
15 External Fixator Use in Femur Diaphysis Fractures 215
Fig. 15.5 Illustration of

the region between two 1 Anterior A. Femoralis
Schanz screws in the 2
proximal femur at the first 3 V. Femoralis
level. Pay attention to the 4 N. Femoralis
safe zone and angle 5
between the Schanz screws 6
7 Safe zone
8
Medial Lateral
N. Ishiadicus
Posterior

the region between two 1 Anterior
A. Femoralis
2
Schanz screws in the V. Femoralis
3
proximal femur at the
4 N. Femoralis
second level. Pay attention
5
to the safe zone and angle Safe zone
6
between the Schanz screws
7
8
Medial Lateral
N. Ishiadicus
Posterior
tion with a 30° angle with the sagittal plane and provided with two Schanz screws in the same
perpendicular to the anatomic axis. Ideally, there angle and parallel to them as in the first level
must be 90° between two Schanz screws. If the (Fig. 15.6).
angle between the screws is about 60–90°, then
fixation with two Schanz screws will be suffi- Fixation at Third Level The femoral neurovascu-
cient if they are also both positioned in two dif- lar bundle is at the posteromedial on this level. The
ferent levels and two different planes. If the first Schanz screw is applied with the same angle as
angle is narrower than 30°, a third screw is in the first level. The second screw is applied from
required (Fig. 15.5). the anteromedial to posteromedial direction with a
30° angle with the frontal plane (Fig. 15.7).
Fixation at the Second Level Schanz screws
are gently threaded in this region to keep the Fixation at the Fourth Level The first screw is
anteromedial (femoral artery) and posterome- applied in the same manner. The second Schanz
dial (sciatic nerve) structures safe. Fixation is screw is applied parallel to the Schanz screws at

1 A. Femoralis Anterior
the region between two
Schanz screws in the 2 V. Femoralis
proximal femoral 3 N. Saphenus
diaphysis at the third level 4
5
6
7
8
Medial Lateral
A. Profunda femoris
N. Ishiadicus
V. Profunda femoris
Posterior

Anterior
the region between the two 1 A. Femoralis
Schanz screws in the 2 V. Femoralis
femoral mid-diaphysial 3
N. Saphenus
region at the fourth level 4
5
6
7
8 Medial Lateral
A. Profunda femoris
N. Ishiadicus
V. Profunda femoris
Posterior
the third level, while maintaining a 60° angle Fixation at Sixth Level Both Schanz screws are
with the sagittal plane and 30° angle with the applied parallel to the screws on the fifth level
frontal plane. The second Schanz is threaded (Fig. 15.10).
symmetric to the first Schanz screw (Fig. 15.8).
Fixation at the Seventh Level The first Schanz
Fixation at the Fifth Level The first screw is screw is applied through the outer to the inner
applied in the same manner. The second Schanz condyle with a 30° angle to the frontal plane. The
screw is threaded at a right angle to the sagittal second screw is applied through the inner to the
plane (Fig. 15.9). outer condyle (Fig. 15.11).

1 Anterior
the region between two A. Femoralis
Schanz screws in femoral 2
V. Femoralis
mid-diaphysial region at 3
4 N. Saphenus
fifth level
5
6
7
8 Medial Lateral
N. Ishiadicus
Posterior
Fig. 15.10
Anterior
Illustration of the 1
region between 2
N. Saphenus
two Schanz 3
screws in distal
4 V. Saphena
femoral
diaphysial region 5 magna
at sixth level 6
7
8 Medial Lateral
A. Femoralis
V. Femoralis
N. Ishiadicus
Posterior
Fixation at the Eighth Level The same fixation do not use K-wires. In our practice, we fre-
of the level 7 is applied. If a K-wire is also used, quently prefer Schanz screws (with 5–6 mm
it must be applied through the outer to the inner diameters).
condyle with a right angle to the sagittal plane Full or half rings may be used for fixation of
(Fig. 15.12). the femur shaft. It is better to use half ring if the
The diameter of the Schanz screws should thigh region is swollen and edematous and if
be 6 mm in adults and 5 mm in children. there is the possibility of increase in swelling.
Ilizarov also used K-wires in this region. We The distal segment is also fixated with a Schanz

the region between two 1
Anterior
2
Schanz screws in distal
femoral region at seventh 3
level 4
5 N. Saphenus
6
7
8
Medial Lateral
V. Saphena
magna
N. Tibialis
A. Poplitea
V. Peroneus
V. Poplitea communis
Posterior

the region between two 1 Anterior
Schanz screws in the 2 N. Saphenus
distal femoral region at 3 V. Saphena magna
the eighth level 4
5
6
7
8 Medial Lateral
A. Poplitea
V. Poplitea N. Peroneus
N. Tibialis Posterior communis
screw applied through two different angles and of the femur, complete rings are almost always
different planes as in the proximal segment. The used. Schanz screws and K-wires may be used at
first screw is applied with a right angle to the the fifth and sixth levels. We prefer Schanz
anatomic axis and with a 30° angle with the sag- screws for fixation in the distal 1/3 of the femur.
ittal plane from posterolateral to anteromedial We use K-wires (with 1.8 and 2 mm diameter)
direction. The second screw is also applied with for fixing the distal end of the femur
a right angle to the anatomic axis and at a 30° (supracondyle).
angle to the sagittal plane from anterolateral to Two full rings are used to fix the distal frag-
posteromedial direction. The ideal angle between ments. The rings used at level 3, 4, and 5 should
the two screws is 90°. If the angle is between 60° be 2–3 sizes larger than the rings at the distal
and 90°, two Schanz screws will be sufficient for femur. A full ring should not be used as a distal
fixation, provided that they are at two different ring to avoid knee stiffness in fractures of the
levels and planes. If the angle is smaller than distal region because in such cases, the posterior
60°, a third fixation is required. At the distal half part of the ring inhibits the flexion movement of
15.3 Femur Diaphysis Fractures
The differences of the femur diaphysis can be

Anterior summarized as follows:
1. Although it is the strongest bone in the human

body, fractures of the femur diaphysis are not
L M rare.
2. The strongest muscles are located around this
bone. These muscles may cause prominent
displacements depending on the location of
the fracture.
Posterior 3. It contains more cortical bone and less cancel-
lous bone. Therefore, reunion takes long time.
Fig. 15.13 The posterior of the ring must be open in the
distal end of the femur
4. Femur diaphysis has a long and straight medul-
lary cavity that is suitable for intramedullar
nailing.
In order to build the proximal system, a 5/8 ring,

a half ring, two threaded rods, and two L connec-
tors are required. The half ring is placed at the
level of the greater trochanter, and the 5/8 ring is
placed 3 cm proximal to the fracture line. The
two rings are connected to each other with two L
connectors from the medial side and with two
threaded rods from the lateral side [5].
For building the distal system, two full rings
or a full ring and a 5/8 ring and three or four rods
are required. The proximal ring of the distal
block must be positioned at 3 cm distal of the
Fig. 15.14 Medial support using L connectors fracture. The distal ring of the distal block is
placed at the base of the condyles near the distal
the knee, and stiffness develops. A 3/4 ring is femur. If the fracture is comminuted and there is
preferred. The open part of the ring is replaced a risk of possible flexion disability, a 5/8 ring
in the posterior to enable flexion (Fig. 15.13). instead of a full ring is placed as the distal ring so
All rings must have a right angle to the ana- that the back of the knee will be suitable for flex-
tomic axis in femur transosseous osteosynthesis. ion. The two systems are connected to each other
Rods that connect the rings must be parallel to with three or four threaded rods. All rings must
the anatomic axis of the bone. Schanz screws and be positioned perpendicularly to the anatomic
K-wires must also be positioned perpendicularly axis of the femur and parallel to the femoral
to the anatomic axis [4]. diaphysis (Fig. 15.15).
Medial fixation may be insufficient because
femur crescents and half rings are used for fixa-
tion in the proximal femur region. Medial sup- 15.3.1 Operation Technique
port is required particularly for subtrochanteric
and trochanteric fractures; L connectors are Stage 1 (Routine Preparation) Skeletal traction
used for that purpose (Fig. 15.14). is applied when the injured side hip is in 30–45°
Fig. 15.15 Illustration of frame prepared for the 1/3 prox- Fig. 15.16 Application of the distal K-wire
imal femur diaphysis fractures. Attention should be payed
to the positions of L connectors used for medial support
abduction, while the patient is in the supine posi- If the prepared ring is not compatible with the
tion on an orthopedic table. The more proximal specifications above, the required changes must
the fracture is, the greater must be the abduction be applied before the application.
angle. The healthy hip is brought into full abduc-
tion in order to provide a healthy image with Stage 3 (Application of the Distal K-Wire) A
C-arm fluoroscopy. Surgical region cleaning is K-wire must be applied through the distal femur.
applied. This wire must be positioned perpendicular to the
anatomic axis of the femur. It must be applied
Stage 2 (Frame Check) The frame prepared from the lateral to medial at the condylar base.
before the operation is applied on the thigh and Rotation must be checked (Fig. 15.16).
checked with the intraoperative fluoroscopy:
Stage 4 (Application of the Proximal Schanz
1. The proximal femoral crescent must be 0.5 cm Screw) A Schanz screw must be applied from the
distal of the trochanter major. posterolateral to anteromedial direction, which pro-
2. The proximal 5/8 ring must be positioned at vides a 30° angle with the frontal and sagittal plane
3 cm proximal of the fracture. at the level of the greater trochanter (Fig. 15.17).
3. The proximal ring of the distal block must be
3 cm distal of the fracture.
Stage 5 (Repositioning of the Fracture)
4. The distal ring must be 3 cm away from the Reduction techniques of the displaced fragments
distal joint orientation line of the femur and on with circular external fixator will be explained in
the base of the condyles. following chapters.
5. All rods must be parallel to the anatomic axis
of the femur and each other. Stage 6 (Building the Proximal Block) The
6. All rings must be positioned perpendicularly second Schanz screw is applied in an anterolateral
to the anatomic axis of the femur. to posteromedial direction, providing a 70–90°
15.3.2 Postoperative Period
The patient ambulates on post-op day 1 with two

crutches. Weight bearing on the operated leg is
allowed as much as tolerated. In week 1, the
patient ambulates with a single crutch. The patient
is allowed to weight bear without crutches after
3 weeks. There are four cortexes in two X-rays
which are AP and Lateral. Union must be observed
at least three of them before removing the device.
15.4 P
reparing the Frame for 1/3
Medial Femur Diaphysis
Fractures
These fractures are divided into three categories

(Fig. 15.18):
1. Simple fractures
Fig. 15.17 Application of the proximal Schanz screw
2. Wedge fractures
3. Comminuted fractures
angle with the first Schanz screw. Two Schanz
screws are then applied at the level of the 5/8 ring
parallel to the first two screws. The screws must 15.4.1 Building the Frame
be fixed to the rings with connection apparatus for
building the proximal block. A femoral crescent and a 5/8 ring are required
for the proximal system. The femoral crescent is
Stage 7 (Building the Distal Block) Two Schanz placed around the small trochanter. The 5/8 ring
screws must be applied perpendicular to the ana- is placed 3 cm proximal of the fracture. The two
tomic axis, parallel to the previous screws, with a rings are connected to one another with two L
distance of 3 cm to the fracture line. Two Schanz connectors using two threaded rods in the lat-
screws must be applied from the back of the medial eral side and with two threaded rods in the
and lateral epicondyles providing a 30–40° angle medial side. A full ring is required for the proxi-
with the frontal plane. After the connection of these mal part of the distal block. These two rings are
screws to the distal ring, the distal block is built. connected to each other with three or four
threaded rods. The proximal ring is placed 3 cm
Stage 8 (Connecting the Blocks) The system is distal of the fracture line. The distal ring is
completed by connecting the created proximal placed at the condylar region. The two blocks
and distal blocks with 3–4 threaded rods. are connected to one another with three or four
threaded rods.
Stage 9 (Complementary Procedures) If screws
or wires stretch the skin, an incision is made on the
stretched part to release the tension. All the Schanz 15.4.2 Operation Technique
insertion sites are checked. Cuts on the skin by
Schanz screws or wires showing subcutis are Stage 1: Routine preparations are made.
stitched. Wound dressing is applied at the wire and Stage 2: The frame is checked.
screw sites. All the screws are checked. Loose Stage 3: The distal K-wire is threaded.
screws must be tightened. Stage 4: Proximal Schanz screw is threaded.
a b c
Fig. 15.18 (a) Femoral diaphysis comminuted fracture and frame, (b) femoral diaphysis simple oblique fracture and
frame, (c) femoral wedge fracture and frame
Stage 5: Rotation is checked. Fracture reduction 15.5 P

reparing the Frame for 1/3
is performed if the fracture fragments Distal Femur Diaphysis
are displaced. Fractures
Stage 6: The proximal block is built.
Stage 7: The distal block is built. 15.5.1 General Information
Stage 8: Complementary procedures are performed.
The only difference from the previous fractures is
that it may cause movement restriction due to the
15.4.3 Postoperative Period proximity to the knee joint.
The patient ambulates on post-op day 1 with

two crutches. Weight bearing on the operated 15.5.2 Building the Frame
leg is allowed as much as tolerated. In week 1,
the patient ambulates with one crutch. Three A femoral crescent and a full ring are required.
weeks later the patient is allowed to weight The femur crescent is replaced on the small tro-
bear without crutches. The device can be chanter. The full ring is replaced to 3 cm proximal
removed after observing union at least three of the fracture line. The two rings are connected
cortexes of the four in AP and Lateral X-Rays with two L connectors with two threaded rods in
as mentioned above. the lateral side and with two threaded rods in the
Fig. 15.19 (a, b) Preparing a b

the frame for 1/3 distal
femur diaphysis fractures
medial side. A full ring is required for the proxi- Stage 6: The proximal block is built.
mal of the distal block. These two rings are con- Stage 7: The distal block is built.
nected with three or four threaded rods. The Stage 8: The blocks are connected.
proximal ring is placed 3 cm distal of the fracture. Stage 9:
The complementary procedures are
The distal ring is placed on the condylar region. performed.
The two blocks are connected to one another with
a rod with three or four threaded rods (Fig. 15.19).
15.5.4 Postoperative Period
15.5.3 Operation Technique The patient ambulates on first postoperative day

with two crutches. Weight bearing on the oper-
Stage 1: Routine preparations are made. ated leg is allowed as much as tolerated. In first
Stage 2: The frame is controlled. week, the patient ambulates with one crutch.
Stage 3: The distal K-wire is threaded. Three weeks later the patient is allowed to
Stage 4: Proximal Schanz screw is threaded. weight bear without crutches. When union is
Stage 5: The rotation is checked. Fracture reduc- obtained, at least three cortexes, then the device
tion is performed if the fracture frag- can be removed (Figs. 15.20, 15.21, 15.22, and
ments are displaced. 15.23).
Fig. 15.20 The X-rays of an old

femur diaphysis fracture
Fig. 15.21 Clinical and

radiologic images of the patient
after the operation
References
1. Solomin NL. The basic principles of external fixation
using Ilizarov device. St. Petersburg: Springer; 2005.
2. Catagni MA. Current trends in the treatment of sim-
ple and complex bone deformities using the Ilizarov
method, Instructional Course Lectures. Vol XLI
Chapter;47. 1992.
3. Maiocchi AB, Aronson J. Operative principles of Ilizarov,
ASAMI. Baltimore: Williams Wilkins; 1991. p. 4.
4. Golyakhovsky V, Frankel VH. Operative manual of
Ilizarov techniques. St. Louis: Mosby; 1993. p. 2.
5. Cakmak M, Kocaoğlu M. Surgery and Principles
Fig. 15.22 Clinical photo of the deformity before the of Ilizarov (In: Turkish ) Istanbul: Doruk Graphics;
operation 1999.
Fig. 15.23 Clinical image of the patient after frame removal

Principles of Ilizarov Treatment
in Fractures of Diaphyseal 16
and Metaphyseal Tibia Fractures
Ahmet Salduz
16.1 Overview syndrome. Beginning with the moment the patient

presents, neurologic and circulatory examinations
Tibia fractures comprise an important part of of the patient must be periodically performed and
orthopedic trauma surgery. They are encountered monitored.
relatively often, and the subcutaneous location of For most fractures of the tibia, AP and lateral
tibia makes it susceptible to many complications. X-rays are enough for diagnosis. To assess the
Conservative treatment options include modern 3D configurational properties of proximal and
casting treatment since the 1870s and functional distal tibia and its relationship with the fibula,
orthoses after Sarmiento’s work in the 1960s. direct X-rays may not be enough. In those cases,
The incidence of tibial fractures is a CT scan should be obtained. MR imaging is
41:100,000 in men and 12:100,000 in women. useful in the diagnosis of stress fractures and
The average age is 37 years. Because it affects the accompanying malignancies. Angiographic stud-
young and active population, it brings a serious ies may be warranted if there is a possibility of
socioeconomic burden, and thus it must be care- vascular injury.
fully treated.
Tibial fractures are usually obvious to the
examiner. Pain and the fracture deformation are 16.2 Classification
prominent. They can be easily examined due to
the subcutaneous location of tibia. When ques- Fractures may be classified according to loca-
tioning the patient, the mechanism of the fracture tion or whether they are open or closed. The
and the energy of the trauma must be obtained. most extensive classification is the AO classifi-
Fractures without trauma history should prompt cation by Orthopedic Trauma Association
the investigation of concomitant diseases includ- (OTA) (Table 16.1).
ing malignancies. The neurologic examination is The state of soft tissues is of great importance
important to assess accompanying nerve injuries in tibial fractures. Therefore, soft tissue injuries
and for the differential diagnosis of compartment must also be classified. For this purpose, the
Gustilo-Anderson classification is used for open
fractures, and the Tscherne system is used to
A. Salduz, MD classify soft tissue in closed fractures (Table
Orthopedic & Traumatology Department, Istanbul 16.2). Open fractures should be closed as soon as
University, Istanbul Faculty of Medicine, possible. Delayed wound healing is associated
34190 Istanbul, Turkey with many complications.
e-mail: ahmetsalduz@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_16
228 A. Salduz
Table 16.1 Tibial fracture classification suggested by the Orthopedic Trauma Association
41A extra articular 41B partial articular 41C intra-articular
41-A1 avulsion 41-B1 displacement only 41-C1 articular and metaphyseal simple
41-A2 metaphyseal simple 41-B2 compression only 41-C2 articular simple, metaphyseal
41-A3 metaphyseal comminuted 41-B3 displacement and comminuted
compression 41-C3 articular comminuted
42A simple fracture 42B wedge fracture 42C complex fracture
42-A1 spiral 42-B1 spiral wedge 42-C1 spiral
42-A2 oblique (> 30) 42-B2 bending wedge 42-C2 segmental
42-A3 transverse (<30) 42-B3 comminuted wedge 42-C3 irregular
43A extra-articular 43B partial articular 43C intra-articular
43-A1 simple 43-B1 displacement only 43-C1 articular and metaphyseal simple
43-A2 wedge 43-B2 displacement and 43-C2 articular simple, metaphyseal
43-A3 complex compression comminuted
43-B3 comminuted compression 43-C3 articular comminuted
44A below syndesmosis fracture 44B syndesmotic fibula fracture 44C suprasyndesmotic fracture
44A1 – isolated 44B1 isolated 44C1 simple fibula diaphyseal fracture
44-A2 with medial malleolus 44B2 with medial malleolus lesion 44C2 comminuted fibula diaphyseal
fracture 44B3 medial lesion and Volkmann fracture
44-A3 with posteromedial fracture fracture 44C3 proximal fibula lesion
Table 16.2 Gustilo-Anderson open fracture and Tscherne soft tissue classification system
Gustilo-Anderson open fracture classification Tscherne soft tissue classification
Type I Skin wound less than 1 cm Grade 0 Minimal soft tissue damage
Clean Indirect injury to limb (torsion)
Simple fracture pattern Simple fracture pattern
Type II Skin wound more than 1 cm Grade 1 Superficial abrasion or contusion
Soft tissue damage not extensive Mild fracture pattern
No flaps or avulsions
Simple fracture pattern
Type IIIA Adequate soft tissue cover of bone Grade 2 Deep abrasion
despite extensive soft tissue damage Skin or muscle contusion
Sever fracture pattern
Direct trauma to limb
Type IIIB Extensive soft tissue injury with Grade 3 Extensive skin contusion or crash injury
periosteal stripping and bone exposure Severe damage to underlying muscle
Compartment syndrome
Subcutaneous avulsion
Type IIIC Open fracture with arterial injury
requiring repair
None of the classifications used in tibial frac- lary nails and plates. However, treatment can
tures can fully predict the prognosis by itself. cause some systemic, biologic, mechanical prob-
When planning treatment, patient’s age, health lems in patients with bone loss, extensive soft tis-
status, social conditions, activity prior to fracture, sue injuries, segmentary fractures, and multiple
and expectations must be considered. traumas with multiple fractures. In these patients,
treatment with external fixation stands out.
16.3 Treatment
16.3.1 External Fixators in Tibial
The purpose of treatment is achieving union Fractures
while maintaining alignment and length. There
are various treatment modalities for this purpose. The oldest treatment method of tibial fractures is
The most commonly employed are intramedul- external fixators. While their use diminished
16 Principles of Ilizarov Treatment in Fractures of Diaphyseal and Metaphyseal Tibia Fractures 229
after WW2, they became popular once again in accompanied by soft tissue edema, which
the 1970s. In its most basic form, it consists of a affects the diameter of the extremity. Tscherne
uniplanar external fixator applied to the antero- devised a classification to assess the severity of
medial subcutaneous surface of the tibia. Modern the soft tissue injury in closed fractures of the
uniplanar external fixators can be fixated on tibia (Table 16.2).
multiple planes or combined with multiple-plane This classification is valuable in predicting soft
fixation systems. With the circular frames of tissue edema. Especially in grade 3 injuries, wide-
Ilizarov, the principles of treatment with these spread skin, subcutaneous, and muscle injury is
frames, use of Ilizarov-type external fixators present, and the increase in diameter is large.
became widespread. Many studies have compared the biomechanical
properties and complications of different frame
configurations in tibia fractures. These studies
16.3.2 Frame Preparation failed to demonstrate the superiority of one design
over another. Therefore, the frame should be con-
While in the original Russian technique the fix- structed such that it allows the best possible fixa-
ator was constructed intraoperatively, American tion of the fracture. If the fracture is not in the
and Italian surgeons suggested constructing the proximal third, the frame can be constructed in a
fixator before the operation to save time. way that allows knee flexion (Fig. 16.1). The pos-
In order to construct the frame properly, it is terior half ring is connected with a three- or four-
essential to take accurate measurements of the part cube so that it stays more distally. That way,
patient. Like in the other extremities, there the frame will allow patient’s knee motion. The
should be 2 cm between the skin and the frame. connection between the half rings can be achieved
Tibial fractures are almost always splinted until with cubes for the first ring. However, it must be
the surgery, which makes direct measurements kept in mind that an unnecessarily long step can
impossible. The length and diameter of the cause the deformation of the ring structure during
frame must be measured in either 1:1 ratio the stretching of the proximal tibia guide wire,
X-rays of the patient or the healthy leg. and a step should not be prepared longer than a
However, tibial fractures are more or less three-part cube.
Fig. 16.1 Frame design

allowing knee flexion
(step cut). The posterior
half ring is connected
with a three- or four-part
cube so that it stays more
distally. That way, the
frame will allow motion
of the patient’s knee
230 A. Salduz
16.3.3 Preparation
in the Operating Room
The patient should be laid on a radiolucent table

with an elevation of the ipsilateral hip to prevent
external rotation. Traction during operation can
be achieved with systems adapted to the table. In
that case, if a calcaneal wire is present, it is left in
place and connected to the sterile traction set.
The patient is draped in a sterile manner leaving
the knee joint open.
16.3.4 Operation
When fixing the frame to the bone, care must be

taken so that the anatomic axis of the tibia is per-
pendicular to the rings and parallel to the rods,
and the extremity is equidistant to the device in
both AP and lateral plane.
When mounting the frame, the first step is to
send guide K-wires parallel to the joint. For that,
K-wires are sent parallel to the joint orientation line
under fluoroscopic guidance. The K-wire is located
at the level of the fibular head proximally and just
above the ankle joint orientation line distally.
Proximally, the fibular head and, distally, the
lateral malleolus must be fixed with a K-wire
with olive (stopped K-wire). When stretching the
K-wire at the lateral malleolus, the ankle must be Fig. 16.2 An example of the use of stopped K-wires to
held in full dorsiflexion. achieve reduction
In tibial fractures, the best position for the
Schanz screws is the anteromedial subcutaneous
surface. After the entry point is decided, the bony
surface is accessed through a 1 cm incision in the stopped K-wires. If necessary, stopped K-wires
skin. If a non-subcutaneous entry point is are sent through the middle ring to correct the
selected, the muscle should be penetrated but diaphyseal alignment (Fig. 16.2).
rather dissected in the corresponding plane to Screws are sent through the proximal, middle
reach the bone. Each screw must pass both corti- and distal rings to stabilize the systems. Rotation
ces. The screws should be sent manually, instead must be checked in all stages clinically. Stopped
of with high energy. K-wires should be stretched on both sides.
In cases of oblique fracture lines (spiral and During this stretching reduction loss due to
oblique fractures, wedge fractures), interfrag- asymmetric stretching should be checked with
mentary compression should be achieved with fluoroscopy.
16.3.5 Tibia Metaphyseal can be achieved with stopped K-wires near the
and Diaphyseal Fractures fracture line. In AO 42.B-type fractures, the
wedge-shaped fragments can be fixed with a
The first essential step comes when the system stopped K-wire.
is adapted after the proximal and distal joint In AO 42.C-type fractures, the configuration
guide wires are placed. If proximal and distal of the fracture determines the design of the frame.
tibia are not at the middle of the ring or not at It is not imperative that all fragments in an AO
the same plane, it is not possible to fix the trans- 42.C3-type fracture are fixated, but large frag-
lation and angulation later with other methods. ments, which may help the stability, should be
Rotation is also determined at this stage. Unless fixated. In these fractures, the main aim is to
these are controlled, the later stages should be bridge the fracture and achieve relative stability.
initiated. First, the original length of the tibia In AO 42.C2-type fractures, the middle segment
should be restored. The contralateral tibia can must be fixed with an intermediate ring. The
be used as a reference. When length is restored, frame should be constructed in such a way that it
most of the time reduction is also achieved, but treats the proximal and the distal parts of the seg-
this is not enough. In order for optimal fixation, ments as different fractures and applies compres-
a ring must be placed near the fracture line. If sion. The direction of the K-wires and screws is
appropriate fixation at the fracture line is not demonstrated in Figs. 16.3, 16.4, 16.5, 16.6, 16.7,
achieved, pulling in the appropriate directions 16.8, 16.9, and 16.10.
1
2
Anterior
3
4
5
6
7
Medial Lateral
8
N. Saphenus
V. Saphena magna
A. Peroneus
A. Poplitea communis
V. Poplitea
N. tibialis
Posterior
Fig. 16.3 K-wire and Schanz screw application techniques in cruris, important anatomical structures at first level
232 A. Salduz
1
2 Anterior
3
4
5
6 Medial Lateral
7
8
V. Tibialis anterior
V. Saphena parva
N. Cutaneus surae
medialis
N. Peroneus superficialis
N. Peroneus profundus
A. Tibialis posterior
V. Tibialis posterior
N. tibialis Posterior V. Saphena magna
N. suralis
Fig. 16.4 K-wire and Schanz screw application techniques in cruris, important anatomical structures at second level
1
Anterior
2
3
4
5 Medial Lateral
6
7
8
A. Tibialis anterior
V. Saphena magna
N. suralis
V. Tibialis posterior V. Saphena parva
N. tibialis N. Cutaneus surae
Posterior medialis
Fig. 16.5 K-wire and Schanz screw application techniques in cruris, important anatomical structures at third level
1 Anterior
2
3
4
5 Medial Lateral
6
7
8 A. Tibialis anterior
N. Saphenus
V. Saphena magna
V. Tibialis posterior
N. tibialis V. Saphena parva
Posterior
N. Cutaneus surae medialis
Fig. 16.6 K-wire and Schanz screw application techniques in cruris, important anatomical structures at fourth level
1 Anterior
2
3
4
Medial Lateral
5
6
A. Tibialis anterior
7
8 N. Peroneus profundus
N. Saphenus
V. Saphena magna
N. tibialis Posterior N. Cutaneus surae medialis
Fig. 16.7 K-wire and Schanz screw application techniques in cruris, important anatomical structures at fifth level
234 A. Salduz
1 Anterior
2
3
4
5
Medial Lateral
6
7
N. Saphenus
V. Saphena magna
N. tibialis N. Cutaneus surae Medialis
Posterior
Fig. 16.8 K-wire and Schanz screw application techniques in cruris, important anatomical structures at sixth level
1 Anterior A. Tibialis anterior

2 V. Tibialis anterior
3 N. Peroneus profundus
4
5 Medial Lateral
6
7
8
N. Saphenus
V. Saphena magna
V. Tibialis posterior Posterior V. Saphena parva
N. tibialis N. Suralis
Fig. 16.9 K-wire and Schanz screw application techniques in cruris, important anatomical structures at seventh level
1 Anterior
3 V. Tibialis anterior
4
5
Medial
6
Lateral
7
8
N. Saphenus
V. Saphena magna
N. tibialis Posterior N. Suralis
Fig. 16.10 K-wire and Schanz screw application techniques in cruris, important anatomical structures at eighth level
16.4 Special Applications distance to the bony injury at the tibial metaphysis
without an overlying skin problem (Fig. 16.11).
16.4.1 Acute Shortening
and Progressive Lengthening
16.4.2 Wound Healing
Through Acute Angulation
Skin defects occur after high-energy injuries of the
tibia due to direct trauma or after debridement in
In some cases, the soft tissue injuries accompanying
the follow-up. In most cases, closure of skin defects
open tibia fractures cannot be closed by primary or
caused by high-energy trauma due to the subcuta-
secondary intention. The closure of transverse
neous location of the tibia primary is not possible.
wounds in particular poses a great difficulty. Free or
Secondary closure is also not an option due to the
local flaps could be used, but complications have
lack of soft tissue coverage of the bone. In these
been reported. Primary wound closure with acute
cases, skin closure may be achieved with various
angulation of the tibia is a simple method that pro-
wound closure methods and using of local and free
motes early wound healing and prevents complica-
flaps alongside bone resection. This method is best
tions arising from more complicated methods.
for transverse skin wounds. Addition of Z-plasty
Because wound closure happens much quicker than
may be necessary in longitudinal injuries or wide
bone healing, the angulation is corrected progres-
defects. The most important issue with acute short-
sively through the frame system after the skin is
ening is the complications in neurovascular struc-
healed, and the anatomic alignment is restored.
tures. There is no widely agreed net-shortening
length. Some studies suggest a shortening no lon-
ger than 3 cm, whereas others report safe shorten- 16.4.3 Hexapodal Systems
ing up to 6 cm. Therefore, treatment should be
planned according to the state of the patient and the After the introduction of computer-assisted sys-
extremity. Lengthening equal to the shortening can tems in orthopedic surgery, developments have
be achieved through an osteotomy performed at a occurred in the Ilizarov surgery as well. The
236 A. Salduz
Fig. 16.11 Woman aged 37 years with grade 3B open part of the tibia was performed. Note the initial bone loss
crus fracture treated with circular external fixator. and limb length equality at the end of the treatment
Progressive compression and lengthening from proximal
foremost of these is the use of hexapodal sys- toe-touch. After 3-week partial weight bearing
tems. Hexapodal systems consist of two frames and later with progressive union, total weight
sitting on six pods, which are not parallel to bearing is allowed. If joint distraction is applied,
each other. These six hexagonally placed pods total weight bearing is allowed depending on the
can be shortened or lengthened at will, and the shape of fixation through the joint. Non-union
translation-angulation-shortening-lengthening is not often encountered because intra-articular
of the frame is achieved as desired. The most fractures concern metaphyseal region. The suc-
important advantage of hexapodal systems is cess of the restoration of the joint surface is the
the precise spatial placement of the hinge in the most important parameter that determines clinical
Ilizarov system such that deformities are treated outcomes.
simultaneously with high precision. This comes In diaphyseal fractures, risk of complication
into prominence in deformity surgery. These increases as the surface area of the fracture line
systems are useful in achieving acute or pro- decreases. Compression is advised if callus for-
gressive reduction over the quickly applied sys- mation is absent at the end of the first month or if
tems during trauma operations. Hexapodal the callus does not form as expected. In these
systems are more stable due to their geometric fractures, the fixator can be removed when union
structure. Studies show that hexapodal systems of three cortices is confirmed.
are superior to Ilizarov-type external fixators in
deformity restoration, especially in oblique
plane deformities. Bibliography
1. Peltier LF. Fractures: a history and iconography of their
treatment. San Francisco: Norman Publishing; 1990.
16.5 Post-op Follow-Up 2. Sarmiento A. A functional below-the-knee cast for

tibial fractures. J Bone Joint Surg Am. 1967;49(5):
The follow-up of post-op tibial fractures is simi- 855–75.
3. Sarmiento A, Sharpe FE, Ebramzadeh E, Normand

lar to the follow-up of other circular external fix- P, Shankwiler J. Factors influencing the outcome of
ators. To preserve joint motion, exercises should closed tibial fractures treated with functional bracing.
be initiated at day 2 and should be continued until Clin Orthop Relat Res. 1995;315:8–24.
the fixator is removed. 4. Gustilo RB, Mendoza RM, Williams DN. Problems in
the management of type III (severe) open fractures: a
In intra-articular fractures, early weight bear- new classification of type III open fractures. J Trauma
ing is not allowed; they are only mobilized with Acute Care Surg. 1984;24(8):742–6.
5. Haas N, Krettek C, Schandelmaier P, Frigg R, 17. Calhoun JH, Li F, Ledbetter BR, Gill CA. Biomechanics
Tscherne H. A new solid unreamed tibial nail for of the Ilizarov fixator for fracture fixation. Clin Orthop
shaft fractures with severe soft tissue injury. Injury. Relat Res. 1992;280:15–22.
1993;24(1):49–54. 18. Paley D, Catagni MA, Argnani F, Villa A, Bijnedetti
6. Oestern HJ, Tscherne H. Pathophysiology and classi- GB, Cattaneo R. Ilizarov treatment of tibial nonunions
fication of soft tissue damage in fractures. Orthopade. with bone loss. Clin Orthop Relat Res. 1989;241:
1983;12(1):2. 146–65.
7. Gopal S, Majumder S, Batchelor AGB, Knight SL, De 19. Cierny Iii G, Zorn KE. Segmental tibia1 defects com-
Boer P, Smith RM. Fix and flap: the radical orthopae- paring conventional and Ilizarov methodologies. Clin
dic and plastic treatment of severe open fractures of Orthop Relat Res. 1994;301:118–23.
the tibia. J Bone Joint Surg Br. 2000;82(7):959–66. 20. Marsh JL, Prokuski L, Biermann JS. Chronic infected
8. Heckman JD, Bucholz RW. Rockwood and green’s tibia1 nonunions with bone loss conventional tech-
fractures in adults. Philadelphia: Lippincott Williams niques versus bone transport. Clin Orthop Relat Res.
& Wilkins; 2001. 1994;301:139–46.
9. Müller ME, Koch P, Nazarian S, Schatzker J. The 21. Tsuchiya H, Tomita K. Distraction osteogenesis for
comprehensive classification of fractures of long treatment of bone loss in the lower extremity. J Orthop
bones. Berlin/New York: Springer Science & Business Sci. 2003;8(1):116–24.
Media; 1990. 22. Simpson A, Andrews C, Giele H. Skin closure after acute
10. Ilizarov GA. Clinical application of the tension-stress shortening. J Bone Joint Surg Br. 2001;83(5):668–71.
effect for limb lengthening. Clin Orthop Relat Res. 23. Vocke AK, Schmid A. Prevention of skin and soft tis-
1990;250:8–26. sue entrapment in tibial segment transportation. Int
11. Ilizarov GA, Ledyaev VI. The replacement of long Orthop. 1999;23(4):249–51.
tubular bone defects by lengthening distraction oste- 24. Saleh M, Rees A. Bifocal surgery for deformity and
otomy of one of the fragments. Clin Orthop Relat Res. bone loss after lower-limb fractures. Comparison of
1992;280:7–10. bone-transport and compression-distraction methods.
12. Ilizarov GA. Transosseous Osteosynthesis. Berlin/
J Bone Joint Surg Br. 1995;77(3):429–34.
Heidelberg/London: Springer; 1992. 25. Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M. Bifocal
13. Golyakhovsky V, Frankel VH, Ferrara PL. Operative compression-distraction in the acute treatment of grade
manual of Ilizarov techniques. St. Louis: Year Book III open tibia fractures with bone and soft-tissue loss:
Medical Pub.; 1993. a report of 24 cases. J Orthop Trauma. 2004;18(3):
14. II GWW. General principles of fracture treatment. In: 150–7.
Canale ST, JHB, editors. Campbell’s operative ortho- 26. Mahaluxmivala J, Nadarajah R, Allen PW, Hill

paedics. 12th ed. Philadelphia: Elsevier Inc.; 2013. RA. Ilizarov external fixator: acute shortening and
15. Tscherne H. Management of injuries of the distal lengthening versus bone transport in the management
tibia and foot. Langenbecks Archiv fur Chirurgie. of tibial non-unions. Injury. 2005;36(5):662–8.
1985;369:539–42. 27. Gulsen M, Özkan C. Angular shortening and delayed
16. Tucker HL, Kendra JC, Kinnebrew TE. Management of gradual distraction for the treatment of asymmetrical
unstable open and closed tibial fractures using the Ilizarov bone and soft tissue defects of tibia: a case series.
method. Clin Orthop Relat Res. 1992;280:125–35. J Trauma Acute Care Surg. 2009;66(5):E61–E6.
Part II
Ilizarov Approach in Deformity Surgery
Introduction to Deformity Analysis
and Planning 17
İlker Eren
The expression “deformity planning” is easily and required to accurately define the three-dimensional
incompletely understood as the analysis of imag- problem: rotation and length. These four values
ing of a patient; it is the complete analysis of the form the basic characteristics of a deformity.
patient. Etiologies, previous interventions, age, To analyze the deviation from “normal,” the
patient expectations, level of activity, deformity normal anatomy has to be defined. Many studies
being either static or dynamic, and patient patience have assessed and tried to quantify the normal
play important roles in deciding the treatment lower extremity measurements. Different
strategy. A treatment plan may sometimes aim to researchers reported different methods to analyze
overcorrect or under-correct a deformity or even and interpret deformities [1–5]. This resulted in
create a deformity in a normal bone segment to conflicting values and incompatible methods in
compensate for another. Therefore, an analysis of the literature. Paley finally defined the current
an extremity deformity and treatment planning method, which is widely used, and standardized
starts before referring the patient to the radiology the deformity analysis [6]. Abbreviations follow
department and is never limited to imaging. this constant order: (1) mechanical (m) or ana-
tomic (a); (2) medial (M), lateral (L), anterior
(A), or posterior (P); (3) proximal (P) or distal
17.1 Normal Anatomy (D); (4) femoral (F) or tibial (T); and (5), the last
and Standard Values letter “A” for “angle.” Details of this concept,
normal values, and principles of the analysis will
To define a deformity, normal limb alignment has be covered in the following chapters.
to be defined. Three-dimensional bone and joint
architecture and three-dimensional deformities
cannot be interpreted and quantified alone. 17.2 Radiologic Assessment
Therefore, dividing the deformity into frontal and Methods
sagittal planes is an established concept. Even the
most complex deformities are measured in these Proper radiologic imaging is the mainstay of
two planes. However, two more parameters are deformity analysis and can only be obtained with
careful teamwork. Drawing correct lines or inter-
preting the measurements is only one aspect of this
İ. Eren, MD procedure. Technicians should be meticulously
Department of Orthopaedics and Traumatology,
Koç University, School of Medicine, Koç University
trained in clinics that deal with deformities, and
Hospital, Istanbul, Turkey briefly informing the patient about the position is
e-mail: ilker.eren@gmail.com necessary to achieve best results.
https://doi.org/10.1007/978-3-319-45675-1_17
242 İ. Eren
knee flexion–extension plane is used to determine

the correct rotation. Another critical point is to
adjust limb shortening with blocks. Patients tend
to compensate the shortening with contralateral
hip and knee flexion, ipsilateral equinus, pelvic
tilt, and spinal angulation. Technicians should sup-
port the short limb with blocks so that the patient
evenly bears weight in both limbs without the
mentioned mechanisms and both anterior superior
iliac spines are level (Fig. 17.2) [6].
Sagittal plane assessment requires the extrem-
ity placed perpendicular to the beam axis. As
with the frontal plane, sagittal plane assessment
also requires weight-bearing radiographs. There
is a 3–5° rotational difference between flexion–
extension axis of the knee and the orthogonal
plane of patella anterior position [7]. Both can be
used; however, the ideal position is the orthogo-
nal plane to the patella forward position, where
the femoral condyles do not overlap. To move
the contralateral hip and pelvis out of the view,
the pelvis is rotated 30–45° externally.
17.2.1 Plain Radiographs

Fig. 17.1 To determine the correct anteroposterior posi-
tion, the extremity is rotated so that the patella faces It is the most basic imaging method used in defor-
forward mity analysis. Although never adequate for a
proper analysis, it will accurately and reliably
assess the deformity in a bone segment or a joint.
There are several techniques for assessing Two orthogonal weight-bearing images are
lower extremity alignment and quantifying defor- obtained for standard evaluation. Reference val-
mities. An ideal radiologic assessment method ues are obtained from the contralateral side or
should be low in cost and radiation while remain- standard values are used. Plain radiographs can
ing accurate and reliable. Conventional tech- only be used as an analysis tool, if the deformity
niques have various advantages and drawbacks, is localized in a segment and other anatomic loca-
each of which will be discussed in this chapter. tions are previously assessed. Otherwise, com-
Recent advances in radiologic techniques offer pensatory secondary deformities or accompanying
low-dose accurate and reliable imaging. deformities can easily be missed. It can be used
Regardless of the radiologic method, patient alone for deformity analysis of upper extremities
positioning is the key element of obtaining proper or for follow-up of a long bone segment.
imaging. For frontal plane assessment, the lower
extremity rotational reference point is always the
patella. It is positioned by palpating the patella 17.2.2 Teleroentgenogram
between thumb and index fingers and rotating the
lower extremity to orient it forward (Fig. 17.1) [2]. A long 1.3 m (51 in) cassette is used and a tube is
This technique eliminates errors related to tor- placed at 305 cm (10 ft). This method causes a
sional deformities of tibia. The exception is fixed magnification error of 4–5 %. If necessary, a mag-
subluxation or dislocation of the patella, where the nification marker can be positioned on the same
17 Introduction to Deformity Analysis and Planning 243
Fig. 17.2 Blocks in various sizes help the technician to level the anterior superior iliac spine and distribute body weight
evenly between extremities
plane with the bone to correct the error. With this wide with 5 cm grid cassette is placed behind the
technique, a beam is targeted at the knee; therefore, standing patient. Three images targeting the hip,
the upper and lower ends of the image show bright- knee, and ankle are obtained and combined to
ness problems and distortion [8]. A single shot form a single, long, standing image. Unlike in
requires a higher dose to create an image on a wider scanograms, there is no gap between the images
surface. This is the most common method used. and one continues into the other. The patient has
to stand very still between shots. This is the most
accurate conventional imaging technique, mini-
17.2.3 Scanogram mizing the distortion and magnification error
(Parallax). Magnification markers can be used to
Scanograms utilize three consecutive shots to form increase the precision of measurements.
the image. Images target the hip, knee, and ankle
and are not combined; therefore, it is not possible
to perform a complete deformity analysis. It is pos- 17.2.5 Computerized Tomography
sible to assess the orientation and angular relation (CT) and CT Scanogram
of joints to each other; however, anatomic axis and
diaphyseal deformities cannot be assessed. Low- This technique utilizes the lowest dose and flexion
dose radiation is the advantage of this technique contractures do not affect the obtained image. The
and can be used in specific clinical scenarios. beam is always orthogonal to the bone; therefore,
there is no magnification error. However, the costs
of the hardware and non-weight-bearing image
17.2.4 Orthoroentgenogram are the disadvantages of the technique. CT is the
only radiologic assessment method to measure
This was first described by Green et al. in 1946 rotational deformities. It is useful as a comple-
and later modified as a standing imaging tech- mentary imaging method, instead of a stand-alone
nique by Saleh et al. [9, 10]. A 105 cm high, 35 cm deformity analysis tool.
244 İ. Eren
17.2.6 EOS 4. Krackow K. Approaches to planning lower extremity

alignment for total knee arthroplasty and osteotomy
about the knee. Adv Orthop Surg. 1983;7:69–88.
Low-dose stereoradiography is a new imaging 5. Moreland JR, Bassett L, Hanker G. Radiographic anal-
technique based on a multiwire proportion cham- ysis of the axial alignment of the lower extremity. The
ber for particle detectors, named EOS (EOS Journal of Bone & Joint Surgery. 1987;69(5):745–9.
6. Paley D et al. Deformity planning for frontal and sag-
Imaging, Paris, France). The system consists of a
ittal plane corrective osteotomies. Orthop Clin North
C-shaped vertical travelling arm that supports Am. 1994;25(3):425–65.
two image acquisition systems placed orthogo- 7. Hollister AM et al. The axes of rotation of the knee.
nally, each composed of an X-ray tube and a lin- Clinical orthopaedics and related research.
1993;290:259–68.
ear detector. The source and detector thus move
8. Horsfield D, Jones S. Assessment of inequality in length
together, with the beam always horizontal to the of the lower limb. Radiography. 1985;52(605):223–7.
patient [11–13]. The system provides 3D images, 9. Green WT, Wyatt GM, Anderson
with low-dose radiation. The patient stands sta- M. Orthoroentgenography as a method of measuring
the bones of the lower extremities. J Bone Joint Surg
tionary during the 20 s scanning process, it is
Am. 1946;28:60–5.
therefore vulnerable to motion artifact, but it is 10. Saleh M, Milne A. Weight-bearing parallel-beam scanog-
more accurate than an orthoroentgenogram [14]. raphy for the measurement of leg length and joint align-
ment. J Bone Joint Surg Br. 1994;76(1):156–7.
11. Guenoun B et al. Reliability of a new method for
lower-extremity measurements based on stereora-
References diographic three-dimensional reconstruction.
Orthopaedics & Traumatology: Surgery & Research.
1. Chao E et al. Biomechanics of malalignment. The 2012;98(5):506–13.
Orthopedic Clinics of North America. 1994;25(3): 12. Kalifa G et al. Evaluation of a new low-dose digital
379–86. x-ray device: first dosimetric and clinical results in
2. Cooke T, Siu D, Fisher B. The use of standardized radio- children. Pediatric radiology. 1998;28(7):557–61.
graphs to identify the deformities associated with osteo- 13. Dubousset J et al. EOS stereo-radiography system:
arthritis. Recent developments in orthopedic Surgery. whole-body simultaneous anteroposterior and lateral
Manchester: Manchester University Press; 1987. radiographs with very low radiation dose. Revue de
3. Cooke T, Li J, Scudamore RA. Radiographic assessment chirurgie orthopédique et réparatrice de l'appareil
of bony contributions to knee deformity. The Orthopedic moteur. 2007;93(6 Suppl):141.
Clinics of North America. 1994;25(3):387–93. 14. Altongy JF, Harcke HT, Bowen JR. Measurement of leg
length inequalities by Micro-Dose digital radiographs.
Journal of Pediatric Orthopaedics. 1987;7(3):311–6.
Frontal Plane Deformities
and Drawing Axes of the 18
Long Bones
Every long bone has two axes, the anatomic compared with the anatomic or mechanical axis
axis and the mechanical axis. In order to have of the same bone.
a better understanding before analyzing the Mechanical axis deviation (MAD): The dis-
deformities, these axes and the relations tance between the mechanical axis and the mid-
between them and some terms of use must be point of knee joint surface line, which is normally
understood. 9.7 mm medially.
Mechanical axis: A straight line that connects
the midpoints of the proximal and distal joints of
a long bone. 18.1 D
rawing the Mechanical Axis
Anatomic axis: A straight line that connects of the Femur
the midpoints of the diaphysis of a long bone.
Alignment: The physiologic position of the First, midpoints of the proximal and distal joints
hip, knee, and ankle joints. The midpoints of of the femur must be determined.
these joints should be in a straight line. Center of the femoral head: The midpoint of
Malalignment: The pathologic position of the the proximal joint is exactly at the center of the
hip, knee, and ankle joints. The conjunction of femoral head. Femoral head center can be deter-
the midpoints of these joints does not form a mined in four ways.
straight line.
Orientation: The physiologic position of a 1. Draw two parallel lines, one of which should
joint surface line of a long bone (femur or tibia) be on top of the femoral head and the other at
compared with the anatomic or mechanical axis the bottom. The line has to be tangential to
of the same bone. the femoral head. When the dots are con-
Malorientation: The pathologic position of the nected (Fig. 18.1a, x and y dots), there we can
joint surface line of a long bone (femur or tibia) pinpoint the diameter of the femoral head.
The midpoint of the diameter is the center of
the femoral head. If we now draw a random
tangential line, a right-angle line from the
connection point shows the center of the fem-
M. Çakmak, Prof. MD (*) • M. Cıvan, MD oral head (C) (Fig. 18.1b, z dot).
Istanbul University, Istanbul Faculty of Medicine, 2. If you make a square by adding two vertical
lines tangential to the medial and lateral bor-
e-mail: profcakmak@gmail.com; ders of the head, the center of the square is the
melihcivan@gmail.com center of the femoral head (Fig. 18.2a).

https://doi.org/10.1007/978-3-319-45675-1_18
Fig. 18.1 (a, b)
Determination of the
center of the femoral head a x b
using tangential lines x
z
C
y y
Fig. 18.2 (a, b) Determination b

a x x
of the center of the femoral head
using the diagonal lines of the
head square
y y
The center is revealed when the diagonal lines

of the square cross the center (Fig. 18.2b).
3. The center can be found using the Moses cir-
cles (Fig. 18.3).
4. In practice we can use the circular side of the
goniometer to determine the center of the
femoral head (Fig. 18.4).
The center of the femoral distal joint surface

can be found in two ways:
1. The top point of the femoral notch can be used

(Fig. 18.5a). The femoral notch is compatible
with the midpoint of the femoral distal joint Fig. 18.3 Determination of the center of the femoral
surface. head using Moses circles
18 Frontal Plane Deformities and Drawing Axes of the Long Bones 247
2. The outer borders of the joint are measured a b

and the midpoint of the connecting line is the
center of the joint (Fig. 18.5b).
After the determination of the proximal and

distal joint surfaces of the femur, these dots
should be combined such that the mechanical
axis of the femur becomes clear (Fig. 18.6a).
Fig. 18.4 Determination of the center of the femoral

head using a goniometer
Fig. 18.6 Axes of the femur, (a) mechanical axis, (b)
anatomic axis
a b
Fig. 18.5 Determination of the center

of the distal femoral joint surface by (a)
using the femoral notch, (b) using the
femoral condyles
18.2 Anatomic Axis of the Femur connection line is the center point of the
joint surface.
When the midpoint of random horizontal lines on
The center of the tibia distal joint surface can
the femoral shaft is connected, the anatomic axis
be determined in four ways:
of the femur becomes clear (Fig. 18.6b).
1. Using the mortise joint’s surface (Fig.

18.8a)
18.3 Mechanical Axis of the Tibia 2. Using the bones (Fig. 18.8b)
3. Using the soft tissue (Fig. 18.9a)
First, the center points of the proximal and distal 4. Using the talus bone (Fig. 18.9b)
joints of the tibia have to be found for drawing
the mechanical axis of the tibia. After connecting the centers of the proximal
There are two ways to determine the center of and distal joints of the tibia, the mechanical axis
the proximal tibia joint surface: can be drawn (Fig. 18.10a).
1. Using the intercondylar tubercles (Fig.

18.7a). 18.4 Anatomical Axis of the Tibia
2. Using the joint surfaces midpoint (Fig. 18.7b).
For this method a horizontal line is drawn from First, we have to find the midpoints of at least
the edge of the medial plateau. In the same three random horizontal lines of the tibia shaft
way, a horizontal line is drawn from the edge and connect them. The line revealed is the ana-
of the lateral plateau. The center of the tomic axis of the tibia (Fig. 18.10b).
a b
Fig. 18.7 Determination
of the center of the tibia
proximal joint surface. (a)
Using the intercondylar
tubercles and (b) using the
joint tibia proximal joint
margins
Fig. 18.8 The center of the a b

tibiotalar joint line. (a) Midpoint
of the distal tibia joint surface,
(b) center of the bone structure
Fig. 18.9 Center of the distal a b

tibia joint surface, (a) midpoint of
the soft tissues, (b) midpoint of
the talus dome
a b c
MECHANICAL
AXIS
ANATOMIC
AXIS
Fig. 18.10 Axes of the tibia

(a) mechanical axis, (b)
anatomic axis, (c) relation
between the anatomic (blue
line) and the mechanical (red
line) axes of the tibia
18.5 R
elations Between the On the frontal plane, the anatomic and the
Anatomic and the mechanical axes of the femur are different; there is
Mechanical Axes a 7° ± 2° difference between these lines (Fig. 18.11).
The mechanical axis of the tibia is a straight line.

On the frontal plane, the anatomic and the 18.6 J oint Orientation Lines
mechanical axes of the tibia are parallel, only a of the Tibia
few mm separating them. Therefore, in practice,
these lines are the same (Fig. 18.10c). For drawing the tibia distal joint orientation line,
it is essential to determine the distal tibia sub-
chondral horizontal line (Fig. 18.12a).
The concave points of both tibia plateau sub-
chondral lines should be connected when draw-
7° ± 2° ing the tibia distal joint orientation line (Fig.
18.12b).
18.7 J oint Orientation Lines

of the Femur
For drawing the distal femoral joint orientation

line of the femur on the frontal plane, the sub-
chondral line of the distal femur should be deter-
mined (Fig. 18.13).
Two lines are essential for determining the
femoral proximal joint orientation line on the
frontal plane:
1. A connecting line between the tip of the great

trochanter and the center of the femoral head
(Fig. 18.14a)
2. A connecting line between the midline of the
Fig. 18.11 The anatomic (blue line) and the mechanical femoral neck and the center of the femoral
(red line) axes of the femur on the frontal plane head (Fig. 18.14b)
a b
Fig. 18.12 (a) The distal joint

orientation line of the tibia on
frontal plane, (b) the proximal
tibia joint orientation line of
the tibia on frontal plane
18.8 R
elations Between the Joint aMPFA The connecting line between the center
Orientation Lines and the of the femoral head and the tip of the great tro-
Mechanical and the chanter makes an 84° angle with the anatomic axis
Anatomic Axes on the medial side. This angle is called the “ana-
tomic medial proximal femoral angle” (aMPFA)
mLPFA The connecting line between the center and varies between 80 and 89° (Fig. 18.16).
of the femoral head and the tip of the great tro- We define the angles with four letters. The
chanter makes a right angle with the mechanical first letter describes the side of the angle. There
axis of the femur on the lateral side. This angle is are two sides of the angle on the frontal plane,
called the “mechanical lateral proximal femoral
angle” (mLPFA) (Fig. 18.15) and varies between
85 and 95°.
mLPFA=90°
(85°-90°)
Fig. 18.15 The relation between the mechanical axis of

Fig. 18.13 The distal joint orientation line of the femur the femur and the proximal joint orientation line on the
on frontal plane frontal plane
a b
Fig. 18.14 The proximal

femur joint orientation
lines on the frontal plane,
(a) the connecting line
between the center of the
femoral head and the tip of
the great trochanter, (b) the
connecting line between
the center of the femoral
head and the midline of the
femoral neck
aMPFA=84°
(80°- 89°) aMNSA=130°
(124°-136°)
Fig. 18.17 The relation between the anatomical axes of

Fig. 18.16 The relation between the anatomic axis of the
the neck and shaft of the femur on the frontal plane. It is
femur and the proximal joint orientation line on the fron-
called “medial neck-shaft angle”
tal plane
medial and lateral. On the sagittal plane it is mechanical axis of about 87°. This angle varies
anterior or posterior. Therefore, the first letter between 85 and 90° and is called the mechanical
should be the one of the letters L, M, A, or P. lateral distal femoral angle (mLDFA) (Fig.
The second letter determines the position of the 18.18). The distal femoral joint orientation line
angle, which can be proximal or distal. Therefore, makes an angle with the anatomic axis of the
the second letter should be either P or D. femur at about 81°. This angle varies between 79
The third letter determines the bone. For the and 83° and is called the “anatomic lateral distal
tibia it takes the letter T, and for the femur it takes femoral angle” (aLDFA) (Fig. 18.19).
the letter F.
The fourth letter is the same in all angles. The mMPTA The proximal tibia joint orientation
letter A refers to the word “angle.” line makes an angle with the mechanical axis of
Before all these letters, we have to specify the the tibia on the medial side of about 87°. This
axis we are using. If we are using the anatomic angle varies between 85 and 90° and is called
axis, a small letter “a” comes first, and the small the “medial proximal tibial angle” (mMPTA)
letter “m” is used for the mechanical axis. (Fig. 18.20). The proximal tibial joint orienta-
tion line makes the same angle with the ana-
aMNSA The connecting line between the center tomic axis of the tibia because the anatomic and
of the head of the femur and the midline of the mechanical axes of the tibia are practically the
femoral neck makes an angle of 130° with the same lines.
anatomic axis at the medial side. This angle varies
between 124 and 136° and is called the “medial mLDTA The distal tibial joint orientation line
neck-shaft angle” (aMNSA) (Fig. 18.17). makes an angle with the anatomic or mechanical
axis of the tibia of about 89°. This angle varies
mLDFA and aLDFA The distal femoral joint between 86 and 92° and is called the “lateral dis-
orientation line makes an angle with the femoral tal tibial angle” (mLDTA) (Fig. 18.21).
mLDFA=87°
(85°-90°)
aLDFA=81°
(79°- 83°)
Fig. 18.19 Relation between the femoral distal joint ori-

Fig. 18.18 Relation between the femoral distal joint orientation line and anatomic axis of the femur
entation line and mechanical axis of the femur
mMPTA=87°
(85°-90°)
mLDTA=89°
(86°-92°)
Fig. 18.21 The relation between the tibia distal joint ori-
entation line and the anatomic or mechanical axis of the
Fig. 18.20 The relation between the tibia proximal joint tibia on the frontal plane
orientation line and the anatomic or mechanical axis of
the tibia on frontal plane
Biblography 3. Green S. Three dimensional analysis of deformities. In:

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advanced Ilizarov course lecture notes. Vol. 1. Adana:
1999. p. 62–73.
Çukuova University Medical School, Department of
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Malalignment Test
19
When planning a deformity analysis on a patient, If the mechanical axis of the lower extremity
the first question to ask is whether there is a defor- crosses the knee joint on the lateral side regard-
mity. Although some deformities are obvious, less of the distance, it is called “valgus” defor-
some are barely recognizable. A proper deformity mity (Fig. 19.3).
analysis has to be performed before the ultimate
indication. The first procedure is running an
“MAT” test regardless of the presence of an obvi- 19.2 M
alalignment Test 1
ous deformity for analysis because the data (Where Is the Deformity?
obtained is necessary for subsequent procedures. Is It on the Femur?)
To answer this question, the first angle to mea-

19.1 M
alalignment Test 0 sure is the lateral distal femoral angle (LDFA).
(Is There a Deformity?) When we connect the center of the femoral head
First, the center of the femoral head and the mid-

point of the tibiotalar joint have to be determined. MAD 8 ± 7mm
When these two points are connected with a line, medial
the mechanical axis of that lower extremity is
drawn. This line crosses the knee about 8 ± 7 mm
medially (Fig. 19.1).
The medial deviation of the mechanical axis at
the knee region is accepted as normal up to
15 mm. However, when it exceeds 15 mm, it is
called “mechanical axis deviation” (MAD). If
MAD is more than 15 mm, it is called “varus”
deformity (Fig. 19.2).
M. Çakmak, Prof. MD (*) • M. Cıvan, MD

Istanbul University, Istanbul Medicine Faculty,
e-mail: profcakmak@gmail.com; Fig. 19.1 The mechanical axis of the lower extremity
melihcivan@gmail.com crosses the knee joint about 8 ± 7 mm medially on frontal
plane

https://doi.org/10.1007/978-3-319-45675-1_19
MAD > 15mm

medial
mLDFA
87°
Fig. 19.4 To determine whether there is a femoral defor-

mity, mLDFA is the first angle to measure. This angle is
about 87°
Varus mLDFA > 90
Fig. 19.2 If the mechanical axis of the lower extremity

crosses the knee joint with a distance greater than 15 mm,
it is called “varus” deformity
MAD lateral
Varus
Fig. 19.5 Femur deformity on frontal plane. If the LDFA

is more than 90°, it is called varus deformity
to the femoral distal joint midpoint, the mechani-

cal axis of the femur is drawn. The distal femur
joint orientation line then has to be drawn by con-
necting the subchondral line at the condyles of
Valgus
the femur. These two lines make an angle called
mLDFA, which is normally about 87° (Fig. 19.4).
Fig. 19.3 If the mechanical line of the lower extremity
crosses the knee directly form the lateral side, it is called If the LDFA is more than 90°, this means there
valgus deformity is a varus deformity on the femur (Fig. 19.5).
19 Malalignment Test 257
mLDFA < 85
MPTA
87∞ ± 2∞
Fig. 19.7 The MPTA is the first angle to measure when

determining whether there is a deformity on the tibia. This
Valgus
angle is about 87°
Fig. 19.6 If the LDFA is less than 85°, it is called valgus

deformity on frontal plane
If the angle is less than 85°, there is a valgus

deformity on the femur (Fig. 19.6).
19.3 M
alalignment Test 2
(Where Is the Deformity? MPTA < 85
Is It on the Tibia?)
Varus
For answering this question, the first angle to
measure is the medial proximal tibial angle
(MPTA). When we connect the midpoint of
the proximal tibial joint surface to the distal
tibial joint midpoint, the mechanical axis of the
Fig. 19.8 Tibia deformity on frontal plane. If the MPTA
tibia is drawn. Then the proximal tibial joint
is less than 85°, it is called varus deformity
orientation line has to be drawn by connecting
the subchondral line at the plateau of the tibia.
These two lines make an angle called the 19.4 M
alalignment Test 3
MPTA, which is normally about 87° (Figs. 19.7 (Where Is the Deformity?
and 19.8). Is It on the Knee Joint?)
If the MPTA is more than 90°, this means there
is a valgus deformity on the tibia (Fig. 19.9). If the For answering this question, the first angle to mea-
angle is less than 85°, there is a varus deformity sure is the joint line congruence angle (JLCA).
on the tibia (Fig. 19.8). When the bottom of the subchondral side of the
JLCA = > 2
MPTA > 90
Valgus
Valgus
Fig. 19.9 Tibia deformity on frontal plane. If the MPTA

is more than 90°, it is called valgus deformity
Fig. 19.11 If the JLCA is more than 2° to the medial
side, it means that there is a valgus deformity on the knee
joint on frontal plane
JLCA = > 2
JLCA = 0-2 Varus
Fig. 19.10 For determining the joint deformities, JLCA has

to be drawn on the frontal plane. This angle is normally 0°
femoral condyles is connected, this line is called

the distal femur joint orientation line. The horizon- Fig. 19.12 If the JLCA is more than 2° to the lateral side,
tal lines that refer to the surface of the tibial pla- it means there is a varus deformity on the knee joint on the
frontal plane
teau then have to be connected. These lines must
be parallel. There is a maximum 2° of angle
allowed between these lines. If the angle is more than 2°, it is called a valgus deformity (Figs. 19.10
than 2°, it means that the deformity is on the knee and 19.11). If there is an angulation on the lateral
joint. This angle is normally between 0 and 2°. If side and more than 2 °, it is called a varus defor-
there is an angulation on the medial side and more mity (Fig. 19.12).
19.5 A
ddition 1 (Is There any 19.6 A
ddition 2 (Is There Any
Luxation at the Knee Joint?) Malpositioning
at the Femoral Condyles?)
To solve this problem, we have to draw joint ori-
entation lines of the distal femur and proximal First, both femoral condyles and tibial plateau have
tibia. The midpoints of these orientation lines to be drawn. There are two plateau lines on the
must be aligned horizontally without any transla- proximal tibia. These are both horizontal, in the
tion (Fig. 19.13). If there is a translation more same direction, and placed without stepping. If this
than 3 mm, this means the malalignment is positioning fails with any angulation at one of them,
because of knee joint luxation (Fig. 19.14). or fragmentation with collapse or subsidence, it
Translations less than 3 mm are normal. means that there is a malalignment at the knee joint.
The same principle is applied for the femoral con-
dyles; however, the condyles are round, so measur-
ing these is much more difficult (Fig. 19.15).
19.7 Malalignment Test (MAT)
If there is malalignment at the joint surfaces of the

knee, the mechanical axis deviation comes after.
This situation is determined with MAT. MAT
reveals the wrong orientation in the knee joint
with the mechanical axis deviation.
However, the situation at the hip and ankle
joint is different. When there is deformity at the
distal tibial joint or proximal femur, it is possi-
ble not to observe mechanical axis deviation.
Fig. 19.13 In a normal knee joint, the midpoint of the dis-

tal femoral joint orientation line and the proximal tibial joint
orientation line align horizontally without any translation
0-3 mm Normal
> 3mm Knee Joint
Subluxation
Fig. 19.14 For determining whether there is any sublux- Fig. 19.15 The horizontal surfaces of the tibia plateau at
ation on the knee joint, the mid reference points of the the knee joint must be at the same level. Any angulation
knee have to align horizontally without translation between the surfaces leads to a deformity
For this reason, deformities close to the ankle Application of the MAT-1
or hip region cannot be revealed with MAT. If an
accurate deformity analysis is wanted, ankle or hip 1. Connect the center of the femoral head and
malorientation test (MOT) must be performed. the tip of the great trochanter.
2. Draw the mechanical axis of the femur.
3. Measure the mLPFA.
19.7.1 Hip MOT 4. Normally mLPFA is about 90°. (Varies

between 86 and 92°)
19.7.1.1 Trochanter–Head Line
The trochanter–head line connects the tip of the Application of the MAT-2
great trochanter to the center of the femoral
head (Fig. 19.16). For the hip MOT, relations 1. Connect the center of the femoral head and
between this line and the anatomic and the the tip of the great trochanter.
mechanical axis of the femur have to be studied 2. Draw the anatomic axis of the femur.
(Figs. 19.16,19.17, and 19.18). 3. Measure the aMPFA.
4. Normally aMPFA is about 84°. (Varies

between 80 and 89°)
19.7.1.2 Head–Neck Line

Head–neck line connects the center of the femo-
ral head to the midline of the neck (Fig. 19.19).
Hip MOT is the relation between this line and the
anatomic axis of the femur.
19.7.1.3 D istal Tibial Joint

Orientation Line
For determining whether there is a malorientation
at the distal tibial joint surface, a lateral distal tibial
angle (LDTA) has to be drawn. For drawing the
Fig. 19.16 Trochanter–head line LDTA, first we have to determine the distal tibial
mLPFA aMPFA
Fig. 19.17 The relation between the trochanter–head Fig. 19.18 The relation between the trochanter–head
line and the mechanical axis of the femur line and the anatomic axis of the femur
MNSA
Fig. 19.19 Head–neck line (left). Pathologic position

according to the anatomic axis (right)
mLDTA = 89° aLDTA = 89°

(89° ± 3°) (89° ± 3°)
Fig. 19.20 The relation between the distal tibial joint Fig. 19.21 Mechanical axes of a patient with deformities
orientation line and the anatomic (left) or the mechanical in both lower extremities
axis (right)
joint orientation line. After drawing the anatomic 3 . Measure the LDTA.
or the mechanical axis of the tibia, the lateral distal 4. Normally LDTA is about 89° (varies

tibial angle must be measured. This angle is nor- between 86 and 92°) (Figs. 19.20, 19.21,
mally 89° and varies between 86 and 92°. 19.22, 19.23, 19.24, 19.25, 19.26, 19.27,
19.28, and 19.29).
Application of the MAT-3
1 . Draw the distal tibial joint orientation line.

2. Draw the anatomic or mechanical axis of the
tibia.
Fig. 19.22 Measuring the MAD of both lower extremi- Fig. 19.23 MAD is positive on the right side because the
ties of the patient. This patient has two different deformi- mechanical axis of the right lower extremity crosses the
ties in both lower extremities because of the mechanical knee joint laterally. This means the deformity is on the
axis of the whole extremity crossing the knee joint later- right side. The left side is normal because the line crosses
ally on the right side and crossing about 16 mm medially the knee joint across the center
on the left side
Fig. 19.24 The mechanical axis is on the medial side at Fig. 19.25 There is a valgus deformity on the right
the right extremity, but the distance is less than 16 mm. femur. mLDFA is less than 85°. On the left side, LDFA is
This means there is no deformity. On the left side, the more than 90° and there is a varus deformity
mechanical axis crosses laterally, which means there is a
deformity on this side and MAD is positive
Fig. 19.27 There is a deformity on the right tibia because

the MPTA is more than 90°. On the left tibia, there is no
deformity because the MPTA is 90°
Fig. 19.26 There is no deformity on the right femur
because the mLDFA is 89°. There is no deformity on the
left side because the LDFA is 90°
Fig. 19.28 There is no deformity on the right tibia Fig. 19.29 There is a deformity on the right tibia because
because the MPTA is 90°. On the left tibia, MPTA is more the MPTA is more than 90°. There is no deformity on the
than 90° so there is a deformity left side because the MPTA is 90°
Bibliography 3. Green S. Three dimensional analysis of deformities.

In: Third meeting of the A.S.A.M.I international lec-
ture. Doruk Graphics, Istanbul; 2004.
1. Cakmak M, Bilen FE. The hinge types and the position-
ing. In: Cakmak M, Kocaoğlu M, editors. The princi-
ples of the Ilizarov surgery. Doruk Graphics, Istanbul;
advanced Ilizarov course lecture notes. Vol. 1. Adana:
1999. p. 63–78.
Çukuova University Medical School, Department of
2. Gulsen M. The principles of the deformity correction.
Orthopedics and Traumatology. 1997. p. 12–30.
In: Çakmak M, Kocaoglu M, editors. The principles of
5. Paley D. Frontal plane mechanical and anatomical
the Ilizarov surgery. Doruk Graphics, Istanbul; 1999.
axis planning. In: Paley D, editor. Principles of defor-
p. 145–66.
mity correction. Berlin: Springer; 2002. p. 61–97.
Sagittal Plane Deformities
and Malorientation Test 20
The knee joint moves in the sagittal plane. For The knee rotation center is not at just one loca-
that reason, the knee, hip, and ankle alignment on tion. It moves at each flexion degree during the
the sagittal plane varies in walking phases. knee joint movement. It makes a letter J when
Although we use the static deformity analysis moving to extension from flexion. The rotational
on the frontal plane, dynamic factors have to center explained in this analysis is the mean
be considered for determining sagittal plane point. For drawing the mechanical axis of the
deformities. femur on the sagittal plane, knee and hip rota-
tional center must be connected (Fig. 20.1c)
[1–3].
20.1 T
he Mechanical Axis
of the Femur
20.2 T
he Anatomic Axis
The rotational centers of the hip and knee joints of the Femur
have to be determined first for drawing the
mechanical axis of the femur on the sagittal plane For drawing the anatomic axis of the femur on the
(Fig. 20.1a, b). sagittal plane, random three or four horizontal lines
Hip rotation center: The center of the femoral have to be drawn first. When the midpoints of these
head on the lateral X-ray view is the hip rotation lines are connected, the anatomic axis appears.
center. This point can be determined similar to The shaft of the femur does not have a straight
the way for frontal plane deformities explained in bone structure on the sagittal plane. Thus the ana-
previous chapters (Fig. 20.1a). tomic axis is also curved on sagittal plane. This
Knee rotation center: The intersection point of forces us to determine the anatomic axis of the
the Blumensaat line and the line that continues proximal and distal segments independently (Fig.
from the femoral posterior cortex to the inferior 20.3). There is a 10-degree angle between the
is the sagittal plane rotation center of the knee proximal and distal anatomic axes of the femur
joint (Fig. 20.2). on the sagittal plane (Fig. 20.4).

e-mail: profcakmak@gmail.com;
melihcivan@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_20
a b c
Center of the
femoral head
Sagittal Plane
Sagittal Plane
Mechanical
Rotation Centre
Axis of the
of the Knee
Femur
Fig. 20.1 Sagittal plane center of rotation of hip (a) and knee (b) joints. Sagittal plane mechanical axis
of femur (c)
a b
Posterior
Cortical
Line
Blumensaat
Line
Sagittal Plane Rotation

Center of Knee Joint
Fig. 20.3 The anatomic axis of the femur on the sagittal
Fig. 20.2 The crossing point of the Blumentsaat line and plane, (a) The midpoints of the horizontal femoral lines,
posterior cortical line is the knee rotation center (b) the anatomic axis of the proximal half of the femur
20 Sagittal Plane Deformities and Malorientation Test 269
a b 20.3 T
he Mechanical Axis
of the Tibia
For drawing the mechanical axis of the tibia on

sagittal plane, we have to determine the proximal
and distal joint midpoints.
The proximal joint midpoint of tibia: First
anterior and posterior cortex lines of the tibia
10°
must be extended above. The midpoint of the dis-
tance of these lines is the midpoint of the joint on
the sagittal plane (Fig. 20.5a, b).
The distal joint midpoint of tibia: First ante-
rior and posterior cortical line of the tibia must be
extended below. The midpoint of the distance of
these lines is the midpoint of the joint on the sag-
ittal plane (Fig. 20.5a, b).
By connecting the distal and proximal joint
centers of tibia on the sagittal plane, the mechani-
cal axis of the tibia on the sagittal plane can be
drawn (Fig. 20.5c) [3, 4].
Fig. 20.4 (a) The anatomic axis of the distal half of the
femur. (b) There is 10° angle between the distal and proxi-
mal anatomic axes
a b c
Fig. 20.5 The mechanical axis of the tibia on

the sagittal plane. (a) The cortical lines at the
anterior and posterior must be extended above.
(b) The distance between the anterior and
posterior lines. (c) Both midpoints are
connected
20.4 T
he Anatomic Axis a b c
of the Tibia
The anatomic axis and the mechanical axis of the

tibia are the same lines. For drawing, use the
same method previously described for the
mechanical axis (Fig. 20.6).
Distal Femur Orientation Line If the growing

plate is open, the anterior and posterior end-
points of the physis must be connected (Fig.
20.7). After the growing plate is closed, the cal-
cific residue of the physis must be considered
(Fig. 20.7b). If the calcific physis line is lost,
then the metaphysis-diaphysis border must be
considered (Fig. 20.7c).
Fig. 20.7 The distal joint orientation line of the femur on

the sagittal plane. (a) When the growing plate is open, (b)
after calcification of the growing plate, and (c) when there
is no evidence of physis residue
20.5 T
he Orientation Lines
a b
of the Tibia
The proximal tibia orientation line is just below the

subchondral surfaces beneath the plateau of the
tibia (Fig. 20.8a). The line between the anterior
and posterior corners of the distal tibia is the dis-
tal tibial orientation line on the sagittal plane
(Fig. 20.8b).
20.6 The Relations

Between the Orientation
Lines and Bone Axes
1-aPDFA The distal femoral orientation line

makes an angle with the anatomic axis of the
femur on the sagittal plane of about 83°. This
angle is called the “posterior distal femoral
angle” (aPDFA) and varies between 79 and 87°.
(Fig. 20.9a). The anatomic axis of the femur
Fig. 20.6 The anatomic axis of the tibia on the sagittal crosses the distal femoral orientation line at the
plane anterior 2/3 point (Fig. 20.9b).
a b
a b
2/3 1/3
PDFA
83±5
Fig. 20.9 The angle between the anatomic axis of the

femur and the distal femur orientation line: (a) posterior dis-
tal femoral angle, (b) the anatomic axis crosses the orienta-
tion line at the anterior 2/3 point
Fig. 20.8 The proximal (a) and distal (b) joint orienta-
tion lines of the tibia on the sagittal plane
a b
2-PPTA The proximal anatomic axis on the sag-
ittal plane makes an angle with the proximal tibia
4/5 1/5
orientation line and is about 81°. This angle is
PPTA
called the “posterior proximal tibial angle” 81°
(aPPTA) and varies between 77 and 84°. The ana-
tomic axis of the tibia on the sagittal plane crosses
1/5 anteriorly to the proximal joint surface (Fig.
20.10a).
3-ADTA The distal tibial joint orientation line

makes an angle with the anatomic axis of about
80°. This angle is called the “anterior distal tibial
angle” (aADTA) and varies between 78 and 82°
(Fig. 20.11).
Every movement position on the lower
Fig. 20.10 The angle between the tibia proximal joint
extremity on the sagittal plane can mimic a orientation line and the anatomic axis
malaligned position. For that reason, sagittal
plane d eformities of the lower extremities can be
better tolerated. Recurvatum and lesser procurva- Another reason for malalignment in the lower
tum deformities are two such examples [4, 5]. extremity in the sagittal plane is knee joint sub-
20.7 T
he Lower Extremity
Mechanical Axis
in the Sagittal Plane
The connecting line between the hip rotational

center and ankle rotational center is the mechani-
cal axis of the lower extremity in the sagittal
plane.
The ankle rotation center is the lateral process
of the talus. At full knee extension, the mechani-
cal axis of the lower extremity in the sagittal
plane crosses the knee rotation center anteriorly
(Fig. 20.13). This provides a locking mechanism
to the knee joint when standing. For the exact
ADTA 80°±2°
vertical alignment position, the knee has to be at
5–10° flexion (Fig. 20.14) [5, 6].
Fig. 20.11 Anterior distal tibial angle
a b Hip Rotation
Center
Knee
Rotation
Center
Fig. 20.12 (a) Normal alignment of the knee in the sagit-

tal plane (b) Posterior subluxation
Ankle
luxation. The midpoints of the femoral condyles Rotation
in the sagittal view are aligned horizontally with Center
the midpoints of the proximal tibial joint surface.

If the tibial midpoint moves forward, anterior
joint subluxation of the knee occurs. If the tibial
Fig. 20.13 At full knee extension, the mechanical axis of
midpoint moves to the posterior, posterior knee the lower extremity in sagittal plane crosses the knee rota-
joint subluxation occurs (Fig. 20.12). tion center anteriorly
a b
Hip Rotation
Center
Knee
Rotation
Center
Ankle
Rotation
Center
Fig. 20.14 At 5° flexion of the knee, the mechanical axis

of the lower extremity in the sagittal plane is in
alignment
Fig. 20.15 Malalignment positions of the lower

extremity: (a) Flexion malalignment, (b) extension
malalignment
20.8 S
agittal Plane Malalignment the standing position himself while getting a
Test (MAT) whole lower extremity X-ray. For example, if a
patient without extension malalignment has an
The frontal plane malalignment test (MAT) is X-ray in flexion, the surgeon could interpret this
used to determine whether there is a deformity in situation as flexion malalignment. Therefore,
the frontal plane. For the same purposes on the MAT in the sagittal plane is not as accurate as
sagittal plane, we use the sagittal plane MAT. MAT frontal plane MAT and can be deceptive.
investigates flexion and extension malalignment.
Flexion malalignment At the lateral view of 20.8.1 Sagittal Malalignment Test 1

the knee at full extension, if the mechanical axis (Are There Any Deformities
does not cross the knee rotational point anteri- at the Distal Femur?)
orly, there is flexion malalignment (Fig. 20.15b).
1 . Draw the distal anatomic axis of the femur.
Extension malalignment If knee joint exten- 2. Draw the distal femur joint orientation line.
sion exceeds 5° in the sagittal plane, there is sag- 3. Measure the posterior angle between these

ittal plane extension malalignment in that knee previous lines called PDFA. Normally this
joint (Fig. 20.15b). To perform a correct malalign- angle is about 83° and varies between 78 and
ment test, the orthopedic surgeon must arrange 88° (Figs. 20.16 and 20.17).
b
PDFA > 81° PDFA < 79°
Fig. 20.17 Sagittal malalignment test-1, recurvatum

2/3 1/3 deformity if PDFA is more than 81°, procurvatum defor-
mity if PDFA is less than 79°
PDFA
83±5
Fig. 20.16 Sagittal malalignment test 1
a b c
Fig. 20.18 Sagittal
malalignment test-3,
(a) normal knee joint,
(b) flexion malalignment,
and (c) extension
malalignment
20.8.2 Sagittal Malalignment Test 2 References

(Are There Any Deformities
in the Proximal Tibia?) 1. Çakmak M, Bilen FE. The hinge types and the posi-
tioning. In: Çakmak M, Kocaoğlu M, editors. The
principles of the Ilizarov surgery. Doruk Grafik:
1 . Draw the anatomic axis of the tibia. Istanbul; 1999. p. 62–78.
2. Draw the proximal tibia joint orientation line. 2. Green S. Three dimensional analysis of deformities.
3. Measure the posterior angle between these pre- In: Third meeting of the A.S.A.M.I international lec-
ture. Doruk Graphics: Istanbull; 2004.
vious lines called PPTA. Normally this angle is
about 81° and varies between 77 and 85°. In: Çakmak M, Kocaoglu M, editors. The principles of
the Ilizarov surgery. Doruk Grafik: Istanbul; 1999.
p. 145–66.
20.8.3 Malalignment Test 3 (Are 4. Paley D. Malalignment. In: Paley D, editor. Principles
There Any Contractures of deformity correction. Berlin: Springer; 2002.
p. 19–23.
at the Knee Joint?) 5. Paley D. Frontal plane mechanical and anatomical
Extend the anterior cortical lines of the femur and mity correction. Berlin: Springer; 2002. p. 61–97.
tibia and measure the angle between. Normally 6. Paley D. Sagittal plane mechanical and anatomical
there is no angulation. If there is an angulation, it
mity correction. Berlin: Springer; 2002. p. 155–74.
means there is an extension or flection malalign-
ment (Fig. 20.18).
Oblique Plane Deformities
21
The frontal (coronal) and sagittal planes are the posterior (procurvatum, recurvatum) directions
standard reference planes. Radiographs that cor- can be seen for each plane. For an oblique plane
respond with these planes are AP and lateral deformity, for each X-ray view (AP and LAT),
X-rays, respectively. If there is an angulation on there is an apical direction of angulation (Figs.
both frontal and sagittal planes, it means the 21.3 and 21.4) [1, 2].
deformity is on the oblique plane. Deformities As a combination, oblique plane deformi-
other than those on the frontal and sagittal planes ties can be classified in four types according
are oblique plane deformities. These deformities to the apical direction of angulation. Sagittal
were previously known as biplanar deformities. plane must be stated first for the classification
However, this description was wrong because [3, 4]:
they were uniplanar angular deformities in the
oblique plane (Figs. 21.1 and 21.2). 1. Anteromedial deformities; a combination of
varus and procurvatum deformities
2. Anterolateral deformities; a combination of
21.1 Apical Direction valgus and procurvatum deformities
of Angulation 3. Posteromedial deformities; a combination of
varus and recurvatum deformities
Angular deformities may occur on any plane. For 4. Posterolateral deformities; a combination of
the frontal plane, medial and lateral (varus, val- valgus and recurvatum deformities
gus), and for the sagittal plane, anterior and


https://doi.org/10.1007/978-3-319-45675-1_21
Fig. 21.1 An oblique

plane deformity of the
left tibia; clinical view
(left), AP radiography
(right)
Fig. 21.2 An oblique

plane deformity of the
left tibia; clinical
sagittal view (left),
lateral radiography
(right)
21 Oblique Plane Deformities 279
21.2 The Magnitude

of the Deformity
There is no absolute correlation between the

actual angle of deformity and those measured
on both AP and LAT X-rays. This angle we
measured on both AP and LAT are only projec-
tions. The actual angle can only be measured if
the X-ray is taken perpendicular to the defor-
mity plane.
Before the operation, the maximum or actual
angulation of the deformity must be measured
and the right deformity plane must be deter-
mined. Using the angulation values on the AP
and LAT X-rays, the actual value can be mea-
sured using trigonometric calculations; however,
this is quite difficult. In practice, we use a similar
method to that developed by D. Paley for the cal-
culations. It is simple and can be used very
quickly [5].
Fig. 21.3 Right tibia of a patient with an anterolateral
oblique plane deformity, AP X-ray shows an apical direc-
tion of angulation to the lateral side
21.3 Paley’s Graphic Method
Before this practical method, we used some nor-

mograms defined by Bar and Breitfuss in 1989
and Ilizarov in 1989. Because these methods con-
tain some trigonometric calculations, charts, and
tables, we use Paley’s graphic method (1990–
1992), which is simpler to use and without any
miscalculations [6, 7].
Let’s analyze the deformity of the patient on
the Figs. 21.1 and 21.2 and establish the actual
angulation angle using Paley’s graphic method.
Step 1
CORA and the angulation on the AP and LAT
X-rays must be determined with the same
method, as explained in previous chapters
(Chaps. 2 and 3).
For this case, on the left tibia AP X-ray,
there is a 20° valgus angulation, and the apical
direction of angulation is on the lateral side.
On the lateral X-ray, there is a procurvatum
deformity of about 35°, and the apical direc-
Fig. 21.4 The right tibia of a patient with an anterolateral
oblique plane deformity (same patient as shown in Fig. tion of angulation is on the anterior side (Figs.
21.3). Lateral X-ray shows an apical direction of angula- 21.1 and 21.2).
tion to the anterior side
y y
A
6 6
5 5
4 4
35 mm = 35º
3 3
20 mm = 20º
2 2
1 1
–6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 x –6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 x
–1 –1
L M
–2 –2
–3 –3
–4 –4
–5 –5
–6 –6
P
Fig. 21.5 Drawing of the coordinate graph with x- and Fig. 21.7 Placement of the angulation values. Each mm
y-axes and determination of the (+) and (−) sides refers to 1° of angulation
y
A
is the (+) side and the lower side of the y-axis is
6 (−) side (Fig. 21.5).
5 The capital letters of the anterior (A), medial
4 (M), lateral (L), and posterior (P) have to be
3 added to the graph. When analyzing, pay atten-
2 tion to the extremity side especially. When the
1 sides are positioned on the graph, look down to
your own extremity. If the deformity is on the
–6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 x
–1 right or left extremity, position the sides accord-
L M
–2 ing to you (Fig. 21.6).
–3
–4 For the right side The (+) side of the x-axis is
–5 lateral; the (−) side is medial.
–6 The (+) side of the y-axis is anterior; the (−)
P
side is posterior.
Fig. 21.6 Drawing of the coordinate graph with x- and For the left side The (+) side of the x-axis is
y-axes and positioning of the anatomic sides medial, the (−) side is lateral.
The (+) side of the y-axis is anterior, the (−)
Step 2 side is posterior (Fig. 21.5).
Draw a coordinate graph with x- and y-axes on
the paper. The x-axis refers to the frontal plane; Step 3
the y-axis refers to the sagittal plane. The surface Place landmarks 1 mm on the x- and y-axes. 1 mm
of the graph refers to the transverse plane. The refers to 1° of angulation. In this case, the 20° of
right of the x-axis is the (+) side, and the left of angulation must be placed on the x-axis, and the 35°
the x-axis is (−) side. The upper side of the y-axis of angulation must be placed on y-axis (Fig. 21.7).
y Step 4
A Draw a perpendicular line from the marked
6 points of the axes. The crossing point must be
5
connected to the center. This line revealed
Anterolateral 4
refers to an oblique plane deformity (Fig. 21.8).
45 3
2
mm
1
Step 5
After all this planning, measure the angle
–6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 x between the new line and the x-axis. This angle
–1
L M refers to the plane of deformity according to the
–2
frontal plane. In this case, the deformity plane
–3
makes an angle between the frontal plane of 55°
–4
and sagittal plane of 35° (Fig. 21.9).
–5
–6
P Step 6
After determining the angulation correction axis,
Fig. 21.8 After connecting the perpendicular lines from
the deformity plane bone and soft tissue projec-
the marked points, the apical direction of angulation on tion must be added to the chart (Fig. 21.10).
the oblique plane is revealed
Step 7
A Positioning the hinge: After the actual deformity
6 axis and plane has been determined, the diameter
5 of the bone at the deformity level must be mea-
4 sured, which is shown in Fig. 21.11. If the hinges
on
3 cti are positioned tangential to the farthest anterolat-
o rre
2 io nc
lat
gu )
1 An CA
(A
55° is
Ax y
–6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6
–1
L M 6
–2
De
5
for
–3
mi
4 )
ty
–4 CA
pla
3 (A
ne
(D
–5 P
P)
2
–6 1
Fig. 21.9 Determining the deformity plane and angula- –6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 x

–1
tion correction axis (ACA)
–2
The apex of the deformity must be considered –3

–4
while placing the values on the chart. On the AP
–5
X-ray, the 20° varus deformity is on the lateral Deformity
side. For this value, 2 cm on the (−) side of the –6 plane
x-axis must be marked. On the LAT X-ray, the

apex of the procurvatum deformity is on the ante-
Fig. 21.10 Addition of the bone and soft tissue reference
rior side. For this value, 3.5 cm on the (+) side of after the determination of the deformity plane and the
the y-axis must be marked. hinge axis
y 21.4 A
ngulation Correction Axis
(ACA)
6
5
ACA is perpendicular to the deformity plane
4 )
CA (Fig. 21.9). This means that varus–valgus defor-
3 (A
mities are corrected on the frontal plane, and
2
recurvatum– procurvatum deformities are cor-
1
rected on the sagittal plane.
–6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 x The angulation correction axis of an oblique
–1
plane deformity is a line perpendicular to the
–2
deformity plane. The correction axis can be
–3 drawn from the CORA point in the radiograph.
–4
If an open-wedge osteotomy is planned, ACA
–5 Deformity must be on the convex cortex of the bone. If
–6 plane a closed-wedge osteotomy is planned, ACA
must be on the concave cortex of the bone (Fig.
21.11). The transverse projection of the bone
Fig. 21.11 Hinge positioning. There are three major
hinge positions for the osteotomy. Use the anterior line for must be drawn on the graph for the correc-
the open wedge, and for the closed wedge, use the poste- tion osteotomy. The diameter of the bone must
rior line be measured on both lateral and AP views,
Fig. 21.12 Clinical
photos of the patient in
Figs. 21.1 and 21.2
during treatment
eral cortex, this means the correction comes with and the bone shape must be drawn inside the
lengthening as in an open-wedge osteotomy. If the marked points. After elongation, the lines refer
hinges are positioned tangential to the posterome- to the angulation plane; a perpendicular line
dial cortex, this means the correction comes with to this axis must be drawn (Figs. 21.12 and
shortening, as in a closed-wedge osteotomy. 21.13).
Fig. 21.13 Clinical
photos of the patient in
Figs. 21.1 and 21.2
after the treatment
References the Ilizarov surgery. Istanbul: Doruk Grafik; 1999.

p. 145–66.
5. Kocaoglu M. Treatment of the oblique plane defor-
1. Bar HF, Breitfuss H. Analysis of angular deformities on
mities with ilizarov type external fixators. First
radiographs. J Bone and Joint Surg Br. 1989;71:710–1.
advanced ilzarov course lecture notes, vol. 1. Adana:
2. Cakmak M, Bilen FE. The hinge types and the posi-
Cukurova University Faculty of Medicine,
tioning. In: Cakmak M, Kocaoğlu M, editors. The
Orthopedics and Traumatology Department; 1977.
principles of the Ilizarov surgery. Istanbul: Doruk
p. 12–30.
Grafik; 1999. p. 62–78.
6. Paley D. Oblique plane deformity analysis. Bull Hosp
3. Green S. Three dimensional analysis of deformities.
Joint Disease. 1992;52:35–6.
In: Third meeting of the A.S.A.M.I international lec-
7. Paley D. Oblique plane deformities. In: Paley D, edi-
ture. Istanbul: Doruk Graphics; 2004.
tor. Principles of deformity correction. Berlin:
Springer-Verlag; 2002. p. 175–94.
Multiapical Deformities
22
We will try to explain multiapical deformities in solution CORA will be explained in the treat-
this chapter. We must identify the location and ment part.
size of the deformity. Therefore, we draw the If there are multiple deformities, then there
anatomic and mechanical axes of the bone either must also be an intermediate part in addition to
on the distal or proximal side of the deformity the proximal and distal part. The axis of the inter-
(Fig. 22.1a). mediate part is drawn. It is called the multiapical
The intersection point of the axes of the proxi- deformity if more than one apex or CORA are
mal and distal sections is the CORA (Fig. 22.1b). identified. CORA-1 is the intersection point of
The CORA is the abbreviated form of “center of the axis of the intermediate part and mechanical
rotation of angulation,” and it is the center point axis of the proximal section, the intersection
of the deformity. There is an apex and generally point of the axis of the intermediate part, and
an apex or one CORA on the CORA region (Fig. mechanical axis of the distal section is CORA-2.
22.1c). Deformities with one apex or one CORA Apex-1 is present on CORA-1 and apex-2 is
are defined as uniapical deformities. present on CORA-2 [1, 2] (Fig. 22.2b, c).
Bone deformity is often not simple. There
may be more complex deformities. A more
complex deformity is shown in the figure above 22.1 S
ignificance of Multiapical
(Fig. 22.2). The anatomic and mechanical axes Deformities
of the bone are drawn proximal and distal of
the deformity to identify the location and size These can be classified in two main groups as
of the deformity, and the CORA is identified in diagnosis and in treatment. We will try to
(Fig. 22.2a). explain the significance in diagnosis with an
However, this is not the true CORA. It is “the example. A deformity is present in the tibia
solution CORA,” because there is no deformity (Fig. 22.3).
or apex on this part of bone. Therefore, we have It seems like a uniapical deformity at first
to find the true CORAs. The importance of the glance. The proximal tibial axis is drawn to iden-
tify the location and degree of the deformity.
Then, the distal tibial axis is drawn. These two
M. Çakmak, Prof. MD (*) • M. Cıvan, MD lines interconnect in the apex region. It would be
Istanbul University, Istanbul Faculty of Medicine, defined as a multiapical deformity if they had not
Orthopedic & Traumatology Department, interconnected in that region. This will be further
e-mail: profcakmak@gmail.com; explained in the diagnosis section.

https://doi.org/10.1007/978-3-319-45675-1_22
a b c a b c
CORA 1
Solution
1 APEX Solution
Solution CORA
APEX CORA 1 CORA CORA
CORA
CORA 2
Fig. 22.1 Uniapical deformities have one axis and CORA. Fig. 22.2 Multiapical deformities. Positioning of the multi-
Step by step (a, b and c) determination of the apex and ple CORA points and solutions CORA by drawing the proxi-
CORA by drawing the proximal and distal anatomical axis mal, distal and interpositioned anatomical axis. (a, b and c)
Fig. 22.3
Is it a
multiapical
or uniapical
deformity?
87˚
CORA 1 CORA 1
CORA ?
80˚
Is this really a uniapical deformity? Let’s opposite tibia. The axis of the opposite tibia is
check it again. The deformed tibia is com- then drawn.
pared with the tibia on the opposite side by The medial angle, also known as MPTA,
measuring some parts to determine whether between the joint line and the axis line is mea-
the other tibia is healthy. A tangent line is sured. This angle is 87° on the healthy part and
drawn to the proximal joint surface of the when it is normal (Fig. 22.4). A tangent line is
22 Multiapical Deformities 287
87˚
87˚
MTPA
CORA 1
CORA 2
LDTA
LDTA 80˚
90˚
Fig. 22.4 Normal angle values of the joint surfaces of tibia Fig. 22.5 Identification of a second deformity by mea-
suring the lateral distal tibial angle; the normal value of
LDTA is 90°. Remember the question in figure 22.3
drawn on the joint surface of the distal tibia to
measure the angle on the deformed side. The osteotomy. The anatomic axis can be fixed with
angle is 87°. A tangent line is drawn on the single osteotomy, but the mechanical axis will
distal joint surface of the healthy tibia. The deteriorate, and the anatomic axis will deterio-
angle between this line and the axis of tibia rate when the mechanical axis is fixed [3, 4].
(LDTA) is 90°. This deformity can anatomically be fixed with
A tangent line is drawn on the distal joint sur- a single osteotomy from the CORA-1.
face of the deformed tibia. The LDTA angle is Deformity fixation with open-wedge oste-
measured again, and it is 80° (Fig. 22.5). otomy (Fig. 22.6). If we draw the anatomic
This indicates the existence of a second defor- axis now, it becomes normal. Let’s also check
mity. If we draw a vertical line from the center of the mechanical axis. A tangent line is drawn on
the ankle, it gives the mechanical axis of the dis- the proximal joint surface of the tibia. The two
tal tibia. The intersection point of both lines gives lines are expected to be parallel to each other,
the second CORA. Thus, we understand that this but they are not (Fig. 22.7). This means that the
is a multiapical deformity, not a uniapical defor- joint surface orientations were not fixed. We
mity (Fig. 22.5). will better understand if we compare it with the
We can conclude that multiapical deformities healthy tibia.
may be missed unless examined carefully. If the opposite side is normal, then a tangent
Therefore, each case must be examined line is drawn on the proximal joint surface, and
carefully. joint surfaces are found to be parallel to one
What happens if the deformity is missed? another. The mechanical axis of the proximal
The deformity will be evaluated as a uniapical region is corrected, but the mechanical axis of the
deformity and will be corrected with a single distal region remains defected.
a b
CORA 1
CORA
CORA 2
Fig. 22.6 Correction of the deformity with open-wedge

osteotomy
a b
Fig. 22.8 Identification of the solution CORA
Diagnosis A multiapical deformity must be con-

sidered if the CORA point is not on the bone. A
tangent line is drawn on the proximal joint surfaces
of a tibia deformity. A line with an 87-degree angle
is drawn from the center of the knee.
This line shows the anatomic or mechanical
axis of the proximal tibia. A tangent line is then
drawn on the distal joint surface of tibia. If we
draw a line from the center of the ankle to this
line, it provides the mechanical axis of the distal
tibia. Interconnection points of these lines are not
the true CORA because the interconnection point
is outside of the bone. There is a second defor-
mity. The midpoints of the intermediate fragment
are identified to find the true CORAs (Fig. 22.8).
Multiapical deformity must be considered if the
CORA is not found in the bone. However, this is par-
tially true for the tibia. Both anatomic and mechani-
cal axes of tibia are located in the bone (Fig. 22.9).
Fig. 22.7 For correction of the lateral distal tibial angle
(LDFA), a secondary open-wedge osteotomy was per- This is not true for femur (Fig. 22.10). The
fomed at distal tibia distal half of the mechanical axis of the bone is
located on the bone; however, the proximal half

is located outside of the bone. If we draw
according to the mechanical axis, it is normal to
find the CORA outside of the bone on the proxi-
mal femur.
Let’s check this on a case: A tibia deformity
with 4 cm shortness is shown below (Fig.
22.11).
The first step is to do the malalignment test to
check the deformity. A line is drawn from the
center of the femoral head to the center of the
ankle. A varus-type malalignment is observed in
the tibia (Fig. 22.12).
Anatomic Axis Mechanical Axis A tangent line is drawn on the distal femur to
identify the bone with the deformity. The center
of the femoral head and the center of knee are
connected, and the angle (LDFA) between this
axis and the tangent axis is measured. Normally,
this angle is about 87°. This angle is found nor-
mal on both sides. A tangent line is then drawn
to the proximal of tibia. The center of the knee
Fig. 22.9 The anatomic and mechanical axis of tibia are and the center of the ankle are connected. The
the same line and always located on the bone medial angle (MPTA) between these two lines is
measured. Normally, this angle is about 87°.
This angle is found normal on the left side, but
it is not normal on the right side.
We have found that it is a tibial deformity; now
we must find the location of the deformity. The
mechanical axis of the proximal tibia is drawn.
First, the mechanical axis of femur must be drawn.
If it is normal, the mechanical axis of the proximal
tibia is found by drawing the line toward below.
First, a parallel line is drawn to the distal sur-
face of the tibia in order to draw the mechanical
axis of the distal tibia. A vertical line is drawn
from the center of the ankle to this line. The inter-
connection of the mechanical axes of the distal
and proximal tibia is the CORA, but this is not
the true CORA, because the interconnection
Anatomic axis Mechanical axis point is outside of the tibia. A line is drawn to
pass from the center points of the intermediate
fragment to find the true CORAs. Intersection
points of this line with the other two lines are the
true CORAs (Fig. 22.13).
The mechanical axis of the lower extremity is
drawn from the center of the femoral head to the
Fig. 22.10 The anatomic and mechanical axes of the center of the ankle; minimal varus axis deviation
femur are different lines is present. The mechanical axis of femur is drawn
Fig. 22.11 A patient with

a deformity on the right
tibia
from the center of the femoral head to the center The malalignment is tested to evaluate the
of the knee. Then the LDFA is measured. The deformity. Axis deviation is obvious on both
LDFA is normal. The mechanical axis of femur is sides. The center of the femoral head and center
extended distally. This gives us the mechanical of knee are connected and LDFA is measured
axis of the proximal tibia. A parallel line is drawn (Fig. 22.15).
to the distal surface of tibia and a vertical line is The mechanical axis of the proximal femur is
drawn from the center of the ankle, and this gives drawn to evaluate the femur deformity. First, the
us the mechanical axis of the distal tibia. The anatomic axis of the proximal femur must be
intersection point of both lines is not located on drawn. A parallel line that passes through the
the deformity region. It shows us that there is center of the femoral head is drawn to this line.
another deformity on the extremity. The mechanical axis of the proximal femur has a
Let’s check this on a real case, an O-leg defor- 7-degree angle with this line. The mechanical
mity due to rickets (Fig. 22.14). axis of the distal femur is drawn. A tangent line is
Visible apex
Fig. 22.12 Demonstration of a varus deformity on tibia
Fig. 22.14 Demonstration of an genu varum deformity

due to rickets
LDFA
CORA
CORA
CORA
CORA
Fig. 22.13 Identification of the CORAs on multiapical

deformities Fig. 22.15 Malalignment test
line, we will obtain the mechanical axis of the

distal femur. The intersection point of these two
lines is the solution apex. The angle between
them is 35° (Fig. 22.17). Then, the mechanical
axis of the distal femur is extended distally in
order to draw the mechanical axis of the proxi-
mal tibia.
A tangent line is drawn to the distal joint sur-
CORA face of the tibia such that the mechanic axis of the
distal tibia may be drawn. The mechanical axis of
the distal tibia is obtained if we draw a line from
the center of the ankle to this line. These two
lines intersect with a 37-degree angle. The inter-
section point is defined as the solution CORA. The
malalignment of the extremity is fixed with
open-wedge osteotomy with a 35-degree angle
from the solution CORA on the femur and with a
37-degree angle from the tibial solution CORA;
the orientation of the ankle, knee, and hip have a
normal shape, but the zigzag shape will develop
on the anatomic axis (Fig. 22.17).
Identification of the CORA A tangent line is

Fig. 22.16 Identification of the CORA on a different drawn to the distal of femur. A line is drawn with
point other than the deformity is an indication of a multi- a LDFA angle toward the proximal. This is the
apical deformity
distal mechanic axis of the femur.
A line is drawn from the center of the femoral
drawn to the joint surface of the distal femur to be head to the line that connects the upper part of the
able to draw the mechanical axis. A line with 87° trochanter major to the center of the femoral
is drawn from the center of knee; these two lines head. This line is the mechanical axis of the prox-
interconnect in another location other than the imal femur. Mid-diaphyseal line of the medium
deformity region, which indicates that it is a mul- fragment is drawn to identify the mechanical
tiapical deformity (Fig. 22.16). axis. A line is drawn distally starting from the
The anatomic axis of the proximal femur intersection point of the mechanical axis of the
must be drawn first in order to draw the mechan- proximal femur (CORA-1) and the bone. This
ical axis of the proximal femur. A parallel line line must have a 7-degree angle with the mechan-
that passes through the center of the femoral ical axis. Intersection of this line with the
head is drawn. The mechanical axis of the prox- mechanical axis of the distal femur gives the
imal femur is obtained by drawing a line at 7° CORA. The angles are measured. CORA-1 is 20°
from the center of the femur. Secondly, the and CORA-2 is 15°. The location of the osteot-
mechanical axis of the distal femur is drawn. A omy will be the CORA-1 and CORA-2. The oste-
parallel line is drawn to the joint surface of the otomy must be in the direction of the angle
distal femur. If we draw a line with 87° to this bisector [5] (Fig. 22.18).
a b c
35°
CORA
37°
Fig. 22.17 Correction of multiapical deformities of the femur and tibia with a single open-wedge osteotomy (a, b). A zigzag
deformity develops on the anatomic axes as shown in (c)
LPFA
90˚
20˚
15˚ LDFA
87˚
MPTA
87˚
21˚
16˚
LDTA
90˚
Fig. 22.18 Correction of the deformity with more than one open-wedge osteotomy. Multiple osteotomies on the ana-
tomic axes prevent the development of the zigzag deformity
References Third meeting of the A.S.A.M.I international lecture.

4. Kocaoğlu M. Treatment of the frontal and sagittal plane
1. Cakmak M, Bilen FE. The hinge types and the applica-
deformities with Ilizarov method, The lecture notes of
tions. In: Cakmak M, Kocaoglu M, editors. Ilizarov sur-
the 1st advanced Ilizarov Course, vol. 1. Adana:
gery and its principles. Istanbul: Doruk Grafik; 1999.
Cukurova Faculty of Medicine, Department of
p. 63–78.
Orthopaedics and Traumatology; 1977. p. 12–30.
2. Gulsen M. The principles of the deformity correction. In:
5. Paley D. The frontal plane mechanical and anatomic axis
Cakmak M, Kocaoglu M, editors. Ilizarov surgery and
planning. In: Paley D, editor. Principles of deformity cor-
its principles. Istanbul: Doruk Grafik; 1999. p. 145–66.
rection. Berlin: Springer- Verlag; 2002. p. 61–97.
3. Green S. Three dimensional analysis of deformities. In:
Anatomic and Mechanical
Planning and Finding the Cora 23
Cengiz Şen and Gökhan Polat
Before analyzing a deformity on a lower extrem-

ity, we have to be sure that the orthoroentgeno-
gram, commonly known as the “scanogram,” has
been taken properly. This X-ray has to be taken
while the patient is standing, three meters from
the tube; the pelvis and the ankle must be included
with the patella in a neutral position (Fig. 23.1).
The X-ray has to be acquired after compensation
of the joint contractures and limb length discrepan-
cies. After the ideal orthoroentgenogram has been
taken, the deformity analysis can be undertaken.
23.1 P
lanning of the Frontal Plane
Deformities
23.1.1 Femur
While analyzing the femur or the tibia and deter-

mining the center of rotation of angulation
(CORA), in practice there are various steps that
must be taken in a proper order. According to
these steps, the mechanical axis of the lower
extremity must be drawn first, and it has to be
determined whether there is a mechanical axis
deviation (MAD) (Fig. 23.2).
C. Şen, MD (*) • G. Polat, MD

Orthopaedic & Traumatology Department,
34190 Istanbul, Turkey Fig. 23.1 An orthoroentgenogram, commonly known as
e-mail: senc64@gmail.com; the “scanogram,” has to include the pelvis and ankle while
gokhanpolat7@gmail.com the patella are in a neutral position

https://doi.org/10.1007/978-3-319-45675-1_23
296 C. Şen and G. Polat
a b
MAD 8 ± 7mm
medial
Fig. 23.2 Normal mechanical axis of a lower extremity is

shown
Fig. 23.3 Mechanical planning of femur. (a) Anatomic

After drawing the mechanical axis, the lateral axis of the proximal segment of the femur. (b) The parallel
proximal femoral angle (mLPFA), lateral distal line that crosses the center of the femoral head
femoral angle (mLDFA), medial proximal tibial
angle (mMPTA), and lateral distal tibial angle
(mLDTA) have to be measured. After these mea-
surements, if the tibia is normal, femur can be oral head as a new mechanical axis of the
considered as deformed and the analysis of the proximal femur (Fig. 23.4). This last step reveals
femur can be performed. the mechanical axis of the proximal femur
(PMA).
23.1.1.1 M echanical Planning of The next step is drawing the mechanical axis
Femur Deformities of the distal femur. To do that, a tangential line
For finding the CORA at the deformed femur, to the distal joint, which is known as the distal
proximal mechanical axis of the femur (PME) and joint orientation line, has to be drawn. After
distal mechanical axis of the femur (DME) have measuring the LDFA, if this angle is within the
to be drawn. First at the proximal femur, below normal range (87 ± 3°), we can use this angle
the trochanter minor, the reference points have to (Fig. 23.5).
be marked far from the tip of trochanter minor, If the mLDFA angle is not within the normal
about 5 and 10 cm at the lateral and medial cortex. range, a virtual normal angle must be drawn
Afterward, the anatomic axis of the proximal section because the LDFA or the mechanical axis of the
can be drawn as a line that crosses the midpoints of tibia can be extended upward if the tibia has nor-
the transverse lines connecting the reference points mal alignment (Fig. 23.6). Thus, the mechanical
of the proximal femur and piriformis fossa (Fig. axis of the distal femur (DMA) has now been
23.3a). Next, this line has to be moved parallel to drawn (Fig. 23.6). The crossing point of these
the center of the femoral head (Fig. 23.3b). two axes reveals the CORA (the center of the
Afterward, a new line has to be drawn mak- deformity), and the angle between these axes
ing a 7-degree angle from the center of the fem- reveals the magnitude of the deformity.
23 Anatomic and Mechanical Planning and Finding the Cora 297
mLDFA = 87°
7°
Fig. 23.4 The mechanical axis of the proximal femur Fig. 23.5 Drawing the mechanical axis of the distal
(PMA) femur with the measurement of lateral distal femoral
angle (LDFA)
23.1.1.2 Anatomic Planning

Let’s analyze a femoral deformity using the of Femoral Deformities
method of mechanical planning. For this As mentioned before, the anatomic axis of the prox-
patient, there is a genu valgum deformity on imal segment (PAA) has to be drawn first. For deter-
the right knee. After drawing the mechanical mining the anatomic axis of the p roximal femur, a
axis of the whole lower extremity, the mechan- line that starts from the fossa piriformis has to be
ical axis deviation (MAD) can be shown. extended below previously drawn line. This line is
Afterward, a section of the deformity must be the anatomic axis of the proximal femur (Fig. 23.8).
investigated. After determining a normal tibia, Afterward, a tangential line has to be drawn to
femur analysis can be initiated. The anatomic the femoral condyles. The anatomic axis of the
axis of the femur must be drawn first. distal femur starts from 8 to 10 mm medially to
Subsequently, this line has to be moved paral- the intercondylar notch. If the MPTA of the prox-
lel to the center of the femoral head. A new line imal tibia segment is normal, the anatomic axis of
that makes an angle with the last must be drawn the tibia must be extended upward. If the angle is
from the center of the femoral head. This not normal, the contralateral side angle can also
reveals the new mechanical axis of the proxi- be considered. If the contralateral LDFA angle is
mal segment, which was 7° to this line. The not normal, a virtual line that makes an 81-degree
mechanical axis of the tibia can be extended angle between the joint orientation line must be
upward, and the crossing point of these two drawn. The midpoints of the supracondylar
axes reveals the CORA because the tibia is region can be used as another solution. This line
normal. The magnitude of deformity is 23° on is the anatomic axis of the distal femur (DAA)
this patient (Fig. 23.7). (Fig. 23.9).
mLDFA = 87°
Fig. 23.7 The analysis of a valgus knee with the mechan-

ical planning method
Fig. 23.6 If there is no deformity on the tibia, the
mechanical axis of the tibia can be extended upward
23.1.2 Tibia
The crossing point of these both lines is the As mentioned before, there is 2 mm of transla-
CORA, and the angle between them shows the tion between the anatomic and the mechanical
magnitude of the deformity (Fig. 23.10). On a axes of the tibia. However, if both these axes are
well-taken X-ray, CORAs, which are found by exactly parallel, we consider them as the same
the anatomic or mechanical method, have to be line. The mechanical axis has to be used for the
on the same side as the deformity angle. analysis.
Let’s analyze a case using anatomic planning. The first step of deformity analysis of the tibia
First, we have to draw the mechanical axis of the is drawing the mechanical axis. A tangential line
lower extremity. This reveals a mechanical axis to the tibial plateau must be drawn. The midpoint
deviation (MAD). The next step is to draw the of the ankle must be marked. The midpoint of
anatomic axis of the proximal segment, which both eminencies and ankle must be connected
starts from the fossa piriformis. After determin- (Fig. 23.12). With the joint orientation lines and
ing the distal femoral joint orientation line, a vir- the mechanical axis, we now can measure the
tual line is drawn that makes an 81-degree angle angles we use.
(aLDFA) between the joint orientation line. The After drawing the mechanical axis of the tibia,
crossing point of these two axes is the CORA. The MPTA and LDTA angles must be measured. For
magnitude of the deformity is 8° (Fig. 23.11). determination of the CORA, the mechanical axis
CORA
Fig. 23.8 The anatomic axis of the proximal femur

(PAA)
Fig. 23.10 The crossing point of the distal and the proxi-
mal anatomic axis is the CORA
of the proximal and the distal segment must be

drawn. For determination of the mechanical axis
of the proximal tibia, if the femur is normal, the
mechanical axis of the femur can be extended
below. If there is a deformed femur, the normal
value of the contralateral side can be used or a
virtual line that makes an 87-degree angle can be
drawn. This reveals the proximal axis of the tibia
(Fig. 23.13).
To determine the mechanical axis of the distal
aLDFA = 81° tibia, the contralateral LDTA has to be measured.
If this angle is within the normal range, it can be
used. If the angle is not within normal range, a
standard value of 89° has to be taken. This line is
the mechanical axis of the distal tibia (tDMA)
Fig. 23.9 The anatomic axis of the distal femur (Fig. 23.14).
Fig. 23.11 Analysis of

the distal segment
deformity using anatomic
planning
CORA: 8º
The crossing point of these two lines is the MPTA is not within the normal range, the
CORA, and the angle between them reveals the mechanical axis of the distal tibia must be
magnitude of the deformity (Fig. 23.15). extended upward. After determination of the
Let’s analyze a case and find the deformity of joint orientation line, a virtual line that makes an
a tibia using mechanical planning. The mechani- 87-degree angle is drawn, and the crossing point
cal axis of the tibia has to be determined first. is CORA. The magnitude of the deformity is 12°
MPTA and LDTA have to be measured. If the (Fig. 23.16).
Mechanical
axis
Anatomic mLDTA = 89°
axis
Fig. 23.12 The mechanical and the anatomic axis of the Fig. 23.14 The mechanical axis of the distal tibia
tibia are practically the same
MPTA = 87° MPTA = 87°
mLDTA = 89°
CORA
Fig. 23.13 The mechanical axis of the proximal tibia Fig. 23.15 The crossing point of the distal and the proxi-
(tPMA) mal mechanical axis of the tibia is the CORA
Fig. 23.16 Determination of a tibial

deformity using mechanical planning
23.2 P
lanning of Sagittal Plane X-rays, and the knee must be in full extension
Deformities while shooting. The sinus tarsi and the head of
the femur must be determined on this X-ray. The
There is a difference between sagittal and frontal line starts from the center of the femoral head and
plane deformities. Because the deformity axis is must reach the sinus tarsi. This line is the sagittal
parallel to the joint movement axis of the ankle, mechanical axis of the lower extremity. At the
hip, and knee, deformities can be detected too late. knee, this line passes anteriorly to the crossing
Yet the deformity can be detected incidentally on point of the posterior cortex and Blumensaat’s
X-rays; therefore, the treatment can be neglected. line (Fig. 23.17).
However, sagittal plane deformities that are closer After the mechanical axis, Blumensaat’s line
to the joints can lead to arthrosis in the near future. must be drawn (Fig. 23.18).
For this reason, these patients could need some Afterward, at least two levels must be marked
additional procedures to preserve the joint struc- at the supracondylar region on the anterior and
ture. Recurvation deformities on the knee and posterior cortex. When the midpoints of these
ankle can be tolerated better, whereas procurvatum dots are connected, the revealed line must be
deformities, especially of the ankle, lead to some extended below. Thus, this line crosses 1/3 ante-
impingement symptoms. riorly with Blumensaat’s line. The posterior angle
Before sagittal plane analysis, some reference can be defined as the anatomic posterior distal
points must be determined. The center of the femoral angle (aPDFA) and is about 83° ± 5°
femoral head and the ankle must be visible on (Fig. 23.19).
Center of
rotation for hip
Center of rotation
for knee
Center of rotation
for ankle
Fig. 23.17 The sagittal mechanical axis of the lower Fig. 23.18 Blumensaat’s line
extremity
Afterward, the orientation lines of the tibia 23.2.1 Femur

must be determined. The tangential lines to the
proximal and the distal joints of tibia must be Before the analysis, a proper X-ray must be
drawn (Fig. 23.20). taken. The knee must be at full extension, the
The line starts from 1/5 anterior of the tibia posterior aspects of the femoral condyles must
and must connect to the midpoint of the ankle. be superimposed and the center of the femoral
This line is the anatomic axis of the tibia on the head, and the ankle must include the footpad.
sagittal plane (Fig. 23.21). On this X-ray, sagittal malalignment test must
Between this axis and the joint orientation line be applied. With this test, alignment problems
of the knee, there is an angle called the anatomic are revealed. aPDFA, aPPTA, and aADTA must
posterior proximal tibial angle (aPPTA), which is be drawn. The anatomic axis of the proximal
about 81° ± 4°. The angle between the sagittal segment can be determined with the mid-diaph-
plane axis and the ankle joint orientation line is ysis points (PAA). For drawing the distal femo-
the anatomic anterior distal tibial angle (aADTA), ral anatomic axis, the ipsilateral tibia can be
and this angle is about 80° ± 2° (Fig. 23.22). considered. If the aPPTA is normal, the ana-
After drawing the orientation lines and the tomic axis of the tibia must be extended upward.
angles, the center of the deformity has to be If not normal, a virtual line that makes an
determined. Because of the only use of anatomic 83-degree angle must be drawn as aPDFA. This
axis in sagittal plane, the anatomic planning will line is the anatomic axis of the distal segment of
only be explained. the femur (DAA). The crossing point of these
Fig. 23.19 The relation between

the anatomic axis of the femur a b
and distal femur joint orientation
line on sagittal plane. (a) PDFA,
which is between the anatomic
axis of the femur and the distal
femur joint orientation line. (b)
The anatomic axis crosses the
distal joint orientation line at the
2/3 anterior
2/3 1/3
PDFA
83±5
lines is the CORA, and the angle between them there is a deformity on the femur, a virtual line
shows the magnitude of the deformity (Fig. that makes an angle of 81° with the joint orienta-
23.23). tion line and starts from the 1/5 anteriorly named
aPPTA must be drawn. This line is the anatomic
axis of the tibia (PAA). After that, a line must be
23.2.2 Tibia extended upward from the midpoint of the ankle
joint while crossing the mid-diaphysis points of
A malalignment test (MAT) must be applied to the tibia. This line is the anatomic axis of the
the previously mentioned X-ray. After the distal tibia. If there is a deformity on the distal
malalignment has been detected on the tibia, tibia, the aADTA angle must be considered as
aPDFA, aPPTA, and aADTA angles must be 80° while drawing a virtual line of axis (DAA).
drawn. The task is to find the center of the defor- The crossing point of both lines is the CORA,
mity. If the distal femur is normal, the anatomic and the angle between them shows the magnitude
axis of the femur must be extended downward. If of the deformity (Fig. 23.24).
a b
ADTA 80º ± 2º
Fig. 23.20 While determining the orientation angles of the Fig. 23.22 The aADTA angle between the ankle joint
tibia, first, tangential lines to the proximal and distal joint of orientation line and the anatomic axis of the tibia on the
the tibia must be drawn. (a) Proximal tibia. (b) Distal tibia sagittal plane
a b
4/5 1/5
PPTA
81º
CORA
PDFA = 83º
Deformity
angle
Fig. 23.21 (a) aPPTA angle that is between the knee

joint and the anatomic axis of the tibia on sagittal plane.
(b) The sagittal axis of the tibia starts from 1/5 anterior of Fig. 23.23 The crossing point of the distal and proximal
the tibia anatomic axis of the femur is the CORA
23.2.3 Sagittal Plane Deformities the bone deformity, while it can also be seen
with Soft Tissue Problems isolated. Therefore, before treatment, a sagittal
plane analysis must be done, and both bone
Although not common, soft tissue contractures and soft tissue must be considered for
or laxities can present with sagittal plane treatment.
deformities. This pathology can be seen with In the lateral full-extension X-ray, the ante-
rior cortex of the distal femur must cross the
anterior cortex of the tibia. At the fixed flexion
deformity (FFD) and the hyperextension (HE)
deformity, the angle between the anterior cor-
tex of the tibia and femur, the anterior cortical
angle (ACA), is revealed. Any positive value
PPTA = 81º on the anterior side means FFD, and more
than 5° posteriorly means an HE deformity
(Fig. 23.25).
CORA While running a sagittal plane analysis with
these patients, the malalignment test must be
applied first. As mentioned before, aPDFA and
Deformity angle aPPTA must be measured before determining the
anterior cortical angle (ACA). If the aPDFA and
ADTA = 80º aPPTA are not normal, bone correction must be
applied. If these angles are normal, then soft tis-
sue corrections must be added with the bone cor-
rection (Fig. 23.26a, b).
Fig. 23.24 The crossing point of the distal and proximal
anatomic axes is the CORA
FFD > 0º HE > 5º
Fig. 23.25 Fixed flexion

deformity and hyperex-
tension deformity
Fig. 23.26 Analysis of a b

FFD (a) and HE (b)
deformities
aPDFA = 83º
aPDFA = 83º
FFD:30º
HE:20º
aPPTA = 81º
aPPTA = 81º
Bibliography avanced Ilizarov course lecture notes, vol. 1. Adana:

Çukurova University Medical School, Department of
1. Çakmak M, Bilen FE. Hinge types and positioning. In:
4. Paley D. Frontal plane mechanical and anatomic axis
Çakmak M, Kocaoğlu M, editors. The principles of the
planning. In: Paley D, editor. Principles of deformity
Ilizarov surgery. Istanbul: Doruk Grafik; 1999.
correction. Berlin: Springer; 2002. p. 61–97.
p. 62–73.
5. Paley D. Oblique plane deformities. In: Paley D, editor.
Principles of deformity correction. Berlin: Springer;
2002. p. 195–234.
the Ilizarov surgery. Istanbul: Doruk Grafik; 1999.
6. Paley D. Malalignment. In: Paley D, editor. Principles of
p. 145–66.
deformity correction. Berlin: Springer; 2002. p. 19–23.
Translation and Angulation-
Translation Deformities 24
Cengiz Şen and Turgut Akgül
24.1 Translation Deformities 24.1.1 Plane
Description Translation is the movement of one Translation deformities can be on sagittal, fron-
fragment relative to another. Translation deformi- tal, and oblique planes.
ties can be accompanied by an angulation defor-
mity, which are known as angulation-translation (a) Frontal plane translation: This deformity can
deformities. Although translation deformities are be seen on AP X-rays, but not on lateral
seen with angulation deformities, both deformi- X-rays. Translation deformities on the frontal
ties can be seen on the same plane or on separate plane cause mechanical axis deviation on the
planes. lower extremity, which leads to further
Translation of bone endings limits contact of degenerative arthritis (Figs. 24.1 and 24.2).
bone fragments. On the contrary, with angula- (b) Sagittal plane translation: This deformity
tion, bone surface contact remains. Therefore, can be directed on either the anterior (for-
translation deformities are commonly seen with ward) or posterior (backward) side.
the nonunion and malunion. Translation cannot be seen in AP X-rays but
If the magnitude of the translation is more is clearly visible in LAT X-rays (Fig. 24.3).
than the affected bone’s diameter, the bone frag-
ments cannot contact each other. Also, weight- In sagittal plane translation deformities, the
bearing forces and muscle contractions cause the MAD does not occur because the axis deviation
bone endings to shorten. This shortening means in the sagittal plane can easily be compensated
movement of the bone through the axial plane. for by movements of the knee, ankle, and hip
Translation is the movement of the bone perpen- joints. The risk for osteoarthritis is minimal.
dicular to the long axis of the bone. Shortening
and translation are usually seen together. (c) Oblique plane translation: Translation on
Translation deformities can be explained both AP and LAT X-rays refers to oblique
according to four different parameters [1–6]. plane translation (Fig. 24.4).
The smaller the angle between the oblique

C. Şen, MD (*) • T. Akgül, MD plane and the frontal plane, the MAD increases,
Istanbul University, Istanbul Faculty of Medicine, which leads to more severe osteoarthritis. If the
34190 Istanbul, Turkey deformity is closer to the sagittal plane, the risk
e-mail: senc64@gmail.com; doktorturgut@yahoo.com of osteoarthritis reduces.

https://doi.org/10.1007/978-3-319-45675-1_24
310 C. Şen and T. Akgül
Fig. 24.1 Translation
deformities of the femur
can be directed laterally or
medially. Medial
translation deformities of
the femur refers to medial
MAD, and lateral
translation deformity refers
to lateral MAD
Fig. 24.2 Frontal plane

translation deformity of
the tibia can be directed
medially or laterally.
Medial translation
deformities of the tibia
refers to medial MAD,
and lateral translation
deformities refers to
lateral MAD
24.1.2 Direction Translation on the sagittal plane can be

directed to the anterior or posterior side. In
The direction of translation can be marked oblique plane deformities, these directions can be
according to the position of the proximal end. to the anteromedial (AM), anterolateral (AL),
Frontal plane translations can be directed to the posteromedial (PM), and posterolateral (PL)
lateral or medial side (Fig. 24.5). sides.
24 Translation and Angulation-Translation Deformities 311
24.1.3 Magnitude
The magnitude of translation deformities can be

measured in millimeters using the distance
between the midpoint of the bone ends (from
center to center or cortex to cortex) (Fig. 24.6).
Translation of the sagittal or frontal planes can be
measured directly from the AP or LAT X-rays,
which allows the determination of the magnitude
of the translation.
The magnitude of the oblique plane translation
can be measured using the mathematical formula
of Pisagor with the AP and LAT X-rays or practi-
cally using Paley’s graphical method.
24.1.3.1 Paley’s Graphical Method

With the methods that have been described in the
oblique plane deformities chapter, let’s find the
Fig. 24.3 Translation of the tibia on sagittal plane. displacement direction and magnitude on AP and
Anterior translation (right) and posterior translation (left)
LAT X-rays.
Fig. 24.5 Translation of the tibia on the frontal plane can

be directed either medially (left) or laterally (right)
Fig. 24.4 Illustration of the oblique plane translation

(Redrawn from Principles of Deformity Correction,
D. Paley, 2002 Springer, p. 195, Fig. 8.1a)
Fig. 24.6 The magnitude

and the level of the
translation (redrawn from
Principles of Deformity
Correction, D. Paley, 2002
Springer, p. 195. Fig. 8.1)
L M
Fig. 24.8 Drawing the x- and y-axes and determination

of the directions
Fig. 24.7 20 mm lateral translation on AP x-ray, 50 mm Step 3: Mark the 1 mm axes separately. 1 mm
posterior translation on LAT x-ray means 1° of angulation in the AP and LAT
X-rays. For this case, mark 20° for the x-axis and
Step 1: Measure translation in millimeters in 50° for the y-axis (Fig. 24.9).
the orthogonal AP and LAT X-rays (Fig. 24.7). Step 4: Draw a perpendicular line to the axes
Step 2: Use the graphic and draw a perpen- beginning from the marked points. When the
dicular line and mark the medial (M), lateral (L), intersection point of these two lines is con-
anterior (A), and posterior (P) directions of the nected with the center of the graphic, the
distal fragment, relative to the proximal fragment oblique plane of the deformity is revealed (Fig.
(Fig. 24.8). 24.10).
24.2 Angulation-Translation
A
20 Deformities
L M
Angulation deformities of the long bones are
commonly accompanied by translation, rota-
tion, and length deformities. Translations are
mostly seen with fractures, malunions, and non-
unions. In situations in which angulation and
translation are seen together, surface, direction,
50 level, and magnitude must be determined
separately.
P In situations with translation but without
Fig. 24.9 1 mm refers to 1°, which helps the determina- angulation, the distance between the proximal
tion of the angulation values and the distal bone endings does not change with
the level of the deformity because the bone frag-
ments are parallel.
20
A When angulation and translation are seen
together, the distance between the axes changes
L M according to the level because the bone axes are
not parallel. In angulation deformities, the mag-
nitude of translation can be measured by the dis-
tance between the proximal and distal axes at the
Postero proximal end, at the level of the distal fragment
lateral (Fig. 24.11).
As an alternative, from the distal end, the level
50 of the proximal bone fragment, to the distal axis
P line, there is a perpendicular axis. However, some
differences can be seen if this method is used
Fig. 24.10 The deformity is directed to the posterolateral (Fig. 24.11). In conclusion, the first method is
side, and the magnitude is actually 20° more accurate.
If there are both angulation and translation
Step 5: After the last line is connected to the deformities on a fracture or pseudoarthrosis, we
center of the graphic, the angle between this line can use a single hinge for both deformities.
and the x-axis has to be measured. The angle Wherever the hinges are positioned, the bisec-
between the x-axis and the line shows the side of tor is called translation hinge. Translation
the frontal plane deformity. In this example, the hinges can be positioned proximal or distal to
deformity is on an oblique plane making 70° on the bisector line. Translation-angulation hinges
the frontal plane and 20° on the sagittal plane. can be positioned on three different sides of the
bone.
A: Convex side
24.1.4 Level B: Bone outline
C: Concave side (Fig. 24.12a–c)
The level of the translation deformity is the
region in which bone endings move separately. A. The hinges are positioned on the convex side
Oblique plane X-rays show the real magni- of the deformity:
tude of the deformity, orientation of the sur- These hinges serve as a “translation-distraction
face, and direction of the translation hinge,” which increases the distance between
deformity. points A and B (Fig. 24.12a, b).
Fig. 24.11 Measurement
of translation (Redrawn
from Principles of
Deformity Correction,
D. Paley, 2002 Springer,
p. 203, Fig. 8.6a, b)
24.2.1 Reduction Techniques

B. The hinges are positioned on the bone outline: for the Translation
These hinges serve as a translation hinges. Deformities
The distance between the points A and B remains
the same (Fig. 24.12c, d).
24.2.1.1 Reduction with Olive K-wires
C. The hinges are positioned on the concave side The first technique for correcting translation
of the deformity: deformities on the frontal plane is reduction with
These hinges serve as translation-compres- olive K-wires. Traction of the symmetrically
sion hinges that decrease the distance between positioned olive K-wires close to the fracture site
points A and B and allow reduction (Fig. at the osteotomy level reduces d isplacement and
24.12e, f). corrects the deformity (Fig. 24.13).
Fig. 24.12 (a) The hinges are positioned proximally on hinges are on the bone outline for translation only. The
the convex side for simultaneous translation and distrac- distance between points A and B remains the same. (e)
tion. (b) The hinges are positioned distally on the convex The proximal hinges are positioned on the concave side
side for simultaneous translation and distraction. (c) for translation and compression. The distance between
These proximally positioned hinges are on the bone out- points A and B decreases. (f) The distal hinges are posi-
line for translation only. The distance between points A tioned on the concave side for translation and compres-
and B remains the same. (d) These distally positioned sion. The distance between points A and B decreases
Case of Example A man aged 43 years with a using rods and plates at two different points
Schatzker type 5 tibia fracture with joint involve- makes the reduction (Fig. 24.15).
ment treated with olive K-wires (Fig. 24.14a, b). There is an alternative method of reduction
using rods for translation deformities. With this
24.2.1.2 Reduction with Rods technique, rods are asymmetrically positioned in
For the reduction of translation deformities on different holes with washers. With this kind of
the frontal plane, plates and rods can also be positioning, the deformity can be treated with
used. Compressing through the same direction compression (Fig. 24.16).
Fig. 24.13 Reduction
technique with the olive
K-wires
a b
Fig. 24.14 (a, b) Schatzker type 5 tibia fracture with the joint involvement and reduction of the fracture with the olive
K-wires
24.2.2 Reduction Techniques positioning. However, slight distraction must

for Translation-Angulation be applied initially to avoid bone contact and
Deformities stuct.
Translation-angulation deformities are much more Case 1 Hypertrophic pseudoarthrosis woman

complex deformities. For this reason, hinges are aged 23 years. With hinges positioned superior
more useful for reduction. In recent years, with and medial of the fracture site, a proper position
technologic development, computer-assisted fix- can be obtained (Fig. 24.17a–c).
ators have augmented our treatment protocols and Successful union after treatment of the
techniques. With proper planning, deformities can translation-angulation deformity (Fig. 24.17c).
be repaired on every plane at the same time using
computer-assisted fixators. Both techniques Case 2 Distal femoral deformity of a woman
require initial distraction of about 5–10 mm. This aged 44 years. In addition to angulation (LDFA
distraction avoids the stucking of the bone frag- < 87°), there patient had a translation defor-
ments at the beginning of the correction. mity (MAD crossed through the lateral com-
partment). For this reason, hinges were
24.2.2.1 Reduction with Hinges positioned to juxta-articular region for reduc-
Both angulation and translation deformities tion of both the angulation and translation
can be treated by the same hinges with proper deformities (Fig. 24.18a, b).
Fig. 24.15 Reduction with the rod-plate system
Case 3 A girl aged 15 years with an ankle defor- Case 4 A male patient aged 17 years with a
mity because of a burning sequela. Deformity hypertrophic pseudoarthrosis with an
analysis showed both angulation and translation angulation-translation deformity. After deter-
deformities at the ankle. Juxta-articular hinges mination of the CORA through anatomic plan-
were used to treat the deformity because the ning, hinges were positioned slightly
CORA was on the joint surface (Fig. 24.19a–d). proximally and laterally. This led to simultane-
Fig. 24.16 Correction of the translation deformity with rods and washers
ous correction of angulation-translation defor- multiple adjustments and corrections. As such,

mity, and union was obtained without the use of the computer-assisted fixators has
distraction (Fig. 24.20a–d). expanded day by day. However, this new
method can be devastating if preoperative plan-
ning is not well considered. As a result, proper
24.2.2.2 R eduction with Computer- deformity analysis must be performed before
Assisted Fixators the procedures.
Translation-angulation deformities are the most
complicated and difficult deformities to fix. Case A male patient aged 17 years with a distal
However, although correction can be achieved tibia fracture was conservatively treated. Because
through the methods previously described, of malpositioning, a computerized-assisted fi
xator
these procedures can be time-consuming and was used for the correction and union was
labor intensive for surgeons because of the obtained (Fig. 24.21a–g).
a b c
Fig. 24.17 (a, b) Hinge treatment of a translation-angulation deformity (From the Ilizarov Archives of Istanbul
University Orthopedic and Traumatology Department). (c) Follow-up X-ray after treatment
a b
LDFA:72°
MAD:45 mm
Fig. 24.18 (a, b) Treatment of angulation-translation deformities of a patient with genu valgum with hinges
Fig. 24.19 (a–d) A
patient with an angulation- a b
translation deformity and
the correction of the
deformity using hinges
CORA
c d
a b c
d e
Fig. 24.20 (a–e) Union after treatment with hinges of the patient with hypertrophic pseudoarthrosis and malposition
a b c d
e f
Fig. 24.21 (a–g) Deformity correction with complete union using a computer-assisted fixator
advanced Ilizarov course lecture notes, vol. 1. Adana:

References Çukurova University Medical School, Department of
1. Çakmak M, Bilen FE. Hinge types and positioning. 4. Paley D. Frontal plane mechanical and anatomical
In: Çakmak M, Kocaoğlu M, editors. The principles axis planning. In: Paley D, editor. Principles of
of the Ilizarov surgery. Istanbul: Doruk Grafik; 1999. deformity correction. Berlin: Springer; 2002.
p. 62–73. p. 61–97.
2. Gulsen M. The principles of the deformity correction. 5. Paley D. Translation and angulation – translation
In: Çakmak M, Kocaoglu M, editors. The principles deformities. In: Paley D, editor. Principles of defor-
of the Ilizarov surgery. Istanbul: Doruk Grafik; 1999. mity correction. Berlin: Springer; 2002. p. 195–234.
p. 145–66. 6. Paley D. Malalignment. In: Paley D, editor. Principles
3. Kocaoğlu M. The correction of the sagittal and frontal of deformity correction. Berlin: Springer; 2002.
plane deformities with the Ilizarov method, first p. 19–23.
Rotation and Rotation-Angulation
Deformities 25
Cengiz Şen and Omer Naci Ergin
25.1 Rotation Deformities superpositioning the axial cuts at the levels of

femoral neck and femoral condyles at the same
Rotation deformities are termed as angulation on plan yields the femoral anteversion. When CT is
the axial or longitudinal axis of the bone. These not available, torsional deformities can be deter-
deformities also change the orientation of the mined using X-rays taken in two different projec-
ankle, knee, and hip joints. Rotation deformity of tions. Trigonometric calculation of angles
the lower extremity is evaluated clinically and between the femoral neck and shaft in two sepa-
radiologically [1–6]. rate X-rays reveals the femoral neck anteversion
The physical examination of the patient starts angle. Trigonometric calculation of the distance
with observing the gait. The torsional profile of between the medial and lateral malleolus also
the patient is determined during the gait examina- reveals torsion of the ankle.
tion. The thigh-foot angle is measured in the
supine position. Normally, when the knee is in
90° of flexion, axis of the thigh is in line with the 25.2 Treatment
second metatarsal. If the foot is positioned lateral
to the thigh, measurement takes a positive sign The level of the osteotomy is critically important
(+), whereas if it is medial to it, the sign is nega- for rotational deformities. For the correction of
tive (−). Additionally, axes are measured in the tibial torsion, osteotomy can be made at both lev-
standing position with the patella in a neutral els because the level of the osteotomy (i.e., proxi-
position angle between the foot and tibia. This mal or distal) does not lead to malalignment. For
also yields the tibial torsion angle. the correction of femoral rotational deformities,
In addition to clinical measurement methods, an osteotomy at that level can lead to malalign-
CT is the most effective method for the assessment because there is an angular difference
ment of either femoral anteversion or tibial between the anatomic and mechanical axes at the
torsion angles. The measurement obtained by
proximal level. An osteotomy at this level does
not lead to malalignment because these axes
intersect at the distal femur; therefore, rotational
deformities of the femur should be corrected at
C. Şen, MD (*) • O.N. Ergin, MD the distal level [2–4].
Istanbul University, Istanbul Faculty of Medicine, Apart from this, determination of the level of
34190 Istanbul, Turkey rotation is also very important. The corrective
e-mail: senc64@gmail.com; omnaer@gmail.com osteotomy must be made according to the

https://doi.org/10.1007/978-3-319-45675-1_25
328 C. Şen and O.N. Ergin
l ocation of the center of rotation. For example, in release must be performed after the osteotomies at
cases of congenital short femur, the osteotomy the distal femur and proximal tibia because the
must be performed at a proximal level because peroneal nerve will get stretched when the distal
the center of rotation deformity is localized prox- fragment is internally rotated acutely. Prophylactic
imally. However, there is a valgus deformity in tarsal tunnel release must be performed before
addition to rotation at distal femur in cases of correction in distal tibial osteotomies because
increased femoral anteversion; thus, the correc- posterior tibial nerve injury may occur when the
tive osteotomy should be made distally. When distal fragment is externally rotated.
dealing with the tibia, the location of the rotation
center, in terms of being proximal or distal to the
tibial tubercle, determines the osteotomy level. 25.2.1 Correction Techniques
The same is true for the commonly seen external
tibial torsion deformity; when the center of rota- 25.2.1.1 Correction Using Frames
tion is proximal to tibial tubercle, the corrective Many techniques can be performed for correction
osteotomy must be performed above the tibial of rotation deformities. The most important point
tubercle in order to correct maltracking of the while using frames for correction is positioning
patella at the same time [4–6]. the bone at the center of the ring. Proximal and
When acute correction is preferred, care must distal rings are connected to each other by way of
be taken about the peroneal and posterior tibial transverse plates and rods. The nuts are tightened
nerves. If the degree of rotation does not exceed in such a way that the distal ring turns in a coun-
15°, acute correction can be performed. If acute terclockwise direction and the derotation is com-
correction is planned, prophylactic peroneal nerve pleted [1] (Fig. 25.1a, b).
Fig. 25.1 (a, b) Derotation with plates and rods

25 Rotation and Rotation-Angulation Deformities 329
25.2.1.2 Correction Using Rods according to the normally aligned wire position.
When the classic Ilizarov method is reviewed, it Afterward, the two ends of the wire are tightened
can be seen that derotation can be achieved using simultaneously using two separate wire tension-
four rods placed asymmetrically between two ers (Fig. 25.3a, b).
rings. Proximal and distal rings are connected When adequate derotation is achieved, wire
with four obliquely aligned rods in the direction fixation bolts are fastened and fixed with nuts at
of planned rotation. Thus, anterior and posterior both ends. Additional K-wires are applied to
rods become positioned parallel with each other. increase the stability [1] (Fig. 25.3c).
As the rods become parallel with the bone, when
the nuts are tightened, rotation of the bone also 25.2.1.4 C orrection with the Help
gets corrected. Ten degrees of derotation is of Translation-Rotation
achieved when the asymmetrically placed rods Device
are aligned by way of tightened nuts because The method we currently use more frequently is
there is an approximate 10° of alignment angle correction with the translation-rotation device,
between the holes [1] (Fig. 25.2a, b). which was introduced by Dr. Paley. When trans-
lation and malrotation deformities coexist, first
25.2.1.3 C orrection Using K-wires the malrotation and then the overall translation
Without Olives are corrected using this device [5] (Fig. 25.4).
A K-wire without olive is passed through the This method is extremely practical, and cor-
bone, taking care that the bone is centered in the rection can be performed easily using at least
ring. Each end of the wire is positioned asym- three devices in same plane. However, the follow-
metrically in the ring with a shift of 1 or 2 holes ing three clauses must be taken as prerequisites:
Fig. 25.2 (a, b) Correction of rotation with the help of rods

Fig. 25.4 Paley translation-rotation device
tation is performed by gradually turning the dom-

ino-shaped button of the device in a
counterclockwise direction. If adequate derota-
tion is not achieved when the rods reach their lim-
its, the system is rebuilt at this final position for
further derotation [1, 6] (Fig. 25.5a–c).
Case A woman aged 42 years. A pelvic support

osteotomy was performed for high dislocation of
her hip. The remaining external rotation posture
was treated using the Paley translation-rotation
device (Fig. 25.6a, b).
25.2.1.5 C orrection Using Computer-

Assisted Fixators
In addition to these methods, the easiest and
effective method used nowadays is computer-
aided external fixators. Using these devices,
deformities can be corrected acutely and gradu-
ally, particularly in severe rotational deformities.
Fig. 25.3 (a, b) Correction of the rotation by tensioning 25.2.2 Rotation-Angulation

an asymmetrically positioned K-wire. (c) Increasing the
Deformities
stability with an additional K-wire
Rotation deformities can frequently be encoun-

(1) devices are placed at equal distances to each tered as isolated deformities and combined defor-
other and tangential to the ring, (2) all devices mity with angulation or translation. Some cases
move in the same direction, and (3) the proximal may also comprise all of these components.
and distal rings are parallel with each other. Furthermore, rotation deformities end up with
Subsequently, after checking that the rods con- translation deformity when intended to be cor-
nected to the devices are attached to the opposite rected at the proximal femoral level. Therefore,
side of the planned direction of translation, dero- these deformities are called combined deformities.
Fig. 25.5 (a–c) Correction with translation-rotation device
a b
Fig. 25.6 (a, b) Correction

of the external rotation
deformity of the femur
using a Paley translation-
derotation device
The combined deformities are required to be using computer-

aided fixator achieving com-
corrected concurrently in congenital diseases plete union in the pseudoarthrosis site (Fig.
such as proximal femoral focal deficiency (PFFD), 25.9a–g).
Blount’s disease, and fibular or tibial hemimelia.
Therefore, while preplanning, each of these defor- 25.2.2.2 Multiapical Deformities
mities should be corrected in an algorithmic order. Although deformities usually have one apex,
If there is shortness, distraction should be under- deformities that develop because of metabolic
taken first. Thereafter, angulation, rotation, and diseases can be multiapical and can affect more
translation should be corrected successively. than one bone in the same extremity. In these
kinds of severe and complex deformities, it is
25.2.2.1 Correction Methods possible to correct the alignment of the extremity
After determining the center of deformity with fine preoperative planning [2, 3, 5].
(CORA) according to the pre-mentioned ana- There are some key points in the correction of
tomic or mechanical planning methods, all of these deformities. If an acute correction is meant
these deformities can be corrected using the clas- for a severe genu valgum deformity exceeding
sic Ilizarov principles. 30°, peroneal nerve release performed before the
First, shortness and angulation are corrected correction can ensure avoiding nerve injury that
using hinges. Then, malrotation and final overall can occur after the correction.
translation must be corrected using translation- Moreover, for patients in the pediatric age
rotation devices. Furthermore, it is possible to group, psychosocial cooperation must be evalu-
correct all these deformities at once with a ated before surgery. Otherwise, problems can be
computer-aided fixator using a single program. encountered because of the prolonged treatment
Ignoring the costs and considering comfort of and repeating readjustments during the treatment
patient and physician, the current preference is period. In order to facilitate the compliance of the
using computer-aided fixators in the management patient to treatment, I prefer acute correction with
these kinds of complex cases [2, 5, 6]. monolateral fixators for femur and computer-aided
fixator if there is a multiapical tibial deformity.
Case 1 A boy aged 14 years old with a metabolic
bone disease had severe genu varum, translation, Case 1 Boy aged 10 years with multiple osteo-
and internal tibial torsion deformities. After mak- chondromatosis and kidney transplant. After pre-
ing two osteotomies, all of the deformity compo- operative deformity analysis and planning, genu
nents were corrected using a computer- aided valgum was identified that originated both from
fixator (Fig. 25.7a–f). the femur and tibia. In addition, since an accom-
panying tibial rotational deformity was detected,
Case 2 A woman aged 52 years with medial a tibial osteotomy was also performed. A mono-
compartment arthrosis and external tibial torsion. lateral fixator for femur and computer-aided fix-
Deformity analysis revealed the CORA at the ator for tibia were preferred (Fig. 25.10a–g).
joint level. Both angulation and translation defor-
mities were corrected using a computer-aided fix- Case 2 A boy aged 8 years with very severe and
ator. Ten degrees of derotation was also achieved complex deformities because of hereditary hypo-
simultaneously (Fig. 25.8a–f). phosphatasia. Preoperative planning revealed
multiapical CORA at the femur and tibia. A sin-
Case 3 A man aged 27 years old with genu gle osteotomy and monolateral fixator were used
varum underwent an open-wedge osteotomy for the femur. For the tibia, two separate osteoto-
with plate fixation on the right knee. However, mies were performed, and computer-aided fixator
because of the developed pseudoarthrosis, after was used for correction because of the biplanar
deformity planning, both frontal and sagittal deformity accompanied by a rotational deformity
plane deformities were simultaneously corrected (Fig. 25.11a–j).
a b c
d e f
Fig. 25.7 (a–f) Correction of all deformity components with computer-aided fixator in a patient with metabolic
disease
a b c
d e f
Fig. 25.8 (a–f) Correction of angulation, translation, and rotation (deformities of the patient) with a computer-assisted
fixator
a b c
d e f
Fig. 25.9 (a–f) With computer-assisted fixator, correction of biplanar deformities and union of the pseudoarthrosis that
had developed in a patient after an open-wedge osteotomy
a b c d
e f g
Fig. 25.10 (a–h) Pre- and postoperative images of the patient

a b c
d e f
Fig. 25.11 (a–j) Images of a patient with severe genu valgum and triplanar tibial deformity due to a metabolic syn-
drome after the correction of all his deformities with a single femoral and double tibial osteotomies
g h i j
advanced Ilizarov course lecture notes, vol. 1.

References Çukurova University Medical School, Department of
Orthopedics and Traumatology: Adana; 1997.
1. Çakmak M, Bilen FE. The hinge types and the posi- p. 12–30.
tioning. In: Çakmak M, Kocaoğlu M, editors. The 4. Paley D. Frontal plane mechanical and anatomical
principles of the Ilizarov surgery. Istanbul: Doruk axis planning. In: Paley D, editor. Principles of defor-
Grafik; 1999. p. 62–73. mity correction. Berlin: Springer; 2002. p. 61–97.
2. Gulsen M. The principles of the deformity correction. 5. Paley D. Translation and angulation – translation
In: Çakmak M, Kocaoglu M, editors. The principles deformities. In: Paley D, editor. Principles of defor-
of the Ilizarov surgery. Istanbul: Doruk Grafik; 1999. mity correction. Berlin: Springer; 2002. p. 195–234.
p. 145–66. 6. Paley D. Malalignment. In: Paley D, editor. Principles
3. Kocaoğlu M. The correction of the sagittal and frontal of deformity correction. Berlin: Springer; 2002.
plane deformities with the Ilizarov method, first p. 19–23.
Osteotomy Rules and Types
26
Mustafa Uysal
Osteotomy as a term consists of two words, deformity, but it is constant during the deformity
“osteo” and “tomy.” It defines the procedure that correction. ACA and osteotomy level vary
is cutting or dividing the bone into pieces. An depending on surgical technique. Osteotomy level
osteotomy can be performed for various purposes depends on the anatomic requirements. Knowing
such as shortening, lengthening, angulation, the effects of these variables on deformity allows
translation, compression, or distraction. us to predict the correction after treatment.
There are some principles to achieve success-
ful osteotomy with minimal damage to tissues
[1, 2]. Osteotomy rules deal with how to make a 26.1 CORA
correction after osteotomy. These rules are deci-
sive about the treatment method that will be CORA is a term formed from the initials of center
used. Any deficiency in understanding and appli- of rotation of angulation. It expresses the apex of
cation of rules may lead to trouble in planning a deformity on the bone. It can be calculated with
for complex deformities [3]. Although osteot- both mechanic and anatomic axes. Both anatomic
omy rules have been used by many surgeons and mechanical axes of long bones in lower
who deal with deformity surgery for a long time, extremities are straight lines except in the sagittal
Dr. Dror Paley tells them in an easy-to-under- axis in the femur. Deformity creates a break in
stand didactic way [4, 5]. these straight lines. Angular deformities divide
Some terms must be clarified to better under- the bone into two fragments such as proximal and
stand osteotomy rules: distal fragments. Both these fragments have their
own anatomic and mechanical axes. Intersection
1. CORA point of proximal and distal axes is the CORA of
2. ACA the deformity, the apex of the deformity (Fig.
3. Osteotomy level 26.1). The degree between proximal and distal
axes indicates the magnitude of deformity [6].
Osteotomy rules consist of a combination of CORA is shown as a point in both the sagittal and
these three variables. CORA differs for each frontal dimensional planes.
M. Uysal, MD
Sakarya University, School of Medicine, Department
of Orthopedics and Traumatology, Sakarya, Turkey
e-mail: mstfysl@hotmail.com

https://doi.org/10.1007/978-3-319-45675-1_26
340 M. Uysal
87º
87º
ACA CORA
CORA
89º
89º
Fig. 26.2 Correct plane of ACA in three-dimensional

plane and the pin represents the axis in two-dimensional
Fig. 26.1 Intersection point of axes of proximal and dis- plane
tal segments shows CORA
plane is used for analyzing the deformity. The

26.2 ACA bisector line is a reference line describing the
relation between the locations of ACA and
ACA is formed from the initials of angulation deformity.
correction axis. It defines the axis used for the
correction of angulation. It is an imaginary line
of reference for correction, not a point. ACA is 26.2.1 Bisector Line
dependent on the reference line preferred by the
surgeon, not on the location of the deformity. It is The intersection point of distal and proximal axes
marked in Ilizarov systems according to the posi- creates the CORA level. Two couples of angles
tion of hinges. Imaginary lines between hinges equal to each other, medial and lateral, occur at
give us the direction of ACA. Although ACA is that level. The bisector line of the medial and lat-
shown as a point in a drawing template, in reality eral angles is called the transverse bisector line
it is a three-dimensional line. (TBL), and the bisector line of the proximal and
For a better understanding, when we look at distal angles is called longitudinal bisector line
the page from the front, the pin inserted upright (LBL) (Fig. 26.3). The two bisector lines form a
to the paper is seen as a point. When we change 90° angle to each other, which creates an analyti-
the angle, it is seen as a line (Fig. 26.2). ACA is cal plane used for deformity planning. Each point
represented as a point because a perpendicular on the TBL is equal to the distance from the axis
26 Osteotomy Rules and Types 341
Table 26.1 The variables belonging to osteotomy rules

and relations with each other
87° Level CORA ACA Osteotomy
Rule 1 Same Same Same
Rule 2 Same Same Different
Rule 3 Different Different
deformity, ligaments and tendons attachments,

bone quality, and soft tissue condition. The
TBL
shape of osteotomy can be transverse, oblique,
or curved (dome osteotomy). The level of oste-
otomy is more important than the shape. The
level of osteotomy does not have to be on the
ACA same level of deformity. There are two differ-
ent scenarios for osteotomy level according to
the rules of osteotomy. Osteotomy is at the
same or different level with CORA. The same
level means that osteotomy and bisector lines
are at the same level. Scenarios with these two
conditions will be analyzed with the osteotomy
rules.
LBL
89°
26.3.1 Osteotomy Rules
Osteotomy rules are based on mathematic calcu-

lations that are based on basic geometric rules.
Fig. 26.3 TBL (transverse bisector line) and LBL (longi- The rules are valid for all kinds of extremity
tudinal bisector line), which represents yellow lines and reconstruction methods, although they were
angled at 90° degree to each other creating the analytic explained for the Ilizarov’s circular fixator sys-
plane. ACA can be located in anywhere on that plane
tem. They can be used for acute or gradual cor-
rection using circular or unilateral fixators and
of proximal and distal segments of the bone. plates or intramedullary nailing Table 26.1.
Wherever ACA is located on the TBL, it means
ACA was on the same level as the TBL. This is
generally a preferable situation because this pro- 26.3.2 Osteotomy Rule 1
vides a symmetric correction on both segments.
This is the most basic rule. It means that if the
osteotomy line, ACA, and CORA are on the
26.3 Osteotomy same level, the mechanical axis will be perfectly
corrected and bone edges will be angulated at
There are two major components of osteotomy the end of the correction. If osteotomy is per-
to be determined before planning. One is the formed at the apex of the deformity (CORA)
level of osteotomy and the other is its shape. and the hinges (ACA) are positioned at the same
Many factors affect these two components such level with TBL, osteotomy rule number one
as the fixation method (ex-fix, intramedullary would be valid in the system, and axis of proxi-
nail, plate and screw fixation), shape and mag- mal and distal segments would be aligned on a
nitude of deformity, physeal lines close to the straight line. A single mechanical or anatomic
342 M. Uysal
Fig. 26.4 Distraction and A

angulation between edge
of bone segments after
open-up osteotomy A
B B
axis for the entire bone is formed, so deformity 2. Close-up osteotomy

is corrected. The bone edges become angulated
because of the positional changes on edges after If ACA (hinges in the Ilizarov’s system) is
correction. positioned on the concave side of the deformity,
If the ACA and CORA are on bisector line, then the edges of bone segments correct with
the axis will be corrected without any problem. angulation and compression. The amount of
Nevertheless, changing the ACA’s location on angulation is equal to CORA (Fig. 26.5).
the bisector line so as to move away from The amount of compression is proportional to
CORA causes compression or distraction the distance between ACA and CORA.
between bone edges and changes the length of Compression length can also be calculated by
the bone. That effect can occur in three differ- using the similar triangles method in geometry.
ent scenarios, which are valid for the other Bone length will increase according to compres-
osteotomy rules [7]. sion length in this scenario.
These are the three scenarios:
3. Neutral wedge osteotomy
1. Open-up osteotomy
This rule occurs when ACA of the frame
Open-up osteotomy occurs when the ACA is passes directly through the CORA. Distraction
placed on the convex side of deformity. on the concave side and compression on the con-
Angulation with distraction happens in bone vex side are seen in this situation. Bone length
edges after correction. The amount of angulation does not change because of the equilibrium on
is equal to the magnitude of CORA. both sides. Angulation of the bone edges is equal
The open-up effect occurs in case of hinge to the degree of CORA. The amount of
placement on the concave side of the deformity. compression and distraction is proportional to the
Distraction and angulation occurs between edges width of the bone (Fig. 26.6).
of the bone segments. The angulation has the same
amount of degrees as CORA. The amount of dis-
traction is proportional to the distance between 26.3.3 Osteotomy Rule 2
ACA and CORA. The distraction length can be cal-
culated by using similar triangle methods in geom- ACA and CORA are at the same level in oste-
etry. The bone length will be increased according otomy rule 2 as in rule 1, but osteotomy is per-
to the distraction length in this scenario (Fig. 26.4). formed at the different level. The axes of the
Fig. 26.5 Compression
and angulation between
edge of bone segments
after close-up osteotomy
Fig. 26.6 Distraction on

concave site and
compression on convex
site occur after neutral
wedge osteotomy
proximal and distal segments are well aligned. Translation between bone edges is proportion-
The angulation in bone edges occurs accord- ate to the distance between osteotomy line
ing to the three scenarios above. Additionally, and ACA. An explanation of a special osteot-
as a result of the change in the anatomy of the omy type will be helpful to understand osteot-
bone, a translation effect occurs in the edges omy rule 2.
of the bone (Fig. 26.7). Translation has to
appear in bone edges because osteotomy was 26.3.3.1 Focal Dome Osteotomy
at a different level. Focal dome osteotomy has a curved osteotomy
Osteotomy rule 2 is usually seen when line, and it is an alternative to straight osteotomy
CORA is located at joint level (malorienta- lines in several situations. In spite of the difficul-
tion), or osteotomy could not be performed at ties in performing curved osteotomies to the
the CORA level. The osteotomy line can be bone, there are some advantages: it helps to
carried proximal or distal to the CORA level repair the bone by increasing the contact surface
depending on the anatomic situations. and stability between edges. Dr. Paley first
344 M. Uysal
described focal dome osteotomy [1, 8]. It is

especially helpful in malorientation, which
ACA
means that a deformity is too close to the joint
CORA
line. ACA and CORA are at the same level in
focal dome osteotomy. That means the hinges of
a frame should be located at the joint level
(juxta-articular hinges). Hinges are at the center
of the circle on the curved osteotomy line. The
distance from deformity to osteotomy line gives
the radius of the circle. Osteotomy rule 2 is valid
in focal dome osteotomy. Axes are perfectly
aligned after correction, besides, translation
happens because of sliding of bone edges on
each other. This is an anatomic obligation to cor-
rect the mechanical axis.
Focal dome osteotomy is used to correct the
deformity in Fig. 26.7. One of the hinges placed
on the joint level can be seen in the picture during
the operation. The tibial osteotomy is away from
the hinges in this case because of malorientation
deformity. Mechanical and anatomic axes
Fig. 26.7 CORA and ACA are the same level in focal
dome osteotomy. Osteotomy is performed on the circle correction will be provided with this frame con-
centering the CORA and ACA. Translation occurs due to figuration (Fig. 26.8).
shift of bone edges
Fig. 26.8 Hinge on the level of joint marked with red arrow and circular osteotomy faced concave side; up is marked
with yellow arrow
26.3.4 Osteotomy Rule 3 level from CORA. The joint level becomes paral-
lel to the ground after the correction, but mechan-
Osteotomy rule 3 actually explains an unwanted ical axis will be shifted. There will be translation
situation in deformity correction. between proximal and distal axes (Fig. 26.10).
Mechanical axis is corrected with the other This kind of osteotomy in the proximal tibia
two rules but not in rule 3. If the ACA is on a dif- was known as Maquet osteotomy [10]. It has
ferent level from CORA due to any reason, then some disadvantages because it causes translation
translation happens between axes [9]. Axes of in mechanical and anatomic axes. Focal dome
proximal and distal segments will be parallel and osteotomy is superior to dome osteotomy accord-
have a certain amount of translation (Fig. 26.9). ing to osteotomy rules.
The amount of translation is proportional to What could be done to further understand dis-
the distance between the ACA and CORA. It placements of the bone? An analytical method
sometimes happens unintentionally in cases of can be used for measurement. An analytical plane
poor placement of hinges during the operation. formed by the transverse and longitudinal bisec-
Knowing osteotomy rule 3 is helpful to detect tor lines is formed, and ACA is placed in the cen-
and solve the problem. Rule 3 is used less often ter of this plane. Correction is measured in two
for planning to correct translation and angulation planes; projection of angular correction in both
deformities. Dome osteotomy, which is the oppo- axes on the analytic plane gives us lateral and
site of focal dome osteotomy, is a good example longitudinal displacement (Fig. 26.11).
to explain that condition. Three variables such as CORA on bone defor-
mity, ACA on hinge location, and anatomic
26.3.4.1 Dome Osteotomy requirements on the osteotomy line should be
If we are planning to correct a malorientation taken into consideration before using osteotomy
deformity with dome osteotomy, which CORA is rules in deformity.
on the joint level, the center of the circle that fol- After understanding the rules of osteotomy, they
lows the osteotomy line would be at a different can be used for correcting all kinds of deformity
Fig. 26.9 When ACA and CORA is on different levels, If same amount of angular correction is done, these two
ACA is on the hinge level and CORA is on the deformity points on different circular routes proceed different way.
level. In that circumstance, two points within equal dis- The difference between routes gives the amount of
tance to CORA will be within different distance to hinges. translation
346 M. Uysal
and limb reconstruction. There are many kinds of

CORA
correction techniques described in literature, but
principles are always the same.
Acute correction with an intramedullary nail
is one of the simple correction techniques.
Osteotomy has to be close to the apex of defor-
mity because the deformity is corrected over the
ACA
anatomic axis. Bone contact is provided at the
convex site of osteotomy line, which is why
CORA should be located on the lateral cortex and
distraction occurs on the concave side of the
deformity. An intramedullary nail is inserted into
medullar cavity, and anatomic axis is forced to
correct. Anatomic axis correction results in the
correction of deformity (Fig. 26.12).
Another technique is plate fixation after acute
or gradual correction with an external fixator
[11]. The external fixator is removed after plate
fixation. This technique allows a surgeon to make
controlled corrections and also enables him to
remove the fixator at an earlier period (Figs.
26.13 and 26.14).
Fig. 26.10 Translation between axes occurs because Fixator-assisted nailing (FAN) technique is
CORA and ACA are on different level in correcting with described as the first correction of a deformity with
dome osteotomy
LBL
LBL
TBL
t
TBL
α
ACA
L α
Fig. 26.11 Analytical
method for measurement
of displacement in bone
edges
Fig. 26.12 Opening in osteotomy line after intramedul-

lary nail-assisted correction of anatomic axis
Fig. 26.13 Lengthening and hyperextension with Ilizarov external fixator after distal femur osteotomy in polio patient
348 M. Uysal
Fig. 26.14 External fixator was

removed after plate application.
The protection from loss of
correction was achieved with
plate in consolidation area
Fig. 26.15 Acute
correction was obtained
osteotomy with external
fixator on the knee with
genu valgum, and then
retrograde nailing was
performed. Deformity in
corrected position can be
seen after removal of
external fixator
an external fixator and, second, nail fixation with 4. Paley D et al. Deformity planning for frontal and sag-
an intramedullary nail. It is used especially for con- ittal plane corrective osteotomies. Orthop Clin North
Am. 1994;25(3):425–65.
trolling proximal or distal segments in deformities 5. Paley D. Principles of deformity correction. 3rd ed.
around the joint. The external fixator allows to Berlin: Springer-Verlag; 2005.
avoid position changes during nailing (Fig. 26.15). 6. Paley D, Tetsworth K. Mechanical axis deviation of
the lower limbs. Preoperative planning of multiapical
frontal plane angular and bowing deformities of the
femur and tibia. Clin Orthop Relat Res.
1992;280:65–71.
References 7. Çakmak MB, Kocaoğlu M, editors. İlizarov cerrahisi
ve prensipleri. İstanbul: Doruk grafik; 1999.
1. Paley D, Maar DC, Herzenberg JE. New concepts in 8. Hankemeier S et al. Knee para-articular focal dome
high tibial osteotomy for medial compartment osteoar- osteotomy. Orthopade. 2004;33(2):170–7.
thritis. Orthop Clin North Am. 1994;25(3):483–98. 9. Çakmak MÖ, Şen C, editors. Travmada İlizarov
2. Paley D, Tetsworth K. Percutaneous osteotomies. Uygulamaları. İstanbul: İklim Matbaa; 2013.
Osteotome and Gigli saw techniques. Orthop Clin 10. Maquet P. Valgus osteotomy for osteoarthritis of the
North Am. 1991;22(4):613–24. knee. Clin Orthop Relat Res. 1976;120:143–8.
3. Catagni MA. Current trends in the treatment of simple 11. Uysal M et al. Plating After Lengthening (PAL): tech-
and complex bone deformities using the Ilizarov nical notes and preliminary clinical experiences. Arch
method. Instr Course Lect. 1992;41:423–30. Orthop Trauma Surg. 2007;127(10):889–93.
Hip Deformities: Pelvic Support
Osteotomy for Neglected High Hip 27
Dislocation and Other Sequelae
Around the Hip
Levent Eralp
Neglected hip dysplasia, neurologic pathologies effect on the subtrochanteric region, in level of
(cerebral palsy, poliomyelitis, myelomeningo- the ischium. The osteotomy aimed an increased
cele), sequelae of septic hip arthritis, and proxi- abduction, decreased lumbar lordosis, and
mal femur osteomyelitis lead to severe problems increased abductor lever arm, thus decreasing
in adulthood, if left untreated. limping during the gait [4, 5].
In cases with neglected hip dysplasia, the fem- The major shortcomings of these osteotomies
oral head is oriented posteriorly by the pull of are unattended limb length discrepancy and lat-
gluteus medius muscle, which is an unsupported eral shift of the mechanical lower extremity axis.
dislocation. In cases with anterior dislocation, Ilizarov added a distal, meta-/diaphyseal femoral
there is a pelvic support pseudoacetabulum, osteotomy, to compensate for these unattended
called neocotile [1–5]. In cases with bilateral, points of classical pelvic support osteotomies,
neglected high hip dislocation, the ground reac- called the Z-osteotomy [3, 15–17].
tion vector passes anterior to the femoral heads, The preoperative planning necessitates two
resulting in hip flexion contracture and increased radiographs, a one-leg-standing anteroposterior
lumbar lordosis [5–7]. Furthermore, the greater pelvic x-ray on the pathologic side and a supine
trochanters lie close to the pelvis, shortening the anteroposterior x-ray with the pathologic hip in
lever arm of hip abductor muscles, leading to maximum adduction (Figs. 27.1 and 27.2). The
Trendelenburg’s limp [5–8]. amount of extension to be added to the osteotomy
This patient group is mostly treated by total site is determined on a standing lateral lumbopel-
joint replacement or a form of pelvic support visacral x-ray (Fig. 27.3). The distal, compensa-
osteotomy. Especially in younger patients, total tory osteotomy is planned by drawing a line
joint replacements are prone to midterm and perpendicular to the horizontal axis of the pelvis
long-term problems [9–14]. Therefore, adolescent through the first osteotomy site and the mechani-
and young adult patients are good candidates for cal axis of the femur (Fig. 27.4). The derotation
biologic reconstructions. Initial pelvic support effect and sagittal alignment of the distal bone
osteotomies created an abduction and extension fragment are determined by clinical examination.
An Ilizarov frame is assembled preopera-
tively, which includes a pelvic arch for the proxi-
mal, a full circle for the middle, and one or two
L. Eralp, Prof. MD
full circles for the most distal fragment. At the
Department of Orthopedic and Traumatology,
Istanbul Faculty of Medicine, Istanbul University,
Istanbul, Turkey

https://doi.org/10.1007/978-3-319-45675-1_27
352 L. Eralp
40˚
50˚
Fig. 27.1 Illustration of the standing position anteropos-

terior x-ray of the pelvis and lower limbs
Fig. 27.3 Illustrated lateral x-ray of the pelvis which

reveals the relationship between the pelvis and the femur
at the sagittal plane
40˚
end of the operation, the pelvic arch and middle

circle should be parallel to each other.
Intraoperatively, the proximal fragment is fixed
50˚ by Schanz screws, while the leg is held in maxi-
mum adduction. The arch is tilted posteriorly to
create an extension effect following the osteot-
omy (Fig. 27.5). The middle fragment is fixed by
Schanz screws. The distal full arches are mounted
on a K-wire inserted parallel to the knee joint.
On the first postoperative day, the patient is
mobilized with two crutches and is allowed
full weightbearing. Stretching and range of
Fig. 27.2 Illustration of the anteroposterior x-ray of the motion exercises are initiated. A standing x-ray
pelvis and femur in supine position while pathological
side is on maximum adduction is ordered to measure the alignment and calcu-
27 Hip Deformities 353
87˚
Fig. 27.4 Illustration of the compensatory osteotomy and

mechanical axis of the lower extremity after osteotomy Fig. 27.6 Postoperative x-ray of a patient shows both
osteotomy lines. Lengthening from distal osteotomy is
goint to be started in seventh-tenth days
late postoperative correction and lengthening

(Fig. 27.6). The correction on the distal oste-
otomy is started between the seventh–tenth
postoperative days at a rate of 3–4 x ¼ milli-
meters a day. The correction is followed up by
weekly x-rays (Fig. 27.7a–e).
The purpose of the Z-osteotomy is to restore the
pelvifemoral alignment in the sagittal plane, decrease
the lumbar lordosis, create a support for the frontal
pelvifemoral alignment, diminish Trendelenburg’s
Fig. 27.5 Extension effect in the proximal osteotomy gate, and prevent a distal valgus alignment of the
intraoperatively by the use of Italian femoral arches femur while preventing limb length discrepancy [18].
354 L. Eralp
a b c
d e
Fig. 27.7 A 30-year-old patient with neglected hip disloca- Clinical photo of the patient which shows the lengthening
tion. (a) Preoperative clinical photo reveals the limb length during treatment. (d) Clinical photo after removal of the fix-
discrepancies. (b) Preoperative orthoroentgenogram. (c) ator. (e) Orthoroentgenogram after removal of the fixator
27.1 Hip Arthrodesis Hip arthrodesis with an external fixator is

preferably applied on a traction table or a
The use of external fixators for hip arthrodesis is radiolucent table with a soft support under the
limited. The technique is suitable for patients who buttock. Initially, the joint surfaces are debrided
have recurrent septic arthritis and/or o steomyelitis from cartilage, and the femoral head is reduced
with a high risk of postoperative infection. Hip in its position. The femur should be in 10
arthrodesis has been widely used previously. degrees abduction and 20–30 degrees flexion.
Anyhow, even if applied in a good position, a fixed In case of bone defect, autogenous grafts from
hip creates degenerative changes in neighbor joints the iliac crest are used. The frame consists of a
in the long run. Therefore, mobile reconstruction pelvic arch on the iliac wing, a pelvic arch on
techniques are applied, currently. The Z-osteotomy the proximal femur, and a full arch on the knee
described in the previous section is a vivid alterna- joint. The pelvic arches are compressed (Fig.
tive in young patients with a high risk for infection. 27.8a). If the patient has a previous hip arthrod-
A particular patient group includes cases with esis in a malposition, the deformity is corrected
previous hip arthrodesis but still have a malalign- by a subtrochanteric osteotomy utilizing the
ment of the pelvifemoral axis. External fixators same frame configuration [19] (Fig. 27.8b, c)
are used in this patient group to restore a proper (Fig. 27.9a–g).
alignment [19–21].
a b c
Fig. 27.8 Illustration of the Ilizarov frame which is used lower extremity alignment and hip arthrodesis. (c) After
for hip arthrodesis. (a) Only application of the arthrodesis arthrodesis removal of the upper ring and following
procedure. (b) Building of the frame for correction of the lengthening procedure
356 L. Eralp
a b c
d e g
Fig. 27.9 A 20-year-old male patient who had undergone x-ray of the patient. (e) Application of the guide half-pin
arthrodesis procedure due to hip tuberculosis, adduction intraoperatively. (f) After correction of angulation. (g)
posture, and shortness is shown in figure. (a–c) Orthoroentgenogram after treatment
Preoperative clinical view of the patient. (d) Preoperative
27.2 Proximal Femur Defects Distalization of the greater trochanter creates glu-
teus medius function and hinders Trendelenburg’s
Previous hip septic arthritis and/or proximal femur gait [22] (Fig. 27.11).
osteomyelitis, avascular necrosis following surgery In case of complete loss of the femoral head
during infancy, burn sequelae, and blast or crush and neck, an osteotomy below the minor trochan-
injuries cause intra- or extra-articular bone defects ter is used to place it into the acetabulum (Fig.
in the proximal femur. These patients usually do not 27.12). The proximal fragment is fixed in a val-
benefit from classical corrective osteotomies. gus position, the minor trochanter serves as a
External fixation methods provide a good restor- pseudofemoral head, and the abductor mechanics
ative solution for these patients, by correcting con- is restored [22] (Fig. 27.13).
tractures, filling bone defects by transport, and If the pathologies listed above are complicated
lengthening and creating pelvic support points [22]. by restricted, painful, hip range of motion, head
The purpose of treatment is to create a pelvic sup- resection, capsulotomy, adductor, and iliopsoas,
port point between the remaining femur and pelvis, tenotomies are added to the operation. Early
to restore the pelvifemoral alignment by adding postoperative range of motion exercises are
angular correction and lengthening (Fig. 27.10). started with the help of an epidural catheter, to
prevent postoperative soft tissue contractures
(Fig. 27.14a–e).
A1 O
1
O A
A1O1 < AO
O1
A1 O
A
A1O1 > AO
Fig. 27.11 After lowering and translation of trochanter

Fig. 27.10 Correction of pelvic and femoral biomechan- major distally and laterally, restoration of biomechanics
ics with osteotomy which originated from proximal femo- of gluteus medius, and maintaining the alignment with
ral defect of the hip distal osteotomy
358 L. Eralp
Fig. 27.12 Osteotomy for impacting

the trochanter minor to the acetabulum
which is used when there is a defect on
the femoral head and neck
Fig. 27.13 Osteotomy for impacting the

trochanter minor to the obturator notch
which is used when there is a defect on
the acetabulum
c d
Fig. 27.14 A 16-year-old male patient who has been from the surgical site. (c) Preparation of the rectus abdomi-
operated for septic arthritis on the left hip. Patient has nis flap for tissue reconstruction. (d) Reconstruction of the
proximal femur osteomyelitis, fixated pelvic contractures, soft tissue. (e) Clinical and radiological findings of the
fistulas, and bone defects. (a) Preoperative clinical photo treated patient who has undergone abduction osteotomy,
and x-ray. (b) Infected bone and soft tissue which are taken mobile hip reconstruction, and lengthening osteotomy
360 L. Eralp
27.3 Perthes Disease (PD) The main mistake here is to confuse “nonweight-
bearing” and “weight hindering.” It is well
Despite all new treatment techniques, the treat- known that even during total bed rest, muscle
ment philosophy of PD still has many controver- contractions around the hip joint cause compres-
sies. The main purpose is to obtain and maintain sive forces exceeding two times the total body
physiologic hip range of motion. Especially in weight. To neutralize all compressive forces, the
patients with more than 50% head involvement, hip joint should be stabilized and distracted by
acetabular coverage and maintenance of hip an external fixator. Meanwhile, the subluxated
range of motion are of big importance [23]. femoral head can be relocated. It is well known
Abduction splints, proximal femoral and/or peri- that the cartilage covering laterally the sublux-
acetabular osteotomies, and shelf procedures all ated femoral head epiphysis proliferates outside
serve to this purpose [24–29]. If the damage of the acetabulum [34]. The main purpose of dis-
the femoral head compromises more than 50%, tracting the femoral head with an external fixator
distressing spheric hip motion, all of the treat- in PD is to relocate the laterally subluxated fem-
ment modalities listed above are contraindicated oral head into the acetabulum and to stimulate
[25]. Perthes was the first author to support the cartilage growth onto the collapsed epiphyseal
theory of weight hindering of the hip joint [30]. cartilage. In addition, the contracted joint cap-
Complete bed rest and Snyder brace serve to this sule and tendons are lengthened, thus increasing
purpose, but none of them has been proven to range of motion. The first joint distraction for PD
change the natural history of the disease [31–33]. has been performed by Paley et al. in 1989 [35].
a b c
Fig. 27.15 AP and frogleg x-rays of the patient before arthrodiastasis and external fixator application for the right hip
with Perthes disease. (a) Pelvic x-ray. (b) AP arthrography. (c) Frogleg arthrography
Fig. 27.17 Axis crossing midpoint of the femoral head

on sagittal plane
formed when needed. A K-wire is inserted into

the center of the femoral head, to show the flex-
ion–extension axis, under fluoroscopic guidance
(Fig. 27.16). The operated lower extremity is held
in 15 degrees of abduction, the knee in neutral
extension, and the patella in forward position.
Fig. 27.16 K-wire revealing flexion and extension axis Another 2.5-millimeter Steinmann pin is inserted,
of the hip
while the femur is visualized on lateral view, into
the center of the acetabulum (Fig. 27.17).
The patient is placed supine on the operating If a unilateral hip distraction fixator is utilized,
table. The pelvis should lie parallel to the ground this Steinmann pin is kept in its rotation hole. The
without any hip support beneath. Initially, an ileum and proximal femur are fixed by 5- or
arthrography of the hip joint should be performed, 6-millimeter Schanz screws, depending on the
and anteroposterior and frogleg images should be bone diameter. Keeping the neutral position of
taken (Fig. 27.15a–c). Percutaneous adductor the patella is of big importance. The flexion and
tenotomy and open iliopsoas tenotomy are per- extension capability of the hip joint is checked.
362 L. Eralp
Acute distraction is performed under fluoroscopic subluxation of the femoral head should be cor-
guidance, until the Shenton’s line is broken dis- rected. For this purpose, either hip abduction is
tally for 1–2 mm (Fig. 27.18). At this step, lateral increased or the proximal femur is medialized on
the transfixing Schanz screws. The system is kept
in full extension during bed rest, to prevent flex-
ion contracture. Ilizarov-type external fixators are
mechanically advantageous to keep hip abduction
and prevent flexion contracture (Fig. 27.19a, b).
Flexion–extension exercises and resting in
prone position are the main steps of physical
therapy and are started early in the postoperative
period (Fig. 27.20). Walking by partial weight-
bearing, not exceeding 50%, is encouraged. The
treatment period is approximately 3 months or
until the lateral pillar looks ossified on radiologic
follow-up images. Following external fixator
removal, the hip joint is protected in an abduc-
tion splint, in 30 degrees of abduction, for 6 more
weeks. The patient is mobilized with two
crutches.
Hip distraction in PD is suitable for all patients
in all age groups, who present with bad prognos-
tic signs, like lateral subluxation, joint stiffness,
and femoral head compression, and who have
contraindications for classical surgical proce-
dures (Figs. 27.21, 27.22, 27.23, 27.24, 27.25,
Fig. 27.18 Restoration of Shenton line after uniplanar 27.26, 27.27, and 27.28).
arthrodiastasis
a b
Fig. 27.19 Arthrodiastasis of a patient with Perthes disease with external fixator. (a) Gradual correction hinge for the
hip. (b) Anterior rod for preserving full extension of the hip
Fig. 27.20 Rehabilitation on prone position
Fig. 27.22 Clinical photo revealing adduction contrac-

ture preoperatively
Fig. 27.21 A 10 year-old male patient with Perthes disease

on his right hip. Preoperative AP x-ray. (Figs. 27.21 – 28 are
from the same patient)
Fig. 27.23 AP x-ray revealing adduction contracture

preoperatively
364 L. Eralp
Fig. 27.24 AP x-ray reveals the arthrodiastasis with the

circular external fixator
Fig. 27.27 AP x-ray 5 years after treatment
Fig. 27.25 Clinical photo revealing hip adduction 2

years after treatment
Fig. 27.28 Frogleg X-ray 5 years after treatment
References
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Femur Deformities
28
Halil Ibrahim Balci
Femoral deformities are the main subject of the Another definition can be made with the
Ilizarov surgery. They can be congenital or angles between femoral neck midline and corpus.
acquired. Many different methods can be used to This angle is about 120° and less is called coxa
correct these deformities. Acute or gradual cor- vara deformity. Incidence is 1/25,000 without
rection and internal or external fixation can be any distinguish of sex and ethnicity. Thirty per-
chosen according to etiology of disease and expe- cent of the case are bilateral. Hoffa first described
rience of the surgeon. We will mention mainly the term of developmental coxa valga in 1905
our experience. and classified as developmental, congenital, dys-
This book mentions about many of the femo- plastic, or acquired [1–9].
ral deformities in different sections. In our chap- Another terms for developmental coxa vara
ter we will mention mainly the subjects that are are congenital coxa vara, infantile coxa vara, and
not discussed in other chapters. cervical coxa vara. The hips are normal at birth.
Because of the cartilage defect on femoral neck,
trochanter major enlarges, neck shortens, and
28.1 Proximal Femur Deformities angle between femoral neck and corpus decreases.
The physis gets vertical in time with develop-
28.1.1 Coxa Vara ment and varus deformity reveals (Fig. 28.2).
The line that connects the center of the femoral a b

head and the tip of the trochanter major makes an
angle between the mechanical axis of the femur
about 90° (90 ± 5). This angle is called lateral
proximal femoral angle (mLPFA) and normally
it’s 90°. If it is less than 85°, deformity is called
coxa valga; if it is more than 95°, the deformity is
called coxa vara (Fig. 28.1) [19, 20].
H.I. Balci
Assistant professor, Department of Orthopedic
Surgery and Traumatology, Istanbul University,
Istanbul Faculty of Medicine, Istanbul, Turkey
e-mail: balcihalili@hotmail.com Fig. 28.1 Coxa valga (a) and coxa vara (b) deformities

https://doi.org/10.1007/978-3-319-45675-1_28
368 H.I. Balci
Fig. 28.3 Short femoral neck, increased anteversion

Fig. 28.2 Characteristic x-ray view of coxa vara angle, and radiolucent lines both positioned medially and
laterally with triangle-shaped bone fragment around the
neck
Developmental coxa vara is a continuing
process. Deformity must be followed until Acquired reasons are slipped capital femoral
patient’s skeletal maturation stops. After early epiphysis (SCFE), sequelae after osteonecrosis of
surgeries deformity can reemerge. Due to the the femoral head which can be seen after trauma,
excessive advance of the deformity, growing infections, septic necrosis, Legg–Calve–Perthes
plate medially positioned around femoral neck disease, developmental hip disorder, postreduc-
can be injured which augments the deformity tion osteonecrosis, pathological bone diseases,
more [4–7]. osteogenesis imperfecta, fibrous dysplasia, rickets
On radiological views typically angle between with renal osteodystrophia, osteopetrosis, and
femur neck and corpus reduces and neck shortens other bone-weakening conditions [4].
and, because of the fact that great trochanter On bilateral situations, skeletal dysplasia
remains the same, relatively enlarges. (cleidocranial dysostosis, metaphyseal dysosto-
Vertically positioned growth plate, short extrem- sis, Jansen-type and Kozlowski-type dysplasia,
ity, enlargement of the proximal physis, triangle- spondylometaphyseal dysplasia) must be taken
shaped bone fragment medially positioned around into consideration for differential diagnosis. On
the neck and radiolucent lines both medially and pathogenesis there is an enchondral ossification
laterally, short neck, and decreased anteversion defect on the medial side of the neck which
angle are other findings (Fig. 28.2) [5–8]. causes increase on varus deformity [5–9].
Decreased angulation between femoral neck Patients with developmental coxa vara might
and corpus can be seen on PFFD and congenital feel the need to have medical examination
short femur. However, deformities are more because of slight limping, owing itself to the
severe with increased shortness, three-planar weakness on abductor muscles and limb length
deformity, and soft tissue contractures on PFFD discrepancies. If the pathology is monolateral,
(Fig. 28.3). Trendelenburg gait is common.
Fairbank classifies coxa vara in three sub- Particular lines and angles are described on
groups: congenital, developmental, and acquired. AP radiographs which are neck–corpus angle,
Congenital reasons are proximal focal femoral head–corpus angle (angle between long axis of
deficiency (PFFD) and congenital short femur. femur and perpendicular line to the physis), and
28 Femur Deformities 369
Hilgenreiner–physeal angle (angle between become symptomatic and have limping or

Hilgenreiner line and physis line). Hilgenreiner– Trendelenburg gait or progressive deformity with
physeal angle is the most important angle for more than 60° of H-E angle, 90–100° of or less
prognosis. A study of Weinstein et al. gives the femur neck– corpus angle need surgery.
normal value of this angle of 16° (0–25) [13, 17]. Conservative approaches such as bed rest, abduc-
For developmental coxa vara if this angle is more tion splints, traction, and exercise are useless in
than 60°, the deformity can get worse; however, that condition. For surgery, proximal femur val-
if the angle is less than 45°, progression of defor- gization, flexion, and derotation osteotomy must
mity is not expected even regression can occur. If be performed. With valgization of femur, ante-
H-E angle is between 45 and 60°, the patient version is increased, and derotation is necessary
must be followed up closely [13, 17]. There is no for distal femur [7–11].
primary treatment for the developmental coxa On literature besides the osteotomies for val-
vara because of the unknown etiology. gization described by Langenskiold and Pauwels
Nevertheless, secondary deformities are the pri- (Fig. 28.4), Borden also described another form
mary concern. On a horizontal physis while com- of valgization osteotomy which is performed at
pressive forces are positioned medially, tensile subtrochanteric region. Early-age osteotomies
forces are positioned laterally. In coxa vara com- come with the disadvantage of recurrence
pressive forces are normally expected to make because of remodeling capacity and failure for
sheading forces because of more vertically posi- fixation of proximal femur [10, 11]. On the other
tioned physis. As a result, the medial side of the hand, with the delayed osteotomies, acetabular
femoral neck doesn’t elongate because the expan- dysplasia may increase. For these reasons the
sion of the lateral side and tip of the trochanter optimal timing for surgery is the time when suf-
major elevate and deformity increases [13]. ficient ossification is detected. The most secure
Because of the shortness on the neck of the femur, fixation can be obtained with closed-wedge oste-
abductor distance and compressive forces on otomy and plate fixation. Besides, external fixa-
femoral neck expand which leads more bending tion can be also applied with subtrochanteric
on femur [1–9]. osteotomy. External fixators have certain advan-
Diagnosis is important on developmental coxa tages of gradual correction options. Osteotomies
vara (DCV). The goal for treatment is to obtain performed from a distance to CORA come with
normal varus angle, normal head–corpus angle, the disadvantage of translations while correc-
turning abnormal sheading forces into compres- tion, named as osteotomy rule 2 described
sion forces on physis. Consequently, normal ossi- according to Paley. This translation remodels on
fication and union are acquired. The secondary the maturation, remodeling process of the
goal is to obtain normal muscle tone for abductor patient, and doesn’t pose an obstacle to our treat-
muscle group which corrects biomechanics. ment (Fig. 28.5).
Asymptomatic patient that has normal H-E angle With the coxa vara deformity, valgus deformity
must be investigated for skeletal dysplasias and can be developed in lower extremity (Fig. 28.6)
must be evaluated for limb length discrepancies At this point valgization will be performed on
if it’s unilateral. Periodic x-ray imagining must the hip which exerts difficulties on walking
be performed until skeletal maturation. If H-E because of the increase of total valgus. With the
angle is between 45 and 59, more frequent serial preoperative anatomical and surgical planning
imaging is necessary. If the patients are symp- performed on orthoroentgenogram, necessity for
tomatic on this group , deformity gets worse or distal osteotomies and controlled corrections
H-E angle gets more than 60° surgical interven- (epiphysiodesis, gradual correction with external
tion and becomes substantial [13–17]. If patients fixator) must be determined (Fig. 28.7).
370 H.I. Balci
Fig. 28.4 (a) Postoperative x-ray for bilateral Pauwels omy for the coxa vara deformity in adolescence period.
valgization osteotomy during the childhood. Osteotomy Fixation is done with external fixator. Expected transla-
fixation is done with plates. (b) Subtrochanteric osteot- tion according to osteotomy rule 2
Proximal focal femoral deficiency is a dis- deformity. Subject will be discussed in another
order of femur with shortness of femoral neck chapter [16].
and shaft with discontinuity. It is a rare con- Some pathologies, tumors (fibrous dysplasia),
genital disorder with partial absence of proxi- metabolic disorders (rickets), and repetitive path-
mal femur, and abnormal ossification PFFD is ological fractures (osteogenesis imperfecta) can
15% bilateral, and 50% of patients have addi- cause coxa vara also. The aim of the treatment of
tional congenital abnormalities. Not only the such pathologies is to correct hip biomechanics
hips and the femur but also the knee joint is and prevent secondary complications (Figs. 28.8,
affected; it is also a reason for coxa vara 28.9, and 28.10).
45˚ 45˚
15˚
16˚ 43˚
16˚
Fig. 28.5 Compensatoire valgus deformity on lower extremity due to coxa vara for the patient with epiphyseal dyspla-
sia. MAD is valgus althougth that we have coxa vara deformity on the hips
Fig. 28.6 Compensatoire valgus

deformity on lower extremity due to
coxa vara for the patient with
epiphyseal dysplasia and preoperative
planning for the valgization
osteotomy, Pauwels osteotomy, and
distal transfer of great trochanter.
Pauwels osteotomy changes the
direction of the forces that affect the
femur physis. Perpendicular force that
can cause shearing becomes vertical
after the operation
372 H.I. Balci
Fig. 28.8 Coxa vara due to rickets
Fig. 28.7 Postoperative x-ray of a patient that under-

gone a surgery of valgization osteotomy for the right hip
joint, hemiepiphysiodesis on distal femur, and correction
with external fixators at proximal tibia with peroneal
nerve release. This patient’s valgus deformity originated
from distal femur is expected to be corrected with the
effect of hemiepiphysiodesis gradually. But for early
weight-bearing deformity at proximal, tibia is corrected
with external fixation. In case of correction of more than
20-degree valgus deformity, we suggest peroneal nerve
release
Fig. 28.9 Coxa vara due to osteogenesis imperfect.

Intramedullary rodding corrected the diaphyseal defor-
mity but not the proximal femoral deformity
Fig. 28.11 Bilateral coxa valga deformity on a patient

with cerebral palsy, with increase in anteversion
Fig. 28.10 Coxa vara due to fibrous dysplasia. Internal

mechanical support is needed to correct and keep it
28.2 Coxa Valga
When the angle between femoral neck and shaft

exceeds 135°, the deformity is called coxa valga. Fig. 28.12 Bilateral varization, derotation osteotomy for
Angle between the mechanical axes and tip of the coxa valga. As the CORA of the deformity in at the phy-
trochanter major, called mLPFA, is less than 85°. sis, with an osteotomy at the trochanteric region we need
translation not to have osteotomy rule 3
Normally this angle is about 90° (Fig. 28.1) (var-
ies between 85 and 95°) [20].
Coxa valga can be acquired or congenital. A formed. Because of the improvement on the joint
femoral neck fracture, metabolic bone disease, consistency and extended circulation due to hip
multiple exostosis, osteogenesis imperfecta, region osteotomy, further arthrosis can be pre-
Paget’s disease, fibrous dysplasia, cerebral palsy, vented (Fig. 28.13).
or developmental hip dysplasia can cause a coxa At clinical practice coxa valga is presented
valga deformity (Fig. 28.11). with increase anteversion angle which leads to
With a varization osteotomy that enables cor- intoeing. At these cases for protecting the bio-
rection at the intertrochanteric region, c ompression mechanical features of the hip, derotation proce-
forces spread to a wider area at the joint, and con- dure must be added to varization osteotomy.
centric reduction is obtained for the hip joint (Fig. Until 8–10 years old, the hips are tent to get
28.12). external rotation posture. If the deformity is uni-
If we obtain more concentric reduction with lateral or physical examination on prone position
the abduction internal rotation x-ray of the hip reveals 80° or more of internal rotation defor-
joint, varization derotation osteotomy can be per- mity and on regular examinations, no progress is
374 H.I. Balci
Fig. 28.13 A patient with coxarthrosis at the right hip

joint due to developmental hip dysplasia treated with
varization, derotation, and translation osteotomy
Fig. 28.14 A patient with bilateral valgus deformity with
increase anteversion deformity treated with derotation
osteotomy. Fixation is performed with intramedullary
detected clinically; surgical intervention can be nailing on the right side and plate on the left side
planned earlier. Otherwise it is much proper to
wait until 10 years old according to our experi- The degree of derotation performed during these
ences (Fig. 28.14). osteotomies is determined according to lower
For the treatment of osteoarthritis for dys- extremity rotational profile obtained with clini-
plastic hip joints, Pauwels 1 (varization) and cal examination under anesthesia [12–14].
Pauwels 2 (valgization) osteotomies can be per-
formed. If the hip joint is reducted on the abduc-
tion x-ray images, varization osteotomy, 28.3 S
lipped Capital Femoral
however, for the adduction x-rays, is the best Epiphysis
option. If there is no consistency in both situa-
tions, the best option is translation osteotomy Usually it is a problem for pubertal ages. Classically,
described by Mc Murray that translates distal when a 12–14-year-old adolescent comes with
fragment medially that allows the mechanical limping, slipped capitis femoris is first diagnosis to
axis to cross more medially which eventually rule out. Hypertrophic zone of the growth plate
decreases the forces to the hip with adductor and leads migration of the proximal side of the femoral
iliopsoas loosening. Intertrochanteric femoral head superiorly and anteriorly because of the shear-
osteotomies (varus, valgus, flexion, extension, ing forces. Femoral head remains inside acetabu-
translation) that improve the joint surface con- lum. In fact it is not the epiphysis which slips but
sistency and that increase contact area cartilage the distal part of the physis. By the way it cause a
of the hip, replace joint rotation center medially. huge deformity. It is more common on the left
side, African-Americans, and male sex. Obesity

and endocrinopathies are probably main factors.
On endocrinopathies 50% of patients are bilateral.
If the patient weight is less than 50 percentile and
younger than 10 years old, endocrinologic rea-
sons must be investigated especially hypothyroid-
ism, hypogonadism, renal osteodystrophy, and
growth hormone therapy. HLA-DR4 phenotype is
common for this patients [13, 17].
Patients usually have medial pain on the leg
and knee. External rotation deformity, shortness
of 1–2 cm, limping, and reduced range of motion
are the main findings.
SCFE is classified according to stability of Fig. 28.15 SCFE on the right hip. Klein’s line doesn’t
the growth plate, onset of the complaints, and cross the physis on the right side while left is normal
radiology. While acute clinical situation is less
than 3 weeks, chronic is more than 3 weeks.
Acute SCF on chronic base is defined as slip of
the femoral head after 3 weeks of mild chronic
discomfort. If patient can weight bear to the
affected side, it is called stable; if not, it is called
unstable. Classification can be made according
to the difference of the head–corpus angle
between two hips. If the difference is less than
30°, it is called mild, 30–50° is moderate, and
more than 50° is called as severe SCFE. Clinical
diagnosis is made according to AP and frog leg
x-rays. At the upper side of the neck of the femur,
tangential line to the neck cortex, called as
Klein’s line, doesn’t contact with the head of the Fig. 28.16 Lateral x-ray of the R hip after the surgery for
the SCFE. An incorrect fixation which is unable to hold
femur on the AP view of the hip joint. It is an
the physis and has risks for chondrolysis. Mostly, we do
another diagnostic feature used for especially not need three screws as trauma surgeon has the experi-
mild cases [17] (Fig. 28.15). ences from collum femoris fractures
Purpose of the emergency treatment is to stop
the progression. Meanwhile, complications (Fig. 28.16). A trauma surgeon can easily miss
such as chondrolysis or avascular necrosis must the epiphysis and can penetrate the joint with
be prevented. Extensive forces for deformity screw.
correction aren’t recommended on acute situa- Screw must be placed on anterolateral–posterior
tions. If the deformity correction isn’t obtained medial direction. Otherwise, missing of the physis
or there is a chronical phase underlying, in situ and penetration of screw to joint can be seen. Proper
pinning with one screw will be adequate. direction for screw is from anterior to p osterior in
Surgery must be performed according to struc- femoral neck. Prophylactic pinning for contralateral
ture of the deformity. Experience is also impor- side is recommended for patients with endocrinopa-
tant in proper fixation of the femur physis. In thies and patients younger than 10 years old.
proper fixation can increase the risk for chon- On chronic phase the goal is to increase the
drolysis. Fixation technique should be different range of motion and maintain the joint structure
from what is done with collum femoris fracture and correction of the deformity. The key point for
376 H.I. Balci
correction of the deformity is determining the bring the intact surface of the femoral head to the
CORA with proper analysis and making osteot- face in acetabulum. In other words, we should try
omy at the CORA. Because of the nature of the to bring the weight-bearing surface of the acetab-
intracapsular deformity, there is a great risk for ulum on intact surface of the femoral head. For
avascular necrosis for the correction. Surgical that reason on varus osteotomy, lateral side of the
interventions described are three-planar intertro- femur head, and for the valgus osteotomy medial
chanteric osteotomy described by Southwick and side of the femur head must be intact. While flex-
subcapital osteotomy described by Ganz. With the ion osteotomy can be performed with intact ante-
technique of safe dislocation and intracapsular rior region on sagittal plane, intact posterior
osteotomy described by Ganz, it is possible to region indicates extension osteotomy. Also bipla-
reach CORA and correct the deformity. With these nar correction can be performed (Fig. 28.18).
techniques, femoroacetabulary impingement can
be prevented. Major complication of SCF is chon-
drolysis and avascular necrosis that is especially
seen after the hard tries for correction (Fig. 28.17).
Later phases of the disease that subchondral
collapse are seen; pain gets worse; joint move-
ments are restricted; and mainly internal rotation
is restricted more.
Radiological findings that determine progno-
sis are collapse of the cartilage, magnitude of the
necrotic area, subsidence at the femoral head,
and involvement of the acetabulum. As referred
on many studies, more than 50% of involvement
is the primary reason of failure of the intertro-
chanteric osteotomies. The main principle for
these osteotomies is to maintain the consistency
Fig. 28.18 Valgization and extension osteotomy for the
of the joint at the superior side that allows transi- hip in a case of SCFE. Because of the osteotomy per-
tion of the weight. According the finding seen on formed from a different place other than CORA, defor-
MRI, we can decide the best osteotomy that will mity is corrected with translation
Fig. 28.17 Avascular necrosis after treatment of closed pinning of a SCFE case with hard reduction. Postoperative
x-ray shows a well acute correction of the deformity
Proximal femoral osteotomies decrease the defects, pain, limping, decrease in activity, and
motion on the hip joint. For this reason patient increase in risk of osteoarthritis.
needs up to 70° of flexion. Fixed external rotation If the mechanical lateral femoral distal angle
contractures are contraindications. The fixation (m LDFA) is not in the range of 85–90°, we call
materials such as external fixators or plates it as frontal plain deformity. If it is less than 85°,
depend on the surgeon for these osteotomies. we call as valgus deformity, and if it is more
External fixators have some advantages such as than 90°, we call as varus deformity. If the pos-
postoperative manipulation and progressive cor- terior distal femoral angle is not between the
rection. A careful preoperative planning and tem- range of 79–87°, we call it as sagittal plain
plate preparation will prevent complications and deformity. Rotational abnormalities are decided
mistakes on internal fixation. It must be consid- after the physical examination where we deter-
ered that proximal femur osteotomies can redi- mine the rotation profile of the lower extremity
rect the mechanical axis of lower extremity. [19, 20].
Sometimes additional correction procedures can Not every deformities are operated. The main
be added for distal femur or proximal tibia to indications for the operations in frontal plain are
obtain proper mechanical axis of lower extrem- more than 15 mm deviation in mechanical axis,
ity. In summary template preparation is essential more than 10° of varus–valgus deformities, and
and highly recommended [12]. more than 2–3 cm of shortening (Figs. 28.19,
28.20, and 28.21). In case of sagittal plain adap-
tation of the knee joint is an important factor for
28.4 Distal Femur Deformities the decision. In case of flexion deformity of the
knee that cause over activity of quadriceps and
The distal femur deformities can be grouped as hyperextension deformity that cause posterior
frontal plain, sagittal plain, rotational, and shorten- soft tissue laxity, we suggest to correct the
ing deformities. Main complains are the functional deformity [13].
Fig. 28.19 Lateral deviation of the

mechanical axis because of the distal
femoral deformity, mLDFA 78
378 H.I. Balci
Fig. 28.20 Deformity described in

Fig. 28.19 is planned to correct by an
open-up osteotomy. Circular-type
external fixator is preferred. Hinges
are placed medially and motor unit
laterally
a b
Fig. 28.21 (a) Radiological result of the treatment. with internal fixation with close-up osteotomy technique
Before and after the removal of the external fixator. (b) with acceptance of up to 1–1.5 cm of shortening. In both
Valgus deformity at the distal femur can also be corrected methods mechanical axis is corrected
Fig. 28.22 Correction of distal femoral valgus and rotational deformity with monoplanar external fixator
To find out the CORA of the deformity, the monolateral external fixator to increase the
malalignment test described by Paley should be comfort. In case of the monolateral fixator, sur-
performed. After the finding of the CORA, we geon has to have experience on external fixators.
should decide to make and open-wedge or closed- Angle of the Schanz screws should be well cal-
wedge osteotomy according to the limb length culated to correct the deformity on three plains.
discrepancy. If we have the shortening, we should In case of the monolateral external fixator
prefer open-wedge osteotomy, and if we need to applied laterally, it is possible to correct the
shorten the extremity, we should prefer closed- frontal plain residual deformity after the opera-
wedge osteotomy to correct the deformity. In tion with swivel clamps, but sagittal and rota-
case of valgus deformities, if we have more than tional deformity cannot be corrected after the
20° of deformity or in revision case, we have to operation (Fig. 28.22).
decompress the peroneal nerve both around the Sagittal plain deformity of the femur also
fibular head peroneal fascia and between the affects lower extremity biomechanics. Most of the
anterior and anterolateral compartment and inter- sagittal plain deformities result in deformity in the
muscular septum [21]. knee joint as the clinical presentation. X-ray taken
Correction of the deformity with an external with the knee joint in full extension on the lateral
fixator has some advantages. First, you can con- plain and application of malalignment tests reveal
tinue to correction after the operation. Second, the reason of the knee deformity; it is a soft tissue
there is no hardware inside that needs to take contracture or bone deformity. Bone deformity
out. But it has also some disadvantages: pin care can originate from tibia or femur. Full extension
and lack of the comfort. Therefore we can use for these patients is important to walk. Flexion
380 H.I. Balci
Fig. 28.24 In pure soft tissue contracture of the knee

joint, hinges are placed to the center of rotation of knee
joint and motor units placed posteriorly. Distraction is
limited as 1 mm on the soft tissue at the posterior part of
the knee (vascular and nerve tissues)
mity with a supracondylar femur extension

osteotomy. Theoretically, such a procedure will
prevent the last flexion of the knee as much as cor-
rection angle maintained with supracondylar
femur osteotomy. In mild deformities, less than
Fig. 28.23 Knee flexion contracture case with a
40-degree flexion deformity. As there is no deformity on
15–20°, it is not clinically significant [18].
sagittal plain (mPDFA and mPPTA are in normal ranges),
we can talk about a pure soft tissue contracture in that case
References
deformity of femur or tibia can be corrected with
extension osteotomy. Gradual correction of the 1. Beals RK. Coxa vara in childhood: evaluation and man-
agement. J Am Acad Orthop Surg. 1998;6(2):03–9.
deformity especially if it is more than 20°, with 2. Herring JA. Congenital coxa vara. In: Herring JA,
external fixator, will prevent vascular and nerve editor. Tachdjijan’s pediatric orthopedics. fourth ed.
injuries that can be seen in case of acute correc- Philadelphia: Saunders Elsevier; 2008. p. 897–912.
tion (Figs. 28.23 and 28.24). But in case of the 3. Blockey NJ. Observations on infantile coxa vara.
J Bone Joint Surg Br. 1969;51(1):106–11.
soft tissue contracture and intraarticular pathol- 4. Fairbank H. Coxa Vara due to congenital defect of the
ogy, we have to correct the deformity from the neck of the femur. J Anat. 1928;62:232.
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soft tissue releases should be performed before coxa vara. Clin Orthop Relat Res. 1972;86:2–5.
6. Say B, Taysi K, Pirnar T, Tokgözoğlu N, Inan
the application of external fixator. In mild soft tis- E. Dominant. Congenital coxa vara. J Bone Joint Surg
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N. Hereditary congenital coxa vara with dominant J. 2009;8:3.
inheritance? Humangenetik. 1971;11(3):266–8. 16.
Paley D, Shawn C. Standart Lenghtening
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hip. New York: Springer; 1976. 879–83.
11. Cordes S, Dickens DR, Cole WG. Correction of coxa 19. Paley D. Normal lower limb alignment and joint ori-
vara in childhood. The use of Pauwels Y – Shaped entation. Chapter 1. In: Kelly D, editor. Principles
osteotomy. J Bone Joint Surg Br. 1991;73:3–6. of deformity correction. New York: Springer; 2003.
12. Desai SS, Johnson LO. Long term results of valgus p. 1–17.
osteotomy for congenital coxa vara. Clin Orthop Relat 20. Paley D. Frontal plan mechanical and anatomic axis
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Knee Deformities
29
Cengiz Şen and Ahmet Salduz
29.1 Monocompartment The degenerative arthropathy due to the

Osteoarthritis of the Knee malalignment problems is an insidious process. It
is generally asymptomatic, and patients can live
True alignment is important for procedures such without any symptoms for years. However, when
as fracture reposition, arthroplasty, and deformity patients present to hospital for the first time, the
correction. There is a general opinion that the arthritis has usually already settled. Therefore,
cause of degenerative arthritis is mechanical correction of the deformity before arthritis
rather than inflammatory. Although the patho- becomes established is the main goal of treat-
genesis has not yet been explained, it is believed ment. These patients are generally middle aged
that there is a correlation between malalignment with high activity levels and high demands.
and arthritis [6, 9, 13]. Arthritis is known as a Therefore, the main goal of treatment is to post-
reflex response to abnormal loading of cartilage. pone total knee or unicondylar knee arthroplasty.
Mechanical axis of the lower extremity crosses Although there are three compartments in the
the knee joint in the middle or 8–10 mm medially knee, the most common compartment affected is
of the midpoint. In biomechanical studies, it has the medial compartment. This section focuses
been shown that 70% of loading is on the medial predominantly on medial compartment osteoar-
side of the knee joint. Malalignment in the coro- thritis as well as frontal plane deformities of the
nal plane changes the loading distribution of knee. High tibial osteotomy (HTO) is one of the
weight and the reflex response of the knee joint to preferred methods for medial compartment
this loading. When the axis of the loading is osteoarthritis. In this technique, many osteotomy
changed, a new moment arm is revealed with the methods have been recommended in a historical
increased loading in the medial and lateral knee perspective, but the most common methods are
compartments. This moment arm changes the closed wedge and open wedge osteotomies.
loading of the cartilage and increases loading on Satisfactory short- and long-term results have
the same surface. been reported for both closed and open wedge
osteotomies [1–5, 8, 11, 12, 14]. The common
goal for these HTO procedures is to shift the
C. Şen, MD • A. Salduz, MD (*) mechanical axis from the medial compartment to
Istanbul University, Istanbul Medicine Faculty, the lateral compartment [6]. In addition to open
Orthopaedics and Traumatology Department,
and closed wedge tibial osteotomies, distal
e-mail: senc64@gmail.com; femur osteotomies are frequently used for defor-
ahmet_salduz@yahoo.com mities of the distal femur.

https://doi.org/10.1007/978-3-319-45675-1_29
384 C. Şen and A. Salduz
29.2 T
ype of Osteotomy of the advantages of distraction osteogenesis is
and Fixation that one can continue correction after the opera-
tion and can solve additional problems and com-
HTO can be performed as open or closed wedge plications such as procurvatum, recurvatum, and
osteotomies with plates. However, these osteoto- shortening at the same time.
mies do not allow postoperative correction,
which may result with insufficient correction.
Furthermore, these osteotomies do not allow 29.3 Preoperative Planning
translation, which can result with secondary
varus deformities in the ankle joint. Closed For accurate preoperative planning, a standing
wedge osteotomies can cause bone defects and AP and lateral orthoroentgenography with the
shortening. The preferred methods in deformity pelvis, hip, knee, and ankle included is required.
correction surgery are transverse osteotomy or Malorientation and malalignment tests should be
dome osteotomy for knee deformities [11]. performed to identify the source of the defor-
Osteotomy can be performed by multiple drilling mity. If all of the deformity is in one bone (femur
techniques or by using a Gigli saw. Although the or tibia), the osteotomy should be performed in
level of osteotomy is usually at the supracondylar that bone. Stress radiographs are necessary to
region in the femoral side, it can be either below exclude joint laxity components of joint line
or above the tibial tubercle in the tibial side. After congruency angle (JLCA). A tibial osteotomy is
the re-defined deformity concepts and treatments recommended when the medial proximal tibial
described by Dr. Paley, tibial osteotomies should angle (MPTA) is clearly varus (<85°) and
be performed below the tibial tubercle and the mLDFA is normal (85–90°) (Fig. 29.1). Femoral
direction of the concavity must be faced proxi- osteotomy (FO) is used when the mLDFA is
mally (focal dome osteotomy). By this method, clearly varus (>93°) or slightly varus (90–93°)
progressive correction can be obtained after the and the MPTA is within the normal range
operation, and mechanical axis of the bone seg- (85–90°) (Fig. 29.2).
ments can be reestablished more accurately. At If the deformity is in both the distal femur and
the same time, secondary deformities in the ankle proximal tibia in the same limb, it can be described
joint can be prevented [9, 10]. as a combined deformity. These particular defor-
External fixators and distraction osteogenesis mities, which are defined as “bad combination”
are other commonly used methods for deformity among the combined deformities, are genu val-
surgery. This technique was first described by gum for the distal femur (LDFA<87°) and genu
Gavriil A. Ilizarov from Kurgan, Russia, as a varum for the proximal tibia (MPTA<87°). In this
technique for bone lengthening [7]. Later, this type of combined deformity, shearing forces are
technique was learned by Dr. M. Catagni from increased at the knee joint. Surgical interventions
Italy and Dr. Dror Paley from the United States are recommended for this particular deformity to
[2, 10]. Therefore, the western world was intro- avoid knee subluxation in the early period and to
duced to this unknown method for the first time. prevent degenerative arthritis later. In the opposite
Distraction osteogenesis has also been used for type of deformity, which is genu varum for the
deformities around the knee as an alternative distal femur (LDFA<87°) and genu valgum for
treatment option. The surgical indications of this the proximal tibia (MPTA<87°), the prevalence of
technique are similar to the other techniques. The degenerative arthritis is extremely rare, and the
ideal patient for this technique is defined as aged knee is stable. Surgery is rarely indicated and
less than 60 years with medial knee arthritis and close follow-up is recommended. Although it is
more than 90 degree ROM, less than 10° flexion seen with medial ligamentous instability, these
contracture, with the absence of patella-femoral patients generally report limping and early fatigue
arthritis and severe ligamentous instability. One because of excessive energy consumption.
29 Knee Deformities 385
a b c d e
f g h
Fig. 29.1 (a) On the orthoroentgenography of this women of the tibia. Mechanical axis deviation [1], medial proxi-
aged 53 years, there is a genu varum deformity with CORA mal tibial angle (MPTA), lateral distal femoral angle
on the knee joint. The Fujisawa point was determined as (LDFA), and lateral distal tibial angle (LDTA) were mea-
one-third medial of the lateral compartment of the knee. It sured until they reached the expected values. A new
was desired to have the mechanical axis to pass via this mechanical axis was desired to pass at the Fujisawa point,
point. (b, c) On the AP and lateral view of the tibia, which is one-third of the medial part of lateral plateau.
malalignment test was normal. (d, e) A juxta-articular This system could be changed to a rigid rod system during
hinge system was used to correct the deformity. The level the consolidation time, after the correction was completed.
of osteotomy was preferred below the tibial tubercle. Note: (f, h) Union and corrected alignment of the lower limp can
a transfer osteotomy below the CORA requires translation be observed in the X-ray taken in the sixth month
In general, the center of the deformity is posi- must be used; if it is below or above the knee joint,
tioned on the knee joint or very close to the knee a uniplanar hinge can be used. In both types of
joint (below/above). According to this, CORA frame, hinges must be positioned in the same posi-
(center of rotation angulation), two different frames tion as the next hole from the center, and the dis-
must be prepared preoperatively. If the CORA is on tractor (motor unit) must be positioned at the
the knee joint, a “bushing (juxta-articular) hinge” opposite side but the same distance from the hinges.
a b c d
e g h
Fig. 29.2 (a–d) Clinical and radiologic appearance of a hexapod system. (e) Clinical appearance of the patient.
male patient aged 17 years with varus deformity of the The pictures were taken at the early postoperative period,
knee. Malorientation and malalignment tests were per- after correction lengthening, and after removal of the fix-
formed, and the CORA was determined at the distal femur. ator. (g) The computer-assisted hexapod system allows
(f) A transverse osteotomy was performed at the CORA deformity correction and lengthening at the same time.
level and fixation was obtained using a computer-assisted (h) The final orthoroentgenogram1 year postoperatively
29.4 Postoperative Care MCL laxity may be associated with varus or

valgus malalignment. Chronic stretch of the
Range of motion exercises are allowed at the MCL in valgus deformities can lead to MCL lax-
knee and ankle joints on the first postoperative ity in the knee. However, MCL laxity is mostly
day. Patients can walk with the assistance of seen on medial cartilage loss. During the progres-
crutches and are allowed to weight bear as much sion of medial arthritis, shearing forces and lat-
as possible. Daily dressing of the pins is recom- eral subluxation of the tibia on the femur may
mended with iodine solution. lead to LCL laxity and even MCL tightening.
Although mLDFA and mMPTA angles are nor-
mal, the mechanical axis crosses the knee joint
29.5 Malalignment far medially on the standing position. The prob-
Due to Ligamentous Laxity lem originates from the joint line congruency
of the Knee angle (JLCA) in this patient group. Dr. Paley
defined an osteotomy that starts from the bottom
According to a new concept, which was described of the tibial tubercle and ends above the medial
by Dr. Dror Paley, knee deformities can originate collateral ligament insertion at the medial side of
from the distal femur, proximal tibia, or ligamen- the tibia. This open-up focal dome osteotomy
tous laxity of the joint [9, 10]. Ligamentous laxity provides tightening of the medial collateral liga-
can show up frontal, sagittal, and oblique plan ment and correction of the mechanical axis in the
malalignments. The most common causes of lat- standing position [9–11]. There are a limited
eral laxity are chronic stretch due to bony varus number of patients who have medial collateral
malalignment such as Blount’s disease, rickets, ligamentous laxity without any malalignment. In
and medial compartment osteoarthritis or over- this condition you can apply the same technique
growth of the fibula, which is seen in achondropla- as described above (Fig. 29.3).
sia, hypochondroplasia, and pseudoachondroplasia.
Lateral laxity can be treated by direct technique,
which is plication or tightening the ligament, or by 29.6 M
alalignment Due to Knee
the methods of indirect or bony techniques, which Joint Line Deformity
is advancing the insertion of the lax ligament via
moving the fibular head distally. This can be per- So far we mentioned malalignment due to femo-
formed acutely or gradually. Treatment recom- ral and tibial deformities and due to ligament lax-
mendations based on malalignment patterns in the ity. Another reason for knee deformities is
presence of lateral ligamentous laxity are shown in intra-articular deformities because of bone and
Table 29.1. cartilage loss from knee joint surfaces, especially
Table 29.1 Treatment recommendations based on malalignment patterns in the presence of lateral ligamentous laxity
LDFA (degrees) MPTA (degrees) JLCA (degrees) S-JLCA (degrees) Type of Osteotomy
85–90 85 ≥0 >JLCA + 3 TO + LT
85–90 85–90 >0 >JLCA + 3 TO + LT
≥92 85–90 ≥0 >JLCA + 3 FO + LT
90–92 87–90 ≥0 >JLCA + 3 FO + LT
90–92 ≥86 ≥0 >JLCA + 3 TO + LT
92 <85 ≥0 >JLCA + 3 FO + TO + LT
LDFA lateral distal femoral angle, MPTA medial proximal tibial angle, JLCA joint line congruency angle, S-JLCA stress
JLCA, TO tibial osteotomy, FO femoral osteotomy, LT ligament tightening
a c
Fig. 29.3 (a, b) A patient aged 43 years was admitted to open-up fashion (distraction on the medial side).
the hospital with pain and walked with the varus trust style Osteotomy was performed from just below the tibial
on the left knee. There was severe medial arthritis and tubercle toward the medial side of the proximal tibia
associated collateral ligament laxity on stress X-rays. (c) above the medial collateral ligament insertion. The cor-
Orthoroentgenography showed the abnormal JLCA and rection was checked in weekly orthoroentgenographies.
medial axis deviation. The CORA was at the knee level. (f, g) Correction was continued until normal walking
(d, e) The postoperative appearance of the lower extrem- without varus trust style was achieved. Mechanical axis
ity with juxta-articular hinge system. The correction was and ligamentous laxity were corrected at the end of the
started at postoperative day 7 with 3 × 1 mm/day using the treatment
distraction unit. Juxta-articular hinges were prepared with
d e
f g
medial and lateral knee compartments. JLCA plateau, whereas Ellis-van Creveld syndrome
increases because femoral and tibial joint sur- leads to steps in the lateral tibial plateau. In these
faces are no longer parallel. Stress radiographs conditions, malalignment tests are performed
should be obtained to evaluate cartilage space. based on best-fit line. It can be the joint line of the
Dysplasia of one condyle or plateau may occur normal side, which is generally femoral condyle
due to congenital, developmental, or traumatic or the nondeformed plateau.
origin. The results can be depression or stepped. A metaphyseal osteotomy or elevation of the
It is generally seen in the tibia. For example, deformed plateau can be chosen to realign the
Blount’s disease leads to depression of the medial tibial axis (Fig. 29.4).
a b
c d e
Fig. 29.4 (a, b) A patient with epiphyseal dysplasia at proximal tibia osteotomy and valgus deformity of the dis-
the medial side of the knee has varus deformity due to tal femur treated temporary epiphysodesis at the medial
intra-articular joint line deformity and valgus from distal side of the physis. (f) The correction shown in X-rays. The
femur. (c–e) Medial plateau depression was treated with final malalignment and malorientation test was normal
intra-articular medial plateau elevation and subsequently
f
29.7 Malalignment terior tilt of the tibia. If a tibial osteotomy is nec-

Due to Sagittal Plane essary, the PPTA should be below 90° to provide
Deformities of the Knee a normal femoral rollback mechanism.
As with FFD, recurvatum deformity of the knee
Fixed flexion deformity (FFD) and recurvatum may be due to soft tissue and boney causes.
deformity of the knee is discussed in this section. However, recurvatum deformity is usually asymp-
FFD can be symptomatic even in small degrees tomatic. The tibial recurvatum is usually more
of contracture and lead to quadriceps muscle symptomatic than femoral recurvatum because
fatigue. It should be treated nonoperatively with tibial recurvatum can lead to posterior tibial sub-
stretching exercises, physical therapy, or orthotic luxation, patella baja, and patella-femoral and tib-
devices. If nonoperative treatment fails, exten- iofemoral degeneration. Maximum hyperextension
sion of the knee can be obtained surgically by radiographs should be obtained before planning an
soft tissue and bone procedures. Soft tissue pro- osteotomy. If the amount of the hyperextension is
cedures can be performed gradually using exter- greater than the amount of bone deformity, only
nal fixators or acutely by lengthening tendons the bone deformity should be corrected because
and release of the capsuloligamentous structures. soft tissue laxity is not a problem for neuromuscu-
Many patients require both bone and soft tissue larly intact patients. The level of the patella is also
procedures. If there is more than one cause of important to make a tibial osteotomy. If the inser-
FFD, correcting FFD in one bone can be consid- tion of the patellar tendon is normal, tibial osteot-
ered. In such conditions, a femoral osteotomy omy should be performed distal to the tuberosity
should be preferred because of the preserved pos- (Fig. 29.5).
a b
Fig. 29.5 (a, b) A male patient aged 15 years with recur- sagittal and coronal plane. Correction continued until nor-
vation deformity on the left knee 3 years after the initial mal values of axes angulations were obtained. (e) At the
trauma. The CORA was at the proximal tibia on the sagit- end of treatment, successful union was achieved, and the
tal plane. (c, d) A dome osteotomy was performed on both deformity was corrected
Post-op 6th month
Conclusion medial laxity. Eklem hastaliklari ve cerrahisi Joint Dis

Related Surg. 2010;21(2):80–5.
Preoperative planning is key for these proce- 5. Esenkaya I, Unay K. Proximal medial tibial biplanar
dures. Osteotomies should be performed retrotubercle open wedge osteotomy in medial knee
according to the CORA. Juxta-articular hinge arthrosis. Knee. 2012;19(4):416–21.
mechanism can be useful for knee deformities, 6. FuJisawA Y, Masuhara K, Shiomi S. The effect of
high tibial osteotomy on osteoarthritis of the knee. An
especially when the CORA is at the knee level. arthroscopic study of 54 knee joints. Orthopedic Clin
Although deformities are usually seen in a N Am. 1979;10(3):585–608.
single bone segment (femur or tibia), it should 7. Ilizarov GA. The tension-stress effect on the genesis
be taken into account that combined deformi- and growth of tissues: part II The influence of the
rate and frequency of distraction. Clini Orthopaedics
ties, joint line deformities, and sagittal plan Related Res. 1989;239:263–85.
deformities could be the main problem in some 8. Magyar G et al. Open-wedge osteotomy by hemical-
patients. Patients with knee deformity and lotasis or the closed-wedge technique for osteoarthri-
medial ligamentous laxity should be treated tis of the knee a randomised study of 50 operations.
J Bone Joint Surg Br Vol. 1999;81(3):444–8.
with bone osteotomies and tightening of the 9. Paley D. Principles of deformity correction. Berlin:
medial collateral ligament. Springer; 2014.
10. Paley D, Maar DC, Herzenberg JE. New concepts in
high tibial osteotomy for medial compartment osteo-
arthritis. Orthopedic Clini N Am. 1994;25(3):483–98.
References 11. Sen C, Kocaoglu M, Eralp L. The advantages of

circular external fixation used in high tibial osteot-
1. Adili A et al. Valgus high tibial osteotomy. Knee Surg omy (average 6 years follow-up). Knee Surg Sports
Sports Traumatol Arthrosc. 2002;10(3):169–76. Traumatol Arthrosc. 2003;11(3):139–44.
2. Catagni MA et al. Treatment of genu varum in medial 12. Smith TO et al. Opening-or closing-wedged high tib-
compartment osteoarthritis of the knee using the Ilizarov ial osteotomy: a meta-analysis of clinical and radio-
method. Orthopedic Clini N Am. 1994;25(3):509–14. logical outcomes. Knee. 2011;18(6):361–8.
3. Elmalı N et al. Monoplanar versus biplanar medial open- 13. Tetsworth K, Paley D. Malalignment and degenerative
wedge proximal tibial osteotomy for varus gonarthrosis: arthropathy. Orthop Clin N Am. 1994;25(3):367–78.
a comparison of clinical and radiological outcomes. Knee 14. Yim J-H et al. Comparison of high tibial osteotomy
Surg Sports Traumatol Arthrosc. 2013;21(12):2689–95. and unicompartmental knee arthroplasty at a mini-
4. Erdem M et al. Opening focal dome osteotomy in mum follow-up of 3 years. J Arthroplast. 2013;28(2):
the treatment of varus gonarthrosis associated with 243–7.
Knee Arthrodesis
30
Halil Ibrahim Balci
Previously, knee arthrodesis was effectively per- patients. Nelson and Evarts were the first to
formed for instability due to polio sequelae, describe knee arthrodesis as a treatment option
Charcot knee, tuberculosis, osteoarthritis, young for failed arthroplasty in 1971 [6]. Other alterna-
heavy workers with posttraumatic arthritis, rheu- tives besides arthrodesis are antibiotic suppres-
matoid arthritis, osteomyelitis around the joint, sion, artificial arthrodesis, resection arthroplasty,
loss of extensor mechanism, and treatment after or amputation. The greatest challenge after a
tumor resection [1–3]. The main goals of knee failed septic TKA is to achieve bone fusion.
arthrodesis in infected total knee arthroplasty Instability, massive bone loss, repeated opera-
(TKA) are to provide pain relief and stability. tions, soft tissue problems, uncontrolled infec-
Various techniques have been used to achieve a tion, and other medical problems have a negative
solid knee arthrodesis with rates of fusion ranging effect on bone healing. Infections must be eradi-
from 29 to 100%. It has been recognized that cated and a stable construct must be applied.
rigid fixation and compression reduces failure Various knee arthrodesis techniques such as intra-
rates [4, 5]. Charney and Lowe published the suc- medullary (IM) nailing, dual plating, monoplanar
cess of knee arthrodesis with Charney external or circular external fixator, screwed plate, and
fixator with a union ratio close to 99% in 171 cannulated screw fixation are described in the lit-
patients. Knee prosthesis that developed over the erature. Intramedullary (IM) nailing has achieved
years and infections caused by those implants had the best fusion rates of 88–100% and has the
revived the knee arthrodesis, but this time advantage of allowing early weight bearing [7, 8].
Charney’s method was found to be far away from However, with the development of surgical tech-
success because of the decreased bone stock after niques, knee arthrodesis has largely been reserved
knee replacement. Hagemann et al. reported for resistant infections around the knee. Using
arthrodesis rates of 64% after failed knee replace- internal devices in cases of infection can be prob-
ment in their study in 1978. These unsuccessful lematic. The use of either IM nail or external fix-
results provided for the development of new tech- ators has been recommended for cases of infected
niques for fusion. Arthrodesis became a logical TKA. However, IM nailing should only be used
treatment or salvage procedure in most of these after an infection has been treated successfully, as
with other internal fixation devices [4, 9, 10]. On
H.I. Balci, MD the other hand, in cases of soft tissue defects com-
Istanbul University, Istanbul Faculty of Medicine, bined with TKA infection, bone grafting with
Orthopedic and Traumatology Department, intramedullary nail application is not appropriate
34190 Istanbul, Turkey (Figs. 30.1, 30.2, and 30.3).
e-mail: balcihalili@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_30
396 H.I. Balci
Fig. 30.1 Unsuccessful treatment of a patient with dures. Free flaps are contraindicated because of the insuf-
infected knee arthroplasty and soft tissue loss despite ficient arterial blood supply
vacuum-aspirated closure and local flap surgical proce-
Fig. 30.2 After the removal of the implants, knee arthrodesis with a unilateral external fixator has been applied to the
patient shown in Fig. 30.1
30 Knee Arthrodesis 397
Fig. 30.3 After the successful arthrodesis, X-ray views of the knee AP (left) and lateral (right) views
It is also often used in painful ankylosis and with distraction osteogenesis even after surgery,
neuropathic instability, except the mentioned provision of excellent stability and early full
indications above. weight bearing, and continuous compression that
In the event of bilateral knee involvement, can stimulate bone healing with a considerably
ipsilateral hip arthrodesis is considered a contra- lower risk of infection recurrence and dissemina-
indication. It is useful to check ipsilateral joints, tion [11–13]. On the other hand, prolonged appli-
because arthrodesis at the knee joint will increase cation of external fixators, especially circular
the burden on joints in patients with ankle and hip fixators, has a negative impact on patients’ social
arthrosis. and emotional status [13]. Unilateral fixators can
The use of external fixators has several advan- be used to increase comfort and compatibility.
tages: correction of malalignment and shortening Mabry et al. observed higher rates of successful
398 H.I. Balci
union but also a higher risk of recurrent infection and patient satisfaction are low, but with accept-
with IM nails [14]. able pain relief and functionality. We observed
The treatment of infected TKA with a two- that unilateral external fixators increased both
staged procedure using a temporary antibiotic- patient and physician’s comfort for the soft tis-
loaded spacer and initiation of systemic sue care around the knee compared with circular
antibiotics based on tissue cultures has been external fixators.
shown to be safe for the control of infections [15,
16]. Parrate et al. reported complete remission of
infection with external fixator arthrodesis as well 30.1 Preparation of the Patient
as the medical treatment in infected TKA [17].
However, Vlasaket al. reported 18% recurrence The patient’s systemic problems (diabetes mel-
of infection around the knee after knee arthrode- litus, rheumatoid arthritis, chronic renal failure,
sis using external fixators [15]. peripheral artery disease, corticosteroid use)
Stable fixation and good bone contact with should be thoroughly evaluated before surgery.
intact circulation of cancellous bone are impor- Many times these patients have systemic prob-
tant to control infection and to obtain success- lems that should be under control because these
ful and early bone fusion [16]. Removal of conditions reduce surgical success and impact
infected and loosened TKA should be per- on wound healing in the event of infection, as
formed early to prevent progressive failure and proven by the presence of three positive tissue
save bone stock, especially with long-stemmed cultures from the knee, and/or fistulas, or soft
TKAs. Unfortunately, it is not the case in most tissue defect. For most patients, the decision for
patients. Knutson et al. demonstrated that exter- knee fusion is based on failed multiple-stage
nal fixation improved stability in patients with debridement and local and systemic antibio-
poor bone stock, especially in the anteroposte- therapy. We prefer to perform knee arthrodesis
rior (AP) plane. It is important for patients to in two stages. Antibiotic-impregnated cement
fully understand the surgical procedure before spacers are placed after implant removal for
undergoing knee arthrodesis. The patient local infection control in the first stage. For
should not be expected to understand the situa- methicillin-resistant species and samples with
tion when first presented with the information, nonpositive cultures, 2000 mg teicoplanin per
and the patient should be informed about how 40 mg cement is used; gentamycin is used as
life will be after surgery because a long leg cast the antibiotic of choice for other species.
will be used. It helps to eliminate the misunder- Multiple samples are taken during the operation
standing that may occur in the future with the for culture and sensitivity. According to the
patient. The recommended ideal alignment of culture results, appropriate antibiotics were
fusion is 5–8° of valgus in coronal plane, 0–15° given for an average of 6 weeks. After the con-
of flexion in the sagittal plane, and 5–10° of trol of the infection, if there is no soft tissue
external rotation (match other leg) in the axial defect and extensor appareil failure, we discuss
plane. Full extension can be preferable if there the revision arthroplasty with patients.
is marked shortening due to previous bone However, in cases of severe medical problems,
resections [18]. we prefer arthrodesis. Lower limb deformities
The use of monoplanar fixators for arthrode- should be examined before surgery and should
sis in infected TKAs can achieve high fusion be planned.
rates with concurrent control of infection. The anteromedial parapatellar approach is
Patients and families should be informed about used during surgery, which is also used in the
the possibility of prolonged fusion durations. If previous procedures. The most lateral (LAT)
fusion can be achieved, the rate of complications incision should be used so as not to harm the
medial perforator arteries, which provide the the bony ends was performed using image inten-
blood supply to the soft tissue and skin if there sifier guidance.
are scar lesions because of the previous surgical The position of the arthrodesis described for
procedures. If there is a transverse incision plan- the knee is indicated as 7 ± 5° valgus and
ning, obtaining an opinion from plastic surgery 10 ± 5° flexion. Knee replacement cutting
will be an appropriate behavior. However, this guides can be used to provide the alignment of
problem does not usually happen after the per- the knee arthrodesis. In this case, it is abso-
pendicular incision which is performed to these lutely necessary to give flexion to knee. Care
wounds. should be taken about keeping incisions to a
minimum so as not to increase the leg length
difference. The use of the vascularized fibula
30.2 Surgical Techniques graft may be necessary if the amount of defect
is excessive. We try to gain fusion with continu-
Old incisions should be considered when choos- ous compression to the area of arthrodesis
ing the incision to be made in the knee. Anterior instead of tolerating the defect with graft in the
parapatellar incisions are usually preferred for infected cases. Resolving the shortness accord-
knee arthrodesis, which is currently performed ing to principles of osteotomy and distraction
due to knee replacement complications. Some osteogenesis performed over the proximal
difficulties may be experienced in removing the femur or tibia is suitable with regard to prevent-
knee prosthesis or applied cements with antibiot- ing recurrence, especially in infected cases.
ics and spacers because of the stiffness of the Reciprocal merging of the bone ends, progres-
knee. In these situations, the use of the soft tissue sive compression (two quarter rounds a week
releases and extensive incisions described for (half a millimeter) during the union period),
stiff knees may be necessary. The important and live bone tips are important to obtain
advantage of the knee arthrodesis after prosthesis fusion. Bone tip infection decreases fusion
is having proper osteotomies compatible with ratios. Planning of the arthrodesis on the
both prosthesis and arthrodesis. infected ground may be in two stages according
Resection guides from the instruments used to the preference of the surgeon. The first stage
for total knee replacement are used to obtain involves debridement, spacer application with
large bone surfaces and valgus angulations at antibiotics, and antibiotherapy, which is accor-
the distal femora. After the reduction and align- dant with the results of the culture. The second
ment checks under X-ray, we temporarily fix the stage is repetitive debridement and revitaliza-
tibia and femur with two 3-mm Kirschner wires. tion of the bone tips with multiple drills, and
The wounds are closed before the application of arthrodesis can be planned. Shortness of the
external fixators using monofilamentous surgi- limb is a desirable condition after knee arthrod-
cal threads [9]. Long unilateral external fixators, esis to aid lifting of the foot without dragging it
LRS type with custom-prepared long side bars, on the ground. A favorable shortness for walk-
are then adapted with Schanz screws. If there ing is about 1.5–2 cm. Patients are mobilized
are no soft tissue defects, we use Schanz screws using crutches just after the operation.
perpendicular to the anatomic axis of the femur Fusion is determined as trabecular bridging
in the sagittal plane, central to the distal femur, between the femora and tibia in anteroposterior
especially in the frontal plane. In patients with (AP) and lateral (LAT) plane knee X-rays. When
osteoporosis who have a low cortex-medulla three cortical fusions are detected, external fix-
ratio, it is also possible to use a second unilat- ators are replaced with custom-made orthotics to
eral fixators in the frontal plane or circular protect the fusions (Fig. 30.4). Fusion is achieved
external fixator. Intraoperative compression of in 4–7 months.
400 H.I. Balci
a b c d
Fig. 30.4 We protect the fusion side with custom-made orthotics after removal of the external fixator
Fig. 30.5 Unilateral LRS-type external fixator applied to a patient on the anterolateral side for the knee arthrodesis
30.3 K
nee Arthrodesis with 30.4 Knee Arthrodesis
Unilateral External Fixator with Circular External Fixator
It has been shown that applying unilateral exter- These are outstanding implants because of the
nal fixators anteriorly increases the stability. superior stability, applied easily with the least
Anterolateral or both anterior and lateral applica- soft tissue damage, and loading can be given at
tions increase patient comfort and provide simi- an early stage. It is possible to correct alignment
lar degrees of stability and union as circular and residual deformities in the postsurgical
external fixators (Fig. 30.5). period. Setting the special arthrodesis position
fixator in principle. Our preferred method con-

tains two full rings 10 cm apart between the distal
femur and proximal tibia, two full rings that
extend to the ankle from the tibia, and full and
half rings to proximal metaphysis in the femur
and/or the frame that reaches with pelvic rings.
Fixation made with hydroxyapatite-coated
Schanz screws in infectious and osteoporotic
cases increases stability. In the tibia we prefer
fixation with K-wires and Schanz screws in two
different planes per ring, but we prefer fixation
with Schanz screws in the femur for circular fix-
ators. Trying not to apply the Schanz screw 3 cm
proximity to arthrodesis area will increase the
fusion chance by the protected periosteal blood
circulation.
The patients’ mobilization and union must be
followed in controls. Fusion is achieved in
4–7 months. The use of a long leg brace after fix-
ator removal is recommended because it reduces
the possibility of refracture in the early stages.
References
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2. Corona PS et al. Outcome after knee arthrodesis for
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7. Puranen J, Kortelainen P, Jalovaara P. Arthrodesis
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bone graft to obtain union, and fusion will be pro- Joint Surg Am. 1990;72(3):433–42.
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by the method of compression-distraction osteosyn- 16. Peersman G et al. Infection in total knee replacement:
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12. Manzotti A et al. Knee arthrodesis after infected total ments. Clin Orthop Relat Res. 2001(392):15–23.
knee arthroplasty using the Ilizarov method. Clin 17. Parratte S, Madougou S, Villaba M, Stein A,

Orthop Relat Res. 2001;389:143–9. Rochwerger A, Curvale G. Knee arthrodesis with a
13. Benson ER, Resine ST, Lewis CG. Functional out- double mono-bar external fixators to salvage infected
come of arthrodesis for failed total knee arthroplasty. knee arthroplasty: retrospective analysis of 18 knees
Orthopedics. 1998;21(8):875–9. with mean seven-year follow-up [in French]. Rev Chir
14. Mabry TM et al. Comparison of intramedullary nail- Orthop Repar Appar Mot 2007;93(4):373–380.
ing and external fixation knee arthrodesis for the 18. Flyn JM. Orthopaedic knowledge update 10, in

infected knee replacement. Clin Orthop Relat Res. orthopaedic knowledge update. Rosemont: American
2007;464:11–5. Academy of Orthopaedic Surgeons; 2011.
Diaphyseal Deformities
of the Tibia 31
Because of the close relationship with the knee 31.1 Frontal Plane Deformities
joint, proximal deformities of the tibia will be
explained in the chapter on 29. Likewise, distal 31.1.1 Tibia Vara
deformities of the tibia will be explained in the
chapter of 32 because of their close relation- Etiology of the tibia vara is listed below:
ship. Diaphyseal deformities of the tibia (or
bowing deformities) will be explained in this 1 . Malunion of the tibia fractures
chapter. 2. Posteromedial bowing of the tibia
Tibial bowing is the bowing of the bone diaph- 3. Fibular hemimelia (anteromedial bowing)
ysis. There are many etiologies for tibial bowing. 4. Congenital Pseudoarthrosis of Tibia
For better analysis, first we classify diaphysis 5. Skeletal dysplasias
deformities according to the planes. 6. Metabolic bone diseases
7. Physiologic genu varum
Classification
1. Frontal plane deformities Most newborns have 10–15° of physiologic
(a) Tibia vara varus deformity in tibia diaphysis, which is called
(b) Tibia valga physiologic genu varum. This varus deformity
2. Sagittal plane deformities becomes more visible on standing or weight-
(c) Tibial recurvatum bearing. Concomitant internal tibial torsion
(d) Tibial procurvatum emphasizes the deformity.
3. Oblique plane deformities (Fig. 31.1) Genu varum is common between the ages of 6
and 12 months. Between 18 and 24 months, the
deformity migrates to neutral. At 4 years the peak
genu valgum is reached. This genu valgum defor-
mity migrates back to normal physiologic valgus
at 7 years of age.
In varus deformities of the tibia diaphysis,
mechanical axis of the lower extremity crosses
Orthopedic and Traumatology Department, medially, much more from the normal interval of
34190 Istanbul, Turkey the knee joint, which leads to overloading in the
e-mail: profcakmak@gmail.com; medial compartment. In time, medial c ompartment

https://doi.org/10.1007/978-3-319-45675-1_31
Fig. 31.1 Clinical (left)

and radiologic (right)
view of the left tibia vara
arthrosis starts with limitation of joint motion and is needed, an open-wedge osteotomy is the best
pain. In the early stages, if the bowing is u nilateral, choice. After the osteotomy fixation can be made
a D-shaped deformity occurs. If the bowing is bilat- with plates or intramedullary nailing. Plate must
eral, an O-shaped deformity occurs (Fig. 31.2). be positioned to the convex side because of the
The first step in diagnosing the deformity is to distraction of the compressive forces through the
perform a malalignment test. The important bone (Fig. 31.4).
question is after how many degrees the deformity Fixation can also be made with monolateral fix-
will be corrected. Up to 10°, bowing of the tibia ator after the osteotomy. Monolateral fixator tech-
is accepted as benign and does not require correc- nique can also be augmented with fixator-assisted
tion. After 10° of bowing, the deformity must be plating. There is no use for dome osteotomy in
corrected. diaphyseal deformities of the tibia (Fig. 31.5).
For finding the CORA, the anatomic axis of For preparation of the frame, four rings are
the proximal and distal segment must be drawn required. The first ring must be positioned 3–4 cm
separately. The intersection of these two axes is distally to the joint surface of the proximal tibia
the CORA (Fig. 31.3). When the bisector line is and perpendicular to the anatomic axis of the
drawn on the deformity angle, CORA can be proximal section. The second ring must be posi-
translated medially or laterally on this line. The tioned 3–4 cm proximally to the osteotomy level.
intersection between the bisector line and the The third ring must be positioned 3–4 cm distally
convex cortex is the position of the hinge. to the osteotomy level. The fourth ring must be
Osteotomy type can be determined according positioned to the 3–4 cm proximally to the ankle
to the length of the extremity. If limb lengthening joint (Fig. 31.6).
31 Diaphyseal Deformities of the Tibia 405
Fig. 31.2 Translation and

angulation deformity on the left
tibia (left). An orthorontgenogram
is required for the deformity
analysis (right)
CORA
Fig. 31.3 Finding the CORA Fig. 31.4 Osteosynthesis with plate
Fig. 31.5 Fixator-assisted plating
Fig. 31.6 Correction of the angulation and translation with an Ilizarov external fixator (Figs. 31.1, 31.2, and 31.6 are
from same patient)
Hinges must be in line with the level of CORA

medially or laterally. For positioning the motor
unit, points at which the hinges are connected
with the rings must be connected. A perpendicu-
lar line from the midpoint of the connecting line
refers to the motor unit position.
31.1.2 Tibia Valga
The etiology of tibia valga is listed below:
1 . Malunion of tibia fractures

2. Posterolateral bowing of the tibia
3. Physiologic genu valgum
4. Congenital pseudoarthrosis of tibia
5. Skeletal dysplasias
6. Metabolic bone diseases
7. Focal fibrocartilaginous dysplasia
8. Fibular agenesis or dysgenesis
When there is a valgus deformity on the tibia,

mechanical axis of the lower extremity crosses at
the knee joint laterally. This leads to overloading
in the lateral compartment, which leads to lateral
compartment arthrosis and limited motion of the
knee joint with pain. If the deformity is unilateral
in early stages, it is known as K-shaped legs. If
the deformity is bilateral in early stages, it is
called X-shaped legs.
For diagnosis, a weight-bearing lower extrem- Fig. 31.7 Finding the CORA
ity X-ray must be taken for the deformity analy-
sis. If the mechanical axis of the lower extremity For determining the osteotomy level, CORA
crosses the midpoint of the knee joint laterally, must be found using the proximal and distal ana-
there is a valgus deformity. tomic axes (Figs. 31.7 and 31.8).
Fig. 31.8 Clinical photo after osteotomy
Frame preparation is similar as at the varus the sagittal plane motion of the knee and
deformity. Motor unit must be on the lateral ankle joint.
side.
31.2.1 Recurvatum Deformity

31.2 Sagittal Plane Deformities Figures 31.9 and 31.10
There are two types of deformities on the sag-

ittal plane of the tibia. Although frontal plane 31.2.2 Procurvatum Deformity
deformities cannot be tolerated, sagittal plane
deformities can be easily tolerated because of Figures 31.11 and 31.12
Fig. 31.9 Hyperextension
angle never exceeds 5º in a
normal knee joint
Fig. 31.10 Genu
recurvatum deformity
Fig. 31.11 Procurvatum deformity

on the right leg
Fig. 31.12 Clinical photo after osteotomy

Bibliography 4. Kocaoğlu M. Treatment of the frontal and sagittal

plane deformities with ilizarov external fixator, first
advanced ilizarov course lecture notes. Vol. 1. Adana:
1. Çakmak M, Bilen FE. Hinge types and positioning. In:
Çukurova University Medical Faculty/Orthopedics
Çakmak M, Kocaoğlu M, editors. Principles of ilizarov
and Traumatology Department; 1977. p. 12–30.
surgery. Doruk Graphics, Istanbul; 1999. p. s63–78.
5. Paley D. Frontal plane mechanical and anatomical
2. Gülşen M. Principles of deformity correction. In:
Çakmak M, Kocaoğlu M, editors. Principles of ilizarov
mity correction. Springer: Berlin; 2002. p. s61–97.
Surgery. Doruk Graphics, İstanbul; 1999. p. s145–66.
3. Green S. Three dimentional analysis of deformities.
In: Third meeting of the ASAMI International Lecture.
Ankle Deformities
32
32.1 Introduction related with the ankle. Therefore, we classify

ankle deformities in three categories:
Ilizarov method may be used for treatment of
deformities that develop as a result of traumas, 1 . Deformities of the distal tibia
burns, neuromuscular diseases, and congenital 2. Deformities of soft tissue
deformities such as pes equinovarus, pes equi- 3. Deformities of talus and calcaneus
nus, pes cavus and metatarsus adductus, varus,
and valgus. Ilizarov method may also be used in
the treatment of dynamic deformities such as pes 32.1.1 Classification of the Ankle
calcaneus. Foot movements and ankle movement Deformities
planes must be well understood to better evaluate
ankle deformities. Ankle movements develop in I. Deformities of distal tibia
three different planes. A. Deformities of distal tibia on frontal plane
1. Varus
1. Sagittal plane: Flexion and extension of the (a) Epiphyseal type
foot and ankle (b) Metaphyseal type
2. Coronal (frontal) plane: Inversion and ever- 2. Valgus
sion of the foot (a) Epiphyseal type
3. Horizontal plane: Abduction and adduction of (b) Metaphyseal type
the foot B. Deformities of distal tibia on sagittal plane
(a) Recurvatum
Proximal metaphyseal and epiphyseal defor- (b) Procurvatum
mities of the tibia are closely related with the knee C. Deformities of distal tibia on oblique plane
and deformities of the distal tibia are closely (a) Equinovarus
(b) Equinovalgus
II. Deformities of soft tissue
A. Equinus
M. Çakmak, Prof. MD (*) • M. Cıvan, MD B. Calcaneus
Istanbul University, Istanbul Faculty of Medicine, III. Deformities of the talus and calcaneus
Orthopedic and Traumatology Department, IV. Multiplane foot deformities
e-mail: profcakmak@gmail.com; A. Fibular hemimelia
melihcivan@gmail.com B. Pes equinovarus

https://doi.org/10.1007/978-3-319-45675-1_32
32.2 D
eformities of the Distal These deformities stem from the distal epiph-
Tibia ysis and metaphysis of the tibia. They are divided
into two groups as varus and valgus deformities
The relationship between the distal tibia and ankle (Fig. 32.9).
on frontal plane: The mechanical axes of the lower
extremity must be examined carefully to better
understand the deformities of the ankle and foot
(Fig. 32.1). The anatomic or mechanical axis of
the tibia passes through the middle of the ankle
(Fig. 32.2) and from the 1/3 lateral of the subtalar
joint (Fig. 32.4) with 90° angle with the distal of
Anatomic Axis of
the tibia on the frontal plane (Fig. 32.3). The cal-
Tibia
caneus is medial of the longitudinal axis (5–6 mm)
and moves in parallel with the axis (Figs. 32.4 and
32.5) and has a 90° angle to the ground (Fig. 32.6).
1/2
1/2
32.2.1 Deformities of the Distal Tibia
on the Frontal Plane
When there is orientation disorder on the distal

joint surface of the tibia on the frontal plane, the
subtalar joint tries to compensate, but its com-
pensation capacity is limited. The subtalar joint
Fig. 32.2 The anatomic or mechanical axis of the tibia
compensates varus (Fig. 32.7) deformities up to passes through the middle of the ankle on frontal plane
15° and valgus deformity up to 30° (Fig. 32.8) by
inversion or eversion.
Anatomic Axis
of Tibia
Fig. 32.3 Joint surface of the ankle has 90° angle with
the mechanical axis of the tibia on frontal plane normally
Fig. 32.1 Normal anatomy of the distal tibia, ankle, sub-

talar joint, and heel on the frontal plane
32 Ankle Deformities 415
1/3 1/3
1/3
Fig. 32.6 The mechanical axis of the lower extremity has

a 90° angle with the ground on the frontal plane
a b
Fig. 32.4 The mechanical axis of the lower extremity
passes 1/3 lateral of the subtalar joint
5-6mm medial
Anatomic Axis of
Calcaneus
Fig. 32.5 The mechanical axis of the lower extremity is

parallel to the mechanical axis of the calcaneus and passes
through 5–6 mm medial of the calcaneus
Fig. 32.7 Varus deformity on the distal end of the tibia.

(a) Lack of compensation with the subtalar joint, (b) com-
pensation with the subtalar joint
a b 32.2.1.1 Varus Deformity

Etiology The causes of varus deformities of the
distal tibia on the frontal plane are specified as:
1. Malunion of the distal metaphysis of the tibia

or pilon tibial fractures.
2. Partial damage medial of the distal growth
cartilage of the tibia and growth arrest in
childhood. But bone growth continues in the
lateral part.
3. Congenital soft tissue contractor (pes equin-
ovarus) on the medial tibia or subsequent
solid scars (sequela of burns).
4. Bone dysplasia.
5. Tibial aplasia or hypoplasia.
Clinic Varus deformity of the distal tibia is com-

pensated by the subtalar joint if the deformity is
smaller than 15° and if the subtalar joint is
mobile. Contracture develops on the subtalar
joint if the compensation lasts for a long time on
angled deformities of the distal tibia.
The contracture limits the joint movements.

Compensation masks the deformity. Finally, a zig-
zag deformity develops in the ankle. Degenerative
changes and contracture develop on the joint if
they are not treated. Varus develops in the heel if
the deformity is wider than 15° or if the subtalar
Fig. 32.8 Valgus deformity on the distal end of the tibia. joint is stiff. Patients stand with the distal side of
(a) Absence of compensation with the subtalar joint, (b)
compensation with the subtalar joint the heel or foot (Figs. 32.10, 32.11 and 32.12).
Fig. 32.10 Varus deformity of the right distal tibia. The

Fig. 32.9 The clinical appearance of a valgus deformity patient stands with the external side of the foot (not
in the left tibia compensated)
Fig. 32.11 Pre-op
clinical image with
varus deformity on the
left foot (L). The
patient stands using the
external lateral portion
of the foot
Fig. 32.12 Pre-op images

of both feet of a patient
with varus deformity in the
left foot (L)
Varus deformity of the ankle is a disturbing defor- Arthrosis and eventually movement restriction
mity. Valgus deformities can be tolerated, whereas develop on the joint of the ankle over time.
varus deformities cannot be tolerated. There is Mobility of the subtalar joint is checked by
pain on the external lateral part because the exter- examining movements and using the Coleman
nal lateral ligaments are forced while standing. test.
Fig. 32.13 Post-op clini-

cal images of both feet of a
patient in Fig. 32.11; the
heel after fixation of the
deformity
Fig. 32.14 Post-op
images of both feet of the
patient in Fig. 32.11; the
heel after fixation of the
deformity
The compensation percentage of the subtalar be included on the image). The lateral distal tibial
joint, which helps decide the fixation degree of angle (LDTA) between these lines is measured
the angular deformity, is evaluated (Figs. 32.13 (Fig. 32.15).
and 32.14). This angle is normally between 86° and 92°. If
the degree is over 92°, it indicates a varus defor-
Diagnosis of the Deformity The anatomic or mity in the distal tibia.
mechanical axis of the tibia or distal tibial orien- Malalignment must be checked by drawing the
tation line is drawn on the standing AP radiogra- axes of the tibia, talus, and calcaneus to evaluate
phy of lower extremity (ankle and knee must also pathologies in the back part of the foot and ankle
LDTA (86º-92º) LDTA > 92º LDTA <86°
VALGUS
NORMAL
VARUS
Fig. 32.15 Normally LDTA is 89º± 3º. It is called varus deformity if the angle is over 92° and valgus if it is smaller than 86°
before deciding the type and location of the

osteotomy.
Identification of the CORA A vertical line is

drawn from the middle of the ankle to identify
the degree of deformity and the CORA point.
This vertical line indicates the mechanical axis of
the distal segment of deformity. Its intersection
point with the mechanical axis of proximal
segment shows the CORA. The angle between
the two lines refers to the degree of deformity
(Fig. 32.16).
Osteotomy Options Osteotomy cannot be

performed in cases where the location of the oste-
otomy (the angle bisector passing through the
CORA) is very close to the joint. Therefore, the
location must be shifted. Translation develops
between the axes of two fragments as long as the
osteotomy is performed in a different location
other than the CORA and the angle bisector. If
deformity fixation is planned with closed or open
wedges, then translation must also be fixed. The
Fig. 32.16 Intersection point of the distal and proximal
fibula comes to the opposite of the tibia when the mechanical axes is the CORA
Fig. 32.17 (a) Open-

wedge osteotomy in varus a b c
deformity. (b) Translation
develops after osteotomy.
(c) The corrected form of
translation; the tibia is
aligned with the fibula
proximal fragment is lateralized to fix the transla- planned after osteotomy. Only one ring is fixed
tion (Fig. 32.17). because the distal fragment is not wide enough to
Dome osteotomy must be preferred in such fix two rings (Fig. 32.19). The ring must be placed
cases because it provides translation as long as it about 3 cm proximal of the distal tibial joint sur-
repairs the angulation. Dome osteotomy must not face and 3–4 cm distal of the osteotomy line. The
be chosen when there is a rotational deformity, and ring must also be placed vertically to the mechani-
fixation of this deformity is planned because dome cal axis of the distal segment. Fixation is reinforced
osteotomy provides only single-plane fi xation. If with an offset K-wire because fixation on one level
dome osteotomy is performed in the p resence of will not be sufficient. Both rings are fixed vertically
both varus and rotation, the varus component of the to the mechanical axis of the proximal fragment.
deformity will be fixed, but the rotation component The ring in the middle is fixed 3–4 cm proximal of
cannot be fixed. The rings, the centers of which are the osteotomy line, and the upper ring is fixed
chosen as the CORA, are drawn to perform dome 3–4 cm distal of the proximal joint surface.
osteotomy (Fig. 32.18). The most appropriate place
for osteotomy is the circle with the smallest radius Advantages of Ilizarov Method Postoperative
that intersects both the cortex of the distal tibia and fixation is possible with Ilizarov. No other
the appropriate piece (5–6 cm). Circles 1, 2, and 3 method provides this. Another advantage is that
do not intersect both cortexes on Fig. 32.18 patients can weight bear after the operation.
Circle 5 and circle 6 intersect both cortexes
and provide sufficient length for fixation. If circle Positioning of the Hinges and Motor Unit Two
6 is preferred, then there will be less interaction hinges are fixed to the anterior and posterior of the
between the fragments after fixation; this may ankle. They must be replaced just on the CORA or
cause esthetic defects and bone malunion. Circle on the bisector which passes through the
5 is the most appropriate for fixation (Fig. 32.18). CORA. Hinges are shifted to more lateral of cor-
tex of the convex bone if shortness is present on
Frame Preparation The frame must be prepared the extremity. A straight line is drawn from the
1 day prior to the surgery if fixation with Ilizarov is middle of the vertical line that connects the foot of
Fig. 32.18 Identification
of the dome osteotomy
line. If circles are
numbered as 1, 2, 3, and so
on from the inside out, the
first three circles do not
intersect both cortexes
Fig. 32.19 Rings are

fixed vertically to the
distal and proximal
mechanical axes of the
tibia by fixing one ring
on the proximal and
two rings on the distal
of the osteotomy line
A 3. Congenital soft tissue contractures or acquired

Hinge stiff scars (sequelae of burns) in lateral part of
ankle
4. Bone dysplasia
5. Fibular aplasia or hypoplasia
L M Clinical When there is a valgus deformity in the

Motor Unit distal tibia, the deformity is compensated up to 30°
by inversion of the subtalar joint if the subtalar
joint is mobile. In such cases, a zigzag deformity
develops. This deformity cannot be compensated
Hinge
or can partially be compensated. In both cases, the
contact area on the surface under the talus
P decreases. Therefore, the mass on the unit area
increases. Regardless of the compensation of the
Fig. 32.20 Placement of hinges and the motor unit on valgus deformity, the axis of the foot moves lateral
varus deformity
of the tibial axis (translation develops). Axial mis-
alignment (translation) causes an increase on the
load moment arm and an increase in stress (par-
both hinges. Motor unit is placed at the intersec- ticularly shearing stress) both on the ankle and
tion point of this line with the rings (Fig. 32.20). subtalar joint. If this compensation continues for a
long period of time, contracture develops on the
Identification of the Fixation Degree Fixation subtalar joint over time. The contracture restricts
of angular bone deformities is generally per- the joint movements, and eventually a zigzag
formed as much as the deteriorating angle. The deformity develops in the ankle (Fig. 32.21).
knee and ankle are the exceptional regions in
fixation. The aim of fixation on ankle deformity
is to provide plantigrade step. If the subtalar
joint is mobile, then the fixation will be as much
as the deformity. If the subtalar joint is stiff,
then the angle of the heel with the ground is
evaluated regardless of the bone deformity in
the tibia. If the bone deformity is 30° on the
curved lower end of the tibia, and 15° of defor-
mity is compensated with the inversion of the
subtalar joint, and if this joint is stiff, then the
fixation angle will be 15°.
32.2.1.2 Valgus Deformity

Etiology Causes of valgus deformity can be cat-
egorized as follows:
1. Malunion of fractures of distal tibial metaphy-

sis or pilon
2. Partial defect on distal tibial growth cartilage Fig. 32.21 Posterior appearance of translation when there
in childhood and arrest of the growth at the is a valgus deformity on the tibia and compensated by the
tibia without medial side affected subtalar joint and development of a zigzag deformity
Fig. 32.22 A patient with a valgus deformity in the distal

tibia stands with the inner edge of the heel because the
subtalar joint cannot compensate the deformity
Degenerative changes, joint contracture, and sub-

luxation develop in the subtalar joint if the defor-
mity is not treated. Patients will stand with the
inner edge of the heel and foot if there is a loss in
mobility of the subtalar joint or if the deformity is
greater than 30° (Fig. 32.22).
Varus deformity on the ankle is a mutilating
condition; however, valgus deformity is not as
severe. There is pain on the medial of the ankle
because the medial ligaments are constantly forced
while standing or walking. Arthrosis, pain, and
movement restriction develop in the ankle over Fig. 32.23 Measurement of the angle of deformity on AP
time. radiograph
Diagnosis of the Deformity Anatomic or of the deformity. If we draw the mechanical axis
mechanical axis of the tibia or distal tibial orien- of the proximal segment of deformity, the
tation line is drawn on the standing AP radiogra- intersection point with the first line will be the
phy of the lower extremity (ankle and knee must CORA (Fig. 32.24).
be included) (Fig. 32.23). The external lateral
angle (LDTA) between these two lines is mea- Osteotomy Options Distal tibial deformities
sured. This angle is normally 89°. Angles between stem from the metaphysis and epiphysis. The
86° and 92° are considered normal. If the angle is location of the osteotomy in epiphyseal deformi-
smaller than 86°, it is considered as valgus ties is on the joint space of the angle bisector pass-
deformity. ing through the CORA and talus. In such cases,
we have to change the location of the osteotomy
Identification of the CORA A line is drawn because it cannot be performed in this area. Let’s
from the middle of the ankle to find the degree remember the osteotomy rules: If osteotomy is
of deformity and CORA point. This line gives performed on another location other than on the
us the mechanical axis of the distal segment CORA and the angle bisector, then translation
Identification of the Fixation Degree Fixation

will not always be as much as the degree of
deformity. If there is a rigid compensation on the
subtalar joint, correction as much as the defor-
mity degree fixes the tibial orientation, but the
patient will still have difficulty on stepping.
Fixation will be as much as the deformity degree
if the compensation is not rigid. If the compensa-
tion is rigid, then the rigidity degree is extracted
from the deformity degree. Fixation will be as
much as the remaining angle.
Building the Frame This is the same as

explained in varus deformity. The only difference
between the two frames is that the motor unit is
medial in varus deformities and lateral in valgus
deformities.
Positioning of the Hinge and the Motor

Unit Two hinges are fixed proximal to the ankle,
distal of the crus and on the anterior surface on
the line of CORA, and to the posterior. Hinges
must only be fixed on the CORA (Figs. 32.25,
32.26, and 32.27).
They must be shifted to the lateral if there is
shortness on extremity. A straight line is drawn
toward the medial to the medium of the line that
Fig. 32.24 Identification of CORA in a valgus interconnects the two hinges. The motor unit is
deformity placed at the intersection point of this line.
will develop between the axes of two fragments. A
Dome osteotomy must be preferred when there is

Hinge
a need for a different location for osteotomy other
than the CORA. Therefore, dome osteotomy must
be preferred for epiphyseal deformities. There
will be no problem on metaphyseal deformities.
Closed-wedge, open-wedge, or dome osteotomy
may be performed. If shortness is present on the
L M
extremity, straight osteotomy and fixation with
Motor Unit
open wedge is preferred.
Level of the Osteotomy Level of the osteotomy

is generally on the bisector angle passing through
the CORA when straight osteotomy with open
wedge is preferred. If a dome osteotomy will be Hinge
performed, then circles are drawn by fixing the
P
point of a compass on the CORA point. The place
of the osteotomy will be on the circle that inter- Fig. 32.25 Placement of the hinge and motor unit on
sects both cortexes and has the smallest radius. varus deformity
Fig. 32.26 AP radiograph and clinical

appearance of a valgus deformity in a patient
with short foot and nonexistent fibula
Fig. 32.27 Image of a

recovered valgus
deformity in a patient
with short leg and left
fibular agenesia
Full recovery with osteotomy is only possible ties on the sagittal plane originate from the distal
when the hinges and motor unit are appropriately epiphysis and metaphysic region. They develop
placed. as procurvatum and recurvatum.
32.2.2.1 Deformity of Recurvatum

32.2.2 Distal Tibial Deformities Clinic If the ADTA angle is less than 78° in the
on Sagittal Plane distal tibia, it is called recurvatum (Fig. 32.30).
Dorsiflexion movement of the ankle increases
The Relationship Between the Foot and Distal
but plantar flexion decreases. This situation
Tibia on the Sagittal Plane There is an 80°
decreases the loading surface and leads to arthro-
angle (ADTA) between the mechanical or
sis, pain, and restriction at the joint range of
anatomic axis of the tibia and distal joint orienta-
motion over time. They must be treated if changes
tion line on the sagittal plane. In other words,
of pre-arthrosis and symptoms are present.
there is a 10° angle between the horizontal axis
and distal tibial joint line (Fig. 32.28). The
Deformity Diagnosis A standing lateral X-ray
mechanical axis of the tibia passes through the
must be taken including the knee and ankle joint.
middle of the ankle and external ledge of the
The anatomic axis of the tibia and distal tibial
talus (rotation center of the ankle) and is vertical
orientation line is drawn on the radiograph, and
to the ground (Fig. 32.29). Distal tibial deformi-
the ADTA degree is measured. A normal value is
80°. Measurements below 78° indicate recurva-
tum on the distal tibia.
Identification of the CORA The center of the

deformity (CORA) must be identified to
determine the osteotomy level. A vertical line is
drawn from the middle of the ankle to proximal
region with an 80° angle. This line shows the
mechanical axis of the distal segment of the
deformity. The intersection point of the mechani-
cal axis of the proximal segment of the deformity
Fig. 32.28 There is a 10° angle between the distal joint

surface of the tibia and the horizontal axis on sagittal plane
ADTA < 78°
Fig. 32.29 The mechanical axis of the tibia passes

through the middle of the ankle and external ledge of the Fig. 32.30 If ADTA is less than 78° then recurvatum is
talus and is vertical to the ground present on the extremity
ADTA < 78°
Translation
Fig. 32.31 Identification of the CORA on recurvatum

deformity
Fig. 32.33 Translation present with open-wedge osteotomy
Deformity Angle
Wedge Angle
aesthetic flaw
Fig. 32.32 Identification of the wedge angle to be

extracted in open-wedge osteotomy
with this line will be the CORA (Fig. 32.31). The

angle between these two lines is the deformity
angle. An angle bisector is drawn after the CORA
is identified. If a straight osteotomy will be pre-
ferred, then it will be placed on the bisector.
Fig. 32.34 The esthetic flaw encountered while fixing
Osteotomy Options The options are classified translation with open-wedge osteotomy
as metaphyseal and epiphyseal osteotomies. The
CORA is generally on the joint cartilage or very The same problem develops if the deformity is
near to it on epiphyseal osteotomies. In such fixed using a closed-wedge osteotomy (Figs.
cases, the location of the osteotomy has to be 32.35 and 32.36).
changed. Translation will develop after the Straight and open-wedge osteotomy is pre-
change. Translation must also be fixed. A signifi- ferred for fixing the deformity if the extremity is
cant translation will develop and this deformity is congenitally short. Straight osteotomy is replaced
fixed with an open osteotomy. Esthetic defects from the CORA point and toward the bisector.
develop after fixation of the translation (Figs. Circles are drawn to perform dome osteotomy,
32.32, 32.33, and 32.34). the center of which will be the CORA. The most
1
2
3
Fig. 32.37 Drawing circles centralized on the CORA to

Fig. 32.35 Translation developed while fixation using identify the location of the osteotomy, best option for
closed-wedge osteotomy dome osteotomy can be applied on circle 5 (pay attention
to the circles from 1 to 5)
aesthetic flaw
Fig. 32.38 Fixation of the deformity after dome

osteotomy
Fig. 32.36 Esthetic flaw is obvious even if the translation

that develops while fixing with closed-wedge osteotomy full ring or a 5/8 open ring so as not to restrict
is fixed flexion movement of the knee. The second ring is
fixed vertical to the anatomic axis and 4 cm prox-
appropriate place for osteotomy is the circle that imal of the osteotomy region. A ring is fixed
intersects both cortexes of bone and has the short- 3–4 cm proximal of the distal joint surface and
est radius (Figs. 32.37 and 32.38). The contact vertical to the anatomic axis of the distal frag-
area of the fragment will be wider after fixation if ment for fixing the distal fragment (Fig. 32.39).
the circle with the smallest radius is chosen.
Positioning of the Hinges If shortness is not
Frame Preparation A ring at the level of the present on the extremity, two hinges are fixed on
tuberositas tibia is fixed 3–4 cm distal of the joint the CORA, one to the medial and the other to the
surface and vertical to the anatomic axis for fixa- lateral, and the motor unit is fixed to the anterior
tion of the proximal fragment. This ring may be a (Fig. 32.40).
ADTA > 82º
Fig. 32.41 Procurvatum deformity – ADTA angle is

wider than 82°
32.2.2.2 Procurvatum
Clinical If the ADTA angle is over 82°, it is
called procurvatum (Fig. 32.41). The loading
axis of the foot moves to the anterior on procur-
vatum (Fig. 32.42). Plantar flexion of the ankle
increases with procurvatum in the distal tibia
(Fig. 32.43). However, dorsiflexor movement
Fig. 32.39 Preparation of the frame and appearance of decreases (Fig. 32.44). Recurvatum deformity is
the bone after dome osteotomy
well tolerated in the distal tibia, but procurva-
tum is difficult to tolerate. Impingement and
P pain are common between the anterior of the
talus and tibia during dorsiflexion movement on
the anterior of the ankle. This impingement
causes early period symptoms. Arthrosis, pain,
and movement restriction develop in the ankle
over time.
Hinge
L M
Hinge Diagnosis of the Deformity Standing LAT
radiograph of the tibia, ankle, and foot (Figs.
32.43 and 32.44). The anatomic axis of the tibia
is drawn on the radiograph. Lower ends of joint
surface of the distal tibia are connected. There is
generally an 80° angle on the anterior between
A these two lines. An angle over 82° indicates a
Motor Unit procurvatum deformity in the distal tibia.
Determination of the CORA The center of

Fig. 32.40 Fixation of the hinges and the motor unit on the deformity (CORA) must be identified to
recurvatum determine the osteotomy level (Fig. 32.43). A
Fig. 32.42 Clinical appearance of procurvatum deformity
CORA
Fig. 32.44 Radiograph of a patient with procurvatum

deformity in dorsiflexion at the lower end of the left tibia
the distal segment of the deformity. The inter-

section point of this line and the mechanical
axis of the proximal segment of the deformity is
the CORA. The angle between these two lines
gives the degree of the deformity. If a straight
osteotomy will be performed, then it must be
fixed on the bisector.
Fig. 32.43 Radiograph of a patient in plantar flexion Osteotomy Options A straight osteotomy with
with procurvatum deformity at the lower end of the tibia open wedge is preferred when there is shortness
in the extremity. An osteotomy is fixed that
vertical line is drawn from the middle of the passes through the CORA and in the direction of
ankle joint to proximal section with an 80° the bisector. To perform a dome osteotomy, the
angle. This line shows the mechanical axis of center of the circles placed on the CORA is
drawn. The most appropriate place will be the

intersection point of both cortexes of the bone
with the circle that has the smallest radius (Fig.
32.44). A larger surface area will be provided
after fixation of the deformity if the circle with
the smallest radius is used.
Tibia Ground
Frame Preparation The frame must be pre- Angle 130°
pared as explained with recurvatum. The only
difference is that the motor unit is placed to the
anterior on recurvatum and to the posterior on
procurvatum.
Equinus Angle 40°
Replacing the Hinges Two hinges are fixed to
the medial and lateral of the CORA on both
straight and dome osteotomy. The distraction
unit is fixed to the intersection point of the lines Fig. 32.45 Tibia-ground angle is 130° and equinus angle
is 40° on equinus deformity (equinus angle = tibia-ground
on the ring. The motor unit must be replaced on angle – 90°; 130°– 90° = 40°)
the posterior. If there is shortness in the extrem-
ity, the hinge is shifted out of the borders of bone
on the bisector. Extremity lengthening and
deformity fixation are performed together in this
method.
32.3 Equinus Deformity
32.3.1 Definition
Fixed position of the ankle in any position

between neutral and 45° in the sagittal plane and
inability for active or passive dorsiflexion move-
ment to the starting point are called equinus
deformity. The calcaneus and talus are also
involved in true equinus. The distal end of the
calcaneus moves toward plantar flexion, and the
proximal end moves toward the upper direction. Fig. 32.46 Tibia-ground angle: the angle between the
Plantar flexion deformity is present in the calca- horizontal line connecting the lower end of the head of
the first metatarsal with the long axis of the tibia and
neus. The talus also moves to plantar flexion
calcaneus. This angle is 90° in normal standing radio-
with calcaneus (Fig. 32.45). graph. The tibia-plantar angle increases on equinus
Incorrected part of plantar flexion from the deformity
neutral is defined as equinus. Normal value
between the tibia and ground angle is 90°. A
tibia-ground angle over 90° is defined as equinus involved in this deformity. The center of the foot
deformity (Fig. 32.46). and forefoot is observed on plantar flexion start-
Pes equino-cavus is the other deformity ing from the Chopart joint. This is defined as
observed on sagittal plane. The calcaneus is not forefoot equinus (Fig. 32.47).
7. Equinus may develop as a complication of

tibial lengthening.
8. Equinus deformity may develop as a compli-
cation during translation of the distal segment
proximally for the treatment of proximal tibial
defect pseudoarthrosis.
32.3.3 Clinical
Equinus deformity is evaluated in three

categories:
1 . Mild: Between 0° and 20°

2. Moderate: Between 20° and 40°
3. Severe: The degrees over than 40
Fig. 32.47 Forefoot equinus

Most mild equinus deformities and some mod-
erate deformities may be fixed with nonsurgical
approaches such as stretching, plastering, and
orthosis. Most moderate deformities can be treated
32.3.2 Etiology
with achilloplasty methods particularly with Hoke
percutaneous achilloplasty. Equinus deformity up
32.3.2.1 Causes of Equinus Deformity
to 45° is generally a result of compensation of
1. Myelodysplasia: Equinus deformity is present
about 5 cm shortness at the lower extremity.
in 22 % of all cases.
Equinus deformities may be classified as the
2. Poliomyelitis: Develops when plantar flexors
following according to the treatment options:
are normal or slightly abnormal and dorsiflex-
ors are paralytic or develops due to gravity
1. Equinus deformities smaller than 45°:
when all foot muscles are paralytic.
(a). Mild and moderate: Treated with
3. Cerebral paralysis: Equinus develops over time
achilloplasty.
if gastrocnemius and soleus muscles are spastic.
(b). Severe: Ilizarov method is used in addi-
4. Shortness in extremity: Patients hold the foot
tion to achilloplasty.
in the equinus position to compensate for the
2. Achilloplasty and lengthening with Ilizarov
shortness while walking. Equinus position
methods are used in the treatment of equinus
(the foot can be actively moved toward dorsi-
deformities up to 45° with 5 cm shortness at
flexion) transforms to equinus deformity (foot
the same lower extremity.
cannot move toward normal dorsiflexion and
3. Equinus deformities between 45° and 60°

to the starting point actively) over time.
where pes cavus is involved (explained in pes
5. Post-trauma: Covering open and closed tibial
cavus section).
fractures with plaster for extended periods
4. Equinus deformities over 60° are always pres-
when the ankle is in the equinus position may
ent with cavus deformity, and scythe osteot-
cause equinus deformities.
omy is used in treatment.
6. Paralysis of the fibular nerve: The foot cannot
move toward the zero point and to dorsiflex-
ion actively because the ankle dorsiflexors are 32.3.4 The Clinical Measurement
paralyzed. Passive movement to the zero point of Equinus Deformity
is possible; but this is defined as drop foot
deformity, not equinus. Drop foot may trans- Tibia-ground angle: The patient is requested to
form to equinus over time. move the ankle to dorsiflexion in the supine
Fig. 32.48 Normal dorsiflexion angle of the ankle is 20°
Fig. 32.50 The angle between the tibia and the first
metatarsal
Fig. 32.49 Plantar flexion angle of the ankle is 40°

(130°−90° = 40°)
position when the extremity is in a neutral posi-

tion (midinguinal, center of the patella, center of
the ankle, and the first and second finger of the
foot must be on the same level). One face of the
goniometer is placed parallel to the tibia, and the
other face is replaced parallel to the ankle. If the
angle between them is over 90°, it is called an Fig. 32.51 The tibiocalcaneal angle
equinus deformity. Then, the foot is passively
moved to dorsiflexion when the patella is on
extension, and the angle is measured with goni-
ometer again (Figs. 32.48 and 32.49). If there is leg and the whole foot. The angle of equinus
a difference between these two measurements, deformity is obtained by subtracting 90° from the
this shows the tensibility of the Achilles tendon. anterior angle between the long axis of the leg
and long axis of the foot.
The following radiologic measurements are
32.3.5 Radiography Measurement also obtained:
of Equinus Deformity
1. Angle of the tibia and the first metatarsal

Standard lateral X-rays of both feet and ankle in (Fig. 32.50)
a symmetric position and AP X-rays are required. 2. Tibiocalcaneal angle (Fig. 32.51)
A lateral image must show the lower end of the 3. Tibiotalar angle (Fig. 32.52)
32.4.1.2 Open Method

(a). Z method for lengthening: A vertical inci-
sion is made through the medial of the ten-
don by starting from the insertion point of
the Achilles tendon. After the exposure, a
cut in the shape of Z must be performed. The
foot is forced into dorsiflexion.
(b). V method for lengthening: An incision is
made from 1 to 3 distal and posterior to the
calf. Connection points of the gastrocnemius
and soleus are identified. Insertion point of
the soleus to the gastrocnemius is cut in a V
shape. The foot is forced to dorsiflexion. If
Fig. 32.52 The angle between the axis of the talus and
the expected correction is obtained with
horizontal plane is 24.5°. The angle between the axis of forced dorsiflexion, the extremity is covered
the talus and tibial axis is (tibiotalar angle) 115° with plaster and kept in that position for
1.5 months. If the correction is not possible,
the deformity is fixed using Ilizarov method.
32.4 Treatment
The methods used in treatment of deformities

32.4.2 Ilizarov Method
may be classified as classical methods, Ilizarov
method, and combined methods.
There are two parts for the leg and foot. Two sec-
tions are connected with grooved rods. The leg
part consists of two rings. The rings are fixed to
32.4.1 Classical Methods
the tibia with two wires for each part and rods are
fixed to one another (Fig. 32.53).
32.4.1.1 Percutaneous Subtotal
Tenotomy
(a). One-cut method: The Achilles tendon is cut 32.4.2.1 K-Wire Applications
with a no. 15 blade from about one finger’s to the Tibia
width away from the tendon’s insertion The distal tibial ring is fixed to the intersection
point. The surgeon keeps the foot on maxi- line of 1/3 middle and distal sections of the
mum dorsiflexion with the other hand. The tibia. The ring is fixed with two K-wires
dorsiflexion angle increases when the ten- (1.8 mm). The first wire passes through the fib-
don is cut. The dorsiflexion angle is ula and tibia. One stop wire passes through the
increased by force. posterolateral to the anteromedial aspect to pro-
(b). Two-cut method: The Achilles tendon is cut tect the syndesmosis, and the olive stands to the
using a no. 15 blade from about one finger’s proximal fibula. The wire is pulled out at pos-
width away from the tendon’s insertion point teromedial side.
just as in the one-cut method. The sharp end The entrance point of the second wire must be
of the blade is turned 90° and the medial half selected carefully. The distance between the ante-
of the Achilles tendon is cut. A second cut is rior edge of the tibia and fibula is divided into
made from 5 to 6 cm distance. This time the three parts. The anterior zone is a dangerous zone
blade is turned laterally and the lateral half because vessels and nerves pass through. Muscles
of the Achilles is cut. The foot is forced into pass through the middle zone so it is less danger-
dorsiflexion. ous. The second wire is threaded through the tibia
cortex providing the widest angle with the first

screw, but again the screw is not pulled out and is
buried into the cortex.
32.4.2.3 Medium Tibial Ring

The medium tibial ring is fixed approximately to
the intersection of 1/3 upper and 1/3 medium of
the tibia. The first wire is threaded from one fin-
ger’s width posterolateral of the front side of the
tibia and comes up from just the anterior of the
medial edge of the tibia. The entry point of the
second wire is approximately 5 mm below the
first wire. The fibula is palpated and the wire is
pushed through, one finger anterior of the fibula;
the exit point is organized to be one finger length
posteromedial of the front edge of the tibia.
32.4.2.4 Fixation with Schanz Screw

One wire and two Schanz screws may be used
instead of two wires in fixation of medium tibial
ring. One K-wire is pushed through the intercon-
nection point in the upper 1/3 and medium tibia,
from one finger’s width lateral and posterior to
come up through the anterior of the medial end of
the tibia. In the same level, one Schanz screw is
Fig. 32.53 Illustration of the Ilizarov rigid frame fixed to the opposite cortex through the medial
face of the tibia. Fixation can be performed with
only two Schanz screws by fixing the first one to
5 mm distal of the first wire. This wire comes up the medial aspect of the tibia and the other to the
from the anterior of the medial edge of the tibia. crista of the tibia.
Surgeons must avoid damaging the great saphe-
nous vein. 32.4.2.5 M ild to Moderate Equinus
Deformity up to 45 Degrees
32.4.2.2 Fixation with Schanz Screw Three-holed screw plaques and a half ring are
Rings on the distal tibia can be fixed with Schanz used on the bases of heads of the metatarsus if the
screws or a hybrid system. First, one K-wire of deformity is mild to moderate and if the patient is
the distal ring is threaded through the fibula to the a child or an adolescent, particularly in cases
tibia. The first Schanz screw is then threaded with cerebral palsy. Two K-wires and a full ring
through the intersection point of the middle and are replaced to the proximal tibia. This ring is
lower 1/3 of the tibia, thus from the medial end of supported with two three-holed plaques and a
the tibia. The screw passes the first cortex and is connecting wire. Half ring is placed to the
buried to the opposite cortex, but the screw is not forefoot and fixed with two K-wires. Tibial full
pulled out of the cortex. The second Schanz ring and half ring of the forefoot are attached
screw is adopted to the ring in the level of medial with two telescopic rods, and the Achilles tendon
surface of the tibia using three or four cannulated is relaxed with subtotal tenotomy. On the seventh
cubes. The second screw is sent to the opposite day after the operation, lengthening of the
Achilles tendon is initiated. Fixation of the defor- of anterolateral edge of the tibia. The thick cortex
mity starts with stretching of the telescopic rods. just in the back of medial line of the tibia is the
target. A reference K-wire and a Schanz screw
32.4.2.6 S evere Equinus Deformity may also be used as an alternative method. Bone is
up to 45 Degrees drilled with a cannulated drill from a K-wire pass-
Two full rings (one to the interconnection point ing through the center of the capitulum of the fib-
of 1/3 proximal and 1/3 medium, the other one is ula to fix a second Schanz screw. The Schanz
fixed to the interconnection point of medium 1/3 screw is then threaded through the anteromedial of
and distal 1/3 part) are used. The entry point of the tibia by passing through the capitulum of the
the second wire is one finger distance anterior of fibula.
the palpable end of the fibula and 5 mm below the
first wire. The exit point of the first wire is just 32.4.2.8 The Foot Region
anterior of the medial end of the tibia. The entry The wires pass through three different parts on
point of the first wire is one finger distance pos- the foot:
terolateral of the front edge of the tibia.
The exit point of the second wire is one finger 1. Calcaneus
distance posteromedial of the front edge of the 2. Midtarsal region
tibia. A 140° angle is placed to the palpable edge 3. Metatarsal heads
of the fibula and fixed with two K-wires. One half
ring is fixed to calcaneus and one half ring is fixed 1. Calcaneal wires: Posterior tibial arterial pulse
to the forefoot. Rings are connected with rods. is checked, and first wire is threaded through a
finger width posterior of the pulse. The wire is
32.4.2.7 The Proximal Ring threaded through the anterolateral (about 30°).
First wire is threaded parallel to the joint surface to The second wire is threaded through 1 cm
come up from the posterior of the vertical line anterior point of the first wire and proceeds on
drawn on the patella medial by passing through the anterolateral (about 30°) (Figs. 32.54, 32.55,
center of the capitulum of the fibula. The second and 32.56).
wire is threaded parallel to the joint by passing 2. Wires on midtarsal region: These wires are
through the posterior vertical line drawn vertically used when there is a pes cavus deformity
from the lateral edge of the patella on the antero- accompanying an equinus deformity. The
lateral edge of the tibia about 5 mm distal of the first wire is threaded through the tuberosity
center of the capitulum of the fibula, and the wire of the navicular and exits from the center of
is threaded to come up in the same level of the the external surface of cuboid. The second
entrance point and in the anterior point of the wire is threaded to provide a 30° with the
medial edge of the tibia. A third wire may also be first wire.
used if lengthening is planned. The third wire is 3. Wires on the metatarsal heads: The first wire
threaded to come up from the medial edge of the is threaded through the external surface
tibia passing through the lateral edge of the ante- between the head and neck of the fifth meta-
rior of the capitulum of the fibula. First, a refer- tarsal head. The wire passes through the third,
ence wire is threaded through the anterolateral of
the lateral condyle of the tibia and one finger front
of capitulum of the fibula and parallel to the knee
if Schanz screw is used in proximal ring. The sec-
ond K-wire is then threaded through the center of
the capitulum of the fibula as defined above. A
Schanz screw is threaded through a vertical line
drawn from the lateral edge of the patella, about Fig. 32.54 Positions of wires on the calcaneus and the
12 mm below the reference K-wire and upper end metatarsus
Fig. 32.55 Side view of the calcaneus wires
Fig. 32.56 Illustration of the upper view of calcaneal

wires Fig. 32.57 Positions of K-wires in standard approach
fourth, and fifth metatarsal head and comes up

frame. Tibial corticotomy is performed after fixa-
from the dorsal of the foot. The second wire is
tion of the frame.
threaded through the medial surface of the
first metatarsal head and comes up from the
Tibial Osteotomy Corticotomy is completed by
dorsal surface of the foot passing through the
entering with a 10–15 mm longitudinal incision
second metatarsal (Fig. 32.57).
1 cm below and lateral to the tuberositas tibia.
32.4.2.9 Equinus Deformity Fibula Osteotomy Fibula osteotomy is per-

with Extremity Shortness formed on the 1/3 interconnection points of the
A proximal tibial ring must be added to the frame medium and distal of the fibula. In patients with
on the level of the fibula head if lengthening is poliomyelitis, the osteotomy is performed in the
planned simultaneously with fixation (Fig. 32.58). middle of the fibula shaft due to muscular
Fibular osteotomy is performed before fixing the atrophy.
Fig. 32.58 Locations of tibial

lengthening rings
32.4.3 Flexible Hybrid Frame Method applied to the short leg or AFO is applied to keep
the ankle in 10° dorsiflexion. The AFO is removed
A flexible frame is used on simple deformities a few times per day, and range of motion (ROM)
with one direction and when there is no bone exercises are conducted with the ankle. Fixation is
deformity. This frame consists of a tibial ring, a applied on natural rotation centers of the joints in
calcaneal half ring, and a metatarsal half ring. the flexible frame technique. There are two crucial
The tibial ring is fixed to the 1/3 medium and points to avoid complications in this technique.
distal interconnection point of the leg and fixed The first is to apply distraction to the ankle before
to the bone with three Schanz screws and a fixation and the second is to fix the hinges to
K-wire. A calcaneal wire is threaded from the enable translational movement.
internal side to the external side to avoid harming
the blood vessels and the nerves. The metatarsal 32.4.3.1 Scythe Osteotomy
wire is threaded from internal side to external A scythe osteotomy is performed when the
side toward the first metatarsal to the fifth meta- equinus angle is narrower than 30–35°, the sub-
tarsal. A metatarsal half ring is tied to the tibial talar joint has defects and joint stiffness is pres-
ring with telescopic rods. In the same way, calca- ent on tibiotalar joint, or fixation of a supination
neal half ring is fixed to the tibial ring with tele- pronation deformity is also planned with equi-
scopic rods. nus deformity. V osteotomy must be used when
Deformity fixation is initiated when the patient equinus angle is greater than 30–35° and fore-
feels comfortable after the operation (on the first to and hindfoot deformities (cavus, varus, and val-
third day). All telescopic rods are stretched and the gus) are present. Ilizarov frame is fixed to the
ankle is opened. This process avoids cartilage leg and foot as explained above. Two K-wires
pressure. Each day a 3 mm fixation is performed. are threaded through the talus and are adopted
The level of fixation is measured by examining the to the frame. Osteotomy can be performed with
X-ray images taken in the first, second, fourth, and 5.5 cm curved osteotome or with 1–2 cm
sixth weeks. Fixation is terminated when the ankle straight osteotomes. Osteotomy is initiated
comes to 5–10° dorsiflexion. The device stays on from the posterior of the lateral malleol after
extremity after procedure about 2–6 weeks due to the lateral incision, and osteotomy is ended on
the stiffness of the soft tissue. A walking cast is the talar neck passing through the calcaneus
pronation deformities, these deformities are

fixed with rotation movements on sagittal-fron-
tal planes.
32.4.3.2 Correction
Correction is initiated on the seventh day of the
operation (the day of operation is considered the
first day). Compression is applied to the rods on
the anterior and distraction is applied on the pos-
terior to fix the equinus deformity. A 0.25 mm
distraction and compression is applied four times
per day. The hinges on the proximal side are
adjusted when 10–15° fixation is provided. The
frame is preserved at least for 6 weeks or for a
period of fixation after fixation.
32.4.3.3 Complications
Fig. 32.59 Scythe osteotomy may also be performed Mechanical Mechanical complications gener-
using a small incision of 1–2 cm osteotomy. Osteotomy of ally develop during fixation. The foot may sub-
the posterior calcaneus, medium part of the calcaneus, and
luxate to the anterior (the talus moves to the
talus neck
anterior). Treatment may be possible by increas-
ing distraction on the posterior rods. If this dis-
1–1.5 cm below the posterior subtalar joint and traction is not sufficient, then the hinge is shifted
through the base of the sinus tarsi (Fig. 32.59). to the inferior. Ruptures may occur on wires due
Back and medium of the calcaneus and talus to load. This could be prevented by replacing just
neck will be osteotomized, and the foot will be one wire at the beginning, or the wires must be
divided into two parts with this process. The changed when complications occur.
bone part is the upper part of the talus and cal-
caneus attached to the subtalar joint, and the Biologic Superficial infection may develop at
other is the remaining part of the foot that could the far end of the wire and is generally treated
be dislocated with the curved osteotomy. with local ulcer care and antibiotics. Fixation is
Sagittal plane rotation is applied to the foot delayed or temporarily terminated if soft tissue
after osteotomy to fix the equinus deformity. problems such as edema and bulla develop.
The rotation center in horizontal plane is the
intersection point of the lines passing through
0.5 cm anterior of the anatomic axis of the tibia Bibliography
and 1 cm distal of the articular talar trochlea.
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for complex foot and ankle deformities. New York:
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if the rotation center is moved more to the ante- of equinus foot by Ilizarov technique. New Delhi:
rior than normal. The target is to fix equinus Jaypee Brothers Medical Publishers Ltd; 2006.
3. Paley D. Principles of deformity correction. New York:
deformity and to create a plantigrade foot. Springer; 2005.
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omy surfaces do not slope on one another Ilizarov apparatus assembly: fractures treatment,
because of excess friction, and the gap is closed pseudarthroses, lenghtening, deformity correction.
Medicalplastic S.R.L: Milan; 1998.
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vided. In cases accompanied by supination and principles. Doruk Graphics: Istanbul; 1999.
Foot Deformities
33
Ilizarov’s method can be used for the treatment of langeal joints, hyperflexion of the interphalangeal
congenital deformities such as pes equinovarus, joints, adduction and pronation of the forefoot,
pes equinus, pes cavus, metatarsus adductus, and shortened medial edge and lengthened lateral
varus and valgus foot. Deformities due to burn edge of the foot, dermal callus on the head of the
injury sequelae, trauma and neuromuscular dis- metatarses, and fixed or flexible varus deformity
eases can also be treated with this method. on the heel are other deformities usually seen with
Additionally, for dynamic deformities such as pes cavus deformities (Table 33.1). Nearly all
pes calcaneus, Ilizarov’s method can be used as cases have increased tension on the Achilles ten-
the first-choice treatment (Fig. 33.1). don. On the sagittal plane, the anterior tip of the
calcaneus elevates while the posterior tip moves
to the inferior, which leads a vertical positioned
33.1 Sagıttal Plane Deformities calcaneus. This calcaneal position is called dorsi-
flexion deformity of the calcaneus (Fig. 33.4).
33.1.1 Pes Cavus In dorsiflexion deformities, the inclination
angle of the calcaneus increases. If the forefoot is
33.1.1.1 Definition elevated with the movement of the calcaneus, the
Elevation of the medial longitudinal arch of the
foot, even in weight-bearing position, either
Classification of the foot deformities
through an increase of the equinus of the forefoot
1- Sagittal plane deformities
(pes cavus anterior, Fig. 33.2) or vertically posi-
a. Pes Cavus
tioned calcaneus because of its increased dorsi-
flexion position (pes cavus posterior, Fig. 33.3). b. Pes Planus
Pes cavus does not only mean a high-arched 2- Frontal plane deformities
a. Heel Varus
foot. Along with this, there are other deformities
on the foot. Hyperextension of the metatarsopha- b. Heel Valgus
3- Horizontal plane deformties
a. Forefoot Abduction Deformities
b. Forefoot Adduction Deformities
M. Çakmak, Prof. MD (*) • M. Cıvan, MD 4- Multiplanar foot deformities
Orthopaedic & Traumatology Department, a. Fibular Hemimelia
34190 Istanbul, Turkey b. Pes Equinovarus
melihcivan@gmail.com Fig. 33.1 Classification of foot deformities

https://doi.org/10.1007/978-3-319-45675-1_33
Table 33.1 Typical deformities found in stable Pes

Cavus
1. High-arched foot
2. Pronation and drop of the head of the metatarses
3. Tension on the plantar fascia
4. Hyperextension of all metatarsophalangeal joints
5. Flexion deformity on all interphalangeal joints
6. Varus on heel
7. Heel not in equinus position
Fig. 33.2 Pes cavus anterior
Fig. 33.4 Pes cavus posterior with the dorsiflexion defor-

mity of calcaneus and high arch of the foot
3. Posttraumatic: Pes cavus can be seen after

deep posterior compartment syndrome due to
tibial or fibular fractures or midfoot fractures,
dislocations, malunions, and burns.
33.1.1.3 Clinical Features

Patients with nonprogressive deformities suffer
from the claw foot deformity and shoe deforma-
Fig. 33.3 Pes cavus posterior
tion. Increased periodicity of falling can be the
patients’ main reason for seeking medical treat-
revealed deformity is called “vertical heel” (pes ment, especially with heel varus. Typical defor-
calcaneus). At the pes cavus deformity, forefoot mities found in complete and stable pes cavus
contacts the surface plantigradely. deformity are listed below in Table 33.1.
33.1.1.2 Etiology 33.1.1.4 Radiologic Features

1. Idiopathic: The etiology of this disease cannot The apex and type of the deformity can be deter-
be determined in 80% of cases. mined through X-rays obtained in a weight- bear-
2.
Neuromuscular diseases: poliomyelitis, ing position. Calcaneal inclination angle, ankle
Charcot-Marie-Tooth disease, hereditary joint status, and forefoot pronation can be evalu-
spinocerebellar degeneration, Friedrich’s ated in sagittal X-rays.
ataxia, myopathies, plantar fibromatosis, The degree of the posterior pes cavus defor-
arthrogryposis, and cerebral palsy are com- mity can be determined with the inclination
mon neuromuscular disorders that cause angle of the calcaneus. The degree of the anterior
pes cavus. pes cavus deformity can be determined with
33 Foot Deformities 443
Fig. 33.5 A sagittal

X-ray of the foot in the
weight-bearing position: a
Meary’s angle, b calcaneal
pitch angle, c Hibbs angle,
d is weight-bearing
tibia-plane angle. Meary’s
angle (a) is the angle
between the axis of the
talus and first metatarsus.
Hibbs angle (c) is
normally about 30° and
increases in pes cavus
deformities
Fig. 33.6 Clinical photos of a patient with pes equinocavovarus
Meary’s angle (Fig. 33.5). Normally, the proxi- 2. Pes cavovarus: Only the medial column of the
mal and distal joint surfaces of the first cunei- forefoot is rigid and resistant to passive dorsiflex-
form are parallel to each other. Because of the ion. Other metatarses can be pushed above easily.
bending of the forefoot, which is mostly cen- Phalanx are normal at the early stages and the
tered on the first cuneiform, this parallel posi- foot seems normal. The forefoot is in the equinus
tioning is lost and both joint surfaces tend to position, but the hindfoot is in a neutral position.
combine on the plantar side. 3. Pes calcaneocavus: The heel is in a vertical
position because of the motor function deficit
33.1.1.5 Types of Deformity of the triceps surae; the forefoot is equinus
1. Simple pes cavus: The forefoot is balanced in according to the heel.
this type. Metatarsal loading is equally spread. 4. Pes equinocavovarus: This is the typical end-
The heel is in a normal position or slightly stage deformity of untreated pes equinovarus
valgus. (Figs. 33.6, 33.7, and 33.8).
Fig. 33.7 Clinical photos of the patient in Fig. 33.6 with external fixator
Fig. 33.8 Photos of the same patient after treatment

33.1.1.6 Deformity Classification is the best option for treatment. Ilizarov’s method
Pes cavus can be classified according to the can be used as another option as closed treatment.
mechanism of development:
Class 3 In addition to the first metatarsal, other
1. Anterior cavus deformity: The forefoot is in metatarsi are in stiff equinus position. The heel is
the equinus position according to the hind varus but flexible. In this stage, all of the metatar-
foot. Meary’s angle is pathological. sal heads must be hung. Heel varus can be cor-
2. Posterior cavus deformity: The calcaneus is rected with Dwyer’s osteotomy.
vertical with a dorsiflexion deformity. The
inclination angle of the calcaneus is increased. Class 4 This is the rigid form of the class 1
3. Mixed cavus deformity: Both anterior and pos- deformity and cannot be corrected manually. In
terior cavus deformity are presented in this type. addition to plantar fasciotomy and Dwyer’s oste-
4. Mixed cavus deformity with equinus: Anterior otomy, dorsal wedge osteotomy or Japas’s tarsal
cavus, posterior cavus, and equinus deformi- “V” osteotomy must be performed.
ties are presented together on this type.
Class 5 In class 5, every component is fixed and
33.1.1.7 Classification and Treatment rigid. Triple arthrodesis is the best treatment
The treatment options of pes cavus deformities option. The deformity can also be treated with
must be selected according to the classification Ilizarov’s method with (open Ilizarov method) or
regarding flexibility and elasticity. without (closed Ilizarov method) Achilles tendon
lengthening.
Class 1 The forefoot can be easily elevated in this Treatment for anterior pes cavus with the
flexible deformity. The heel can be neutralized; closed Ilizarov method can be performed if the
no surgical treatment is indication for this type. patient’s skeleton is immature. Mixed cavus
Deformities can be corrected using a conservative deformities can also be treated using the closed
approach. The aim of treatment is to loosen the Ilizarov method. Subcutaneous plantar fasciot-
plantar fascia and prevent the advancement of the omy must be added to the treatment before the
deformity over time. Daily manipulations and frame-building stage because of the more resis-
custom-made shoes are additional components of tant plantar tissues.
the treatment.
33.1.1.8 Frame Building
(a) Daily manipulations: In addition to forcing The frame is part of three sections.
the forefoot to supination and metatarsi to
dorsiflexion, flattening the arch of the foot, 1. Cruris section: Must be in the form of two
forcing the heel to eversion, and flexion of rings. These rings must be perpendicular to
the phalanx from the metatarsophalangeal the anatomic axis of the tibia and parallel to
joints are included motions. each other. One of them must be positioned at
(b) Custom-made shoes: 1 cm of heel support the level between 1/3 proximal and midsec-
must be out of the shoe not inside. A tion of tibia and the other one must be posi-
transverse bar support must be placed below tioned at the level between 1/3 distal and
the head of the metatarsi. midsection of the tibia. Two rings must be
connected with four rods. (For K-wire entries,
refer to the equinus deformity.)
Class 2 At the forefoot, the first metatarsal is at 2. Foot section: The foot section must be made
the equinus position and cannot be manually ele- of two half rings. One of them must be aligned
vated for correction. There is significant contrac- to the head of the metatarsus and positioned
ture on the plantar fascia and the foot is shaped as perpendicularly to the long axis of the foot on
a claw. Jones’s procedure and plantar fasciotomy two planes (sagittal and horizontal plane). The
other half ring, which is also known as the metatarsal half rings. The medial and lateral
“foot plate,” must be positioned to the calca- column of the foot can be elongated for cor-
neus perpendicularly to the longitudinal axis rection of cavus of the foot. At the anterior
of the foot (Fig. 33.9). The calcaneus must be axis there are two hinges on the threaded rods.
fixated with two or three olive K-wires around Anterior rods are connected to the T piece.
the foot. The metatarsus of the foot must be Rods must be positioned tangentially to the
fixated with transverse K-wires. hypothetical circle whose radius is measured
3. Connections: Hinges of the sagittal axis are from the center of the concavity (correction
positioned on the calcaneal half ring and center of the deformity) to the metatarsal half
threaded rods parallel to the tibia medially and ring (Figs. 33.10 and 33.11).
laterally. Medial and lateral rods must be posi-
tioned parallel to the footpad. These two plan- The correction starts with distraction of the
tar rods are connected with hinges and medial and lateral plantar rods 1 mm per day and
compression of the anterior rods 1–1.5 mm per
day. Soft tissues at the plantar section must be
considered at all times. If necessary, the correc-
tion can be stopped or slowed according to the
plantar soft tissues. The correction must start
immediately for the closed treatment and at day
8, the day for open treatment.
Fig. 33.9 Foot plate
Fig. 33.11 Pes cavus anterior and Ilizarov frame for cor-
rection. On top before the correction and on bottom after
Fig. 33.10 Positioning of the frame the correction
33.1.1.9 O pen Treatment for Pes 2. Biologic complications: Complications due to

Cavus Anterior the insufficient soft tissue at the plantar side
For rigid deformities of adult or adolescent can occur. Lengthening of the bones during
patients, open treatment is needed. Treatment correction can make a claw shape at the pha-
option is determined according to the relation lanxes. This complication can be prevented
between the center of the deformity and Chopart’s with K-wire application to the phalanxes dur-
joint. If the center of the deformity is positioned ing the first operation (Fig. 33.13).
behind the Chopart’s joint, talar calcaneal oste-
otomy is used, cuboideonavicular osteotomy for
posterior midfoot cavus, and cuboid cuneiform 33.1.2 Pes Planus
osteotomy for midfoot cavus (Fig. 33.12a, b).
33.1.2.1 Definition
33.1.1.10 Complications In this deformity, the anterior tip of the calca-
1. Mechanical complications: Wrong angula-
neus moves inferiorly, while the posterior tip of
tions can be obtained due to misplaced hinges. the calcaneus moves superiorly; it is called
Additionally, sliding of the half ring, broken plantar flexion deformity of the calcaneus.
wires, or locking of the system are other There are two forms of this deformity, severe
mechanical complications. and mild. In the mild form, which is called pes
planus, the calcaneus is positioned horizontally
and the inclination angle of the calcaneus
a
a
b
b
Fig. 33.12 (a, on top) Talar calcaneal osteotomy. Talus

must be fixated to the cruris section with two K-wires. (b,
on bottom) Correction of pes cavus anterior with talocalca-
neal osteotomy. Distraction of 1 mm per day at the plantar Fig. 33.13 Correction of pes calcaneus with Y osteot-
side of the osteotomy is the optimum correction protocol omy. (a) Before correction, (b) After correction
a b
Fig. 33.14 Correction of the pes planus with the open-wedge osteotomy. (a) Before correction and osteotomy line,
(b) after correction
a b
Fig. 33.15 (a) Application of the Y osteotomy. Angles between the osteotomies must be 120°. (b) After the
correction
decreases to “0.” This reveals itself with the 2. Y osteotomy: At the Y osteotomy, two legs of
disappearance of the medial longitudinal arch the Y are on the calcaneus. One of them is
of the foot. Severe forms are seen in equinus parallel to the subtalar joint and the other is
deformities. parallel to the calcaneocuboid joint. The
body of the Y is at the neck of the talus. The
33.1.2.2 Etiology angles between the osteotomies must
Pes planus can be rigid or loose. Ligamentous be 120°. For the correction, hinges must be
laxity is the main course for loose pes planus. positioned on the rods of the calcaneal half
Rigid pes planus is seen with congenital struc- ring, 5 mm anteriorly to the medial malleo-
tural foot bone deformities such as tarsal coalition lus. The talus must be fixated with two wires
and vertical talus. Clinically, there is no equinus and the calcaneus must be pulled down for
deformity in pes planus with the absence of the correction (Fig. 33.15).
medial longitudinal arch. 3. V osteotomy
33.1.2.3 Treatment This osteotomy is usually performed when the

1. Calcaneus osteotomy: There are several types calcaneus deformities are accompanied with
of osteotomy, such as dome osteotomy or other deformities posterior to the Chopart’s joint.
close-up or open-up osteotomies, for the In other words, this procedure is used when mid-
correction of pes planus, which increase the foot and hindfoot deformities are seen together.
medial longitudinal arch (Fig. 33.14). Two different oblique osteotomies must be
p erformed to the posterior and anterior calcaneus 2. Pes calcaneus: This is a dynamic deformity.
and these osteotomies must cross each other at While the dorsiflexor muscles of the foot are
the very bottom of the calcaneus, while making normal, plantar flexor muscles of the foot are
an angulation of about 60–70°. paralyzed. Two main reasons for this situation
are poliomyelitis and myelodysplasia.
3. Pes cavus posterior type: Calcaneus is

33.1.3 Pes Calcaneus deformed as in pes calcaneus. However, the
foot contacts the floor plantigradely. In this
33.1.3.1 Definition type of foot deformity, only the gap at the
Pes calcaneus is defined as when a patient walks medial side of the foot is enlarged.
on his heel without any contact at the forefoot.
Radiologically, the inclination angle of the calca- 33.1.3.3 Diagnosis
neus must be increased at least 30° for diagnosis. Lateral X-ray of the foot must be acquired in a
In pes cavus, the calcaneus deformity inclination standing position. Connect the lowest end of the
angle is also increased but the footpad does not calcaneus with the head of the fifth metatarsus.
make a contact with the floor. The anterior tip of (Horizontal line) Then draw the anatomic axis of
the calcaneus (joint surface with cuboid bone) the calcaneus. Between these lines there is an
moves above while the posterior tip moves inferi- angle of about 29°. If this angle is more than 29°,
orly. This situation is called a dorsiflexion defor- the deformity can be diagnosed.
mity of the calcaneus. Dorsiflexion deformities
of the calcaneus are usually accompanied by pes 33.1.3.4 Treatment
cavus posterior and congenital calcaneovalgus 1. Congenital pes calcaneovalgus: These patients
deformities with or without calcaneal hypoplasia. do not require surgical treatment. This defor-
In pes calcaneus, the midfoot and forefoot are mity can be treated with casting, exercise, and
also elevated. physical therapy.

2. Pes calcaneovalgus: In this dynamic defor-
33.1.3.2 Etiology mity, the strength of the foot plantar flexor
Pes calcaneus deformity is usually seen in neuro- muscles named gastrocnemius and soleus is
logic disorders when there is a muscle strength poor. However, the strength of the foot dorsi-
imbalance between the plantar flexors and dorsiflexors is normal. These deformities cannot be
flexors of the foot. In this deformity, gastrocne- corrected with osteotomies. They can only be
mius and soleus muscles are paralytic while treated through fixing the muscle imbalance.
dorsiflexors of the phalanxes are normal. Isolated For that, one or two of the tendons of tibialis
calcaneus deformity is rare. It is commonly seen anterior, tibialis posterior, fibularis longus, or
with valgus and rarely with varus. The foot stays brevis muscles must be transferred to the
in dorsiflexion. While walking, the footpad does Achilles tendon. If there is no tendon available
not make contact with the floor. The clinical for transfer procedures or if there is an impaired
types of dorsiflexion deformity of the calcaneus structure at the ankle joint and all previous
are congenital calcaneovalgus, pes calcaneus, procedures before have been unsuccessful, tib-
and pes cavus posterior. iotalar arthrodesis is the best option.

3. Tibiotalar ankle joint arthrodesis: After the
1. Congenital pes calcaneovalgus: This defor-
ankle joint is revealed, joint cartilage of the
mity originates from the intrauterine position tibia, fibula, and talus must be curetted. When
of the feet of the fetus. The foot and calcaneus the foot is in mild equinus position, a temporary
are in dorsiflexion position. The dorsal side of fixation must be performed using two K-wires
the foot almost contacts the anterior aspect of that cross from the calcaneus through the tibia.
the tibia. Plantar flexion of the foot is limited With one olive K-wire, the fibula must be fix-
because of the contractures at the foot and ated to the tibia with lateral compression. With
ankle structures. the olive K-wires crossing talus, tarsal bones,
a b
Fig. 33.16 Anterior physis translation osteotomy for pes calcaneus treatment. (a) Before correction, (b) After
correction
metatarsus, and calcaneus, the foot is fixated to u nderstood. Longitudinal axis of the tibia is par-
the foot ring. Except the K-wires that cross the allel to the mechanical axis of the calcaneus and
talus, compression is prohibited with these aligns medially about 5–6 mm. The loading point
K-wires. These wires are just for stabilization of the calcaneus is on the same line as the longi-
of the foot. After stabilization, the temporary tudinal axis of the tibia.
K-wires placed at the calcaneotibial position
before must be removed. On the third or fourth
postoperative days, limited weight bearing is 33.2.1 Varus Deformity of the Heel
allowed. Because over-compression at the tib-
iotalar joint can cause osteonecrosis, resorp- 33.2.1.1 Definition
tion, nonunion, and shortness, the compression In the clinical definition, this deformity can be
speed must be adjusted to 1 mm per 10 days. diagnosed when the medially rotated heel cannot
The device can be removed after 6 weeks. be solved with active or passive reduction.
After the device is removed, weight bearing Radiologically, varus deformity of the heel means
must be prevented for 1 month. that the loading point of the calcaneus is posi-
tioned medially to the longitudinal axis of the
Especially for paralytic pes calcaneus or tibia (Figs. 33.17 and 33.18).
cases of complications due to over-lengthening
of the Achilles tendon, there is an alternative 33.2.1.2 Etiology
treatment procedure called vertical osteotomy of Varus deformity of the calcaneus can be devel-
anterior physis of the tibia (anterior arthrodesis). oped primarily or secondarily. In the primary
The anterior tibial physis must be translated dis- type, the calcaneus rotates medially from the sub-
tally after the osteotomy to push the neck of the talar joint and there is no deformity in the proxi-
talus to the inferior. This procedure can be done mal region of the calcaneus. The secondary type
gradually or in one single session. With this pro- occurs when another deformity compromises the
cedure, a plantigrade foot with reduced dorsi- mechanical axis in the proximal regions of the
flexion can be obtained (Fig. 33.16). cruris.

33.2 Frontal Plane Deformities In varus deformities of the calcaneus, the heel
rotates medially and patients contact the floor
To evaluate the frontal plane deformities of the with the lateral aspect of their feet. More varus
calcaneus, the axial relationship between the cal- leads to more lateral contact. Lateral side contact
caneus and loading forces must be well of the foot compromises the normal gait and
33.2.1.5 Treatment
Varus deformities can be treated with open or
closed-wedge osteotomies. If the calcaneus is hypo-
plastic, an open-wedge osteotomy is the best option
for the treatment of both varus deformity and hypo-
plasia. In these hypoplastic deformities, Ilizarov’s
technique is the best option. If there is no hypopla-
sia on the calcaneus, a closed-wedge osteotomy is
the best option. In this situation, there is no absolute
Ilizarov’s technique indication. It can be done with
simple K-wires or screws with casting. Another
indication for the Ilizarov’s technique is in cases
Fig. 33.17 Tibia and calcaneus axes from the posterior that also need translations with osteotomies.
perspective
33.2.1.6 Technique
Ilizarov’s circular external fixator must be built in
two sections as foot and cruris. Use of the
Ilizarov’s external fixator to the cruris and foot
has been explained in previous chapters for equi-
nus and cavus deformities.
33.2.2 Valgus Deformity of the Heel
33.2.2.1 Definition
Fig. 33.18 Anatomic axes of both heels in varus Longitudinal axis of the tibia is parallel to the
deformity mechanical axis of the calcaneus and aligns
medially about 5–6 mm. If these two lines are not
parallel to each other and the lines are separated
increases the risk of falling. Arthrosis is inevita- by the distance of this deformity, it is called
ble because of the abnormal loading on the subta- valgus deformity of the heel.
lar joint or Chopart’s joint.
33.2.2.2 Etiology
33.2.1.4 Deformity Diagnosis Valgus deformity in the hindfoot is rare at birth.
An axial image of the calcaneus must be obtained Most of develop after walking. There are signifi-
with both axes of tibia and the calcaneus included. cant roles of the tibial muscles to prevent valgus.
In children, these axes can be easily determined. When there is paralysis on tibial muscles or pero-
However, these axes can be hard to determine in neal muscles are stronger than normal, valgus
adults. For this reason, a specific X-ray must be deformity is inevitable.
taken as described by Salzman. The axis of the
calcaneus and longitudinal axis of the tibia must 33.2.2.3 Clinical Features
be drawn on the axial X-ray of the calcaneus. If It is possible to compensate for the first 30° of
these two lines are not parallel to each other and valgus deformity on the heel. Valgus deformity is
the axis of the calcaneus is rotated medially, we not as crippling as the varus deformity. In spite of
can say there is a varus deformity at the the deformity, walking can even be normal. Most
calcaneus. of complaints are focused on deformed shoes.
33.2.2.4 Diagnosis The medial arch of the foot is concave, whereas

For diagnosis, the same procedures must be pro- the lateral arch is convex shaped.
ceeded as in varus deformity (Figs. 33.19 and 33.20).
33.2.2.5 Treatment There are three clinical types of this deformity.
Treatment is just the same as described in the
varus deformity section. 1 . Actively correctible type
2. Passively correctible type
3. Rigid form, cannot be corrected passively,

33.3 H
orizontal Plane Deformities which causes toe-in gait.
(Forefoot Deformities)
33.3.1.3 Diagnosis
Because of the short structure of the midfoot, there Draw longitudinal axes of the 1st metatarsus and
are no isolated deformities in this section. Even the talus separately on an AP X-ray of the foot.
deformities that originate from the midfoot projects Normally there is no angulation between these
to the forefoot or hindfoot from the clinical and two lines. If there is an angulation is revealed
radiologic perspective. Forefoot deformities may medially, the diagnosis can be made. More angu-
occur especially on horizontal or sagittal planes, lation increases the severity of the deformity
such as abduction or adduction deformities. (Fig. 33.21).
33.3.1.4 Treatment
33.3.1 Metatarsus Adductus
If the deformity is not rigid and can be manually
corrected in the eversion position, surgical treat-
33.3.1.1 Definition
ment is unnecessary. Spontaneous correction
Metatarsus adductus is a deformity term that
occurs in time in these patients. If the rigidity has
refers to an extremely medially rotated forefoot.
a b
Fig. 33.19 15° of varus deformity on the calcaneus. The distance between the axes of the tibia and calcaneus increases
with the distance. (a) Before correction, (b) After correction
Fig. 33.20 Clinical photos

of a patient with left varus
heel deformity. Application
of the Ilizarov’s circular
external fixator and after
treatment
started to develop, Ilizarov’s method can be used about 45 days and after removal, casting is neces-
for correction as an open or closed treatment. sary for 1 month. Overcorrection of about 15°
Close treatment is used when castings are unsuc- must be applied to allow for recurrence (Fig.
cessful. Open treatment is used in adults when all 33.22).
the other treatments are unsuccessful.
33.3.1.6 Open Treatment
33.3.1.5 Closed Treatment Closed treatment is indicated until patients are
This method is used primarily in children when 16 years old. After this age, because of skeletal
previous treatments are unsuccessful. The foot maturation, open treatment is the best option. In
must be flexible and can be corrected manually. A open treatment, a transverse osteotomy in the
standard foot frame is enough for the treatment. midfoot must be performed initially with open
The foot ring must be positioned parallel to the surgery. The rest is the same as with closed treat-
footpad while the calcaneus is centered. Two ment (Fig. 33.23).
crossover wires with olives must be used for fixa-
tion of the calcaneus. Both olives must be posi-
tioned medially. Another olive K-wire must be 33.3.2 Abduction Deformity
crossed through the midfoot from the cuboid to of the Forefoot
the navicular bone. The olive must be on the lat-
eral side near the cuboid bone. The last K-wire This forefoot deformity is mostly seen in pes
must be crossed through the metatarsus, while equinovalgus and vertical talus. Open and closed
the olive is positioned near the first metatarsus methods can be applied for the treatment. For
and medially. 1 mm traction must be applied on closed treatment, the calcaneus must be fixated
the cuboid wire. 1.5 mm compression must be with three olive K-wires. Two of the olives must
applied on the wire, which is positioned medially be positioned at the medial side. An osteotomy
to the metatarses. The frame must remain for must be performed at the distal cuboid and
cuneiform bones. Traction to the wire that crosses
the metatarsus corrects the deformity.
33.4 Multiplanar Deformities
1. Fibular hemimelia (See the specific chapter.)

2. Pes equinovarus deformity (PEV)
33.4.1 Definition
When components of varus, equinus, and supina-

tion are seen together in the forefoot, a multipla-
nar foot deformity, congenital talipes equinovarus
(CTEV) or “Clubfoot” occurs.
33.4.2 Etiology
Fig. 33.21 Normally axes of talus and first metatarsus is
superposed in an AP X-ray of the foot. (left) If there is
This deformity can either be congenital or
angulation at the medial side, it is called an adduction acquired. Some of the neuromuscular diseases
deformity in forefoot. (right)
a b
Fig. 33.22 (a) Forefoot adduction deformity before correction. Notice the positions of the olive wires. (b) After
correction
a b
Fig. 33.23 (a) Frame-building techniques are same as in versely on the cuboid bones and cuneiform bone. Pay
closed treatments. An additional metatarsus half ring must attention to the second olive K-wire positioned proxi-
be added to the forefoot. This strengthens the fixation for mally to the osteotomy. (b) After correction
the midfoot osteotomy, which must be positioned trans-
that cause this deformity are listed below. It can half ring must be positioned perpendicularly to
also be seen after foot and ankle traumas. the axis of the forefoot. The line that connects the
endings of the metatarsal foot ring must be at the
Neuromuscular diseases that cause PEV level of the head of the metatarsus and parallel to
Cerebral palsy the footpad. For correction of supination, the lat-
Poliomyelitis eral end of the ring must be positioned more pla-
Charcot-Marie-Tooth disease narly from the medial side (Fig. 33.24).
Hereditary spinocerebellar degeneration Connections:
Friedreich’s ataxia
Conus medullaris diseases 1. Connection between the calcaneal foot ring
Myopathies and cruris section must be built with three
Plantar fibromatosis threaded rods positioned as medial, lateral, and
Arthrogryposis posterior rods and biplanar hinges. A posterior
rod must be positioned to the center hole of the
calcaneal foot ring while medial and lateral
rods are fixated with biplanar hinges to the
33.4.3 Treatment endings of the half ring (Fig. 33.25).
2. Connections between metatarsal half ring and
1. Closed Treatment cruris section: A T-shaped component must be
linked to the supramalleolar ring of the cruris
This method is especially used for young chil- section at the level of the corpus of the 5th
dren for treatment or preparing the foot for the metatarsus with a curved plate. This plate
open treatment in adults or adolescents. Frame must be connected with a nut and screwed
building is same as in equinus deformity. The loosely for the appropriate motion. One
calcaneus must be fixated to the calcaneal foot female and one male post must be added to the
ring with three K-wires, and calcaneus must be counter side of the twisted plate (Fig. 33.26).
positioned at the center of the foot ring. The foot 3. Connections between the calcaneal and
ring must be positioned parallel to the heel pad. metatarsal half rings: These parts must be
The calcaneal foot ring must mimic the equinus, connected with two rods on both medial and
varus, and adduction deformities. The metatarsal lateral sides.
a b c
28°
90°
90°
Fig. 33.24 (a) A half ring must be positioned with an the half ring of the forefoot must be positioned perpen-
angle of 28° with longitudinal axis of calcaneus to correct dicularly to the calcaneus axis to correct adduction defor-
equinus deformities. (b) The half ring must be positioned mities of the calcaneus. Additionally, the medial side of
perpendicularly to the axis of the calcaneus to correct the half ring must be positioned more anteriorly, accord-
varus deformities. (c) The line that connects both ends of ing to the lateral side
a b
Fig. 33.25 The metatarsal half ring must be positioned positioned at the level of the head of metatarsus. Before (a)
perpendicularly to the longitudinal axis of the forefoot, and and after (b) the correction (redrawn from, Kirienko A,
the lateral ending must be more distally positioned. The Villa A, Calhoun JH. Ilizarov technique for complex foot
line that connects the endings of the metatarsal half ring and ankle deformities. New York: Marcel Dekker; 2004)
must be positioned parallel to the footpad and must be
33.4.4 Correction of the Multiplanar

Foot Deformities
1. Equinus: Can be corrected by lengthening the

posterior rods or shortening the rods between
the T-shaped component and the metatarsal
foot rings.
2. Varus: Varus deformity of the heel can be
corrected by lengthening the medial rod or
shortening the lateral rod of the calcaneal half
ring. If the calcaneal half ring is positioned
correctly, deformity correction will be accom-
plished when this part becomes parallel to the
rings of the cruris section.
3. Cavus: This deformity can be corrected by
lengthening the medial plantar rod, which lays
between the calcaneal and the metatarsal Fig. 33.26 T-shaped components consist of one twisted
half rings. plate, one female post, and one male post with three holes
4. Supination: For correcting equinus, the rods
that connect the T-shaped component to the 5. Adduction of the calcaneus: This can be cor-
metatarsal half ring must be shortened. During rected by lengthening the medial plantar rod
this time, if the lateral rod is shortened more or shortening the lateral plantar rod.
than the medial rod, supination can be cor- 6 . Adduction of the forefoot: Forefoot
rected simultaneously. adduction can be corrected by pushing
the metatarsal foot ring to the lateral side. formed. After the posterior leg, a vertical
Various foot deformities are corrected leg of the osteotomy must be performed. At
retrospectively not simultaneously. First last the anterior leg of the osteotomy must
corrections that respond to the treatment be performed. There must be 120° of angles
is equinus and forefoot adduction. If among these three osteotomies. Hinges
these corrections get harder to make, must be positioned at the medial and lateral
achilloplasty and plantar fasciotomy can ends. The rotational axis must cross from
be performed. Deformities are corrected the inferior of the medial malleolus and
more than neutrally. Varus must be cor- 0.5 cm anterior of the anatomic axis of the
rected until 20° of valgus are obtained. tibia. The talus must be fixated to the cruris
Forefoot adduction must be corrected section with two K-wires similar to the talus
until 30–40° of abduction are obtained. V osteotomy.
Equinus deformity must be corrected
until 25–30° of dorsiflexion are obtained.
Supination deformity must be corrected 33.4.5 Correction
until 20° of pronation are obtained. Cavus
deformity must be corrected until 10° of Correction must begin three or 4 days after the
planus are obtained. The external fixator procedure. Osteotomies must be distracted before
time is about 45 days. In this period the correction. Equinus deformity of the foot can
patients must weight bear using custom- be corrected by distraction of the calcaneal half
made footpads. After the removal of the ring with the help of a posterior rod and by com-
external fixator, overcorrection is cor- pression of the forefoot half ring using a T rod.
rected with casting that lasts for about 2 There is no lengthening procedure at this stage of
months. the correction. Posterior rods must be lengthened
7. Open treatment: This treatment is indicated in 2 mm per day, and plantar rods must be lengthened
adolescents or patients who have undergone 1 mm per day. This will correct cavus and equinus
multiple unsuccessful operations before. The deformities. After the correction, the external fix-
frame is built the same as for closed treatment. ator time must be continued for about 6 weeks for
A Y or V-shaped osteotomy must be per- consolidation. After the frame removal, controlled
formed for the correction. After the osteot- weight bearing must be applied.
omy, the deformity is corrected as in closed
treatment. For open treatment, tenotomy or
lengthening of the Achilles tendon and plantar 33.4.6 Example Case
fasciotomy are also needed. Pinning of the
toes is also necessary for preventing claw- A boy aged 11 years was diagnosed as having R
shaped foot. foot PEV deformity sequelae. The deformity had
8. V osteotomy: Building of the cruris section been corrected with a closed method using an
has been described above. First the poste- Ilizarov’s external fixator (Figs. 33.27, 33.28,
rior part of the Y osteotomy must be per- and 33.29).
Fig. 33.27 Pretreatment clinical photos of the patient
Fig. 33.28 Clinical photos of the patient during treatment

Fig. 33.29 Clinical photos of the patient after the treatment
Bibliography 3. Paley D. Principles of deformity correction. New York:

Springer; 2005.
4. Catagni MA, Malzev V, Kirienko A. Advances in

1. Kirienko A, Villa A, Calhoun JH. Ilizarov technique for
ilizarov apparatus assembly: fractures treatment, pseu-
complex foot and ankle deformities. New York: Marcel
doarthrosis, lengthening, deformity correction. Milan:
Dekker; 2004.
Medicalplastic SRL; 1998.
2. Agraval RA, Pandey S, Ivanovich UV. Management of
5. Çakmak M, Kocaoğlu M. Principles of ilizarov surgery
equinus foot by ilizarov technique. New Delhi: Jaypee
(Tr). Istanbul: Doruk Graphics; 1999.
Brothers Medical Publishers Ltd; 2006.
Upper Limb Deformities
34
Yılmaz Tomak and Engin Eren Desteli
34.1 Introduction 34.2 Etiology
A deformity in the skeletal system is defined as As seen in many diseases or pathologic condi-
any abnormality of size and shape of the bone in tions, the main titles of etiologic factors are simi-
terms of angulation, shortness, or rotational prob- lar in deformities:
lems. An individual with bone deformity has
functional and cosmetic defects, whose severity • Congenital
varies on the severity of the deformity. When skel- • Acquired
etal deformities are mentioned, lower limb defor- • Trauma
mities usually come to mind. In fact, while lower • Bone infections
limb deformities mainly lead to walking prob- • Metabolic bone diseases
lems, deformities of upper extremities, which are • Endocrine diseases
normally associated with fine motor skills, have a • Other
more negative influence on the lives of sufferers.
Depending on the severity of the deformity, the
affected person might not find a job or may even 34.2.1 Congenital Upper Limb
have difficulties with eating and drinking, as well Deformities
as caring for their personal hygiene.
Though a review of the literature on skeletal Congenital anomalies are seen in 1–2 % of all
deformities reveals numerous books, resources, newborns, 10 % of which belong to upper
and methods about lower limb deformities, a extremities [1]. These abnormalities of upper
scant amount is available regarding upper limb limbs are classified according to various systems
deformities. This chapter aims to fulfill this lack in embryologic, teratologic, and anatomic bases.
of knowledge. The most widely accepted classification for con-
genital anomalies is the one designed by Frantz
and O’Rahilly [2] and introduced by Swanson [3]
Y. Tomak, MD (*) (Table 34.1).
Ondokuz Mayıs University, Department of Orthopedic
Surgery and Traumatology, Samsun, Turkey
e-mail: ytomak@hotmail.com 34.2.1.1 Radial Deficiencies
These affect the preaxial border (radial side) of
E.E. Desteli
Hospital of Üsküdar, Department of Orthopedic the extremity. The severity of preaxial deficien-
Surgery and Traumatology, Istanbul, Turkey cies may vary from mild hypoplasia of the thumb

https://doi.org/10.1007/978-3-319-45675-1_34
462 Y. Tomak and E.E. Desteli
Table 34.1 Embryologic classification of congenital (ulnar side) of the extremity, which may be
anomalies
confused with radial deficiencies by physicians
I. Failure of formation of parts unfamiliar with upper limb anomalies (Fig. 34.1).
A. Transverse deficiencies This usually results from integration of the avail-
B. Longitudinal deficiencies able part of the radius to the distal radius (radio-
1. Phocomelia ulnar fusion) (Table 34.3).
2. Radial
3. Central 34.2.1.3 Central Deficiencies
4. Ulnar Cleft hand emerges from longitudinal deficien-
II. Failure of differentiation cies of the central ray (second to fourth digits)
A. Synostosis of the hand, consisting of two types as typical
B. Radial head dislocation
and atypical. Based on varying degrees of defi-
C. Symphalangism
ciency of the long ray, typical cleft hand is a
D. Syndactyly
V-shaped deformity that often exhibits a pres-
E. Contracture
ence of metacarpal bones and absence of pha-
1. Soft tissue
langes. Atypical cleft hand, a form of
(a) Arthrogryposis
symbrachydactyly, involves the absence of the
(b) Pterygium
middle three digits. In fact, it is a U-shaped
(c) Trigger
deformity rather than a V shape.
(d) Absent extensor tendons
(e) Hypoplastic thumb
(f) Clasped thumb
34.2.1.4 Transverse Deficiencies
(g) Retroflexible thumb
Congenital transverse deficiency is defined
(h) Camptodactyly according to the last remaining bone segment.
(i) Windblown hand Short below-elbow stump amputation is the
2. Skeletal most common transverse deficiency of the upper
(a) Clinodactyly limb. Less frequent transverse deficiencies
(b) Kirner deformity include those involving metacarpal bones and
(c) Delta bone the hand.
III. Duplication
A. Thumb 34.2.1.5 Syndactyly
B. Triphalangism/hyperphalangism This is an abnormal adherence between digits,
C. Polydactyly which may be either complete or partial. While
D. Mirror hand adherence at the level of dermal and fibrous tis-
IV. Overgrowth sue is regarded as simple, those at the level of the
A. Limb bone are defined as complex adherences. As a
B. Macrodactyly very common congenital anomaly, it is seen in
V. Undergrowth every 2–3 per 10,000 live births [4].
VI. Congenital constriction band syndrome
VII. Generalized skeletal abnormalities 34.2.1.6 Polydactyly
Polydactyly is the presence of more than five
to complete absence of the radius. The heart is digits on the extremity. Preaxial (radial) poly-
often affected in these children. They should be dactyly is more common in whites, whereas
evaluated with respect to any renal pathology. postaxial (ulnar) polydactyly is more common in
Association with Fanconi anemia is remarkable blacks. Postaxial polydactyly in whites is often
in radial deficiencies (Table 34.2). associated with a syndrome (chondroectodermal
dysplasia or Ellis-van Creveld syndrome).
34.2.1.2 Ulnar Deficiencies Central polydactyly is the presence of an addi-
Encountered 4–10 times less than radial deficien- tional digit within the hand, usually accompa-
cies, these anomalies affect the postaxial border nied by syndactyly.
34 Upper Limb Deformities 463
Table 34.2 Classification of radial longitudinal deficiencies [5]

Type Thumb anomaly Carpal anomalya Distal part of radius Proximal part of radius
N Hypoplastic or absent Normal Normal Normal
0 Hypoplastic or absent Absence, hypoplasia, Normal Normal, radioulnar synostosis,
or coalition or congenital dislocation of the
radial head
1 Hypoplastic or absent Absence, hypoplasia, >2 mm shorter than Normal, radioulnar synostosis,
or coalition ulna or congenital dislocation of the
radial head
2 Hypoplastic or absent Absence, hypoplasia, Hypoplasia Hypoplasia
or coalition
3 Hypoplastic or absent Absence, hypoplasia, Physis absent Variable hypoplasia
or coalition
4 Hypoplastic or absent Absence, hypoplasia, Absent Absent
or coalition
a
Carpal anomaly implies hypoplasia, coalition, or absence of carpal bones. While hypoplasia or absence is more com-
mon on the radial side of carpal bones, coalition tends to be common on the ulnar side. Radiography should be per-
formed after age 8 years due to ossification time of carpal bones
Table 34.3 Classification of ulnar longitudinal defi-

ciencies [6]
Type Severity Characteristics
A Normal Normal first web space and
thumb
B Mild Mild first web and thumb
deficiency
C Moderate Moderate to severe first web and
thumb deficiency; potential loss
of opposition, malrotation of the
thumb into the plane of the other
digits, thumb-index syndactyly,
absent extrinsic tendon function
D Absence Absent thumb
34.2.1.7 Camptodactyly
Camptodactyly, a painless flexion contracture of
the proximal interphalangeal (PIP) joint of the
little finger, often tends to progress gradually.
Metacarpophalangeal (MCP) and distal interpha-
langeal (DIP) joints are not affected. Bilateral
involvement is seen in 2/3 of patients.
34.2.1.8 Clinodactyly
Clinodactyly is an abnormal deviation of the
digit on the coronal plane. It is more common
yet less bothersome than camptodactyly.
Deviation is often toward the radial side. It is
the clinical sign of several genetic disorders. In
Fig. 34.1 A girl aged 3 years with ulnar absence. She had an fact, its prevalence in Down syndrome is
ankylosing elbow and only two digits on the hand (Kozin [4]) 35–79 %. Thumb clinodactyly is the r emarkable
feature of Apert syndrome, Rubinstein-Taybi the lower limbs as walking and standing, upper
syndrome, diastrophic dwarfism, and triphalan- limb functions are more critical in our daily
geal thumbs. activities and so are the alignment and orientation
of their bones.
34.2.1.9 Macrodactyly
Characterized by overgrowth of all structures of
the involved digit, macrodactyly differs from iso- 34.3.1 Upper Limb Bones
lated enlargement of the bone (e.g., enchon-
droma) or vessels (e.g., hemangioma). It may 34.3.1.1 Shoulder Junctıon Bones
involve one or more digits. Digits on the radial
side are more commonly affected. Though often Scapula
an isolated anomaly, it may be accompanied with Its surface above the ribs is called facies costalis;
neurofibromatosis or Klippel-Trenaunay-Weber the surface that points posteriorly is called the
syndrome (hypertrophic extremity, hemangio- facies dorsalis. The spine of the scapula, which
mas, and varicose veins). crosses from the medial to lateral side on the pos-
terior surface, separates the facies dorsalis into
34.2.1.10 Synostosis two grooves: the small and superiorly located
Osseous adhesion between bones, synostosis, often supraspinous fossa and the large and inferiorly
involves the elbow region in no association with located infraspinous fossa. The lateral edge of the
systemic conditions. Radioulnar synostosis is usu- spinous process is thickened, ending as a process
ally isolated and may be associated with radial called the acromion, which articulates with the
head dislocation. Like camptodactyly and clinod- clavicle. The coronoid process extends anteriorly
actyly, radioulnar synostosis may be one of the and inferiorly from the superior border of the
physical signs of trisomy (13 or 21) or fetal alcohol scapula and is called the coracoid process, into
syndromes. The affected child makes use of his/her which some pectoral and humeral muscles are
shoulder or wrist movements to compensate for the inserted. The crater-like structure that forms a
absence of forearm rotation. Mild pronation or joint with the head of the humerus at the outer
supination deformities are tolerated better and margin of the scapula is called the glenoid cavity.
often require no treatment. Nonetheless, children The contacting area between the glenoid cavity
who experience functional problems during daily and humeral head normally constitutes only ¼ of
activities are treated with rotational osteotomies. the humeral head, yet the glenoid labrum
increases this contact surface to ¾ of that by rais-
ing the edges of the glenoid cavity all around. A
34.3 Anatomic, Functional, glenopolar angle, which may be affected in scap-
and Radiologic Evaluation ula fractures at the level of the neck of glenoid
of the Upper Limb and affect shoulder function in scapular anoma-
lies, is present between the axis that connects the
Such a well-known scheme as described by Paley most caudal and cranial points of the glenoid cav-
for the evaluation of lower limbs, which shows ity and the axis connecting the most cranial
lower limb alignment and angle values in coronal points of the glenoid cavity and the most distal
and sagittal planes, does not yet exist for upper point of the scapula (N, 300–450) (Fig. 34.2).
limbs. Therefore, orthopedic surgeons have dif-
ficulties in assessment and planning for the ther- Clavicle
apy of upper limb deformities. Angle values in The clavicle is an S-shaped bone connected to the
the upper extremity are rather described for either sternum with its sternal end (sternal extremity of
anatomic treatment of fracture-based deformities clavicle) and to the acromion with its acromial
by internal fixation or evaluation of fracture end (acromial extremity of clavicle). It articulates
malunions. Differing from the main function of with the sternum by the sternal facet on the
Humeral Neck-shaft
axis angle
Humeral head
center of rotation
150˚
Fig. 34.3 Axial angle of the shoulder
Fig. 34.2 Glenopolar angle
medial end, and with the scapula by the acromial

facet on the lateral end. The clavicle is the only
bone that connects the upper limbs to the trunk.
34.3.1.2 L
ong Bones of the Upper
Lımb
Humerus
The humerus articulates with the scapula superi-
orly and with the ulna and radius inferiorly. The
line between the chondral and non-chondral sur-
face of the humeral head is described as the ana-
tomic neck of the humerus. The humeral head has
a 30–45° posterior rotation according to the elbow
condyles. The tuberculum majus is located on the
lateral side of the superior end and tuberculum
minus at the anterior aspect of the superior end.
The neck connecting the superior end to the shaft
is the metaphyseal region of the humerus; it is
known as the surgical neck because most humeral
fractures occur at this point. The axial angle of the
shoulder is measured in shoulder anteroposterior Fig. 34.4 Neck-diaphyseal angle of the humerus
X-rays and taken where the arm is externally
rotated. It is the angle between the long axis of the The angle between the long axis of the humerus
humerus and the axis that connects the apical and the angle perpendicular to the axis of the ana-
parts of tuberculum majus and minus (N: male, tomic neck is the neck-diaphyseal angle [7]; mean
60°; female, 62°; 40° humerus varus) (Fig. 34.3). values are 135–140° (125–150°) (Fig. 34.4).
Fig. 34.6 Valgus slope of the humerus
M L
5˚ - 7˚
Fig. 34.5 Carrying angle of the elbow P
There are two structures in the inferior end of

the humerus that articulate with the ulna medially Fig. 34.7 Axis of elbow joint in axial plane
and the radius laterally: the pulley-shaped trochlea
humeri and capitellum humeri, respectively. These Normal values are 5–10°. Acceptable limits
two structures have palpable bony processes on vary between 0° and 20°,values above and below
their superior sides, namely, the medial epicondyle these limits are called cubitus valgus and cubitus
at the inner side and lateral epicondyle on the outer varus, respectively. This angle is formed by a
side. The anterior surface of the inferior end under- 6–8° valgus slope between the long axis of the
lies two grooves, fossa radialis in lateral aspect and humerus and joint line (Fig. 34.6).
fossa coronoidea in medial aspect. The fossa olec- In the axial plane, the axis of the joint is located
rani, which is located at posterior surface of infe- 5–7° anteriorly (rotated internally) according to
rior end, is occupied by the summit of the olecranon the intercondylar long axis (Fig. 34.7).
during extension of the forearm. The angle between Condyles are angled 30° superior to the long axis
the long axis of the humerus and the long axis of of the humerus in lateral plane, and the trochlear
the ulna when the elbow is in full extension and notch of the ulna is accordingly also angled 30° pos-
supination is called the carrying angle (Fig. 34.5). terior. An axis of flexion crosses both the capitellum
“safe zone”
Fig. 34.8 Rotational center of the elbow. Axis of flexion Neutral

crosses this point in frontal and sagittal planes
and center of rotation of semilunar notch of ulna,

which is 0–145° where a range of motion of 30–130°
is satisfactory for daily activities (Fig. 34.8) [8].
34.3.1.3 Forearm Bones

Anatomically, the ulna is located medially and
radius laterally. In the resting position, however,
the radius crosses the ulna anteriorly and the
hand has an inward position. B supination Pronation
Radius Fig. 34.9 Motion limits of the proximal radioulnar joint

The head of the radius articulates with capitellum
humeri of the humerus at its superior end. The notch of the ulna. The remaining 120° is nonar-
neck of the radius is located inferior to the radial ticular (safe zone) (Fig. 34.9).
head. A 30° radial angulation exists between the The anatomic structure of the distal radioulnar
radial diaphysis and radial neck. The inferior end joint warrants special considerations in that
of the radius has an ulnar notch in the medial osseous pathologies at this level lead to certain
aspect, which articulates with the ulna. The infe- problems in terms of alignment and joint orienta-
rior surface has two components: a carpal articu- tion. For better understanding of these problems,
lar surface that forms joints with hand/wrist one should be aware of some concepts:
bones and the styloid process at the lateral aspect. Ulnar variance is the position of the assumed
radius distal joint line perpendicular to the long
Ulna axis of the radius and perpendicular line crossing
The olecranon is present at its superior end, the distal ulnar dome (Fig. 34.10).
which forms the distal part of the elbow joint. Radial length is the elevation in the coronal
The anterior border of the olecranon has an ante- plane between the axis that crosses perpendicular
riorly pointed groove, the trochlear notch. The to the long axis of the radius and distal to the
process anterior to this notch is called the coro- radial styloid and the axis crossing the distal joint
noid process. At the inferior end of the ulna, the surface at the ulnar side. It means that the length
ulnar head articulates to the radius and the styloid is 13.5 mm (SD ± 3.8) (Fig. 34.11).
process of the ulna is present. If the ulnar distal joint surface is located more
The radial head has an ovoid shape with about proximal than the radius distal joint surface, this is
40° concavity and a 15°neck-diaphyseal angle. called ulnar minus variance, e.g., acute carpal insta-
Some 240° of the radial head is covered by carti- bility, Kienböck’s disease. If the ulnar distal joint
lage, which articulates with the small sigmoid surface is located more distal than the radius distal
joint surface, this is called ulnar plus variance, e.g., whose normal values vary between 16° and 28°
for wrist fractures, ulnocarpal impaction. (Fig. 34.12).
The radial inclination is the angle in the The radial tilt is the angle in the sagittal plane
coronal plane between the axis that crosses the between the axis that crosses the surface of the
distal joint surfaces of the radius and the axis distal radial joint and the axis perpendicular to
perpendicular to the long axis of the radius,
the long axis of the radius, where normal values
range between 9° and 11° (Fig. 34.13) [9].
RI
UV
Fig. 34.10 Schematic drawing of ulnar variance (From

Campbell’s Operative Orthopaedics)
Fig. 34.12 Schematic drawing of radial inclination

(From Campbell’s Operative Orthopaedics)
RL
RT
Fig. 34.11 Schematic drawing of radial length (From Fig. 34.13 Schematic drawing of radial tilt (From
Campbell’s Operative Orthopaedics) Campbell’s Operative Orthopaedics)
The rotational axis of the forearm obliquely

extends from the radial head distally to the distal
fovea of ulna. While supination of the forearm is
85–90°, pronation is 80–85°.
34.3.1.4 Bones of the Hand
Ossa Carpi
Eight bones aligned in proximal and distal rows
are called wrist bones, which make a groove-
shaped structure whose concave side faces anteri-
orly. The anterior side of this groove is covered
by a band of dense connective tissue called flexor
retinaculum, which turns the groove into a tun-
nel. The long tendons of muscles that extend to
the hand and median nerve run through this tun-
nel, the carpal tunnel.
The proximal row of carpal bones from lat-
eral to medial is scaphoid, lunate, triquetrum,
and pisiform; the distal row from lateral to
medial consists of trapezium, trapezoid, capitate,
Fig. 34.14 Alignment of carpal bones
and hamate. The distance between the base of
the third metacarpal bone and the line extending
perpendicular to the distal radial joint surface is 34.4 Humeral Lengthening
called the carpal height. The mean ratio of the and Deformity Correction
carpal height to the length of the third metacar-
pal bone is 0.54 (SD ± 0.03), and mean ratio of Humeral lengthening is a relatively comfortable
carpal height to the height of capitate is 1.57 and very well-tolerated procedure, contrary to
(SD ± 0.05) (Fig. 34.14). what is believed because of the fear regarding
radial nerve complications. The healing of regen-
Ossa Metacarpi eration usually shows no surprises. The need for
These are five bones located between the digits physical therapy remains low and results are sat-
and the wrist bones. The end pointing toward the isfactory [10].
digits is called basis; the middle part, corpus; and If no infection or shortening is present in
the distal end, the metacarpal head. proximal metaphyseal and diaphyseal deformi-
ties of the humerus, internal fixation methods are
Ossa Digitorum Manus preferred because these offer more improved
There are 14 phalanges, two in the thumb and patient comfort. If humeral deformity is associ-
three in each of the other digits. The thick and ated with shortening, an Ilizarov external fixator
wide proximal ends of digits are called basis; the is more advantageous. It allows for a safe and
middle part, corpus; and the distal end, the pha- gradual correction and lengthening. However, the
langeal head. radial nerve warrants special attention. In suspected
passages, the bone is accessed through a 2–3 cm associated with humera breva deformity, then
skin incision. A Schanz pin is inserted after the double-level treatment would be appropriate.
bone is exposed. Fixation at the level of the dis- First, varus, flexion, and internal rotation is cor-
tal condyle of the humerus deserves special rected at the level of the surgical neck, and then
interest. Wire fixation is performed in the axial length is equalized by gradual lengthening after a
plane, which exits from just posterior to the lat- second osteotomy performed distal to the deltoid
eral condyle of the humerus and just anterior to tubercle.
the medial condyle of the humerus. The second Conditions such as Ollier’s disease and soli-
wire is fixed in a way that it exits just posterior to tary bone tumor lead to impairment in growth of
the medial condyle and just anterior to the lateral the upper humerus, which results in shortening
condyle. The angle of wires to each other should and deformity. Owing to a wide range of motion
be small due to the anatomic structure of the dis- of shoulder joint, angular deformities up to 30°
tal part of the humerus. A 5-mm Schanz pin fixa- are functionally and cosmetically well tolerated.
tion might be performed from the posterolateral Sagittal plane deformities of the distal humerus
to anteromedial direction so as to increase affect wrist range of motion, and deformities in
stability. An alternative fixation at the distal
frontal plane cause cubitus varus-valgus prob-
humerus is fixation using Schanz pins to give a lems in the elbow [11].
reverse V shape with condyles.
If only lengthening is performed in the
humerus, a unilateral fixator is mainly preferred. 34.5 Fixator Type
Prior to humerus lengthening, all joints of the
upper limb should be examined, range of motion If only lengthening will be performed, unilateral
checked, and AP and lateral X-rays obtained to fixators typical of classic LRS (limb reconstruction
show the shoulder and elbow. Functional status system) would be the most appropriate choice (Fig.
and neurologic examination should be recorded. 34.15). These have pediatric and adult types. If an
Achondroplasia is the most common indica- angular deformity is above 30°, Ilizarov external
tion for bilateral humeral lengthening cases. fixator (IEF) or computer-assisted circular fixator
Humeral lengthening in achondroplasia is very is preferred. Open 5/8 ring options for the elbow
useful for facilitating daily activities of patients region are available for these fixators [12].
such as personal hygiene, safe driving, comfort-
able eating, and using various devices. The fact
that flexibility of thoracolumbar vertebra will 34.6 Surgical Technique
decrease as the achondroplasic individual’s age
increases and they gain abdominal weight makes The patient should be taken to a radiolucent table
it difficult for these patients to extend their hands with no metal around the shoulder. The inferior
to the perineal region, which should be evaluated part of the shoulder should be slightly elevated
carefully [11]. by some supportive materials. The scope device
Proximal humerus metaphyseal osteomyelitis should also be covered with sterile drapes.
and septic arthritis of the shoulder may be causal Perpendicular to the long axis of the medial
factors for unilateral shortening, and this clinical humeral cortex, a 1.8-mm Kirschner (K) wire is
feature may sometimes be accompanied by varus passed from lateral to medial just proximal to the
malalignment of the proximal humerus. The olecranon fossa. The position of the K-wire
humerus may be lengthened up to 10 cm in one should be slightly posterior to the midline in the
session, which may improve cosmetic appear- sagittal plane. If proper positioning is confirmed
ance and functions of the upper limb. Correction through the scope, a 4.8-mm cannulated drill bit
of humera vara increases limits of shoulder is introduced over the wire. The wire is removed
motion and decreases impingement of the and a 6-mm Schanz pin is fixed into the bone.
humeral head under acromion. If humera vara is Subsequent Schanz pin passages are guided by
Fig. 34.15 (a) Classic

LRS (limb reconstruction a b
system) external fixator,
(b) At the end of
distraction period, an
achondroplastic patient’s
humerus AP graph using
with LRS external fixator
clamps of the LRS fixator. The passage of the sagittal plane. A virtual midline straight line
next Schanz pin after passage of the first (most should be drawn on the lateral humerus graph for
distal) Schanz pin is ideally performed from the accurate Schanz pin insertion (Fig. 34.16). After
most proximal part. Thus, the length of fixator Schanz pin insertion is finished, clamps are
can be adjusted well and other Schanz pins can locked when the fixator is 3–4 cm away from the
easily be applied. If Schanz pins are inserted skin. Osteotomy is performed after accessing the
from the distal side consecutively, proximal bone by a small incision where the bone is pal-
clamp holes might not be aligned with the mid- pable under the skin in the insertion point of del-
dle part of the bone. Schanz pins are introduced toid tendons to the humerus in anterolateral
from closer holes in the distal portion. The two aspect. The procedure is finalized by a small
distant holes of the proximal clamps are used for osteotome after making multiple holes with drill
passage of Schanz pins. Proximal Schanz pins bit. The humerus can be easily broken due to its
are introduced just proximal to the deltoid tuber- cylindrical shape.
cle. More proximal introduction puts axillary
nerve into risk. The level of about 5 cm below
the acromion is the area where the branch of 34.6.1 Bilateral Humeral
axillary nerve passes. The most risky Schanz pin Lengthening in the Presence
for the radial nerve is the one passed above the of Elbow Flexion Deformity
most distal part. Therefore, this pin should be
applied after the bone is exposed following a In patients with achondroplasia with significant
minor skin incision. The use of a unilateral fix- elbow flexion deformity, osteotomy is performed
ator in achondroplasic humerus may be difficult over the Schanz pin introduced just superior to
due the curved structure of the humerus in the the olecranon. A second Schanz pin of the distal
This technique has several disadvantages like

failure to achieve sufficient lengthening and lim-
ited range of motion due to very close positioning
of the distal Schanz pin to the joint. An alterna-
tive approach consists of an initial lengthening of
7 cm by deltoid osteotomy, followed by acute
correction of the deformity by distal osteotomy
after 1 year, primarily to correct flexion defor-
mity, and achievement of lengthening of the
remaining 3 cm.
34.6.2 Complications
34.6.2.1 Pin-Wire Site Infections

Though being the most common complication of
external fixator surgery, it is not so common in the
upper limb as in the lower limb. Major signs of the
infection are pain, tenderness, erythema, and
discharge from the pin-wire site. Principal treat-
ment consists of removal of necrotic tissues
around the pin site, administration of oral antibi-
otics, tight dressing, and reduction of skin move-
ment around the pin. Pin site care basically
includes elimination of crusts and clearance of
discharge around the pin and cleaning of the
wound with physiologic saline, followed by dry-
ing with sterile sponges and covering with a
dressing [11].
Fig. 34.16 Achondroplastic humerus has a scoliotic
s-shaped appearence on the lateral viwe. If we will use a
monolateral external fixator, we must plan out the pin 34.6.2.2 Nerve Complications
placement to accomodate this curve. A virtual mid- In humeral lengthening, nerve complication may
straight line should be drawn on the lateral humerus graph occur in an acute (surgical trauma) or gradual
for accurate Schanz pin insertion
fashion (due to distraction). Predisposing factors
include tight fibro-osseous tunnel surrounding
part is introduced inferior to the olecranon fossa radial nerve, prior surgery, and scar tissue.
through the elbow rotation center. Two proximal Passage of Schanz pin about 5 cm below the
Schanz pins are passed through the deltoid tuber- acromion is a risk factor for axillary nerve injury.
cle. This Schanz pin insertion mimics the curved The patient should be assessed at 2-week
structure of the bone in the sagittal plane, the intervals during the distraction period.
bone is acutely corrected by osteotomy, so flex- Sensorimotor examination of the limb is per-
ion deformity also becomes corrected. This distal formed paying special attention to signs of cau-
osteotomy is performed after the opening of tri- salgia. If suspected, the rate of lengthening is
ceps muscle using a 1-cm incision in the poste- decreased. If signs persist in spite of rate reduc-
rior midline, which is followed by making tion, the nerve is decompressed surgically.
multiple holes with drill bit and consequent Targeted pretreatment lengthening can only be
cutting of the bone using a small osteotome. achieved in this way.
34.6.2.3 Early Union 34.7 B

one Deformity and Soft
This is more commonly seen in achondroplasia Tissue Contractures
and Ollier’s disease, where the regenerated bone in the Elbow Region
tends to transform into mature bone earlier. If pre-
mature consolidation is confirmed by radiologic Bone deformities commonly seen in the elbow
means, the rate of lengthening is increased to region that develop secondary to elbow fractures
1.5 mm/day for a couple of days. This process is are mostly cubitus varus and cubitus valgus defor-
painful and neuropraxia may occur in the radial mities. As mentioned before, a carrying angle
nerve. In case that distraction area has been below 0° is known as cubitus varus, whereas val-
blocked, osteotomy should be performed at ues above 20°are called cubitus valgus deformi-
another level. Osteotomy from regenerated bone ties. Numerous methods have been described to
leads to more bleeding, is not easy to perform, and correct these types of deformities [13, 14]. A
causes a delay in union. method of gradual correction according to conven-
tional deformity correction principles has been
34.6.2.4 Joint Contracture suggested by Piskin et al. [15]. This method gives
Joint contracture is rarely seen in humeral the deformity angle to be between the line crossing
lengthening at the level of the deltoid tubercle. the long axis of humerus proximally and the line
Contrarily, elbow flexion contracture may occur perpendicular to the valgus inclination angle of
if it is performed at the supracondylar level. For humerus distally. The crossing point of the lines is
this reason, rehabilitation is critical in the length- CORA (center of rotation of angulation). The
ening period. Lengthening should be ceased if plane passing through the bisector of the defor-
physical therapy fails to relieve the problem. mity angle corresponds to the line of osteotomy
and also the axis of correction of angulation
(ACA). Hinges in this plane are put on the convex
34.6.3 Postoperative Care border of the bone to make this correction as an
open wedge osteotomy, which offers an anatomic
A clinical examination is recommended every correction of the deformity without inducing any
other week in the distraction period. These visits shortness or length (Figs. 34.17 and 34.18).
include X-ray assessment and sensorimotor The method is also important for prevention of
examination of the limb. In the consolidation undercorrection or overcorrection problems. In
phase, X-rays should be obtained in monthly vis- addition, no contracture is seen in the elbow
its. Fixator is started to be dynamized in the late because it allows for joint movement as of postop-
phases of the consolidation period. Dynamization erative day 1. Moreover, no ulnar nerve problems
is based on a reduction of load on the fixator and occur that may originate from acute corrections of
a corresponding increase of load on the bone. cubitus varus as a gradual correction is performed.
This procedure in the upper limb is to give a The technique requires experience; iatrogenic
walking stick to the affected hand it leans injuries to the radial nerve warrant special
against. Removal of the distraction a pparatus in attention.
the unilateral fixator and loosening of rods in the
circular fixator also increase load on the bone.
At the end of the distraction period, a follow- 34.7.1 Application of Humeroulnar
up X-ray is examined. All clamps of the fixator Elbow Fixator and Ilizarov
are tightened after ensuring that there is neither External Fixator in Elbow Joint
angulation in the regenerated bone nor abnormal- Contracture
ity in the alignment of the bone and extremity. If
any angulation or alignment defects are observed, The four most common procedures that use these
these must be corrected [1]. fixators are [16]
a b
c d
Fig. 34.17 A boy aged 17 years who developed (c) Dashed line passing through CORA is the bisector,
posttraumatic cubitus valgus. (a) Carrying angle in
plane of osteotomy, and ACA. (d) Hinges are inserted
preoperative AP X-ray is 36°. (b) Schematic appearance into the convex side; the motor unit is on the concave
of preoperative condition. The crossing point of the line side. The deformity is corrected by open wedge osteot-
running through the long axis of the humerus and the omy. (e) AP X-ray in union process after correction of
line perpendicular to the 6–8° valgus inclination accord- deformity. (f) AP X-ray after removal of the frame. The
ing to the axis parallel to elbow joints is CORA. carrying angle is 7°
e f
• Acute instability secondary to complicated over the skin. Pins are inserted to this level and
fracture-dislocations just over. An incision of 4–5 mm through the skin
• Delayed treatment of complicated fracture- serves to expose the bone. First, the most proxi-
dislocations mal Schanz pin is inserted from the most proxi-
• Distraction interposition arthroplasty mal hole of the clamp. Then, a second Schanz pin
• Relaxation of contracture and stabilization of is inserted from the most distal hole of the clamp.
the joint After that, while the forearm is in neutral rotation,
a small incision via no.11 bistoury through the
The key to apply Orthofix (Verona, Italy) is to proximal of the middiaphyseal part of ulna on the
clearly identify the axis of the rotational center of dorsal side of the ulna is performed and middle of
the humeroulnar joint (Fig. 34.19). the diaphysis is passed bicortically with a 3.2 drill
The patient is put into the supine position. A bit before a 3.5–4.5 mm Schanz pin is inserted.
radiolucent hand table is used. The procedure After being introduced from distant holes of the
begins with visualization of the elbow joint in a clamp, pins are fixed to the clamp tightly. Elbow
complete lateral position on the scope. A K-wire movements are then assessed after loosening
is inserted into the center of rotation in AP and connecting screws of fixator at elbow level. If the
lateral plane, which is the most critical and vital wire at the flexion axis of the elbow is bent during
step of the procedure. After ensuring that the this check, it implies poor positioning of the cen-
K-wire is in appropriate position, a template of tral connecting unit, which necessitates loosening
the fixator is used. The first humeral Schanz pin is of the humeral and ulnar moveable joints of fix-
delivered to the bone over this template. The ana- ator. Fine tuning of moveable joints is performed
tomic landmark at this point is the lateral cortical till free elbow movement is ensured without wire
region where the deltoid muscle is attached to the straining by the fixator, and then clamps are tight-
humerus laterally and the bone can be palpated ened. Harmony of joints in full range of motion of
a b c
e f
Fig. 34.18 A man aged 19 years who developed post- dashed line passing through the CORA is the bisector,
traumatic cubitus varus. (a) Carrying angle in the preop- plane of osteotomy, and ACA. (d) Hinges are inserted into
erative AP X-ray is −28°. (b) Schematic appearance of the convex side; the motor unit is on the concave side. The
preoperative condition. The crossing point of the line run- deformity is corrected using an open wedge osteotomy.
ning through the long axis of the humerus and the line (e) AP X-ray in the union process after correction of the
perpendicular to the 6–8° valgus inclination according to deformity. (f) AP X-ray after removal of the frame. The
the axis parallel to the elbow joints is CORA. (c) The carrying angle is 5°
elbow is checked on the scope. The central con- 34.8 Forearm Lengthening
necting unit is locked in an appropriate position and Deformity Correction
within a range of full extension-70° flexion. On
postoperative day 1, supination and pronation Ordinary differences of length between two upper
movements are initiated. Flexion and extension limbs do not constitute a meaningful functional
movements are started on day 4 under the guid- deficit where forearm lengthening procedures are
ance of a physiotherapist after loosening of the rarely performed with the following indications:
central connecting unit. If flexion contracture is
present, compression-distraction apparatus is dis- • If >20 % difference exists between two
tracted (counterclockwise); if extension contrac- forearms
ture is present, it is compressed (clockwise). The • If forearm is shorter than 25 % of ipsilateral
rate of distraction-compression is 1–4 mm/day humerus and the hand fails to reach the mouth
where a movement arc of 100° is targeted. Flexion or buttock in abduction-flexion of humerus
is also a more critical target to achieve [17]. • If isolated shortness of radius or ulna is above
Ilizarov external fixators are also used in elbow 1.5 cm
contractures with the same principles. This
method also requires accurate insertion of hinges Circular fixators are more advantageous
to the elbow rotation center. The anterior part is options for forearm lengthening and deformity
occupied by the motor unit. The rate of distraction- correction procedures although there are con-
compression is as mentioned above (Fig. 34.20). cerns about neurovascular complications during
wire insertions.
Sectional Anatomy for Wire and Schanz Pin
Insertion
Implementation of external fixation in forearm
warrants an excellent knowledge of limb anatomy
to avoid risk of vascular and/or nervous injury [18].
34.8.1 Level of Head of Radius
Fixation of proximal radioulnar joint is achieved

Fig. 34.19 Orthofix humeroulnar fixator by insertion of wire from the anterolateral to
a b
Fig. 34.20 After application of fixator: (a) clinical view of a child who developed elbow flexion contracture secondary
to fracture sequelae in the right elbow after application of fixator, (b) radiologic view
ANTERIOR
Head of
CUT 1
Radius
CUT 1
CUT 2
CUT 3
CUT 4
CUT 5
CUT 2 ANTERIOR
CUT 6
Radial
Styloid
Fig. 34.21 Sectional anatomy of the right forearm. Cut 1: Level of the radial head, Cut 2: Level of proximal 1/3 (From
Catagni and Guerreschi)
posteromedial direction. Meanwhile, the forearm 34.8.2 Level of Proximal 1/3

is thoroughly supinated. Isolated fixation of radius of Forearm
at this level is very difficult due to anteromedial
vessels and medial side of ulna. This procedure is Isolated ulnar fixation is performed by insertion
only succeeded by delivery of 4–5 mm Schanz pin of a wire parallel to the coronal plane. A posterior-
in a 20° angle at sagittal plane from the posterolat- to-anterior Schanz pin in a perpendicular direc-
eral to anterolateral direction (Fig. 34.21, Cut 1). tion to the wire could easily be introduced.
Isolated fixation of the ulna, which is easier to Whereas, isolated fixation of radius at this level is
perform, is achieved by insertion of a transverse relatively hard and risky to perform. Through a
wire and another wire from the anterolateral to 2-cm skin incision from anterior to posterior, soft
the posteromedial direction, posterior to the ulnar tissues should be gently separated till the bone is
nerve. Insertion may also be implemented using a exposed. If the procedure is essential, a Schanz
Schanz pin, provided that they are at a 20° angle pin should be inserted from the posterolateral to
to the sagittal plane and introduced in a posterior- anteromedial side at a 20° angle to the coronal
to-anterior direction. plane (Fig. 34.21, Cut 2).
ANTERIOR
CUT 3
Head of
Radius
CUT 1
CUT 2
CUT 3
CUT 4
CUT 5
CUT 4 ANTERIOR
CUT 6
Radial
Styloid
Fig. 34.22 Sectional anatomy of the right forearm. Cut 3: Level of proximal-middle 1/3, Cut 4: Level of distal-middle
1/3 (From Catagni and Guerreschi)
34.8.3 The Middle 1/3 of the 34.8.4 Distal 1/3 of the Forearm

Forearm
Isolated radial fixation is achieved by introduc-
Isolated radial fixation requires delivery of a wire tion of a wire from the anterolateral to postero-
from the anterolateral to posteromedial side in a medial side at a 40° angle to the coronal plane.
30° angle to the sagittal plane. A Schanz pin is A Schanz pin is applied perpendicular to
applied perpendicular to this wire in a posterolat- this wire in a posterolateral position. Fixation
eral position, whereas fixation of the ulna is of the ulna by wire is performed by an
achieved by introduction of a wire from the antero- anteromedial-to- posterolateral delivery at a
medial to posterolateral side in a 20° angle to the 40° angle to the c oronal plane. A Schanz pin is
coronal plane. A Schanz pin is inserted in a pos- inserted in a posteromedial- to-anterolateral
teromedial-to-anterolateral direction at a 10° angle direction at a 15° angle to the sagittal plane
to the sagittal plane (Fig. 34.22, Cuts 3 and 4). (Fig. 34.23, Cut 5).
ANTERIOR
CUT 5
Head of
Radius
CUT 1
CUT 2
CUT 3
CUT 4
CUT 5
CUT 6 ANTERIOR
CUT 6
Radial
Styloid
Fig. 34.23 Sectional anatomy of the right forearm. Cut 5: Level of distal 1/3, Cut 6: Level of distal radioulnar joint
(From Catagni and Guerreschi)
34.8.5 Distal Radioulnar Level skin incision. A Schanz pin is inserted from the
posterolateral side to the anteromedial side per-
Ulnar fixation is performed through a wire inser- pendicular to the former wire. Fixation of both
tion in an anteromedial-to-posterolateral direction bones with wire is achieved by introduction from
at a 45° angle in the sagittal plane. A Schanz pin the anterolateral to posteromedial at a 20° angle in
is introduced perpendicular to the wire from the the coronal plane (Fig. 34.23, Cut 6).
posteromedial-to-anterolateral side. The radius is
fixed by introducing the wire in an anterolateral- 34.8.5.1 C lassification of Forearm
to-posteromedial direction at a 45° angle in the Deformities
coronal plane. A second wire may be inserted in Deformities of the forearm occur due to various
the anterior-to-posterior direction between the congenital or acquired pathologies. Catagni et al.
tendon of the flexor carpi radialis and the median categorized forearm deformities into six groups
nerve, provided that bone is exposed after a small (Table 34.4) (Fig. 34.24) [18].
Table 34.4 Classification of Forearm Deformities with 34.8.5.2 Principles

Shortening (Catagni and Guerreschi) It is very useful to assemble the frame before-
Type Characteristics hand. The technique should start with fixation of
1 Shortening of the radius alone two wires, inserted distally first and second from
2 Shortening of the ulna alone proximal sides perpendicular to the long axis of
3 Shortening of the ulna with dislocation of the the ulna. Other wire and Schanz pins are inserted
radial head according to anatomic criteria. An osteotomy is
4 One-bone forearm (radius or ulna)
based on multiple drill holes followed by termi-
5 Shortening of radius and ulna to the same
nation using a small osteotome. After a 10-day
proportion
6 Shortening of radius and ulna to different
waiting period, distraction is started. A 0.25 mm
proportions of distraction is performed four times per day
(1 mm in total). Surgical intervention requires the
Fig. 34.24 Classification
of forearm deformities
with shortening (Catagni
and Guerreschi) Type 4 Type 5 Type 6
Fig. 34.25 Schematic
view of type 1 deformity
and its treatment (Catagni
and Guerreschi)
patient to be in the supine position on a radiolu- distal ring after the bone is drilled from the dorsal
cent arm table under scope guidance. to volar side using a 3.2-mm bit. The other two
Surgical approach varies with the forearm pins are inserted to the proximal ring; the first one
deformity type: from the proximal side in an anterolateral-to-pos-
Type 1: Lengthening of the radius alone teromedial direction and the second one from the
(Fig. 34.25) distal side in a posteromedial-to-anterolateral
After a previously prepared frame is passed direction. If a four-ring frame (two rings for each
through the forearm, according to the abovemen- fragment) is preferred, each ring is fixed with two
tioned wire insertion principles, a wire is intro- wires or one wire plus one Schanz pin. Next, after
duced in AP direction from the distal radius a 1-cm dorsal incision, multiple holes are made
perpendicular to the long axis of the ulna and using a drill bit under the protection of periosteal
fixed to the frame. A second wire is inserted elevators or small Hohmann retractors, and an
through the frame at the midforearm level perpen- osteotomy is completed using a fine sharp osteo-
dicular to the long axis of the ulna in an AP direc- tome. The procedure is terminated after the scope
tion. The surgeon should consider that the frame confirms that Schanz pin lengths are correct and
should be at least two fingerbreadths away from the osteotomy is complete. During preparation of
the skin at every level. It is ensured that rods of the the frame, rods should be inserted in a configura-
frame are parallel to the long axis of the ulna. A tion that does not restrict visualization of the bone
second wire is then inserted to the distal radius in AP and lateral X-rays.
from the anterolateral-to-posteromedial direction. Type 2: Lengthening of the ulna alone
If a two-ring frame is preferred, it is strengthened (Fig. 34.26)
by 3 Schanz pins. One of them is the insertion of A similar shape of frame is made in lengthen-
a 5-mm Schanz pin from the proximal side of the ing of the ulna. The distal ring is fixed with one
view of type 2 deformity
and Guerreschi)
wire and Schanz pin. Proximal fixation is per- reduced. Sometimes reduction may be made
formed by insertion of one wire each from radius more anatomic and safer with an olive wire
and ulna plus Schanz pins from the olecranon. inserted through the radial head.
Fixation of both radius and ulna in the proximal Type 4: Lengthening of the ulna in radial apla-
aspect is very important to prevent pulling the sia (Fig. 34.28)
radial head inferiorly against the capitellum. Radial clubhand deformity should ideally be
Proximal ring may be 5/8 in size to allow for corrected prior to lengthening. Correction and
elbow flexion. Carbon rings may be cut from lengthening of the radial clubhand deformity may
anterior parts using Gigli wires after the proce- also be performed simultaneously using the
dure is completed. The appropriate osteotomy Ilizarov method, for which a three-ringed frame is
area is the proximal ulnar metaphysis. prepared. The proximal ring (may be a 5/8 ring or
Type 3: Lengthening of the ulna with reduc- cut from its anterior border using a Gigli wire at
tion of congenital dislocation of the radial head the end of procedure) is at the level of the
(Fig. 34.27) olecranon, which is fixed with a transverse wire
The radius is transfixed to the ulna in the distal plus 2 Schanz pins from the olecranon. The wire is
aspect with a wire inserted in a medial-to-lateral introduced from the medial to lateral side to avoid
direction. The ulna is then further fixed with a ulnar nerve injury. The first Schanz pin is inserted
wire and Schanz pin. The proximal radius is not in posteroanterior direction perpendicularly,
fixed. Proximally, the ulna is fixed with a wire whereas the second pin is inserted at a 45° angle
and a 4–5 mm Schanz pin. Osteotomy is per- and between the wire and first Schanz pin. The dis-
formed through the level of the proximal ulna. tal ulnar ring is fixed by one wire and one or two
Distraction is initiated after a 10-day waiting 4-mm Schanz pin(s). Pins are inserted at 45°
period and the radial head becomes gradually angles from the medial and posteromedial side in
view of a type 3 deformity
and Guerreschi)
Fig. 34.28 Schematic view of type 4 deformity and its treatment (Catagni and Guerreschi)
the coronal plane. The wire is introduced at a 45° arthrodesis in an average of 3 months. The
angle from the anteromedial side to the posterolat- lengthening process of the ulna starts following
eral side in the coronal plane. A transverse wire a 10-day waiting period after the first operation.
from the metacarpal bones is fixed to the ring to If an ulnar deformity is present, an initial frame
correct carpal deviation at the most distal part. is prepared with hinges on it. After correction of
Fixation is strengthened with one or two half- the deformity, hinges are replaced using straight
wires. This last ring is fixed to the distal ulnar ring rods and the lengthening procedure is started.
with two-hinged rods positioned in alignment with Type 5: Lengthening of the radius and ulna to
the deformity correction axis. The motor unit is the same degree
placed at the point where the rings are closest to This type of forearm deformity is rarely treated
each other, perpendicular to the hinges. because elbow and wrist functions are preserved.
To correct the position of the wrist, distrac- Forearm lengthening may be performed only in
tion is started on postoperative day 1 using the selected cases, where inequality between limbs
motor unit in a 3–4 × 1 mm daily fashion. After reaches up to 50 %. These cases require prepara-
correction of wrist position, a second surgical tion of two frames separately to allow for both
intervention is performed to compress the two supination and pronation. Wider description of
most distal rings by decortication of articular this technique will be discussed in type 6 defor-
surfaces after a 3-cm dorsal wrist incision. Good mity section.
alignment of the wrist is confirmed through AP Type 6: Lengthening of both the radius and
and lateral X-rays. The wrist becomes a solid ulna to different degrees (Fig. 34.29)
Fig. 34.29 Schematic view of type 6 deformity and its treatment (Catagni and Guerreschi)
Lengthening of the forearm is primarily indi- sides are prepared. The proximal part is fixed
cated if there is differential length difference using one wire and two Schanz pins inserted into
between the radius and ulna. Difference in length the olecranon, whereas the distal part is fixed
between these two bones is primarily driven by the with a wire and two Schanz pins inserted through
ulna, accompanied by distal radius varus deformity the distal 1/3 level. It needs a proximal ulnar
and associated ulnar clubhand. In these deformi- osteotomy. The correction process lasts till full
ties, the method where two bones are separately correction of the radial deformity. Ulnar correc-
lengthened with two separate frames is preferred. tion is continued up to the point when wrist align-
The distal ring of the radial frame is prepared ment is restored.
perpendicular to the mechanical axis of the distal The classification of Catagni and Guerreschi
metaphysis of the radius, while a proximal ring (5/8 is shortening-based classification. Although
or half-ring) is prepared perpendicular to the proxi- treatment of forearm deformities without
mal radial mechanic axis provided that it is placed shortening primarily consists of osteotomy and
in the proximal-mid 1/3 level. A hinge each from internal fi xation methods, sometimes selected
the symmetrical dorsal and volar sides is placed in cases may be successfully treated using the
the convex surface of the deformity, perpendicular Ilizarov method, especially those with severe
to the coronal plane and tangent to the rotation deformities, those with shortening secondary to
plane. Both the distal ring and proximal half-ring is correction, or those complicated by infection
fixed with one wire plus two Schanz pins. The (Fig. 34.30).
motor unit is placed on the radial side of the frame. In selected cases where we used Ilizarov exter-
Percutaneous dorsal distal radial osteotomy is per- nal fixator in the treatment of forearm deformity
formed through the level of the deformity. and fractures, we detected no significant supina-
The ulnar frame is prepared more easily. A 5/8 tion or pronation contractures after fixation of
and half-ring each from the proximal and distal both bones to the same frame.
a b c
Fig. 34.30 Man aged 24 years with radius oblique plane X-ray, (b) preoperative lateral X-ray, (c) postoperative AP
deformity secondary to trauma. There is a 38° angulation X-ray where an osteotomy is performed at the level of
in the frontal plane and a 28° angulation in the sagittal hinges and CORA, (d) postoperative lateral X-ray, (e) AP,
plane. Hinges are placed and planned according to the and (f) lateral X-ray after removal of the apparatus. The
oblique plane deformity principles. (a) Preoperative AP deformity is corrected
d e f
34.8.5.3 After Surgery wire-pin site care and oral antibiotics offer
The forearm is elevated after surgery. Physical improved outcomes. This condition rarely leads
therapy is started on postoperative day 1, including to deep infection where removal of wire-pin is
the fingers, wrist, elbow, and shoulder. Initially, needed. After removal of the frame, regenerated
the most important exercises are passive move- bone fractures secondary to relatively insignifi-
ments. As long as pain diminishes, active exer- cant traumas may develop. In order to reduce this
cises are also started. risk, Sarmiento-type forearm casts or braces are
Distraction is begun on postoperative day 10 at used, which allow elbow and wrist movements,
a rate of 0.25 mm × 2, daily. The first radiograph for a duration of 1.5–2 months. Paresthesias
is taken on 10th day to visualize the diastasis at detected in the course of the ulnar nerve are
the level of osteotomy. If pain develops during the resolved gradually. Flexion contractures of the
distraction phase, the rate of lengthening is fingers tend to be permanent and may be seen in
reduced to 0.25 mm daily. If flexion contracture all patients to some extent. Intensive physical ther-
develops in the elbow, fingers, or wrist, extension apy performed in rehabilitation phase decreases
splints for 12 h a day are used. Wire-pin sites are these risks.
closed with sponges up to 4–6 weeks after sur-
gery. Use of sponges beyond this time point is not
preferred unless a wire-pin site problem exists.
34.9 B
one Deformities and Soft
Tissue Contractures
34.8.5.4 Complications of the Wrist
Complications divide into two as transient and
permanent. Superficial wire site infections are Unilateral fixators are used for the correction of
largely prevented if wire site tension is avoided deformities related to distal radius malunions.
and the skin surrounding the wire is firmly stabi- Among these, the most recognized one is the
lized with sponges. In case of inflammation, Pennig II Dynamic Wrist Fixator (Orthofix, Verona,
Italy). A Pennig II Dynamic Wrist Fixator with a and extensor pollicis brevis muscles on one side
standard configuration consists of a short and a and extensor carpi radialis longus and extensor
long module with sliding clamps. The central part carpi radialis brevis on the other side, and
comprises a dual moveable round joint connection 14–15 cm distant to the distal pins. The bone is
that corresponds to the carpal height. The distal reached through a 2–3 cm skin incision. Pins are
moveable round joint should be at the level of the inserted after introduction of 2.7-mm drill bits
lunotriquetral joint in the wrist. The structure of the into the cortices perpendicular to the long axis of
dual round joint offers 180° flexion-extension, 90° the bone at a dorsoradial angle of 45°. If a tem-
translation, and 360° rotation. The clamps of the plate fixator is used, a true fixator is fixed to the
fixator allow for rotation and compression-distrac- pins temporarily via a dual drill bit protector.
tion. Schanz pins are 3.3/3.0 mm in diameter, These protectors ensure that the surgeons’ hands
which are inserted after bicortical perforation of the are protected from irradiation and enable perfor-
bone with drill bits of 2.7 mm. If the bone is smaller, mance of stronger reduction. When reduction is
pins 3.0/2.5 mm in diameter may be used, again deemed sufficient, moveable round joints are
after perforation of the bone with drill bits of tightened, protectors are removed sequentially,
2.0 mm. Pennig II Dynamic Wrist Fixator is used and pins are firmly fixed to the clamps. An addi-
in the forearm in two ways: periarticular and trans- tional method is also present for Pennig II
articular [19]. Dynamic Wrist Fixators specific to distal radius
malunions (Fig. 34.31), where the fixator is
applied from the dorsal side. The system consists
34.9.1 Periarticular Application of a compression-distraction module, a short
module, and a T-clamp. A T-clamp is applied
The fixator is applied from the dorsoradial side in from the distal part, while a short module is
acute fractures. Distal Schanz pins are inserted applied from the proximal part and dorsal side.
parallel to the joint line. Lister’s tubercle is an Unlike the dorsoradial application, the pin
anatomic sign, palpable through the skin. A 1-cm
skin incision over the tubercle exposes the bone, a
and a 1.5-mm K-wire is introduced in a
dorsoradial-to-ulnar direction at an angle of 40°.
After the position is confirmed via the scope, this
K-wire is inserted through ulnar hole of dual drill
bit protector. The tendon of extensor pollicis lon-
gus requires special attention in this manner. A b
triangular area without any tendon or muscle
exists proximal to Lister’s tubercle. A second
K-wire through this area between the compart-
ments of the first and second extensor tendons is
introduced to the radial styloid process at the
same angle. After confirmation of the position via c
the scope, these K-wires are withdrawn and a
pilot wire is placed, over which two cortices are
drilled with a 2.7-mm bit followed by insertion of
the pin. After insertion of two pins, the fact that
pin tips do not proceed far from volar cortex is
confirmed through the scope. The superficial
branch of the radial nerve also warrants attention. Fig. 34.31 Schematic view of treatment with Pennig II
Dynamic Wrist Fixator in a distal radius malunion case. (a)
The ideal entrance point of the proximal pins is a
Dorsal osteotomy after application of the fixator, (b) filling
4–6 cm longitudinal space in the middiaphysis of of the defect secondary to deformity correction by bone graft
the radius, adjacent to the abductor pollicis longus and acute correction, (c) correction by gradual distraction
inserted over Lister’s tubercle here is the pin on the same as in the dorsoradial periarticular
the radial side. The pin is inserted from the dorsal application. Distal pins are inserted into the
to volar side parallel to the sagittal distal radial metacarpal bones in radial or dorsoradial direc-
joint line after a 1-cm incision as in a dorsoradial tions. Pins should not be introduced distal to
pin insertion. The second pin is inserted from the metacarpal bones due to the structural charac-
ulnar side of the radius, while the bone is exposed teristics of extensor tendons, for which the
after a 1-cm incision. Proximal pins are intro- choice of proximal middiaphysis of the second
duced after a dorsal skin incision of 3–4 cm until metacarpal is more appropriate. The small bony
exposure of the bone while paying attention for process on the dorsoradial side of the base of
possible soft tissue injuries, especially of the the second metacarpal is the anatomic land-
superficial branch of the radial nerve. An osteot- mark. First, the proximal pin is inserted distal
omy is then performed after a small dorsoradial to this process, and then distal pins are inserted;
incision 1 cm proximal to the distal pins provided 3.0-/2.5-mm pins are appropriate. The distal
that soft tissues are protected by Hohmann retrac- moveable round joint of the fixator should be at
tors. The fixator is fixed to the pins, and the posi- the same plane with the lunocapitate joint.
tion of the distal radius is corrected by support Reduction maneuvers are performed as men-
from dual drill bit protectors before moveable tioned above.
round joints are tightened. After removal of the
protectors and tight fixation of pins to clamps,
consequent spongious chip grafts are filled into 34.9.3 Treatment of Soft Tissue
the triangular space opened on the dorsal side. Contractures of the Wrist
The osteotomy area is slightly compressed. The
same procedure can also be applied in radial These develop mostly secondary to burn
translation and shortening. A gradual correction is sequels or trauma. If no osseous pathology is
also possible by the use of compression-distraction detected in plain X-rays in conditions associ-
module. ated with hand and wrist dysfunctions, inter-
ventions that aim at releasing soft tissue
contractures could be performed with good
34.9.2 Transarticular Application responses to the treatment. Relatively success-
ful results are observed in Pennig II-like dynamic
This procedure is mainly used in comminuted unilateral fixators with distraction-compression
fractures of the distal radius that extend into the apparatus as well as in Ilizarov external fixators
intraarticular space. Radial pin insertions are (Fig. 34.32).
a b
Fig. 34.32 A child with palmar flexion contracture due to a burn sequel at the right wrist. (a) Clinical appearance after
application of the fixator, (b) radiologic view during treatment
34.10 T
reatment of Deformity, the thumb, metacarpal mini Schanz pins are per-
Shortening, and Soft Tissue cutaneously inserted between the tendons of
Contracture in Metacarpal extensor pollicis longus and extensor pollicis
and Phalangeal Area brevis. The second metacarpal is partially cov-
ered by extensor tendons. If the axial section of
Deformities at this level tend to be shortening or metacarpals is assumed to be a 360° cylinder,
amputations. Especially, metacarpal shortenings pins are inserted from the dorsoradial quarter.
may be lengthened for cosmetic purposes to cor- Care should be taken not to damage the extensor
rect parabolic arcs that pass through the metacar- tendon cover around the head of the metacarpal
pal heads. Metacarpal and phalangeal deformities bones by the most distal pin. The third and fourth
may be corrected via corrective osteotomy and metacarpal bones are more complicated for these
internal fixation by wire or miniplates unless interventions. Safe pin insertion areas are nar-
shortening is present. If additional shortening row; proximal insertions are more difficult. Open
exists, pins of the minifixators are inserted per- application is recommended to prevent tendon
pendicular to the long axis of the bone provided involvement by the pin. In general, the third
that two pins are present in each fragment. metacarpal is fixed from the radial side and the
Osteotomy is performed. Osteotomy is acutely fourth metacarpal from the ulnar side. Pin inser-
corrected. Waiting period is prolonged to 15 days, tion to the fifth metacarpal is performed 70°
and afterward, correction is performed by initia- from the dorsoulnar side. The preferred pin
tion of distraction (Fig. 34.33) [20]. diameter is 2.0 mm. After insertion of two pins
Lengthening of metacarpal and phalangeal from each of the proximal and distal sides fol-
bones are achieved using minifixators that have lowed by connection to the minifixator, either
compression-distraction apparatus. Minifixators metaphyseal or rather middiaphyseal o steotomy
are applied from the dorsal side of the hand. In is performed, and completeness of osteotomy is
a b c
Fig. 34.33 A case of brachydactyly with shortening in the right fourth metacarpal. (a) Preoperative AP X-ray view, (b)
AP X-ray view in consolidation period, (c) AP X-ray view after removal of the fixator
confirmed using the scope. After a waiting period 3. Swanson AB. A classification for congenital limb
of 10 days, distraction is initiated at a rate of malformations. J Hand Surg Am. 1976;1:8–22.
4. Kozin SH. Current concepts review. Upper-extremity
2 × 0.25 mm daily. Lengthening is continued till congenital anomalies. J Bone Joint Surg Am. 2003;85:
the planned level. Active-passive exercises are 1564–76.
performed to avoid development of any possible 5. James MA, McCarroll HR, Jr Manske PR. The spec-
contracture during the lengthening process [20]. trum of radial longitudinal deficiency: a modified
classification. J Hand Surg Am. 1999;24:1145–55.
6. Cole RJ, Manske PR. Classification of ulnar defi-
ciency according to the thumb and first web. J Hand
34.10.1 Distraction (Arthrodiastasis) Surg Am. 1997;22:479–88.
and Release of Soft Tissue 7. Iannotti JP, Lippitt SB, William Jr GR. Variation in pros-
thetic design. Am J Orthop. 2007;36(12 Suppl):9–14.
Contracture in Metacarpal 8. Zimmerman NB. Clinical application of advances in
and Phalangeal Joints elbow and forearm anatomy and biomechanics. Hand
Clin. 2002;18:1–19.
The distraction capacity of the minifixator could 9. Crenshaw AH, Perez EA. Chap: 54. Fractures of the
shoulder, arm and forearm. In: Canale ST, Beaty JH, edi-
be used to expand the distance between the first tors. Champbell’s operative orthopaedics, vol. 3. 11th ed.
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adhesions related to burns and scar tissue. 10. Paley D, Kelly D. Lengthening and deformity correc-
Arthrodiastasis may be performed in contractures tion in the upper extremities. Atlas Hand Clin.
2000;5(1):117–72.
of thumb metacarpophalangeal (MCP), proximal 11. Herzenberg JE. Chap: 39. Upper extremity. Humeral
interphalangeal (PIP), and interphalangeal (IP) lengthening and realignment. In: Rozbruch SR,
joints. Reasons for joint stiffness should be clari- Ilizarov S, editors. Limb lengthening and reconstruc-
fied prior to arthrodiastasis. If the etiologic factor tion surgery. 1st ed. New York/London: Informa
Healthcare; 2007. p. 535–43.
is the delayed effect of the tendon injury, no ben- 12. Lavini F, Donadelli A, Pizzoli A. Chap: 13. Diaphyseal
efit from arthrodiastasis should be expected. If and metaphyseal fractures of the humerus. In: De
extensor and flexor tendons function normally, Bastiani G, AG A, Goldberg A, editors. Orthofix
the distraction capacity of the fixator could be external fixation in trauma and orthopaedics. 1st ed.
London/Berlin/Heidelberg: Springer; 2000. p. 121–6.
utilized to broaden articular space. Minifixators 13. Tien YC, Chen JC, Fu YC, Chic TT, Hunag PJ, Wang
with dual moveable round joints and distraction GJ. Supracondylar dome osteotomy for cubitus valgus
nuts are applied in a transarticular way. In very deformity associated with a lateral condylar nonunion
hard joints, dual fixators may be used from both in children. J Bone Joint Surg Am. 2005;87(7):
1456–63.
sides. After successful achievement of distrac- 14. Jain AK, Dhammi IK, Arora A, Singh MP, Luthra
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of cubitus varus and valgus using the Ilizarov method.
The next phase is the mobilization phase. If two J Bone Joint Surg Br. 2007;89(12):1615–9.
minifixators have been used, one of them is 16. Hutchkiss R, Daluiski A, tan V. Chap: 40. The use of
removed, and the dual round joints of the other a hinged external fixation of the elbow. In: Rozbruch
are loosened followed by physiotherapy. A fix- SR, Ilizarov S, editors. Limb lengthening and recon-
struction surgery. 1st ed. New York/London: Informa
ator is applied for about 6 weeks [20]. Healthcare; 2007. p. 544–53.
17. Pennig D, Gausepohl T. Chap: 14. Fractures, fracture
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Congenital Lower Limb
Deformities 35
Gamal Ahmed Hosny, Fuat Bilgili,
and Halil Ibrahim Balci
35.1 Fibular Hemimelia ankle [2]. The embryonic development periods of

the fibula and tibia are normally independent of
Fuat Bilgili each other. The foot is in equinus; the talus and
calcaneus are in the same position horizontally,
Fibular hemimelia is the most common congenital
but the calcaneus is in the lateral position in the
deficiency of the long bones. This disease is charac-
third week of the normal embryonic develop-
terized by the absence of the portion or all of the
ment. The fibula pushes the calcaneus to medial
fibula. It would be more accurate to consider the
under the talus, which is the normal anatomic
anomaly as a postaxial hypoplasia of the lower
position during its development. At the same
extremity because it is accompanied by other anom-
time, equinus is corrected and the foot becomes
alies and deformities of the lower extremity [1].
plantigrade [3]. If normal development of the
ankle does not happen, the calcaneus cannot
move to where it should be and talocalcaneal
35.1.1 Embryonic Development subluxation develops in the case of agenesis of
and Pathologic Anatomy the fibula. Moreover, fusion occurs between the
talus and calcaneus in the majority of cases. The
It is necessary to know the embryonic develop- direction of the Achilles tendon forces axes
ment of the fibula to understand how the fibular changes because of the calcaneus, which is later-
agenesis or fibular hypoplasia affects the foot and alized. This situation can lead to tibiotalar sub-
luxation or dislocation. The force of the
posterolateral muscles of the leg, which is lateral-
G.A. Hosny, Prof. MD (*) ized on the valgus-positioned ankle, causes the
Orthopaedic Department, Benha University Hospitals,
11 Al Israa street, Mohandeseen, Cairo, Egypt development of valgus and procurvatum defor-
e-mail: gamalahosny@yahoo.com mities of the tibia with the same mechanism.
F. Bilgili, MD, FEBOT Similarly, the distal epiphysis of the tibia contrib-
Istanbul University, Istanbul Faculty of Medicine, utes to the development of valgus ankle with the
Department of Orthopedic Surgery and effect of the abnormal muscle forces [1, 4, 5]. A
Traumatology, Istanbul, Turkey fibrous band develops as a residual tissue in the
e-mail: fuatbilgili@gmail.com
place of the absent part of fibula as a result of
H.I. Balci, MD, FEBOT proximal or complete absence of the fibula in the
Istanbul Faculty of Medicine, Orthopaedic and
Traumatology Department, Istanbul University, type 1B and type 2 fibular hemimelia according
Istanbul, Turkey to the Achterman-Kalamchi classification [6].
https://doi.org/10.1007/978-3-319-45675-1_35
494 G.A. Hosny et al.
This fibrous tissue residue, which is known as Type 2 fibular deficiency is a limb with an unre-
fibular remnant or fibular anlage, is a structure coverable foot, regardless of limb shortening.
that contributes to the development of the defor- It is subclassified into two groups according to
mity at the crus [7]. the presence or absence of upper extremity
deficiency:
• Type 2A: The foot is nonpreservable with
35.1.2 Classification intact upper extremity function.
• Type 2B: The foot is nonpreservable with
There are many classifications including Achterman bilateral nonfunctional upper extremities.
and Kalamchi [6], Letts and Vincent [8], Coventry Salvage of the foot should be considered
and Johnson [9], Stanitski [10], Birch [11], and for hand function.
Paley [12]. Most are anatomic and based on the
radiographic appearance. To be useful, a classifica- The Paley classification [12] is based on hind-
tion should guide treatment or predict prognosis. foot deformity and surgically oriented (recon-
struction, not amputation).
35.1.2.1 Achterman-Kalamchi
Classification [6] 35.1.2.4 Paley Classification
Type 1A: Proximal fibula epiphysis is in the dis- Type 1: Stable normal ankle
tal of the growth plate and smaller than nor- Type 2: Dynamic valgus ankle
mal. Distal fibular growth plate is in the Type 3: Fixed equinovalgus ankle (subdivided
proximal part of the talar dome. into four types according to ankle-subtalar
Type 1B: More than 50% absence of the proxi- pathoanatomy)
mal fibula, development of the distal fibula is • Type 3A–ankle type: The ankle joint is
present but it cannot support the ankle. maloriented into procurvatum and valgus.
Type 2: The complete absence of the fibula. • Type 3B–subtalar type: The subtalar joint
has a coalition that is malunited in
35.1.2.2 C oventry and Johnson equinovalgus with lateral translation.
Classification • Type 3C–combined ankle and subtalar:
Type 1: Hypoplastic fibula Combination of the ankle and subtalar
Type 2: Rudimentary or absent fibula deformities above.
Type 3: Bilateral fibular deficiency or the pres- • Type 3D–talar type: Malorientation of the
ence of “associated anomalies” subtalar joint.
Type 4: Fixed equinovarus ankle (clubfoot type).
Birch et al. [13] proposed a functional classifi-
cation on the basis of the functionality of the foot
and limb-length discrepancy as a percentage of 35.1.3 Etiology
the opposite side.
The latest theory assumes that the development
35.1.2.3 Birch Classification of the extremity bud has an important role in the
Type 1 fibular deficiency is a limb with a stable or causes of postaxial hypoplasia (fibular hemi-
salvage foot that has at least three rays. It is melia), although series of theories have been
subclassified according to the percentage of suggested. A pathology that affects the entire

limb-length inequality compared with the extremity can be seen even in cases where the
contralateral limb: fibular defect is limited. The fibular area of
• Type 1A: 0% to <6% overall shortening the extremity bud controls the development of
• Type 1B: 6–10% overall shortening the proximal femur in the fetal period. Femoral,
• Type 1C: 11–30% overall shortening knee, leg, and ankle abnormalities and the other
• Type 1D: >30% overall shortening abnormalities of the foot are associated with the
35 Congenital Lower Limb Deformities 495
fibular area of the extremity bud. Therefore, lower Pelvis and/or hip series are useful to deter-
extremity postaxial hypoplasia is a descriptive mine acetabular dysplasia, proximal femoral
abnormality term that includes this group [14]. deficiency, and proximal femur deformities
(varus, valgus, antirotation, retrorotation).
A knee X-ray is useful to evaluate the valgus
35.1.4 Clinic of the distal femur, hypoplasia of the lateral
femur condyle, and tibial eminence. Lower
A careful physical examination is required to extremity standing orthoroentgenography can
assess the involved limb for associated anomalies show anteromedial bowing of the tibia and con-
in postaxial hypoplasia of the lower extremity genital instability of the knee due to ACL or PCL
(fibular hemimelia). This condition is important deficiency. It can be seen that the patella is small
in the treatment plan, decision to treat, and and elevated, and femoral sulcus is shallow.
informing parents. Foot-ankle X-rays contribute to the determina-
The ankle should be evaluated in terms of tion of the morphology of the ankle, the contribu-
mobility, alignment, and deformities including tion of the fibula to mortise, the morphology of
equinovalgus or equinovarus. Hip and knee joints the distal tibial epiphysis, and the occurrence of
are examined for stability. ACL or PCL defi- tibiotalar valgus, ball-and-socket ankle, and tarsal
ciency in knee joint may be present. coalition. If the calcaneus and talus are overlapped
Associated anomalies that may also be present: on each other in the lateral radiograph of the foot,
the source of ankle valgus is the supramalleolar
1. Fibular anomaly can be from minimal short- region. If the calcaneus and talus are on top of
ness to complete absence of the fibula. each other in the lateral radiograph of the foot, the
2. Proximal femoral deficiency. source of ankle valgus is the subtalar region [15].
3. Coxa vara.
4. External rotation of the femoral hypoplasia.
5. Lateral patellar subluxation. 35.1.6 Treatment
6. Hypoplasia of the lateral femoral condyle.
7. Genu valgum with lateral mechanical axes. The main problems include limb-length discrep-
8. Flattened tibial plateau with the absence of ancy and deformity and instability of the foot and
the cruciate ligament. ankle. The final goal is to obtain maximum func-
9. Short or curved tibia. tion by achieving a lower extremity that has ade-
10. Valgus of the ankle. quate length at maturity, alignment, and stability.
11. Ball-and-socket ankle. It should be kept in mind that the ultimate dis-
12. Absence of the tarsal bones. crepancy at maturity is more important because it
13. Tarsal coalition. gets worse with growth. If it cannot be provided,
14. Absence of the lateral row of the foot. the aim is a functional prothesis that allows the
child to grow with the appropriate scheduled
amputation.
35.1.5 Imaging
Conservative treatment If the child has a func-
Lower extremity orthoroentgenography includ- tional foot without significant deformity and the
ing both legs taken when standing provides the ultimate discrepancy at maturity would be <2 cm,
analysis of the entire affected short leg and allows no surgical treatment is required. Shoe lifting or
comparison with the opposite limb as a control. UCBL (University of California Berkeley
The differences of the length and alignment can Laboratory) orthosis in mild cases is the pre-
be measured. The abnormalities at the specific ferred treatment. The patient should be followed
areas can be imaged and further imaging can be up while growing for progressive knee or ankle
taken if necessary. deformities and leg length inequality [16].
Surgical treatment The patient’s age at the Approximately 5 cm for each treatment and at
time of consultation, the types of malformation, intervals of 4–6 years apart are advised for a total
and other accompanied anomalies should be con- of up to three or even four lengthening treatments
sidered to decide the treatment. Preoperative in severe cases [15]. The parent must be informed
evaluation includes the classification of fibular about the treatment alternatives and treatment
hemimelia, calculation of predicted leg length plan including number and timing of the opera-
discrepancy at skeletal maturity, and the number tions and complications.
of required lengthenings and/or epiphysiodesis Genu valgum can be progressive and should
and correction of knee joint deformity that may be corrected during the osteotomy of tibial defor-
occur later. The treatment is started with soft tis- mity. Temporary medial hemiepiphysiodesis is
sue procedures. Paley developed the SUPERankle recommended in patients with hypoplastic lateral
procedure to make the foot plantigrade in the femoral condyle because of the high rate of
treatment of types 3A, 3B, and 3C when a child is relapsing in early osteotomy.
as young as 1 or 2 years of age. SUPERankle Proposed management guidelines of
includes lengthening peroneal tendons and Achterman-Kalamchi and Coventry for congeni-
Achilles, excision of fibular anlage and intermus- tal fibular deficiency are described (Tables 35.1
cular septum, osteotomy (supramalleolar or sub- and 35.2).
talar or both according to subtypes), transfixion If the foot is functional with at least three rays
wires from the sole of the foot into the tibia, and and the predicted discrepancy is <20 cm, salvage
an external fixator to correct diaphyseal antero- of the foot with the goal of limb-length equaliza-
medial bow. Deformations can be seen in the tion is recommended. Otherwise, Boyd or Syme
tibia and talus joints’ surfaces as a result of the amputation is recommended with deformity cor-
adaptation of the ankle. Supramalleolar osteot- rection using a circular external fixator in the
omy is decided according to a preoperative MRI
of the ankle joint or preoperative arthrography of
Table 35.1 Proposed management guidelines of
the ankle joint. The presence of ankle movement Achterman-Kalamchi for congenital fibular deficiency
affects the decision on timing of lengthening. If
Achterman-Kalamchi classification
the ankle motion is good, lengthening is planned
Type Characteristics Recommended treatment
6 months later to avoid decreasing range of
1A Hypoplastic Epiphysiodesis or
motion in the ankle joint. If the ankle motion is fibula(proximal to lengthening as needed
stiff, lengthening can be applied at the same time talar dome)
with the SUPERankle procedure. Lengthening is 1B Fibula does not Epiphysiodesis or
made at the apex of the deformity if there is support talus lengthening as needed
deformity, otherwise at the proximal metaphysis 2 Bilateral or Syme or Boyd
of tibia [15]. Acetabular orientation operations associated anomalies amputation
are usually performed before the femoral length-
ening if there is an acetabular dysplasia with the Table 35.2 Proposed management guidelines of
shortness. Lengthening osteotomy in the subtro- Coventry for congenital fibular deficiency
chanteric area is not performed if there is a length Coventry classification of fibular deficiency
difference with coxa vara, because both cross- Recommended
sectional areas of this region are small and more Type Characteristics treatment
exposed to bending moment. Instead, intertro- 1 Hypoplastic fibula Epiphysiodesis or
with normal or slight lengthening as
chanteric valgus osteotomy for correction and
deformity of tibia, needed
distal femoral osteotomy for lengthening are ankle, and foot
performed. 2 Fibula rudimentary or Syme or Boyd
Serial lengthenings should be made at regular absent amputation
intervals to minimize the psychologic impact of 3 Bilateral or associated No procedure
operations and hospital stay on children. anomalies anticipated
Table 35.3 Proposed management guidelines of Birch

a b
[13] for congenital fibular deficiency
Birch classification of fibular deficiency
1A Preservable foot No treatment or
<6% LLI orthosis or
epiphysiodesis
1B Preservable foot Epiphysiodesis ±
6–10% LLI lengthening
1C Preservable foot 1 or 2 lengthenings±
11–30% LLI epiphysiodesis or
extension orthosis
1D Preservable foot >2 lengthenings or
≥30% LLI amputation or
extension orthosis
2A Functional upper Amputation
Fig. 35.1 There is a mild level of shortness in type 1A
extremity
fibular hypoplasia; knee is stable. If the expected short-
unpreservable foot
ness is above 5 cm, bone lengthening and deformity cor-
2B Nonfunctional upper Salvage should be rection are performed. If the expected shortness is under
extremity considered 5 cm, shortness compensation is possible. Anteroposterior
unpreservable foot x-ray on the left, lateral x-ray on the right
LLI limb-length inequality
tibia or femur. If the predicted discrepancy is

≤5 cm, a contralateral pan genu epiphysiodesis
can be applied at the appropriate time [16].
Birch et al. recommend amputation for patients
with a nonfunctional foot, unless the upper
extremities also are nonfunctional. For those with
a functional foot, they decide according to leg
length discrepancy compared with contralateral
side (Table 35.3, Figs. 35.1, 35.2, and 35.3).
Paley classification is directed to the more
reconstruction rather than amputation even in
severe cases (Table 35.4, Figs. 35.4 and 35.5).
35.1.7 Application of the Ilizarov

Frame and Correction
of the Deformity
Fig. 35.2 Presence of severe shortness, ankle instability,
Tibia and foot deformities are corrected simulta- equinovalgus foot, and valgus knee, when type 1A lateral
malleolus is not functional. At first, anlage (fibular rem-
neously in the matter of an existing hindfoot nant) resection, ankle centralization, and deformity correc-
deformity by adding foot pieces to the frame that tion are performed. In the second stage, bone lengthening
has been prepared to correct tibial deformity. The and, if necessary, deformity correction are performed.
frame is prepared by inserting three rings in total: Clinical photo (a) and the x-ray (b) of the patient
two rings proximally and one ring distally to the
osteotomy zone. crossed and stopped K-wires. The proximal ring
Two rings inserted on proximal metaphysis is attached to the middle ring with the four rods.
and diaphysis are attached to the tibia with two Two or three olive K-wires are used for distal
ring. These wires are inserted perpendicularly to The hinges should be placed proximal to the oste-
the anatomic axis of the tibia and attached to the otomy zone.
ring. The distal ring is then connected to the mid- Rotational center should pass through the
dle ring using two hinged rods and a motor unit. anteromedial section of the tibial curvature.
Medial hinge must be placed posterior to the
patella and lateral hinge anteriorly in order to
simultaneously correct procurvatum and valgus
deformities.
By laterally rotating the distal ring and by
applying distraction through posterior rod, the
valgus and procurvatum deformity can be cor-
rected. If there is a tibial shortness, the tibia can
be lengthened by distracting all three rods simul-
taneously. A foot frame is added to the distal ring
to correct the equinovalgus deformity of the
ankle. A calcaneal half-ring is fixed to the calca-
neus using three olive K-wires. Then this half-
ring is connected to the distal tibial ring by adding
three rods to the posterior, medial, and lateral of
the half-ring. These rods are fixed to the calca-
neal ring with a hinge to achieve correction of the
valgus deformity. Another half-ring is fixed to the
forefoot, proximal to the metatarsal bones, by
Fig. 35.3 Presence of complete fibula absence, tibia using two or three olive K-wires. This half-ring is
deformity, shortness, ankle instability, equinovalgus foot, fixed to the calcaneal half-ring by using two
and valgus knee of the patient with type 2 fibular hemime-
hinged rods medially and laterally. The forefoot
lia. Fibular remnant resection, cheiloplasty, deformity
correction, bone lengthening, and ankle centralization ring is adapted to the distal tibial ring in a T-shape
were performed with two hinged rods.
Table 35.4 Proposed management guidelines of Paley for congenital fibular deficiency
Paley classification of fibular deficiency
1 Normal ankle Tibial lengthening
Tendo Achilles lengthening
2 Dynamic valgus ankle Tibial lengthening
Tendo Achilles lengthening
Supramalleolar reorientation osteotomy
3 SUPERankle procedure
Soft tissue lengthening (peroneal tendons and tendo Achilles)
Resection of the fibrous anlage and interosseous membrane
Reorientation osteotomy
3A Fixed equinovalgus ankle, ankle type Supramalleolar osteotomy
3B Fixed equinovalgus ankle, subtalar type Subtalar osteotomy
3C Fixed equinovalgus ankle, combined Supramalleolar and subtalar osteotomy
ankle-subtalar type
3D Fixed equinovalgus ankle, talar body type Opening wedge osteotomy of the body of the talus
4 Equinovarus type (clubfoot) Convert the foot position from equinovarus to equinovalgus
with Ponseti cast
SUPERankle procedure
a b
Fig. 35.4 SUPERankle procedure. (a–c) Soft tissue lengthening (peroneal tendons and tendo Achilles), resection of the
fibrous anlage and interosseous membrane
Hindfoot equinovalgus deformity is corrected to the distal tibial ring with a vertical and a
by compressing the medial rod and distracting transverse rod. By c ompressing the transverse
the lateral and posterior rod located between the rod, which means shifting the talus medially, the
calcaneal half-ring and the distal tibial ring. tibiotalar joint is reduced (Figs. 35.6, 35.7, and
Forefoot abduction and equinus deformity is 35.8) [17, 18].
corrected by compressing the two vertical rods, In cases with complete dislocation of the tib-
which are placed anteriorly, and by distracting iotalar joint, initially the Achilles tendon is
the laterally placed horizontal rode. If there is a lengthened, and appropriate alignment of talus
talocalcaneal coalition, an osteotomy should be and calcaneus below the tibia is obtained. This is
applied to the coalition site to correct the followed by tibiotalar joint arthrodesis and by
equinovalgus deformity. After the osteotomy, proper tibial and calcaneal osteotomies if neces-
two K-wires inserted through the talus are fixed sary. As told before, the purpose is to obtain a
to the distal tibial ring with four rods. functional and plantigrade lower extremity.
Other semi-rings of the foot are applied as
described above, but in order to medially trans- Removing the device The patient must be seen
late the calcaneus, small horizontal rods are during the correction of the deformity and
added to the rods connecting the calcaneal semi- lengthening every 15 days; clinical and radio-
ring and the distal tibial ring. Hindfoot graphic examination should be performed. After
equinovalgus deformity is corrected by distract- the deformity correction and lengthening is
ing the lateral and posterior rods, by compress- completed, the patient must be seen once a
ing the medial rod, and by medially shifting the month until the consolidation is over. Treatment
calcaneus with the aid of horizontal rods. If duration of foot deformity is 4–6 weeks on aver-
there is a lateral dislocation of the tibiotalar age. However, treatment of tibial deformity and
joint, the talus is crossed with a stopped K-wire shortness proceeds approximately 3–4 months.
from lateral to medial, and this K-wire is fixed Because of it all of the device can be removed
a b
c d
Fig. 35.5 In type 3B, (a) arthrography of ankle joint shows that there is no deformity on the supramalleolar region. (b,
c) Correction of the deformity with subtalar osteotomy and (d, e) fixation with K-wires are performed
when the consolidation is completed. After 35.1.8 Complications

removing the device, to prevent relapse, patients
can be followed up with a cast or a brace. In The most frequent complication of fibular hemi-
cases with high risk of relapse after tibiotalar melia is the treatment of soft tissue and pin
and subtalar joint deformity correction, an infections. Infections can be treated very often
arthrodesis procedure may be considered when with oral antibiotics and wound care. If an ace-
the patient reaches the proper age. If there is tib- tabular dysplasia accompanies the shortness,
iotalar dislocation with serious lateral soft tissue femoral lengthening without an acetabular direc-
contracture, arthrodesis should be kept in mind tioning operation leads to hip dislocation
but considered as a last choice. Arthrodesis can (Figs. 35.9 and 35.10).
be necessary for the stabilization in the tibiota- Joint contractures are other common compli-
lar and subtalar joint reductions after cations. They are caused by high tension over
12–15 years of age. soft tissues. For the treatment of the flexion
Fig. 35.6 Patient with a b

fibular hemimelia,
preoperative graphs, and
clinical manifestations
contracture of the knee, a femoral frame is added dynamic casting may be used. In cases with early
to the system after the contracture occurs or at consolidation, treatment may continue with a cal-
the beginning of the treatment. If flexion contrac- loclasis procedure. Mechanical problems about
ture of the knee is not treated properly, sublux- fixator may occur such as breaking of K-wires or
ation or dislocation of the knee may occur Schanz screws, abrasion of wires on bones during
(Fig. 35.11). the correction, and soft tissue problems caused
For the treatment of flexion deformities of by wires or screws. In these circumstances the
toes, a temporary percutaneous pinning or frame must be revised.
a b c d
Fig. 35.7 Fibular anlage excision (a) and acute deformity correction (b–d)
a b
Fig. 35.8 Clinical and radiological manifestations in (a–f) and after (g, j) lengthening operation
c d
e f g
h i j
a b
Fig. 35.9 A 12-year-old

male patient with fibular
hemimelia + PFFD and
14 cm of shortness.
Lengthening is
commenced by bifocal
corticotomy. Patients
orthorontgenogram (a),
clinical photo (b),
postoperative x-ray (c)
Fig. 35.10 A hip

dislocation occurs
2 months later
a b
Fig. 35.11 A 4-year-old patient with fibular hemimelia and proximal femoral deficiency. The knee was posteriorly
dislocated (a). After the correction of the deformity (b), reduction is granted and lengthening is completed
35.2 T
he Treatment of Tibial
Hemimelia
Gamal Ahmed Hosny
35.2.1 Introduction
Tibial hemimelia or congenital absence of the

tibia is very rare. The incidence in the United
States is about one per million live births [19,
20]. The term congenital tibial deficiency had
been also used in the literature to describe the
tibial aplasia or hypoplasia with almost normal
fibula [21]. The clinical picture usually includes
Fig. 35.12 Photo of a 4-year-old child with type 2 tibial
flexion knee deformity, tibial shortening, and hemimelia showing severe varus foot deformity and tibial
sometimes femoral lengthening and rigid equin- shortening
ovarus foot deformity (Fig. 35.12). This anomaly
is often accompanied by knee instability and lon-
gitudinal deficiencies of the foot. Associated con-
genital anomalies of the hip, hand, or spine can
be identified (Fig. 35.13) [22]. The mainstay of
treatment was amputation and prosthetic fitting.
35.2.2 Anatomy
The conventional management of tibial hemime-

lia was trans-articular knee amputation.
Examination of the amputated part helped the
researchers to investigate in detail the anatomy of
the soft tissue and bony structures. Tarsal coali-
tions had been frequently reported with this con-
dition [23, 24]. Turker et al. [25] dissected five
lower extremities from four patients with tibial
hemimelia. All patients had type1A (complete
absence of the tibia) tibial deficiencies. Multiple
tendon anomalies were present. The ankle articu-
lation was found to have a nonfunctional unipla-
nar motion (sagittally oriented). The joint surfaces
resembled two flat plates that rotated one on the
other. The talar articulation was found on the pos-
terolateral aspect of the talus and allowed motion
only in one rotational plane. Multiple coalitions
of the osseous structures of the foot were found,
with subtalar coalition the most common. More
midfoot coalitions were found in the medial col- Fig. 35.13 Plain X-ray showing complete absence of the
umn than in the lateral column of the foot. Distal tibia and bifid lower femur
metatarsophalangeal and interphalangeal joints lucis longus was attached to the lateral aspect of
all appeared to be mobile. The number of rays the distal phalax of the right great toe. The extensor
varied from four to eight. In unilateral cases, the digitorum longus tendons were attached to the lat-
affected leg was always shorter with decreased eral four toes. The distal phalanx of the hallux was
calf circumference. Despite the absence of the trifid. The lumbricals were observed over the right
tibia and discrete musculature, the sural, deep and foot. Other muscles of the leg, namely, tibialis
superficial peroneals, and a “posterior tibial” anterior, flexor digitorum longus, peroneus brevis,
nerve were identified in all specimens. The dorsa- and peroneus longus, were normal. The Achilles
lis pedis and posterior tibial arteries were found tendon was attached to the calcaneum. The talus
associated with the nerve bundles. The greater was fused to the calcaneum [28]. The tibia was not
and lesser saphenous veins were also present. The represented by any band during dissection [29].
anterior tibial artery is frequently absent [26].
The posterior tibial neurovascular bundle was
found to be quite short and acted as a tether in all 35.2.3 Classification
of the specimens. The plantar fascia was not iden-
tifiable as a discrete structure in four of the five In spite of the rarity of this anomaly, there are
specimens. An abductor hallucis mass was pres- several classifications. Jones et al. in 1978 [30]
ent in all specimens, even those with hypoplastic reported four radiological types: Type 1A, com-
or absent medial rays. An abductor digiti quinti plete absence of the tibia with hypoplastic lower
was present in all specimens. The lateral and femoral condyles (Fig. 35.14). Type 1B, the tibia
medial calcaneal branches as well as the common is absent except the proximal anlage with almost
toe sensory branches of the “posterior tibial” normal femur. Type II (Fig. 35.15), the proximal
nerve always passed under the medial abductor end of the tibia is well developed, while the distal
mass. The interossei were grossly present both part is absent. Type 3, the proximal part is absent.
plantar and dorsally in all specimens. A quadratus Type 4 (Fig. 35.16), the tibia is short with distal
plantae was identified in all specimens. The flexor tibiofibular diastasis. Kalamchi and Dawe in
hallucis brevis and adductor hallucis were identi- 1985 classified their patients into three types:
fied in the three specimens with five rays. The Type 1, complete absence of the tibia, Type 2,
other two did not have discrete musculature in absence of the distal part. Type 3, dysplasia of the
this layer. The multiple anomalies of the foot and distal tibia with diastasis of the tibiofibular syn-
ankle in tibial hemimelia can prevent the correc- desmosis. More extensive classifications were
tion of these severe deformities [26, 27]. suggested by Weber [31]. The tibial malforma-
The ankle articulation was sagittally oriented tions are divided into seven main groups and
in all five specimens. The joint surfaces resem- eight subgroups. The cartilaginous anlage is
bled two flat plates that rotated one on the other. marked in the subgroups with “a” when it exists
The talar articulation was found on the postero- and with “b” when it is absent. This system has
lateral aspect of the talus and allowed motion not been widely accepted [32]. We used Jones
only in one rotational plane. The fibular articular classification to classify our patients. However,
surface was medially oriented. This placed the there were many cases categorized outside this
foot in a near-coronal orientation in reference to system. An example is congenital hypoplasia of
the trunk. This combination of articular position- the whole tibia with normal fibula (Fig. 35.17),
ing and rotational motion allows the foot to take separate soft tissue cover of dysplastic tibia and
its typical position facing the perineum. fibula, and short deformed tibia with subluxed
In another study, the gastroc-soleus complex tibiofibular joint (Fig. 35.18) [33]. The morpho-
appeared to be fibrotic, and it had its proximal logic features include a dysplastic, short tibia,
attachment to the head of the fibula. The extensor proximal migration of the fibular head, formed
hallucis longus tendon and the extensor digitorum knee and ankle joints, and an equinovarus foot
longus tendon were also fibrotic. The extensor hal- and may be an extramedial ray (Fig. 35.19) [34].
Fig. 35.14 Type 1 Jones classification [complete absence of the tibia]
Fig. 35.15 Type 2

Jones classification
[absent distal tibia]
Fig. 35.16 Type 4

Fig. 35.17 Congenital
hypoplasia of the tibia
with normal fibula
35.2.4 Treatment
Conventional treatment of tibial hemimelia is

amputation and prosthetic fitting. Amputation in
the very young age [before 1 year] can be consid-
ered as congenital amputation [35]. Besides, an
early amputation allows better accommodation
of the child to the prosthesis. The level of ampu-
tation is a matter of debate. It can be designed
according to the longitudinal deficiency [36].
Spiegel et al. in 2003 reported a series of 15
patients [19 limbs] with tibial hemimelia treated
with amputation. Patients with type 1 deficien-
cies were treated by knee disarticulation. There
were no perioperative complications, and no
additional surgical procedures were required. No
specific prosthetic problems were identified at
follow-up. Type 2 deficiencies were treated ini-
tially by foot ablation (Syme or Chopart) and a
tibiofibular synostosis. All patients treated ini-
tially by foot ablation alone developed prosthetic
irritation in the region of the proximal fibula due
to varus alignment of the lower limb associated
with a prominent and unstable proximal fibula.
One patient had difficulties with prosthetic fit fol-
Fig. 35.18 Clinical photo showing separate soft tissue
cover to the proximal tibia and fibula lowing synostosis attributable to a progressive
Fig. 35.19 Severe
deformity with diastasis
of the upper tibiofibular
joint
varus deformity. This was treated effectively by centralization [41–43] or knee disarticulation
fibular epiphysiodesis and medial tibial physeal [35]. It is always difficult to test the quadriceps
stapling 8 years after synostosis. There were no muscle in infants and young children. However,
ongoing prosthetic problems at the time of the the presence of the patella is a strong evidence of
most recent follow-up. Limbs with type 3 defi- the functioning quadriceps. The status of the
ciency were treated by Syme amputation and two extensor mechanism is critical to the decision
developed complications, including symptomatic making, as patients with insufficient quadriceps
instability at either the proximal or distal articu- strength often develop disabling flexion contrac-
lation. Fernandez-Palazzi et al. [35] designed the tures following centralization and consequently
treatment according to Jones classification: cases bad result [21, 30]. Some researchers have
type 1A and 1B were treated with knee disarticu- reported favorable results in the presence of ade-
lation. Treatment of type 2 was tibiofibular syn- quate quadriceps function [42, 43]. Knee insta-
ostosis and below-knee amputation. Type 3 cases bility was reported in most cases. Long-term
were treated with below-knee amputation, while follow-up of type 1A cases treated with recon-
type 4 were treated with talectomy and closure of struction of the knee revealed marked instability
the diastasis to centralize the foot. as the broad femoral condyles face the small fibu-
The role of fibular transfer in cases with com- lar head. Microsurgical transfer of the contralat-
plete deficiency of the tibia [37, 38] is controver- eral fibular head based on anterior tibial vessels
sial. Schoenecker et al. in 1989 [22] reported to broaden the surface of broad proximal tibia to
secondary amputation in 50% of cases treated increase the stability had been reported.
with fibular centralization. Loder revised 87 Anastomoses were performed side to side with
cases from the literature, and he concluded that popliteal artery and end to end with the two venae
53 out of 55 cases of type 1A Jones classification comitantes. Lateral ligaments were reconstructed
treated by Brown procedure had bad results due with local tissues sutured to the periosteum of
to progressive flexion knee deformity [39]. We ipsilateral fibula and to the biceps femoris tendon
would narrow the selection criteria to include stump of the contralateral transferred fibula.
only patients: Follow-up revealed good lateral stability and fair
knee range of motion. However, this was an occa-
(a) With documented quadriceps strength of sional case report [44]. However, most authors
grade III+ or greater prefer early through-knee amputation, given the
(b) Younger than 1 year, because of the greater anticipated good function with modern prosthe-
potential for proximal fibular hypertrophy ses and unsatisfactory long-term results of fibular
(c) Without fibular bowing centralization.
(d) With the physical potential to walk, with
The progressive flexion knee deformity after
other functioning extremities Brown procedure had been treated by fusion of

(e) Without pterygium folds in the popliteal the upper fibula to the lower femoral condyles.
fossa However, in some cases with follow-up, the
arthrodesed knee could develop the flexed posi-
These cause progressive flexion contractures tion again. Management included the application
[40]. There are several modifications to the origi- of Ilizarov frame to the femur and tibia
nal procedure, such as attachment of the patellar (Fig. 35.20). Corticotomy was done at the site of
ligament to the proximal end of the fibula, step the knee. The frame comprised two hinges at the
shortening of the femoral shaft, traction before site of corticotomy placed anteriorly and a poste-
surgery, hamstring releases if necessary, as well riorly placed distractor. After 3 days distraction
as other modifications. started allowing for both gradual correction of
The most controversial topic in the treatment the deformity and lengthening.
of type 1 deficiencies or complete absence of the Management of tibial hemimelia without
tibia has been whether to perform fibular amputation had been reported recently [45–48]
Fig. 35.20 (a) X-ray showing arthrodesed knee in 90° knee; (c) gradual distraction to do lengthening and correc-
flexion deformity; (b) Ilizarov frame applied to the femur tion of the deformity; (d) X-ray at the end of distraction;
and tibia and corticotomy was performed at the site of the (e) X-ray at follow-up after frame removal
e
as amputation was not an acceptable method of and forefoot half-rings was applied concomi-
treatment. Hosny (2005) reported the preliminary tantly to correct the calcaneovarus foot deformity.
results of treatment of tibial hemimelia without The frame was removed 1 month after full cor-
amputation [45]. The treatment of type 1A cases rection of the deformities. Then, Brown proce-
was based upon three stages. The first stage was dure was performed to centralize the already
application of Ilizarov external fixation to the centralized fibular head and to clear the soft tis-
tibia, femur, and foot. The head of the fibula was sue in between the reconstructed joint surfaces.
pulled down at a rate 1 mm per day till its level The fibers of the patellar tendon was sutured to
just below the femoral condyles. The side-to-side the fibula. There was no femoral or fibular short-
translation was applied after changing the frame ening. The limb was kept in above-knee plaster
links at the same rate to centralize the fibula cast for 6 months. Then, Ilizarov external fixator
between the femoral condyles. At the same time, was reapplied to the femur, fibula, and foot to
distraction was applied between the fibular ring correct the residual knee, ankle, and foot defor-
and calcanean half-ring to place the distal fibula mities. For the knee, posterior distractor with two
opposite the talus. Differential lengthening of the anteriorly positioned hinges was applied to dis-
medial and lateral sides between the calcanean tract the joint surfaces during flexion deformity
correction. After removal, above-knee plaster described two techniques of foot centralization
cast was applied for 1 month followed by above- by means of CF arthrodesis or talofibular arthrod-
knee splint and weight bearing. Satisfactory esis [53, 54]. The main problem was the high
results mean no fixed flexion knee deformity, incidence of postoperative loss of correction or
active range of motion 10°–80°, and valgus or recurrence of the deformities. Other authors
varus instability less than 5° [42]. The patients reported ankle centralization with distraction and
who were not ambulating before the operation soft tissue release [45]. Wada et al. in 2015 [55]
could walk using knee-ankle-foot orthosis as presented 19 foot centralizations performed in 14
there was residual instability of the knee and patients with Jones type 1 and 2 tibial hemimelia.
ankle in most cases. The centralized fibula can be The average age of patients at the time of surgery
lengthened once or twice to compensate for the was 1.3 years (range 0.4–3.8 years). The average
limb-length inequality [49, 50]. However, most follow-up postoperative period was 10.2 years
authors contraindicate lengthening in type 1A (range 2.2–22.9). All feet showed equinovarus
[45, 49] and recommend it in the other types. deformity and were treated by foot centralization
Conservative treatment of complete congenital by means of calcaneofibular arthrodesis. At final
deficiency of the tibia is long and fraught with follow-up, four of the operated feet were planti-
complications in spite of early encouraging grade without secondary surgery. The remaining
results [45, 47, 51]. However, after a mean fol- 15 limbs, however, required secondary surgery to
lowup of 18 years, Courvoisier et al. [46] treat postoperative early loss of correction and/or
reported the results of four cases treated conser- recurrent foot deformities such as equinus, varus,
vatively by Ilizarov external fixator at the age of and adduction, in addition to talipes calcaneal
1–4. In one case widening of the fibula was per- deformities, and fibular angular deformity at the
formed through longitudinal osteotomy and grad- fibular shortening osteotomy site. The deformi-
ual distraction through multiple olive wires ties were treated either by repeat foot centraliza-
[transverse lengthening]. One case had bilateral tion or fibular or calcaneal osteotomy. There is a
amputation due to progressive deformity, and possibility for recurrence of the deformity until
another case had knee arthrodesis. Schoenecker the distal fibular epiphysis closes, and the carti-
et al. [22] reported secondary procedures included laginous distal fibular end and calcaneus finally
four femorofibular arthrodeses and six knee dis- achieve ankyloses. Foot centralization has the
articulations out of 14 limbs. Weber patella advantages of preserving the patient’s original
arthroplasty (fibular transfer with patellar flap to forefoot and providing a wide landing area for
replace upper tibial surface) had been used if the ambulation and keeping the distal fibular epiphy-
patella is present [36]. sis, as it could be used as a “biological prosthe-
sis.” However, there is a significant possibility of
deformity recurrence and a high rate of second-
35.2.5 Foot Centralization ary surgical corrections which has to be clarified
to the families before deciding conservative
Multiple surgical procedures may be required to approach [55].
correct deformities of the foot. However, retain- Conservative approach to type 2 and other
ing the foot is mandatory in some areas where the types had been more adopted than type 1 [45, 46,
people refuse amputation due to their culture or 48–50, 55]. Tibiofibular synostosis was usually
traditions [45, 46, 48]. Foot centralization was performed as a first step. Then, Ilizarov external
first described by Myers and Brown [37, 52]. fixator was applied to the tibia [three rings], a
Foot centralization was performed by means of half-ring to the calcaneus, and a half-ring to the
calcaneofibular (CF) arthrodesis. However, even- forefoot. The proximal ring was applied to the
tually a Syme amputation had to be performed to tibia alone, leaving the upper fibula free.
permit use of a below-the-knee prosthesis Corticotomy of the tibial was performed between
because of the recurrence of foot deformity after the upper two rings, and distraction was applied
foot centralization surgery. Various authors have after a waiting period ranging from 3 to 7 days
according to the age of the patients [the younger Cases with congenital hypoplasia had been
the patient, the shorter is the waiting period to treated with application of Ilizarov frame to the
avoid premature consolidation of the regenerate]. femur, tibia, and foot [28]. The tibial frame con-
Distraction was continued till the head of the sisted of two ring mounted to the tibia alone with
fibula regains its normal anatomical position. K-wires leaving the fibula free. Corticotomy was
Then, the patient was admitted to the operating performed between the two rings. After a waiting
theater again, and corticotomy of the fibula was period of 7 days, distraction started at a rate
undertaken with transfixing the head of the fibula 1 mm per day till the upper and lower fibula
to the upper tibia with a K-wire. This wire has to regained the normal anatomical positions. The
end flush with the fibula to avoid any pressure to femoral frame was applied to guard against knee
the common peroneal nerve. Then, distraction subluxation, while the foot frame was used to
was continued for both bones till the targeted correct the foot deformities.
lengthening achieved. Foot deformities were cor-
rected gradually concomitantly with lengthening
[45]. The progressive knee deformity prevented 35.2.6 Complications
reaching the target length for fear of knee sublux-
ation or dislocation. Femoral lengthening at Many complications had been reported in the lit-
another stage was performed in these cases to erature during treatment without amputation. Pin
compensate for residual leg length inequality track infection is the most commonly encoun-
accepting the disadvantage of having the two tered complication which required systemic or
knees at different levels which does not affect the local antibiotic or wire replacement in nonre-
function [56]. Regenerate formation during fibu- sponding cases. Fracture of the regenerate and
lar lengthening had been reported to be slow fracture fibula occurred in few cases. Due to the
[49]. These surgical steps are not fixed in all foot anomalies, it was difficult to hold the calca-
cases as the treatment strategy has to be adapted neus, and cutting through of the calcanean wire
for each case [46]. The most challenging prob- had been reported [45]. Nonunion of tibiofibular
lems during lengthening are knee and ankle sta- synostosis and knee stiffness were the main com-
bility [46]. Ligamentous laxity and intra-articular plications in another series [42].
knee deformities are the possible causes [57]. Shahcheraghi and Javid reported the func-
This might be the reason behind the development tional outcome of cases with tibial hemimelia
of progressive flexion knee deformity during tib- treated with reconstruction. The patients or their
ial lengthening. Management of these deformi- parents filled out the pediatric quality of life and
ties can be possible by application of the frame to the parents’ satisfaction forms. It seems logical
the femur and posterior release. We could not that longitudinally tibial deficiency, especially
elicit any reports of reconstruction of type 3 when it is often associated with other limb defor-
cases. mities as well, cannot be a fully normal individ-
Type 4 deficiencies can be treated successfully ual. They stated that the preserved limb and foot
with limb (including foot) preservation. The ankle cases—when specifically questioned—would
with tibiofibular diastases in the type 4 cases have all been chosen to keep the foot and the leg
would function well and can be improved using where they to decide again. Reconstruction of
tibiofibular synostosis, differential distal epiphys- tibial hemimelia with foot preservation provides
iodesis, and osteotomy [50]. However, in cases good functional outcome in the majority of cases.
with marked separation and angulation of the dis- The reconstructed group had a better functional
tal tibia and fibula, osteotomy at the site of angula- score than the amputated group in the four groups
tion can be performed followed by olive wires of physical, social, psychological, or schooling
application and gradual transverse traction to close scores when assessed separately—noting again
the diastasis. Besides, longitudinal traction to push that most amputated cases were part of bilateral
the talus down is applied concomitantly. hemimelia cases (Fig. 35.21).
Fig. 35.21 (a) X-ray

a
showing congenital
hypoplasia of the femur
with normal fibula. (b)
Application of Ilizarov
frame to the femur,
tibia, and foot and
corticotomy was
performed between the
two tibial frames; (c)
distraction was applied
to the tibia alone; (d)
distraction was
continued; (e) X-ray at
the end of distraction;
(f) X-ray after removal;
(g) follow-up X-ray
b
g
35.2.7 Conclusions development of the proximal femur and acetabu-

lum, which results in a lack of integrity, stability,
Tibial hemimelia is a very rare anomaly, which is and mobility of the hip and knee joints.
frequently associated with other musculoskeletal Malorientation, malrotation, and soft tissue con-
anomalies in addition to lower limb shortening. tractures of the hip and knee are the main obsta-
Conventional treatment is still amputation in cles of treatment. Both deficiencies and deformities
most centers. The debate is usually about the are nonprogressive but difficult to manage. Limb
level of amputation. However, in some countries length discrepancy is especially problematic in
amputation is not an acceptable way of treatment. cases of instable hip and knee joints.
The limb preservation option is recommended in The diagnosis and classification of this disor-
these circumstances which is dependent on knee der were mainly based on plain radiographs and
stability, the expected limb shortening, and the the relationship between the acetabulum and
severity of foot and ankle deformities. Ilizarov proximal femur, but now we have magnetic reso-
principles are a valid option in these cases as nance imaging (MRI) more anatomical findings
functional improvement is expected in all types to organise the treatment. Management of the
of congenital absent tibia. disorder depends on the severity.
The development of distraction osteogenesis
and new findings that have given us a better
understanding of the pathoanatomy provide the
35.3 P
roximal Focal Femoral opportunity to reconstruct the extremity. Van Nes
Deficiency rotationalplasty can also be considered for
extremly short and unconstructable femurs.
Halil Ibrahim Balci
PFFD is a confusing diagnosis because of the
Proximal focal femoral deficiency (PFFD) is a complexity of the terminology. The associated
rare congenital disorder characterized by abnormal fibular deficiency, knee abnormality, foot and
Fig. 35.23 PFFD type 3 according to Paley with absent

femoral head extreme shortening and less than 45° of
motion at knee
valgus deformity. The most common associated

lower extremity congenital disease is fibular hemi-
melia [58]. There are multiple classification sys-
Fig. 35.22 PFFD type 1 according to Paley with well- tems because of all these complexities: Aitken
formed proximal femur and acetabulum
[59], Gillespie [60], Pappas [61], and Paley [62].
Aitken classification, which was the most
ankle problems, and knee instability make the used until a few years ago, does not evaluate the
diagnosis, classification, and treatment much more cartilaginous and soft tissue abnormalities and is
difficult. Just for the femur, the extent of the clini- based primarily on X-ray findings. Class A is
cal presentation can vary from a few centimeters characterized by a short femur with a well-
of shortening with a well-developed hip and knee formed femoral head attached to the femoral
joint to complete absence of the whole femur with shaft and a well-developed acetabulum. In class
lack of hip and knee joint. The shortening and B, the acetabulum is either adequately developed
extent of the development of hip and knee joint or moderately dysplastic. No osseous connection
become important when we talk about the treat- is seen between the femoral head and shaft at
ment of PFFD (Figs. 35.22 and 35.23). Varus, ret- skeletal maturity. The femur is short with a
roversion, and external rotation deformity of the proximal bony tuft. Class C has a severely dys-
proximal femur can associate with pseudoarthro- plastic acetabulum with an absent or very small
sis, stiffness, or complete absence of the femur femoral head that is not attached to the femoral
with different presentation of acetabular dysplasia. shaft. The femur is short with a tapered proximal
The knee joint mostly has hypoplastic or absent end. Class D is the most severe form. The femo-
anterior cruciate ligament, multiplanar instability, ral head and acetabulum are absent. The femur is
and hypoplastic lateral femoral condyle with shortened and often pointed proximally [63, 64].
Fig. 35.24 Preoperative X-ray of type 1 b PFFD accord-

ing to Paley
MRI has allowed us to understand the patho-

anatomy in three dimensions. The presence of a
cartilaginous femoral neck can now be confirmed
with MRI. The coxa vara greater than 90° of Fig. 35.25 Postoperative AP pelvis X-ray of patient
varus and flexion are common fixed abduction Fig. 35.24 after SUPER hip 1 procedure
contracture.
Paley suggested a new classification accord- Paley emphasized the importance of the knee
ing to MRI and anatomic findings. The shorten- joint for the reconstructibility of deficiencies.
ing and hip and knee issues became important to The most common form of deficiency is type 1.
decide whether the limb was reconstructable. He Especially in type 1 deficiencies, if the center
also suggested the SUPER hip 1, 2, and 3 tech- edge angle is more than 20°, the neck shaft angle
niques to solve all of problems in a single opera- is more than 110°, and if the medial proximal
tion in patients as young as 2–3 years of age to femoral angle (MPFA) is not less than 70°, no hip
avoid the problems that prevent lengthening. Dr. surgery is required before the first lengthening.
Paley suggested correcting all of these deformi- There is also no need for the knee surgery if the
ties with a technique described by himself called fixed flexion deformity is less than 10°, the
as Systematic Utilitarian Procedure for Extremity patella tracks with no subluxation laterally, and
Reconstruction (SUPER) hip procedure [62]. there is no evidence of significant rotary sublux-
The proximal femoral reconstruction (SUPER ation or dislocation [62].
hip) prevents worsening of coxa vara deformities, Femoral deformities consist of three planar
proximal migration of the femur, and dislocation bone deformities and soft tissue contractures.
of the hip during lengthening procedures Abductor contracture can cause recurrence.
(Figs. 35.24, 35.25, and 35.26). Varus deformity is associated with extension,
Fig. 35.26 Postoperative
frog leg X-ray of patient
Fig. 35.24 after SUPER
hip 1 procedure
external rotation, and retroversion, which are articular posterior collateral ligament reconstruc-
caused by the piriformis muscle. Reflection of tion (reverse MacIntosh) is performed with
the tensor fascia lata to use for the extra-articular anterior limb of the tensor fascia lata.
reconstruction of cruciate ligaments, hip flexion In cases of knee flexion contracture, after the
contracture release, abduction and external rota- decompression of the peroneal nerve at the fibu-
tion contracture release, and three planar proxi- lar head, posterior soft tissue lengthening and
mal femoral osteotomies are the main components capsular release can be performed.
of the procedure. Fixation of the osteotomy can When patellar maltracking is more significant,
be achieved using plates or rush rods [62]. For medial transfer of the patellar tendon at the insertion
type 2 deficiencies, Paley also achieved ossifica- is performed with the Grammont procedure. When
tion of the collum femoris of the hip with bone fixed subluxation or dislocation is present, the mod-
morphogenic protein. However, he also sug- ified Langenskiold procedure is performed.
gested that rotationplasty was the most reliable Patellar realignment prevents patellar disloca-
solution for Paley type 3 PFFD. tion and knee extension contracture. The ACL-
As the congenital femoral deficiency can also PCL reconstruction prevents knee subluxation/
affect the knee joint (both patellofemoral and tib- dislocation and late problems of knee instability
iofemoral), stabilization of the knee is a critical in adolescence. The “SUPER knee” procedure is
procedure before lengthening. Isolated antero- mostly performed at the same time as the pelvic
posterior instability of the tibiofemoral joint osteotomy and SUPER hip procedure.
without knee joint dislocation or rotatory sublux- In case of acetabular dysplasia, we decide the
ation does not need to be addressed before length- type of acetabular osteotomy according to the
ening. Isolated subluxation or dislocation of the intraoperative findings. Most of the time the defi-
patella should be treated before lengthening [62]. ciency is seen anterolaterally. Therefore, we pre-
Paley described the SUPER knee procedure, fer Dega osteotomy.
which is a combination of the Langenskiold pro- Prior to the introduction of the Ilizarov method
cedure [65], which was designed for congenital and distraction osteogenesis in the Western world
dislocation of the patella, the MacIntosh proce- in the 1980s, lengthening for PFFD was worse
dure [66, 67] (extra-articular reconstruction for than no treatment. The complication rates were
anterior cruciate deficiency), and the Grammont high with little gain in length, and permanent
procedure [68, 69] which was designed for recur- damage to the hip, knee, and ankle was common.
rent dislocation of the patella. Macintosh intra- Only ossified proximal femoral neck cases
and/or extra-articular anterior collateral ligament were lengthenable after correction of the varus,
reconstruction is performed with tensor fascia external rotation, and retroversion deformity of
lata posterior limb tendon harvest, which can be the proximal femur and acetabular dysplasia.
obtained during the SUPER hip procedure. Extra- Cases with delayed ossification and over 90° of
Fig. 35.27 Monoplanar external fixator is combined with

circular ring to secure the knee joint
complex angular deformity had a high recurrence

rate. Recurrence of the deformity prevents us
from lengthening the femur in a safe way.
Stabilizing surgery for the hip and knee joint
makes the lengthening process much easier com-
pared with the past.
For lengthening of the femur in PFFD, we pre- Fig. 35.28 Lengthening of the femur in PFFD patient.
fer distal femoral osteotomy if we do not need to AP X-ray of hip, femur, and knee joint taken during the
perform valgization and/or internal rotation. follow-up to check hip subluxation, regenerate quality,
and lengthening amount
External fixation is the only method in lengthen-
ing of congenital cases. The amount of lengthen-
ing is decided according to the follow-up of the 35.29). After fixation of the hinges, a removable
patient. The quality of bone regenerate, knee and knee extension bar is inserted between the distal
hip range of motion, and joint subluxations are femoral ring and the tibial half-ring. The exten-
the main criteria. The main advantage of external sion bar is removed during the physical therapy.
fixation only is that one can secure the knee joint We start lengthening on the 5–7th day and physi-
with an external fixator without preventing knee cal therapy on the 2nd day after the operation.
joint motion. Our most preferred method with Patients are usually followed up every 2 weeks
circular-type external fixator is to extend the fixa- for radiographic and clinical assessments.
tion to the tibia using hinges placed at the center Clinically hip and knee range of motion, knee
of rotation of the knee, the intersection of the subluxation, and pin-site problems, radiologi-
posterior femoral cortical line, and the distal fem- cally, the distraction gap length, regenerate bone
oral physeal line. We prefer a half-ring placed quality, limb alignment, and joint location, are
perpendicular to the tibia (Figs. 35.27, 35.28, and assessed. We prefer to start 1 mm of lengthening
Fig. 35.29 Lateral X-ray of the femur and knee during Fig. 35.30 Clinical AP view of the patient with a Paley 1
the follow-up to check the knee joint subluxation if any PFFD after the SUPER hip and first lengthening proce-
dures. To prevent LLD patient will need at least two more
lengthening procedures
per day in four increments. But, as in all congeni-

tal disorders, we decrease the speed to 0.75 or ios patients need three lengthening operations,
even 0.5 mm per day after the early consolidation 7–8 cm lengthening in each to reach the goal of
risk decreases (1–2 cm of distraction). As the dis- no limb-length discrepancy (Figs. 35.30 and
traction gap increases, joint motions are restricted. 35.31). The first and sometimes also the second
Close follow-up of the joints (hip and knee) is needs to be performed with an external fixator.
important. Ménard-Shenton line for the hip and However, the third lengthening, if the knee and
lateral view of the knee joints must be checked hip joints are well formed and stable, can be per-
for each visit during the distraction and even formed via implantable internal devices (nails).
early consolidation phases. In congenital cases, The appropriate age group for lengthening is
especially in PFFD after the removal of the exter- children aged 5–7 years, 10–12-year-olds, and
nal fixator, prophylactic rush pin application adolescents. One should never forget that PFFD,
seems logical to prevent fractures and continue even in its less severe form, is the most difficult
the physical therapy more safely. In most scenar- lengthening that an orthopedic surgeon will be
Fig. 35.31 Lateral view of patient Fig. 35.30. Flexion of

the knee joint is well preserved
Fig. 35.32 Van Nes rotationplasty clinical view

faced with during their career. Complications and
sequelae should be overcome by experienced sur-
geons and the team built by the surgeons, physi- (Figs. 35.33 and 35.34); although the procedure
cal therapists, and care center, which is increases the functionality of the lower limb, it
experienced in lengthening procedures. can be difficult for patients to accept rotating the
If the deformity and the shortening are unilat- lower limb to 180°.
eral, the physician should not forget to discuss
the benefits of the epiphysiodesis around the knee
joint of the contralateral extremity. Excessive 35.3.1 Paley Classification
lengthening can be prevented so as to avoid limb- of Congenital Femoral
length discrepancies. Deficiency
In very extreme cases such as Paley type 4 and
3B and 3C cases, one should never forget Van Type 1: “Intact femur” with mobile hip and knee
Nes rotationplasty (Fig. 35.32). Sometimes, the
lack of femur or very short femur makes the defi- (a) Normal ossification proximal femur
ciency difficult to reconstruct. Rotationplasty (b) Delayed ossification proximal femur
enables the ankle joint to be used as a knee if
rotated 180°. Special prostheses are adapted and Type 2: “Mobile pseudarthrosis” with mobile
the patient is educated as to how to fit them. knee
Functionally, patients profit from rotationplasty,
but we should talk and help the patient under- (a) Femoral head mobile in acetabulum
stand the aim of the procedure and what to expect (b) Femoral head absent or stiff in acetabulum
Fig. 35.33 Ankle (new knee) joint in extension
Type 3: “Diaphyseal deficiency” of femur Fig. 35.34 Ankle (new knee) joint is in flexion
(a) Knee motion 45° or more 1/150000 birth), but it has one of the most diffi-
(b) Knee motion less than 45° cult treatments. A lot of mechanical and/or bio-
(c) Complete absence of femur logical techniques which have different success
rates are defined in CPT treatment. Prognosis of
Type 4: “Distal deficiency” of femur CPT has become better through the agency of
vascularized fibula transfers and Ilizarov meth-
ods in recent years [70, 71].
35.4 Congenital Pseudoarthrosis
of Tibia
35.4.2 Clinical Diagnosis
Fuat Bilgili
Anterolateral bowing of bone can be noticed
since first days of life. It may present primary
35.4.1 Introduction pseudoarthrosis in neonatal form or secondary
pseudoarthrosis after pathologic fracture in walk-
Congenital pseudoarthrosis of the tibia (CPT) is ing age. Severity of shortness in the lower extrem-
defined as a bone diaphysis disorder, which pres- ity is variable [72].
ents with pathologic fracture-related medullary Unilateral involvement is often seen in
narrow canal or cyst formation. It presents with CPT. Fibular pseudoarthrosis is also present
different clinical formations variant from mas- in over half of patients. Primary localization is in
sive bone defects related nonunion to simple the middle or distal third of the tibia regardless of
bone defect. CPT is a rare disorder (frequency gender or size [70].
Over half of the patients with CPT have neu- 35.4.3 Imaging
rofibromatosis type 1 (NF1) disease [73, 74]. In
contrast, bone bowing and CPT rate in NF 1 is Simple anterolateral convex bowing or real tibial
less than 4% [74, 75]. NF1 is a multisystemic discontinuity was seen in plane radiography
neurocutaneous disease which is inherited OD (Fig. 35.35).
and occurs one in 4000 births. Bone anomalies in There are also cyst formations starting with
NF1 may be primary bone lesion or secondary to bone bowing between the age of 6 weeks and
soft tissue damage causing bone deformity. For 1 year of life. Cortex in the concave side of curva-
differential diagnosis of isolated CPT from the ture is intact, intense, and thick. Medullary canal
bone deformities in NF type 1, the skin should be is narrow, and cystic appearance may be noticed
examined for café au lait spots, freckling in the in the apex of curvature. Severity of the deformity
axillary or inguinal regions, and neurofibromas. increases when the cortex is fractured. Transverse
Furthermore, family history should be questioned fracture occurs [71]. In dysplastic forms, there is
[74]. There is dysfunction in the differentiation bone bowing in birth, and sometimes even pseu-
of periosteum to myofibroblasts or chondrocytes doarthroses already exist. The tibia is narrow like
whether or not CPT is associated with NF1 [76]. a sandglass, and the medullary cavity is destructed
Bone healing is not affected adversely in CPT here. In these types, the fibula is frequently
related with NF1 [72]. affected. Bone ends could be thin, atrophic, or
In differential diagnosis, ring constriction or hypertrophic when pseudoarthroses occur. These
amniotic band syndrome, fibrous dysplasia, radiological features define the criteria which are
osteomyelitis, fibrosarcoma of infancy, and fibu- the basis in differential diagnosis of CPT.
lar hemimelia also should be considered. Developments in MRI give detailed information
a b c
Fig. 35.35 Preoperative clinical (a) and radiographic view (b, c) of patient with CPT
about bone and soft tissue around pseudoarthro- growth. However, initial classification affects the
sis. New bone perfusion sequence can show vas- prognosis.
cularization defects, determinate borders of El-Rosasy-Paley classification is mostly used
resection, and helps us to understand the patho- in clinical experience [78]. This classification is
physiology of this disease [77]. based on three parameters: (1) history of any pre-
vious surgery (yes or no), (2) clinical examina-
tion of bone ends (mobile or stiff), and (3) the
35.4.4 Classification radiologic type of pseudoarthrosis (atrophic or
hypertrophic) (Table 35.6).
These are some classification systems: Anderson
classification, Crawford classification, Boyd
classification, and Apolin classification [70]. 35.4.5 Prognostic Factors
Anderson classified the pseudoarthrosis under
four morphologies: dysplastic, cystic, late, and a Some prognostic factors for CPT have been
clubfoot type with associated congenital abnor- reported [71, 79, 80]:
malities. Crawford described four types of con-
genital tibial pseudoarthrosis. Anterolateral • If the localization of pseudoarthrosis is in dis-
bowing is common in all types. tal or inferior metaphysis, control of distal
fragment becomes hard. Requirement to
• Type I: intact medullary canal with a cortical involve the ankle and foot in fixation may
thickening at the apex of the bowing. result in articular sequelae.
Follow-up is recommended because of best • The type of pseudoarthrosis is an important
prognosis. parameter. Bone atrophy with severe deformi-
• Type II: there is tabulation defect in the med- ties, significant bone shortness, and small
ullary canal with cortical sclerosis. These bone diameter with intense sclerotic lesions
patients must be protected to avoid fractures. are indicators of poor prognosis.
Surgical treatment should be planned. • Presence of fibular pseudoarthrosis worsens
• Type III: there is a prefracture cystic lesion. the prognosis.
Early surgical treatment is required in this type. • Shortness of the lower extremity is derived
• Type IV: there is fracture or pseudoarthrosis. from superimposed bone edge and angulation.
The worst prognosis is seen in this type. Early Especially, the number of operation, signifi-
surgical treatment is required (Table 35.5). cant angulation which resulted from recurrent
fractures, and remaining bone reserve are
A limitation of all classifications lies in the important prognostic factors. Resorption of
alteration of the disease morphology during the graft is a poor prognostic factor.
Table 35.5 The three classifications (Crawford, Anderson, Boyd) of CPT

Crawford I II III IV
Anderson Sclerotic Cystic Dysplastic Clubfoot + antecurvation of tibia
Boyd I IV III II V: Pseudoarthrosis of fibula VI: Intraosseous
without nonunion of tibia neurofibromatosis
Table 35.6 El-Rosasy-Paley classification of CPT

Bone ends on x-ray Motion of pseudoarthrosis Previous surgery
Type I Atrophic (thin) Mobile No
Type II Atrophic (thin) Mobile Unsuccessful surgery
Type III Hypertrophic (wide) Stiff Yes or no
35.4.6 Treatment EPOS recommends surgical treatment after

3 years of age to avoid difficulty in stabilization
35.4.6.1 Nonoperative Treatment of small bone fragment in young children [82].
Treatment with cast immobilization can be The best results are reported with Ilizarov tech-
applied to very young children with mild defor- nique between 6 and 9 years old in EPOS. Between
mity. Nonsurgical treatment also delays the age 3.5 and 7 years of age, treatment with vascular-
for surgical treatment. Thus, intramedullary fixa- ized bone transfers has good results [84]. A suc-
tion is made of a larger rod, and a greater amount cessful bone healing is concerned with type of
of autologous grafts can be used. Using protec- pseudoarthrosis and choice of the surgical tech-
tive brace including a total-contact ankle-foot nique rather than age.
orthosis (AFO) or knee-ankle-foot orthosis There is no gold standard therapy for all CPT
(KAFO) before walking age postpones the frac- cases today. There are two main difficulties about
tures in cases with bowing and restricts deformi- treatment:
ties in cases with pseudoarthrosis [81].
1. Mechanical difficulty in fixation and stabiliza-
35.4.6.2 Operative Treatment tion of small, osteoporotic bone fragments
CPT gets worse without treatment; deformity and 2. Biologic problem because of hamartomatous
shortness are unavoidable. change of the periosteum
The best treatment methods are intramedul-
lary nailing method, vascularized fibula graft, Preoperative planning must be made to solve
Ilizarov method, or combined treatment. In this these problems. Surgical technique should be
chapter, we will mention about combined treat- decided according to the type of pseudoarthrosis
ment including Ilizarov method, intramedullary and size of the defect.
nailing, and periosteal grafting. If the shortness is little in normal and hyper-
Ilizarov method was shown to be the best surgi- trophic types, Ilizarov or intramedullary nailing
cal technique by EPOS in 2000, in a multicenter with bone graft can be applied.
study which was done with 340 patients, because Controversy is often concerned with which
of protecting the bone length and alignment and its method will cause significant bone loss in atro-
ability of lengthening with bone segment transport phic form. In this situation, vascularized fibula
[82]. Also best results are reported in a multicenter and Ilizarov method with bone transport are bet-
study which was done in Japan with 73 patients ter options.
who have undergone Ilizarov technique and vascu-
larized fibula transfer [80]. Recurrent fractures
may occur due to axial residual deformity after 35.4.7 Ilizarov Technique
treatment with Ilizarov method. Intramedullary
fixation should be applied with the Ilizarov method The first user of Ilizarov method in CPT is
to avoid this complication [83]. Ilizarov himself. External circular fixation
The extent of resection is not defined in the enables us to use a lot of combinations which can
literature. Limit of resection is determined mac- be adopted to the type of pseudoarthrosis. Small
roscopically by evaluating the bone and intra- bone fragments can be stabilized, and limb length
medullary space during the operation. MRI plays discrepancy can be treated with the same proce-
an important role to determine fibrous hamar- dure. External fixation could be extended to the
toma, periosteum, bone lesions, and the extent of foot according to anatomic location of
bone and soft tissue to be resected [77]. pseudoarthrosis.
The state of the child’s family, age, the type Ilizarov method includes direct compression
and localization of pseudoarthrosis, and timing of or progressive compression depending on the
the surgery must be kept in mind while deciding amount of excised dead bone in pseudoarthrosis
on surgical indications. zone. If the amount of excised bone is little, direct
a b
Fig. 35.36 Drawing incision (a) and determining the resection area under fluoroscopy (b)
compression is enough. If a lot of dead bone is and iliac crest stay open at the radiolucent table.
excised, progressive compression with segmental Sterile tourniquet is performed. The pseudoar-
bone transport is required for healing and length- throsis area is opened through an anterior longi-
ening [85]. In order to support healing, simple tudinal incision for type 1 CPT. A transverse
OsteoGen bone graft, inter-tibiofibular bone incision is used for type 2 CPT (Fig. 35.36a, b).
grafting, or a periosteal graft could be applied in Thick periosteum is incised longitudinally at
the same procedure or in the second stage [83]. proximal and distal until normal periosteum is
Recently, bone morphogenetic protein (BMP) is seen. Hamartomatous periosteum around the
another option for graft [86]. pseudoarthrosis site is excised after dissecting
Complications of Ilizarov method are recur- circumferentially.
rent fractures, persistent axial deformities, and During dissection of the fibrous tissue ham-
pin tract infection. It is offered to add intramedul- artoma, posterior tibial neurovascular bundle
lary fixation to external fixation to decrease the and anterior tibial artery must be paid attention
rate of axial deformity and recurrent fracture to. Proximal and the distal segment of the tibia
[72]. Hemiepiphysiodesis or tibial osteotomy is shortened by osteotomy to avoid fracture
may be necessary to treat ankle valgus deformity after multiple drilling. The same procedure is
caused by growth disturbance or persistent pseu- applied to fibular pseudoarthrosis. Proximal and
doarthrosis of the fibula [87]. distal segments of the medulla are opened by
Paley defined a technique using periosteal free drilling. The bone ends are brought into contact
graft as a source of osteoprogenitor cells in the with each other. In type 1 CPT, minimal resec-
periosteum from the iliac wing. This technique tion is adequate to vitalize the bone ends.
includes completely excising the diseased perios- However, more bone resection is required in
teum in pseudoarthrosis zone and wrapping with type 2 CPT. Opening the tourniquet and looking
periosteum graft after filling it with bone graft at the bleeding in the bone suggest the border of
and then external fixation together with intra- dead bone to be resected. If the bone defect is
medullary fixation of the tibia and fibula [88]. more than 3 cm after dead bone tissue resection,
bone transportation is performed with Ilizarov
type of external fixation by making the proxi-
35.4.8 Operation Technique mal tibial osteotomy, and defect is eliminated
gradually in CPT type 2. After lengthening is
The patient is prepared by putting a pillow under completed, periosteal bone graft is applied to
the hip so as to make the whole lower extremity pseudoarthrosis. Intramedullary rod (Paley
modified nail) is placed when the tibia is healed at the distal tibial epiphysis to avoid ankle joint
at both sides and external fixator is removed. If stiffness to allow elongation of the nail during
the bone defect is less than 3 cm after the growth (Graphic 35.1).
removal of the dead bone at the pseudoarthrosis For taking periosteal graft and autogenous
area, bone fragments are brought end to end by graft, an incision is made on the iliac crest
making acute resection. Osteotomy is per- (Fig. 35.37a). The iliac crest apophysis is split in
formed at the proximal metaphyseal area for the middle to expose the inner table of the iliac
lengthening, and intramedullary rod is placed wing bone and medial periosteum. Medial peri-
simultaneously. osteum is separated from the underlying iliacus
Intramedullary nail including K-wire, muscle and removed in the form of a rectangle
Steinmann nail, Rush Pin, or flexible titanium with a blade (Fig. 35.37b). The cancellous bone
nail is chosen according to diameter of the bone is taken from the ilium at the same time. As soon
and age of the patient. This rod is applied from as the periosteal graft is taken, it immediately
distal to proximal above the medial malleolus or shrinks. The periosteal graft is meshed to restore
from proximal to distal at the proximal tibial its size by using skin graft table (Fig. 35.37c).
metaphysis. Recently, Paley has modified Fassier- Suture is placed at both ends of the periosteal
Duval telescopic intramedullary nailing. In this graft to easily wrap around the bone. Periosteal
modification, the nail can be locked with K-wire graft is wrapped around pseudoarthrosis with its
Treatment
algorithm according to Paley classification
Type 2:
Type 1 It depends on bone defect after Type 3
debridement of
pseudoarthrosis
Proximal tibial and distal fibular If bone defect is < 3cm If the bone defect is >3cm
fragments are longitudinally -Acute shorthening and -Partial acute shorthening and - Application of preconstructed
cleavaged and invaginated end proxiamal lengthening proximal lengthening ilizarov external fixator after
to end. osteotomy osteotomy preoperative analysis of
deformity
- Pseudoarthrosis area is not
opened.
- Application of ilizarov external
fixator and beginning bone
Fixation with IM rod into the transport
tibia and fibula. - Gradual shorthening until bone
contact at distal.
- If the fibula is intact, make

osteotomy of fibula.
- Gradual correction of the
Wrapping iliac periostal graft deformity.
around the pseudoarthrosis - Fixation with IM rod after
area and putting autogenous compression of pseudoarthrosis.
graft.
- Wrapping iliac periostal graft
around the pseudoarthrosis area
- After correction, begin
and putting autogenous graft
compression of
pseudoarthrosis.
- After healing, take off eternal
Application of ilizarov external
fixator and apply IM rod to
fixator and compression of the
prevent refracture.
pseudoarthrosis
Graphic 35.1 Treatment algorithm of CPT according to Paley

a b
c d
Fig. 35.37 Taking the periosteum graft from the iliac crest (a, b), preparing (c), and placing it on the pseudoarthrosis
field (d)
cambium layer toward the bone (Fig. 35.37d). year until skeleton maturation is complete
Cancellous bone graft is placed like greenstick (Fig. 35.39a–d).
ring all around bone at the pseudoarthrosis area.
Remained periosteum and bone graft are placed 35.4.8.1 Evaluation of Results
to the fibular area. Recently, BMP-2 is applied to Follow-up until skeletal maturation is required to
the pseudoarthrosis area in addition to autoge- evaluate the result of treatment in CPT. Johnston’s
nous graft. postoperative evaluating method can provide an
The wound is closed in layers. objective comparison in different series [89]. At
After closing the wound, a two-ring pediatric this evaluation:
Ilizarov external fixator is applied for type 1 Stage 1: Complete union and complete func-
CPT. A foot ring is added to control the foot position when bearing full weight. Mild malalign-
tion. The frame is fixed to the bone with three ment (≤10° in the coronal or sagittal plane) or
proximal K-wires (two of them are olive, and one limb length discrepancy (≤3 cm) does not require
of them is straight) placed to proximal metaphysis secondary surgery and affect the outcomes.
and three wires placed to distal metaphysis. These Stage 2: Incomplete union (transverse or lon-
wires should not have contact with intramedullary gitudinal cortical defect in union) but function is
nail. A walking ring is applied not to give full load good. Protective brace is needed to prevent
at the postoperative period. Three-ring frame is refracture. Sagittal deformity (>15° of valgus,
applied for both lengthening and compression of procurvatum or recurvatum) is present. Secondary
pseudoarthrosis in type 3 CPT (Fig. 35.38a–d). surgery is required.
Follow-up protocol: Patients are invited for Stage 3: Recurrent fracture occurs or persis-
control once a month until healing and once a tent pseudoarthrosis is present.
a b
c d
Fig. 35.38 After resection of the pseudoarthrosis area, insertion of intramedullary nail and application of circular
external fixator. Radiological (a, b) and clinical (c, d) views of the patient
a b
c d
Fig. 35.39 Radiological (a, b) and clinical (c, d) view of the patient after healing
35.4.9 Complications 5. Lewin SO, Opitz JM. Fibular a/hypoplasia: review

and documentation of the fibular developmental field.
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embryonic tissue remnant in type II hemimelia cases.
mon complications are as follows:
Eur Sci J. 2015;11(18):36–45.
8. Letts M, Vincent N. Congenital longitudinal defi-
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2003;23(1):30–4.
is another option during primary surgery.
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Deformities of Metabolic
Disorders 36
Levent Eralp
36.1 Introduction calcium or phosphorus (or both) of large enough

quantity such that it interferes with physeal
Faults in the shape, strength, and structure of growth and regular mineralization of the bone
bone tissue due to altered bone mineral homeo- matrix in the growing child [1, 3, 4]. This reduc-
stasis are known as metabolic bone disease [1]. tion in the mentioned serum ion levels may result
The major factors that affect this homeostasis can from insufficient intake or reduced absorption of
be thought as the “three 3s”: the intra- and extra- phosphorus or vitamin D, reduced conversion of
cellular levels of three ions (calcium, phospho- vitamin D to its active form, end-organ insensi-
rus, and magnesium), which are controlled by tivity, impaired release of calcium from the bone,
three hormones (parathyroid hormone, calcito- or phosphate wasting. In addition, there is evi-
nin, and 1,25-dihydroxyvitamin D) and act upon dence that insufficient vitamin D may interfere
three tissues (bone, intestine, and kidney) [1, 2]. with mineralization independent of calcium or
The common clinical characteristics include phosphate levels [1, 3].
electrolyte disturbances, fractures, bone defor- In renal osteodystrophy, glomerular impair-
mity, abnormal gait, and short stature. ment leads to phosphate retention, and tubu-
The most frequently encountered forms of lar damage triggers decreased production of
metabolic bone disease in children are the vari- the active form of vitamin D (i.e., 1,25-
ous types of rickets and renal osteodystrophy. dihydroxyvitamin D) due to the absence of

Other less common but important pediatric met- 1-hydroxylase activity. These two factors severely
abolic conditions include osteoporosis, malab- hinder intestinal calcium absorption and reduce
sorption syndromes, inherited diseases like plasma ionized calcium. The following hypocalce-
hypophosphatasia, X-linked hypophosphate- mia generates secondary hyperparathyroidism,
mia, and several forms of vitamin D-dependent which remains unsuccessful in increasing intestinal
rickets [1, 3]. absorption of calcium. Accordingly, the body’s
Although there are multiple types of rickets, only means of increasing serum calcium levels is
the basic pathogenesis is a relative decline in by bone resorption (Figs. 36.1 and 36.2) [1, 3, 4].
In patients with osteoporosis, the bone is made
normally but is reduced in overall quantity. The
L. Eralp, Prof. MD mechanism is uncertain, but several theories
Istanbul Faculty of Medicine, Department of include increased bone resorption versus
Orthopaedic and Traumatology, Istanbul University, decreased bone formation, possibly due to
deficient 1,25-dihydroxyvitamin D or calcitonin

https://doi.org/10.1007/978-3-319-45675-1_36
542 L. Eralp
Fig. 36.1 Elongation of the physis in rickets

Fig. 36.2 Severe long bone deformities of lower extrem-
ity in vitamin D-resistant rickets
or due to a major interruption in transduction of
mechanical forces that stimulate new bone forma-
tion [1, 3].
calcification (Fig. 36.1) [4, 5]. The widened
growth plate separates rickets from more com-
36.2 Nutritional Rickets mon physiologic angular deformities of the lower
extremity [6]. With treatment, calcification
36.2.1 General occurs and radiography transforms to normal.
Vitamin D deficiency results in an incapac-
The cause of this condition is vitamin D defi- ity to absorb calcium and phosphorus.
ciency in the diet. The primary pathology in the Parathyroid hormone (PTH) is released in
bone is failure of calcification of cartilage and response to hypocalcemia. Thus, serum cal-
osteoid tissue. Thus, radiologically, the physes cium levels become physiologic or slightly
display an elongation and a hazy appearance decreased, but phosphate and vitamin D levels
related to alterations in the provisional zone of persist as low (Table 36.1).
36 Deformities of Metabolic Disorders 543
Table 36.1 Biochemistry parameters in various types of rickets

Pathologic biochemistry
Type Calcium Phosphorous ALP PTH 25(OH) Vit D 1,25 (OH)2 Vit D
Nutritional Rickets N N/↓ ↑ ↑ ↓↓ ↓
Vitamin D resistant N ↓ ↑ N N N
Renal osteodystrophy N/↑ ↑ ↑ ↑↑ N ↓↓
36.2.2 Treatment ization of the bone [2, 6]. There are four main
forms, the most common of which is inherited as
The usual treatment modality is administration of an X-linked dominant trait, followed in occurrence
vitamin D. Radiographs display progress of min- by an autosomal dominant type [2, 4, 6]. The
eralization within 2–4 weeks [4, 6]. If the child inherent pathology is the renal tubule’s incompe-
does not respond to oral vitamin D therapy, vita- tence to preserve phosphate, which causes hypo-
min D-resistant rickets should be suspected. phosphatemia. The third group is characterized by
Since residual deformity is very rarely observed failure of the kidney to achieve the second hydrox-
after medical treatment of nutritional rickets, ylation of vitamin D. This condition can be treated
there is no specific orthopedic treatment. medically simply; thus orthopedic treatment is sel-
dom needed. In the fourth group, also called renal
tubular acidosis, the kidney excretes fixed base
36.3 Rickets of Prematurity and waste bicarbonate, which results in wasting of
calcium and sodium [3, 6]. Laboratory findings are
Premature infants with comorbidities that are fol- listed in Table 36.1.
lowed up in intensive care units sometimes pres- Vitamin D-resistant rickets typically mani-
ent with pathologic fractures, probably caused by fests between the ages 1 and 2 years, slightly
passive motion exercises. With treatment of the older than nutritional rickets. The major com-
rickets, the fractures consolidate with minimal plaints are delayed walking and angular deformi-
orthopedic immobilization techniques [4]. ties of the lower extremities (Fig. 36.2). Systemic
manifestations are generally deficient. The defor-
mities are much more severe when compared
36.4 Drug-Induced Rickets with nutritional rickets. Once affected, genu
varum develops when children begin to walk,
Certain antiepileptic medications have been although genu valgum may occur in some chil-
known to produce rachitic changes in children [7]. dren [4, 6]. Short stature is also a feature of hypo-
These drugs depress vitamin D levels through a phosphatemic rickets, height being generally two
P-450 microsomal enzyme system mechanism in standard deviations below the mean for age in
the liver. Patients commonly present with patho- these patients [8]. Radiologically, the physes are
logic fractures while on treatment for seizures. widened, there is genu varum and coxa valga, and
Medical therapy with vitamin D is suitable. a varus of the tibia causes varus malalignment of
the ankle joint (Fig. 36.3). The upper extremities
are also involved, albeit to a lesser degree [4].
36.5 V
itamin D-Resistant Rickets
(Familial Hypophosphatemic
Rickets) 36.5.1 Treatment
Vitamin D-resistant rickets involves a group of 36.5.1.1 Medical Treatment

disorders in which normal dietary intake of vita- The classic treatment consists of oral replacement
min D is insufficient to complete normal mineral- of phosphorus in large doses and administration of
544 L. Eralp
gist or endocrinologist, as calcium levels tend

to unexpectedly increase with the postoperative
immobilization period. The most common
deformity seen in this patient group is a gradual
anterolateral bowing of the femur accompanied
by tibia vara (Fig. 36.4a, d).
In order to reach a physiologic lower extrem-
ity alignment, multilevel osteotomies are required
[4, 11, 12]. The mechanical axis can be slightly
overcorrected during surgery. The recommended
fixation modality changes among reports.
External fixation allows fine-tuning of the align-
ment postoperatively [13] (Figs. 36.5a–d and
36.6a–e). Intramedullary fixation and plate fixa-
tion are also reported [12, 14–16]. Regardless of
the type of implants utilized, thorough preopera-
tive planning of the surgery of these multiplanar
deformities is essential to successfully reestab-
lish the extremity alignment.
Recurrent deformity is a common sequela of
osteotomies in patients with hypophosphatemic
rickets [4, 12, 14] (Fig. 36.7). As anticipated,
younger patients have a higher risk of recurrence.
Therefore, milder deformities should not undergo
surgery in infancy. Only when gait is compro-
mised by a thrust, or symptoms and pain start,
Fig. 36.3 Lower extremity standing X-ray of a patient of vita- corrective osteotomy should be done.
min D-resistant rickets with bilateral genu varum deformity Short stature is also a main issue for children
with hypophosphatemic rickets. The common
vitamin D. Studies have shown that longitudi- indication for long bone lengthening is a shorten-
nal growth is superior in children who undergo ing of the whole or partial limb in one or both legs
vitamin D treatment [4]. Additionally, treat- [11]. The procedure can be executed by monolat-
ment by growth hormone administration also eral or circular external fixators or by lengthening
increases height and has positive stimulus on over an intramedullary nail (LON) [12].
bone density [9]. Recently, analogs of vitamin
D3 (1, 25-dihydroxyvitamin D3) have been evi-
denced to be more effective than the previous 36.6 A
uthor’s Preferred Method,
supplements [10]. Tips, and Tricks
36.5.1.2 Orthopedic Treatment 36.6.1 Renal Osteodystrophy

The orthotic management of vitamin D-resistant
rickets has not been effective. If patients report 36.6.1.1 General
increased pain and difficulty in walking, angu- As the amount of successful treatment of renal
lar deformities should be corrected surgically failure in children with kidney transplants has
[4, 11]. The postoperative period should be in improved, the prevalence of renal osteodystrophy
close cooperation with the attending nephrolo- has risen. Manifestations of renal osteodystrophy
Fig. 36.4 Anteroposterior a b
(a) and lateral (b) view of
an anterolateral bowing
deformity of the femur of a
patient who was diagnosed
with vitamin D-resistant
rickets
a b c d
27 mm
14 mm
4 mm
xx
Fig. 36.5 Preoperative scanogram (a), preoperative deformity planning templates (b), acute correction with monolat-
eral fixator (c), and postoperative scanogram (d) a patient with vitamin D-resistant rickets
546 L. Eralp
a b
c d
Fig. 36.6 Clinical photo (a) and X-ray (b) of lower extremity deformities of a patient who was diagnosed with vitamin
D-resistant rickets. Ilizarov frame was used to correct deformity gradually (c) and clinical photos (d) after treatment
are present in 66–79% of children with renal fail- changes include the absence of calcification in
ure [18]. Renal osteodystrophy is markedly differ- the zone of provisional calcification of the phy-
ent from either nutritional or hypophosphatemic sis; hyperparathyroidism provokes osteoclastic
rickets. It is often driven by the presence of sec- resorption of the bone.
ondary hyperparathyroidism, which leads to acti- Serum vitamin D and calcium levels are usu-
vation of osteoclasts and resorption of the bone ally low, accompanied by increased blood urea
[2, 4]. nitrogen, creatinine, and acidosis (Table 36.1).
Features of both rickets and hyperparathyroid- Children have a short stature and fragile bone.
ism are existent in renal osteodystrophy. Rachitic Patients have bone pain and fractures happen
because many patients with renal failure, and all

who undergo renal transplant, are treated with
steroids.
36.6.1.2 Treatment
Medical Treatment
Treatment of the causal renal disease is of vital
importance. Dialysis and transplantation prolong
the survey of this patient group. Medical therapy is
started with the 1,25 dihydroxy form of vitamin
D. The use of calcitriol meaningfully decreases
serum PTH levels and delays formation of bone
changes [19]. Treatment of acidosis with sodium
bicarbonate also improves metabolic bone disease.
Decreased growth is an important problem,
possibly due to disturbances in the growth hor-
mone – insulin-like growth factor axis.
Recombinant human growth hormone (rHGH)
restores growth in these children. However,
rHGH also weakens the physes and stimulates
development of SCFE [20]. Parathyroidectomy
may be indicated in renal osteodystrophy refrac-
tory to medical treatment.
Orthopedic Treatment
Patients with renal osteodystrophy are referred
to the orthopedic surgeon for the treatment of
three pathologies: angular deformity of lower
extremity long bones, SCFE, and avascular
Fig. 36.7 After treatment, recurrence of the lower necrosis [4]. Any surgical intervention in this
extremity deformities of a patient with vitamin D-resistant patient population should be carefully consid-
rickets because of metabolic decompensation ered, as the perioperative risks are amplified due
to anemia, hypertension, bleeding tendencies,
e asily. The most common orthopedic patholo- and electrolyte imbalances. The risk of infection
gies are skeletal deformities, usually genu val- is furthermore increased in patients with a renal
gum, articular enlargement of long bones, transplant who are under immunosuppressive
slipped capital femoral epiphysis (SCFE), mus- therapy.
cle weakness, and Trendelenburg gait if SCFE is
present [4]. On radiographs, widespread osteo- Angular Deformity
penia with thin cortices and unclear trabeculae Angular deformity occurs in renal osteodystro-
are existing. The bone has a ground-glass phy because the bone is soft, undermineralized,
appearance. The physes are increased in thick- and prone to bend with weight bearing. Genu val-
ness, with an unclear zone of calcification. In gum (Fig. 36.8) is the most common deformity,
severe and persistent renal failure, aggressive but genu varum (Fig. 36.9) or a “windswept
lytic areas in long bones may develop (brown deformity” (Fig. 36.10) may also occur [4, 21]. If
tumor). Osteonecrosis is expected to develop the renal osteodystrophy begins before a patient
548 L. Eralp
Fig. 36.8 Bilateral genu valgum deformity of a patient with renal osteodystrophy due to renal transplant
is aged 4 years, varus deformity may develop in the distal femoral metaphysis, but some-
because the normal alignment of the leg is in times a supplementary proximal tibial osteot-
slight varus, which is then emphasized when the omy is also needed. Internal or external
bone becomes weak. Similarly, older children are fixation may be used. External fixators have
prone to the development of genu valgum because been successfully applied, taking care of
of the physiologic valgus alignment of the lower achieving stable constructs and using
extremity. Valgus at the ankle may accompany hydroxyapatite-coated Schanz pins, but bone
the genu valgum [22]. healing may be delayed [23]. Recurrence is
Some milder deformities will correct with common in patients with continuing metabolic
medical treatment of the renal osteodystrophy pathology, so medical treatment should be
[4, 22]. Deformities do not respond well to adjusted before and continued after correc-
bracing. If the patient becomes symptomatic tive osteotomy. Elevation of serum alkaline
and has undergone optimum medical treat- phosphatase concentration above 500 U/L is a
ment without resolution of the deformity, cor- worthy marker of ongoing metabolic bone dis-
rective osteotomy should be performed [4, 22] ease [4, 22]. Milder deformities may respond
(Fig. 36.11). Usually, the utmost deformity is to hemiepiphysiodesis.
physeal widening resolves with initiation of

appropriate medical treatment. If the slip is dis-
placed or symptoms continue despite medical
treatment, fixation with one screw, accomplishing
stability cross the physis without closing it, should
be performed.
36.7.2 Avascular Necrosis
Elongated steroid use is the likely cause. Avascular

necrosis occurs frequently bilateral and affects the
hips. Treatment is symptomatic [4].
36.8 Hypophosphatasia
36.8.1 General
Hypophosphatasia is a rare, genetic defect of alka-

line phosphatase production, which results in
pathologic mineralization of the bone. There is a
wide variation in the severity of the disease, and
the prognosis depends on the age of onset; perina-
tal, infantile, childhood, and adult hypophospha-
tasia can occur [4, 25]. The gene for this disorder
Fig. 36.9 Bilateral genu valgum deformity of a patient is determined to be in the tissue-nonspecific alka-
with renal osteodystrophy line phosphatase gene (TNSALP), and many dif-
ferent mutations have been described [26].
The pathology detected in hypophosphatasia
36.7 A
uthor’s Preferred Method, closely resembles that seen in patients with rick-
Tips, and Tricks ets. Osteoid production remains undisturbed, but
osteo-mineralization cannot occur when deprived
36.7.1 Slipped Capital Femoral of effective ALP [4, 25, 26]. As a result, physes
Epiphysis are widened with persistence of the calcification
zone and metaphyseal remnants of cartilage
The clinical picture of a child with “slip” differs islands. If hypercalcemia is added to the clinical
from the usual SCFE. The patients are often picture, heterotopic calcification foci can be
younger, and obesity is not part of the clinical pic- formed. In laboratory tests, ALP levels are
ture. Bilaterality is very common. Radiologic decreased in the serum and in tissues such as the
pathology in the physis is more pronounced, kidney and bone [1, 4]. Serum phosphorus, vita-
accompanied by widening and osteopenia [17, 24]. min D, and PTH levels may remain within nor-
The goal of standard management of SCFE is to mal limits, but hypercalcemia is sometimes
end proximal femoral physeal growth and thus heal present. Characteristically, urine pyrophosphate
the slip. This may not be an appropriate objective in levels are increased [1, 4].
a young child with renal osteodystrophy. Moreover, Infants may be stillborn in the severe perinatal
physeal healing is compromised due to the meta- form. If they survive delivery, they frequently
bolic pathologic condition. Fortunately, pain and die from respiratory infection in early babyhood.
550 L. Eralp
Fig. 36.10 “Wind swept”

deformity of a patient with
renal osteodystrophia
Fig. 36.11 Postoperative results of a patient with bilateral genu valgum deformity because of renal osteodystrophy due
to renal transplantation after procedures of fixator-assisted nailing
All bones display severe demineralization on mic vitamin D-resistant rickets: a longitudinal study.
radiographs. The infantile form starts later, usu- Eur J Pediatr. 1992;151:422–7.
9. Saggase G, Baroncelli GI, Bertelloni S, Perri G. Long-
ally around 6 months of age. These babies have term growth hormone treatment in children with
demineralized bones with severe rachitic changes. renal hypophosphatemic rickets: effects on growth,
Fractures and bowing of the extremities are fre- mineral metabolism, and bone density. J Pediatr.
quent. If these children survive infancy, they tend 1995;127(3):395–402.
10. Peterson BR. Augmenting vitamin D to combat

to improve clinically, but they have a short stature genetic disease. Chem Biol. 2002;9(12):1265–6.
throughout childhood due to the absence of nor- 11. Fucentese SF, Neuhaus TJ, Ramseier LE, Exner

mal endochondral bone growth [1, 4]. GU. Metabolic and orthopedic management of
X-linked vitamin-D resistant hypophosphatemic rick-
ets. J Child Orthop. 2008;2:285–91.
12. Kocaoglu M, Bilen FE, Sen C, Eralp L, Balci

36.8.2 Treatment HI. Combined technique for the correction of lower-
limb deformities resulting from metabolic bone dis-
ease. J Bone Joint Surg Br. 2011;93B:52–6.
Although there is no conventional medical treat- 13. Kanel JS, Price CT. Unilateral external fixation for
ment of hypophosphatasia, successful marrow corrective osteotomies in patients with hypophospha-
cell transplantation with improvement of the dis- temic rickets. J Pediatr Orthop. 1995;15:232–7.
14. Rubinovitch M, Said SE, Glorieux FH, Cruess RL,
ease has been described [27].
Rogala E. Principles and results of corrective lower
Fractures and deformities need orthopedic limb osteotomies for patients with vitamin D-resistant
management. Fracture healing is commonly hypophosphatemic rickets. Clin Orthop Relat Res.
delayed. If deformities are existent, multiple 1988;237:264–70.
15. Petje G, Meizer R, Radler C, Aigner N, Grill

osteotomies with intramedullary fixation are
F. Deformity correction in children with hereditary
required to correct the bowing and provide struc- hypophosphatemic rickets. Clin Orthop Relat Res.
tural support to the long bones [4]. 2008;466:3078–85.
16. Song HR, Soma Raju WJ, Kumar S, Lee SH, Suh SW,
Kim JR, Hong JS. Deformity correction by external
fixation and/or intramedullary nailing in hypophos-
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In Staheli LT, editors. : Pediatric orthopedic secrets. rectable alteration in vitamin D metabolism. JAMA.
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3. Zaleske DJ, Doppelt SH, Mankin HJ. Metabolic and lar lesions. Int Orthop. 1993;17:269–71.
endocrine abnormalities of the immature skeleton. In 19. Morii H, Ishimura E, Inoue T, Tabata T, et al. History
Morrissey RT, editors. Lovell and winter’s pediatric of vitamin D treatment of renal osteodystrophy. Am
orthopaedics. 3rd ed. Philadelphia: J.B. Lippincott; J Nephrol. 1997;17:382–6.
1990. p. 203–261. 20. Greenbaum LA, Del Rio M, Bamgbola F, Kaskel

4. Herring JA. Metabolic and endocrine bone dis- F. Rationale for growth hormone therapy in children
eases. In Herring JA, editors. Tachdjian’s pediatric with chronic kidney disease. Adv Chronic Kidney
orthopaedics. 4th ed. Philadelphia: Elsevier; 2008. Dis. 2004;11:377–86.
p. 1917–1982. 21. Eralp L, Kocaoglu M, Cakmak M, Ozden VE. A cor-
5. Pitt MJ. Rachitic and osteomalacic syndromes. Radiol rection of windswept deformity by fixator assisted
Clin North Am. 1981;19:581. nailing. A report of two cases. J Bone Joint Surg Br.
6. Mankin HJ. Metabolic bone disease. Instr Course 2004;86(7):1065–8.
Lect. 1995;44:3–29. 22. Davids JR, Fisher R, Lum G, Von Glinski S. Angular
7. Crosley CJ, Chee C, Berman PH. Rickets associated deformity of the lower extremity in children with renal
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growth retardation of patients with hypophosphatae- Clin Orthop Relat Res. 1994;301:38–41.
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24. Barrett IR, Papadimitriou DG. Skeletal disorders

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mutated tissue-nonspecific alkaline phosphatase
Computer-Assisted Fixators
for Deformity Surgery 37
Mustafa Celiktas, Mahir Gulsen, and Cenk Ozkan
37.1 Introduction 37.2 F

rom Projective Geometry
to the Stewart-Gough
Extremity discrepancies, short stature, pseudoar- Platform
throsis, infections such as chronic osteomyelitis,
acute trauma with bone loss, and deformities Computer-assisted EFs in current use are based
either in the bones or joints are routine problems on the principle of the Stewart-Gough platform.
dealt with in daily practice. In the majority of In 1965, Stewart designed a triangular platform
these problems, an Ilizarov external fixator (EF) attached to a ball joint over three legs, the lengths
is used, often as the first choice or for revision of of which can be changed, to be used in flight sim-
previously unsuccessful surgery [5]. The Ilizarov ulation training [12]. Almost at the same time,
EF is highly modular, which increases the chance Gough and Whitehall suggested the use of six
of success, but also entails a long learning curve. linear actuators, all in parallel, which made the
Especially in multiplanar deformities, because of platform manipulator a fully actuated system [3].
the hinge positioning difficulties, lengthening Therefore, this platform is generally referred to
and translations are made with different appara- as the Stewart-Gough platform. This mechanism
tus thus the system requires frequent revision [6]. comprised two platforms joined together by six
This situation creates anxiety in the patient and is legs, and the lengths of which could be adjusted,
time-consuming for the physician. Therefore, the with spherical joints at the two ends of each leg
use of circular Ilizarov external fixator is gradu- (Fig. 37.1).
ally being replaced by computer-assisted The point of origin of the Stewart-Gough plat-
fixators. form is art. In the fifteenth to sixteenth centuries,
the desire of artists to represent three-dimensional
objects in two dimensions led to the birth of pro-
jective geometry. Projective geometry is the
study of geometric properties that are invariant
under projective transformations. This means
that compared with elementary geometry, projec-
M. Celiktas, MD (*) • M. Gulsen, MD tive geometry has a different setting, projective
Ortopedia Hospital, Adana, Turkey
e-mail: mstfceliktas@yahoo.com space, and a selective set of basic geometric
concepts.
C. Ozkan, MD
Çukurova University, Department of Orthopedic The subsequent interest of Chasless and
Surgery and Traumatology, Adana, Turkey Poinsot in projective geometry revealed a need for

https://doi.org/10.1007/978-3-319-45675-1_37
554 M. Celiktas et al.
Fig. 37.1 A model of Stewart-Gough platform
movement in planes of six axes (three translations Fig. 37.2 Taylor spatial frame (first generation)
and three rotation planes) for an object to be
brought into the desired position in space, and
these axes were named as the Chasless axes [7]. first device to use a computer program for defor-
The theorems of Chasless and Poinsot were the mity correction. This system, known as the
foundations of Ball’s theorem of screws. The key Taylor spatial frame (TSF), was first used by
feature of this theory is what is referred to as the Charles Taylor and Dror Paley in 1995 (Fig. 37.2)
“duality and reciprocity between instantaneous [13]. The patent for this device was granted in
kinematics and statics, angular, and linear velocities 1997 and the popularity of this computer-assisted
being dual to force and moment, respectively [8]. fixator system increased greatly. Previously used
with a laptop program, from 2002 this device
started to be used with a web-based system.
37.3 F
rom the Stewart-Gough Another device, for which the patent was obtained
Platform to Orthopedic in 1996, came from Germany. By mounting six
Surgery telescopic rods on Ilizarov rings, Seide et al.
developed the hexapod system, which is com-
Following the introduction of the Stewart-Gough puter-assisted in the planning and correction of
platform, mechanisms used in industry to bring deformities. This device is superior to the TSF
an object to the desired position with robotic because it can be mounted on standard Ilizarov
arms started to be used in orthopedic surgery. In rings and is more sensitive than the TSF because
this manner, the first orthopedic device was initi- it offers the facility of adjustment to 0.1 mm.
ated by adding extendable spherical joints to the Again from Germany, the Eisenberg fixator came
already well-known Ilizarov rings, and this was onto the market with use from 1994 and a patent
first designed in France by Philippe Moniot with granted in 1998. The TSF and the two German
the aim of bringing bone ends into the desired devices have been used for many years. In Russia,
position. Although the patent was taken out on Leonid Solomin, Igor Utekhin, and Vilensky
this device in 1985, it was never used clinically developed the Ortho-SUV fixator and obtained
[8]. In the Soviet Union in 1984, S.I. Pisler and the patent in 2010. This correction device with
Y.N. Kostin started to use a bone correction six axes differs from the others in that only three
device with six axes and patented it in 1989. This struts make contact between each two rings and
device did not require mathematics to provide the other struts are used to connect the struts that
correction. In 1994, two American brothers, one have contact between the two rings. The advan-
an engineer and the other a doctor, developed the tage of this system is that it allows different
37 Computer-Assisted Fixators for Deformity Surgery 555
rings. (5/8 rings are being used for free range of

motion near joints).
While the abovementioned devices are all
based on a circular fixator, there have been stud-
ies in various centers of monolateral fixators that
can move in six axes. Apart from lengthening the
monolateral fixator bodies, the idea of adding
other movement axes with or without computer
assistance is ongoing.
37.4 U
se of Computer-Assisted
Systems
As expected, the current widespread use of these

devices is not without problems. Surgery should
not be undertaken with reliance only on com-
puter systems without having made a thorough
deformity analysis. The deformity analysis must
Fig. 37.3 ADAM frame
be made according to the deformity principles;
the deformity must be located and the CORA
shapes and sizes of rings. It has come to the fore point calculated. Whether the deformity is uni-
of the six-axis devices as the most modular device apical or multi-apical must be established, and it
with the simplest mathematics [8]. Various coun- must be determined whether the CORA point is
tries then developed devices that moved in six over the bone. If the CORA point is not over the
axes. The Smart frame was developed in Turkey bone, the actual CORA must be located and the
in 2009 with no rules for the establishment of the osteotomy planned from there. As in the appli-
fixator, with a relationship of independent bone cation of other circular fixators, attention must
geometry and independent fixator. In this system, be paid to the distance of the rings from the
which allows the use of rings of different diame- skin; it should be in accordance with the two-
ters, MR imaging can be obtained. Another finger rule (Fig. 37.4, two-finger rule). The
frame, which was developed in Turkey in 2009 parameters that provide stability of the system
under the supervision of Prof. Paley and Prof. must be taken into consideration: the number of
Gulsen, is the ADAM frame (Fig. 37.3 ADAM rings, diameter of the rings, the distance between
frame). This device can also move in six axes but the rings, the number and diameter of pins and
is different from the others in that it is not a hexa- Schanz screws, wire tension, and the angle
pod, but an octopod. While four vertical struts between the wires [2, 9].
join the rings, four diagonal struts are attached to When the metallurgy of the system is exam-
the vertical struts. This device has greater move- ined, when used compatible with computer-
ment capability than a hexapod, and in addition assisted systems, it is seen to be just as stable and
to web-based use, the system can be easily per- even more than the standard Ilizarov system [7].
ceived visually; it also allows manual deformity In a comparison made between the Ortho-SUV
correction. From the Spider frame from Turkey and Ilizarov systems, the Ortho-SUV was found
in 2011, the TL-Hex systems emerged as hexa- to be 1.2-fold more stable than Ilizarov in the
pods in 2012 from Italy. TL-Hex system has the frontal, sagittal, and longitudinal planes and 2.07-
advantage of being able to connect the struts to fold more stable in the transverse planes [11].
the ring externally and the 3/8 rings present in the The longest struts possible should be placed
system that can be easily assembled with 5/8 when implanting in the bone with computer-
Therefore, it must be known which ring is to be

placed distal and which is proximal. In some sys-
tems, the numbering of the struts changes accord-
ing to the placement of the deformity ring, and
these data are important for the computer input.
When setting up the system, placement of the sys-
tem to mimic the deformity will facilitate the use
in the follow-up of the patient. During these
adjustments or when manually correcting the
deformity, each strut should be brought to its new
measurement values. The point to be careful of
here is that not more than 5 mm change at one
time is made to each strut. In cases where it is
necessary to make more than 5 mm change, the
struts should be adjusted in circular sequence, and
the procedure should be applied in several cycles;
otherwise, the system may become so tight that no
movement can be made. After all the wires have
been placed, an osteotomy should be applied to
correct the deformity. According to the surgeon’s
preference and experience, the osteotomy can be
made with a Gigli saw or an osteotome. Care must
Fig. 37.4 Application of two-finger rule be taken that the osteotomy is applied parallel to
the deformity ring. Following the placement of all
assisted systems, and thus the system should pro- the wires and the osteotomy, there may be an
vide increased deformity correction capacity, and amount of strain in the system. Therefore, in our
the required working area should be obtained. In clinical practice, all the struts are loosened sepa-
a biomechanical study by Henderson et al. [4], it rately from the system and reattached to the rings
was shown that when the angle between the ring in a way that will not be strained.
and the strut fell below 30°, there was a signifi- In a computer-assisted system, the system is
cant decrease in stability, and it was reported that defined by the software using information
the angle between the ring and the strut should be obtained in X-rays and the strut length and ring
30°–70°. In a study of the femur, Skomoroshko diameters input into the system. The rings and
et al. found that a distance of 150 mm between strut lengths must be entered correctly postopera-
the rings provided the greatest correction poten- tively. Some systems need to know in which hole
tial of the system and was the distance that pro- of which ring the strut is attached. Similar to the
vided the required stability [10]. When the rings features demanded by the fixator system, the
are fixed to the bone, great care should be taken X-rays must also be loaded into the system. While
of the anatomic structures, and a safe distance some systems require the X-ray to be completely
should be kept from neurovascular structures. parallel to the deformity ring (Fig. 37.5, ADAM
When a wire passes close to a joint, the joint must X-ray), some require it to be at the absolute mid-
be brought into position with the muscles point of two rings (Fig. 37.6, Smart X-ray).
extended. The necessary angle between the wires Generally, the film cassette is required to be in full
or Schanz screws must be provided. contact with the ring, but in some systems, if not,
When using a computer-assisted fixator, it is the distance between should be entered into the
paramount to be familiar with the features of system as mm. Sometimes the films with the nec-
device being used. Several systems have a defor- essary features cannot be taken because of the
mity ring that moves over the reference ring. pain experienced by the patient or because the
Fig. 37.5 Some
systems require the
X-ray to be completely
parallel to the deformity
ring
patient would be exposed to excessive radiation be examined to determine whether it is compatible

while taking suitable X-rays. Therefore, in our with the aim. This prescription can be printed or
clinical practice, X-rays are taken in the operating sent by email to be shared with the patient.
theatre with the patient under anesthesia. There The patient is given the prescription and is
are various X-ray markers for calibration of some shown how the correction will be made. The sta-
systems and it must not be forgotten that these bility of the system must be checked before the
must be used when taking the X-rays. After enter- patient is discharged. As for the other external
ing the radiographs into the system, the anatomic fixators used in operations, pin site care must be
axes and the midpoints of the proximal and distal explained and checked.
segments are marked on the radiographs. The When a strut needs changing in follow-up
main point here is that the points required by the examinations, if more than one strut is to be
software are correctly marked. changed, they should not be changed at the same
When all the information has been entered into time but separately, and if necessary, strengthen-
the software and the deformity planning has been ing can be applied with additional attachments to
completed, the system gives a prescription showing prevent compression of the system.
what the length of each strut should be on which During treatment, union is expected after
day, and at the same time, an animation is prepared regeneration. When corticalization has developed
showing the gradual correction of the segments in any three cortices, dynamization can be applied
according to the prescription. This animation must by loosening the system or reducing the number
Fig. 37.6 Some
systems require the
X-ray to be at the
absolute midpoint of
two rings
of Schanz screws in the system. After approxi- may also develop with oversensitivity to the
mately 3 weeks of dynamization, the system is metals used.
removed if the patient has no pain in the fracture- In a study that compared computer-assisted
osteotomy line. A 3-week period in a plaster cast fixators with Ilizarov external fixators, statisti-
after removal of the external fixator will prevent cally equal groups were formed in respect of the
new fractures forming in the screw line. age and sex, etiology, and deformity complexity
When applying a computer-assisted external [1]. The consolidation time and the external fix-
fixator system to some patient groups, extra care ator duration were found equal between the two
is required. In very obese patients, besides the groups of computer-assisted fixators and Ilizarov
difficulty of selecting the rings, there are risks external fixators. In the computer-assisted fixator
of losing the fixation and breaking the implant group, although correction was achieved in a
when there is excessive loading on the system. shorter time, the bone healing indexes were found
In elderly patients, those with substance addic- longer. In addition, it was concluded that a more
tion, alcoholics, and those with malnutrition, sensitive correction was achieved with spatial fix-
there may be union problems. It should also be ators because the postoperative residual defor-
kept in mind that there could be problems in the mity was smaller.
application of the prescription to these patients Figures 37.7–37.19 show treatment with a
and to those with mental disorders. Problems computer-assisted frame.
Figs. 37.7, 37.8, and

37.9 Procurvation and
varus deformity of the tibia
in a woman aged 53 years
due to pseudoarthrosis of
high tibial osteotomy
Figs. 37.10 and 37.11 Postoperative photos with spatial frame

Figs. 37.12 and 37.13 After uploading desired photos into computer, mid-axes of both segments lined
Figs. 37.14 and 37.15 Photos show correction of deformity
Figs. 37.16 and 37.17 Patients’ photos with weight bearing

Figs. 37.18 and 37.19 Postoperative X-ray and photo after frame removal
Conclusion 2. Gessmann J, Jettkant B, Könıgshausen M, TA S, Seybold

In conclusion, even if we have the capability D. Improved wire stiffness with modified connection
bolts in Ilizarov external frames:a biomechanical study.
of deformity correction without computer Acta Bioeng Biomech. 2012;14(4):15–21.
assistance, computer-assisted systems offer 3. Gough VE, Whitehall SG. Universal tire test machine.
several advantages, both to the patient and sur- Proceedings of the FISITA ninth international techni-
geon. All components of a complex deformity cal congress. 1962. p. 117–37.
4. Henderson ER, Feldman DS, Lusk C, van Bosse
can be corrected at the same time. Therefore, a HJ, Sala D, Kummer FJ. Conformational instability
computer-assisted system should be consid- of the taylor spatial frame: a case report and biome-
ered as the first choice for patients who require chanical study. J Pediatr Orthop. 2008;28(4):471–7.
deformity correction in at least two planes. doi:10.1097/BPO.0b013e318173ecb1.
5. Ilizarov G, VI L. The replacement of long tubular
bone defects by lengthening distraction osteotomy of
one of the fragments. 1969. Clin Orthop Relat Res.
1992;280:7–10.
References 6. Mutlu H, Akçalı Hİ, Gülsen M. A mathematical model
for the use of a Gough-Stewart platform mechanism
1. Eren I, Eralp L, Kocaoglu M. Comparative clinical as a fixator. J Eng Math. 2006;54:119. doi:10.1007/
study on deformity correction accuracy of different s10665-005-9007-0.
external fixators. Int Orthop. 2013;37(11):2247–52. 7. Paley D. Principles of deformity correction.
doi:10.1007/s00264-013-2116-x. Heidelberg: Springer; 2002.
8. Paley D. History and science behind the six-axis cor- modelling study. Adv Orthop. 2014;2014:268567.
rection external fixation devices in orthopaedic sur- doi:10.1155/2014/268567.
gery. Oper Tech Orthop. 2011;21:125–8. 11. Skomoroshko PV, Vilensky VA, AI H, MD F, LN
9. Sarpel Y, Gulsen M, Togrul E, Capa M, Herdem S. Mechanical rigidity of the Ortho-SUV frame
M. Comparison of mechanical performance among dif- compared to the Ilizarov frame in the correction of
ferent frame configurations of the Ilizarov external fix- femoral deformity. Strategies Trauma Limb Reconstr.
ator: experimental study. J Trauma. 2005;58(3):546–52. 2015;10:5–11.
10. Skomoroshko PV, Vilensky VA, Hammouda AI,
12. Stewart D. A platform with six degrees of freedom.
Fletcher MDA, Solomin LN. Determination of the Proc Instn Mech Eng. 1965;180:371–86.
maximal corrective ability and optimal placement 13. Taylor JC. Correction of general deformity with the
of the Ortho-SUV frame for femoral deformity with Taylor spatial frame fixator www.jcharlestaylor.com.
respect to the soft tissue envelope, a biomechanical 1996.
Part III
Ilizarov Approach in Postraumatic
Complications
Pseudoarthrosis
38
Fracture healing has been studied for years in tific influence encountered with an incomprehen-
orthopedics and still is a hard problem to handle sible resistance until early 80s [2].
for the orthopedic surgeons. Healthy union could There was an obvious requirement of an exter-
be obtained with basic reductions in some frac- nal fixator design to treat especially complex
tures but nonunion may also develop accompany- pseudoarthrosis cases after Second World War.
ing with particular negative factors. In recent Until Ilizarov’s design, European clinics were
years, there have been many developments in this using Judet’s “Fixateur Externe” for treatment.
deep and mystic area of orthopedics thanks to the [3] Ilizarov donated his own instrument set to
basic sciences and various special techniques. Italian surgeons. Beginning from early 90s with
Some sources state that a specific nonunion the rapidly increasing effect of his lifetime scien-
case introduced the Ilizarov’s method to the tific work, his techniques has been embraced by
Western world. This case was from Italy. He was a the world and this especially facilitated the treat-
famous Italian mountaineer, adventurer and pho- ment of complicated nonunion cases [4].
tographer named Carlo Mauri (1932–1982). He The meaning of the word “pseudoarthrosis” is
had been suffering from infected tibia pseudoar- the nonanatomical joint formation between two
throsis for ten years until a successful treatment at fracture ends with synovial fluid. The human body
Russian Ilizarov Scientific Center for Restorative tries to generate a mobile joint together with a false
Traumatology and Orthopaedics in 1977 (RISC- (pseudo)-joint capsule between two fragments of
RTO). With this successful treatment, Ilizarov had the fracture instead of the union of the fragments.
gained the title of “Michelangelo of Orthopedics” The infections at the fracture site, patient’s poor
and invited to the 22nd AO Italy conference in medical condition, low total bone density and bone
Bellagio in June 1981 as a guest speaker [1]. quality negatively affect the reunion.
Ilizarov had been already known by some There are two main factors that cause
orthopedic surgeons and scientist long before delayed union or nonunion. The first one is the
that conference according to some other sources biologic factors and the other is the mechanical
and authors. Despite this acquaintance, his scien- factors. The biologic and mechanic factors
must be appropriate at the same time for healthy
union process or another words “fracture heal-
ing” (Fig. 38.1). The insufficient biologic fac-
M. Çakmak, Prof. MD (*) • M. Cıvan, MD tors frequently lead to avascular or atrophic
pseudoarthrosis, and the mechanic instabilities
Istanbul, Turkey result in hypervascular or hypertrophic
e-mail: profcakmak@gmail.com pseudoarthrosis [5].
https://doi.org/10.1007/978-3-319-45675-1_38
FRACTURE enables the axial loading. Bone defects can be

treated with various techniques such as distraction
or bone transport methods. Much safer weight
bearing could be provided on osteoporotic bones.
Lengthening is possible in extremity shortness.
INSUFFICIENT IMPROPER
BIOLOGICAL FACTORS MECHANICAL FACTORS Acute or gradual correction could be applied for
the deformities and malalignments.
Soft tissue injuries hardly compromise the
bone operations at Ilizarov’s method. Sometimes
safe wound closures with vacuum-assisted tech-
UNION
niques and fracture treatment could be possible at
Fig. 38.1 Without proper biologic and mechanical fac- the same time.
tors, healthy union cannot be obtained at the fracture site The local blood flow can be increased by dis-
traction and compression. The infections can be
treated and the joint contractures can be pre-
Table 38.1 The problems that may be encountered in
pseudoarthrosis vented with early movements.
Various classification systems have been cre-
Inviable soft tissue
ated for Pseudoarthrosis in Europe. First one was
Inadequate local blood flow
published by Zahradníćek in 1939 at SICOT con-
Infections
gress lecture book. This was followed by Judet
Muscle atrophy
and Judet Classification (1960) and Muller
Joint stiffness
Classification (1965) respectively. Oldrich Cech
Arrest of the callus formation
Bone defects
and Bernhard Weber’s well known and accepted
Extremity shortness
work published in 1973 as Weber & Cech
Osteoporotic bones Classification. This classification was made con-
Deformities and malalignment sidering the healing and viability of nonunions.
Simply type 1 is capable of reacting biologically
and type 2 isn’t. [2, 3, 5].
The only problem in pseudoarthrosis cannot As widely accepted classifications Weber &
be limited into bone union phase. Soft tissue Cech, Ilizarov and Paley classifications are going
problems may also affect the union process as to be explained in this chapter.
well. Inadequate blood flow negatively affects
the treatment. The most important regional prob-
lem is infections. Classic sequestrectomy and 38.1 Weber and Cech
bone grafting applications will be insufficient at Classification 1973
the septic nonunions. Muscle atrophies and joint
stiffness also may develop on the affected extrem- 1. Hypertrophic pseudoarthrosis (also known as
ity. In some pseudoarthroses, there could be seri- viable Ps, Ps which are capable of biological
ous bone defects which could be followed by reaction): Vascularized malunions are divided
significant extremity shortness. The other prob- into three subgroups which are hypertrophic
lems are the arrest of the bone callus formation ones with large callus formations (also known
and decrease of the bone density. The malalign- as elephant foot), normotrophic types (also
ment and deformities are also common problems known as horse hoof), and oligotrophic types
in pseudoarthrosis (Table 38.1). (Fig. 38.2).
Ilizarov’s method offers solutions for multiple (a) Elephant foot: This type is rich in callus.
problems in treatment of the pseudoarthrosis Generally develops due to inadequate fix-
simultaneously. Callus formation can be stimu- ation or premature weight bearing. This
lated with proper Ilizarov external fixator which type of pseudoarthrosis is generally viable
38 Pseudoarthrosis 569
first. By the time, thinning and rounding

a b c
develops at the fracture ends and the inac-
tivity causes decalcification at the bone
structure.
2. Atrophic pseudoarthrosis (nonviable Ps, Ps

which are incapable of biological reaction or
avascular pseudoarthrosis): Avascular mal-
unions are classified in four subtypes accord-
ing to bone defects as torsion wedge
(dystrophic), fragmented (necrotic), atro-
phic, and defected. There is an intermediate
bone fragment in wedge and twisted type of
malunions, and consolidation is present only
on one of the main fragments as demon-
strated in Fig. 38.3. One or more intermedi-
ate bone fragments are necrotic on
Fig. 38.2 Classification of vascular malunions: elephant comminuted malunion. One of the fragments
foot (a), horse hoof (b), oligotrophic (c) (Redrawn from is missing in consolidation defects. Such
Weber and Cech [5])
examples are generally due to open fractures,
tumor resections, or after osteotomies. In
tissues. The ossification develops from atrophic cases, osteoporotic and atrophic
the periphery after mechanic instability extremities may also be present. Soft tissue
during the callus formation. The gap interpositioning which bypasses the osteo-
between the fragments is surrounded by a genic potential may be observed on the heal-
fibrous cartilage and filled with a fluid ing tissue.
similar to synovial fluid. This structure is
a pseudo-joint formation. (a) Torsion wedge type (dystrophic P): The
(b) Horse hoof: This moderate hypertrophic blood flow is affected in the intermediate
type is poor in callus and less severe ver- fragment. The growth of the fragment is fre-
sion of elephant foot type. This type is quently toward the proximal or the distal
frequently seen in failed or instable osteo- direction. Stable bridging cannot be obtained
synthesis with plates and screws. A slight because growing is toward one side. One-
sclerotic density may accompany to the sided bridging is related with inadequate vas-
formation of callus in fragment ends. cularization. Treatment of tibial fractures
Loose and instable plate will be broken in with plate screws is a good example for such
this type of pseudoarthrosis by the time. type of pseudoarthrosis. Callus formation of
The plaque will be broken before the for- a single fragment does not provide the
mation of a silent callus. Therefore, silent required stability and the plate is broken due
callus can never transform into fixed to overload by the time. Frequently, the frac-
callus. ture develops 3 or 4 months later. It is also
(c) Oligotrophic: Callus formation is not called as dystrophic pseudoarthrosis.
present at this type of pseudoarthrosis. (b) Fragmented type (necrotic type) (P from
Frequently, the reason for development of comminution): If the number and severity of
such pseudoarthrosis is the overstabiliza- the communion increase, nonunion risk will
tion with an extra gap between fragments, also increase. No callus formation is observed
which prevents the bridging stage. on the radiograph in this type. Plates could
Radiological features remain the same at be broken because of overloading due to the
Fig. 38.3 Classification of avascular a b c d

malunions: torsion wedge (a),
fragmented (b), defected (c), and
atrophic (d) (Redrawn from Weber
and Cech [5])
necrosis of the medial fragments. Implant shortness is more than 2 cm. The vessel structure in
failure will develop later in such fractures fracture segment is ruined on mobile, loose pseu-
because weight bearing is allowed lately. doarthrosis which seems atrophic on the X-rays.
(c) Defected pseudoarthrosis: The defect is Therefore, biologic stimulation is also required
described as the absence of one part of the together with the fracture stabilization. The stimu-
diaphysis. There won’t be union unless the lation can be obtained by progressive compression
missing bone fragment is replaced. This type at the fracture site after proper corticotomy. The
of pseudoarthrosis is commonly encountered vascular structural support increases by corticot-
in tumor surgery and surgical intervention omy and distraction (Fig. 38.4).
due to infection. In almost all cases, frag-
ment ends are alive but the defect zone is 2. Stiff pseudoarthrosis
inviable. This type of pseudoarthrosis trans-
forms into atrophic type by the time. The movement on stiff-type pseudoarthrosis is
( d) Atrophic pseudoarthrosis: They are the worst less than 7°, and the shortness is frequently less
type and ultimate ending of all avascular than 2 cm due to hypertrophy at the pseudoarthro-
pseudoarthroses. The process results in sis site. Almost every time, there is a hypertrophic
osteoporosis and atrophy at the fracture site. fracture ending seen on the radiographs on this
type of pseudoarthrosis. Local vascularization is
significant with plenty of new bone formation in
38.2 Ilizarov Classification this type with the absence of the union. The fibro-
cartilaginous soft tissue in the pseudoarthrosis
1. Loose-type pseudoarthrosis region transforms into solid bone with the com-
pression and distraction forces applied toward
Movement of angulation more than 7° at the axial direction. It should be noted that shearing
pseudoarthrosis site is typical in this type, and forces may lead to this type of pseudoarthrosis.
a b c
Fig. 38.4 The X-ray of a patient with loose-type pseudoarthrosis (a) and clinical demonstration of the movement more
than 7° at the pseudoarthrosis region (b, c)
Therefore, a fixator system must be established in controlling and lengthening of the fragments.
treatment to inhibit the shearing force (Fig. 38.5). Some authors use monolocal and some use
monofocal for the same techniques. Both are
true terms.
38.3 Paley Classification
of Pseudoarthrosis (1989)
Type A: Pseudoarthroses with less than 1 cm 38.4 S

timulation of osteogenesis
bone loss (Fig. 38.6) with the Ilizarov external
fixator
• A1: Loose type (mobile or lax type)
• A2: Stiff type 1. Monolocal compression
–– A2–1: Without deformity
–– A2–2: With deformity Monolocal compression may be applied in
three different ways as longitudinal, transverse,
Type B: Pseudoarthroses with more than 1 cm
and oblique.
bone loss (Fig. 38.7) [6]
(a) Monolocal longitudinal compression: This
• B1: Bone defect (+), shortening (−) method is preferred when the bone defect is
• B2: Bone defect (−), shortening (+) less than 2 cm. Longitudinal monolocal com-
• B3: Bone defect (+), shortening (−) pression is applied on transverse fractures
(Figs. 38.8 and 38.9).
Osteogenesis may be induced by various (b) Monolocal transverse compression: This
mechanisms with Ilizarov-type external fixators. method is used on lower extremity when the
These are compression, distraction, corticotomy, bone defect is smaller than 2 cm and on
and cyclic axial loading. upper extremity when there are larger
The use of Ilizarov-type external fixator defects. Transverse monolocal compression
enables the stimulation of osteogenesis and is the proper treatment option for oblique
fracture lines. Interfragmentary compression is 2. Monolocal distraction

provided using the olive wires (Figs. 38.10
and 38.11). This method can be applied in two ways as lon-
(c) Monolocal oblique compression: This method gitudinal and oblique. Monolocal distraction is used
is used in angulation cases and accompanying when there is 2–3 cm shortness accompanying the
translation (Figs. 38.12 and 38.13). angulation in hypertrophic pseudoarthroses.
a b
Fig. 38.5 The X-ray of stiff femur pseudoarthrosis of a patient (a) and clinic appearance (b)
A.1 A.2-1 A.2-2
Fig. 38.6 Paley’s Classification of nonunions. Type A (redrawn from Campbell’s Operative Orthopedics 12th edition,
Part XV, pg:2984, fig: 53–9)
B.1 B.2 B.3

Fig. 38.7 Paley’s Classification of nonunions. Type B (Redrawn from Campbell’s Operative Orthopedics 12th edition, Part XV, pg:2984,
fig: 53–9 )
MONOLOCAL LONGITUDINAL COMPRESSION
Fig. 38.8 Illustration of monolocal longitudinal compression
(a) Monolocal longitudinal distraction (Figs. pseudoarthrosis region. Initially, compression is

38.14 and 38.15) applied until no gap remains between the fracture
(b) Monolocal oblique distraction (Figs. 38.16 ends. Then, 1 cm distraction is applied. Then, the
and 38.17) compression is repeated. The distraction must be
(c) Monolocal transverse distraction: This terminated and the fixator must be locked after
method is a theoretically possible application the limb length discrepancy eradicated during
on pseudoarthrosis cases, but we have never treatment. If the callus is inadequate, there must
used the technique in our clinic. be an error in one of the treatment stages.
Generally, consecutive compression and distrac-
3. Monolocal simultaneous compression and tion are applied two or three times and rarely four
distraction times. Consecutive compression and distraction
are not proper applications for oblique fracture
Compression develops on the convex region line lines. Shearing forces inhibit the union on oblique
of the same fracture, and distraction develops on the fractures (Figs. 38.21 and 38.22).
concave region with the movement of the hinge dur-
ing the application of the method (Fig. 38.18). This
method is used on angulated, hypertrophic pseudo- 38.5 E
longation of the fragments
arthroses accompanying with shortness smaller (fragment transport =
than 2 cm (Figs. 38.19 and 38.20). ascenseur operation)
4. Monolocal consecutive compression and
1. Bilocal simultaneous compression and
distraction
distraction
Compression and distraction stress must only Elongation from the healthy region is per-
be on the pseudoarthrosis region for such appli- formed with a corticotomy from the metaphysodi-
cations. Shearing forces should not affect the aphyseal region. The length of the total fixator will
a b c
Fig. 38.9 A 43-year-old male patient who has been post-op; f and g, post-op in the first month; h, post-op in
treated with intramedullar nailing for humerus fracture the second month; i, post-op in the third month), the X-ray
has nonunion and malalignment. The X-rays (a, b) and and clinical images after union 5 months after surgery
clinical images (c, d), follow-up of reunion by the time (e, (j–m)
e f g h i
j k l m
MONOLOCAL TRANSVERSE COMPRESSION
Fig. 38.10 Illusturation of monolocal transverse compression
a b
Fig. 38.11 The nonunion after plastering on the right reunion was provided. Preoperative x-ray (a), preopera-
tibial fracture which developed due to a motor vehicle tive clinical photo and pathological movement (b), x-ray
accident. The patient underwent surgery but the nonunion after fixator applied, clinical photos with the fixator (f, g),
was still present. Ilizarov-type external fixator was applied x-rays (h, i) and clinical photos (j, k) of the patients after
in the third operation, but there was still nonunion. We had successful treatment
applied monolocal transverse compression and the
c d e
f g
h i j k
MONOLOCAL OBLIQUE COMPRESSION
Fig. 38.12 Illustration of monolocal oblique compression

a b c d
e f g
Fig. 38.13 A man aged 30 with an infected right femur Preoperative x-ray (a, b) and clinical photos (c, d, e, g) of
pseudoarthrosis. Monolocal oblique compression was the patient. Clinical photos of the patient after fixator
applied because there was a 30° angulation between the application (f). Gradual correction of the deformity and
fracture fragments. The deformity was corrected with a xray follow up until union is obtained (h, i, j, k , l, m).
hinge which was replaced to the posterior of the bone Functional results (n)
h i j k
l m n
MONOLOCAL LONGITUDINAL DISTRACTION
Fig. 38.14 The schematic image of monolocal longitudinal distraction
not change if simultaneous shortening is applied at proximal side of the nonunion site. Simply the
the pseudoarthrosis region. Healty bone tissue same principles are applies as in bilocal tech-
moves to the pseudoarthrosis site and fills the nique (Figs. 38.25 and 38.26).
defect with out changing total fixator length.
Nonunion may be observed on the pseudoarthrosis
docking region, whereas healthy elongation may 38.6 T
reatment of the
be observed on the metaphysodiaphyseal region. Pseudoarthrosis with Bone
In such cases, monolocal compression or consecu- Defects
tive compression and distraction until maximum
1 cm lengthening are applied and locked in com- The fractures with large bone defects are fre-
pression. Bone graft is applied to the docking quently compound fractures. The bone loss may
region if there is no union after all above tech- develop directly as a consequence of trauma or as
niques. Bilocal simultaneous compression and a result of the initial or subsequent treatment.
traction are used for the defected pseudoarthroses Treatment techniques of pseudoarthrosis with
with 3 to 8 cm bone defect (Figs. 38.23 and 38.24). bone loss could be required in tumor surgery, in
treatment of congenital pseudoarthrosis and on
2. Trilocal simultaneous compression and infected nonunions.
distraction Various treatment modalities are listed below:
1. Spongious bone grafting with/without exter-
The pseudoarthroses with bone defects over 8 nal fixator
cm are treated with trilocal simultaneous com- 2. Allograft applications
pression and distraction method. The defect fill- 3. Free vascularized bone grafts (iliac wing and
ing period is shortened by bone transport with fibula)
two different osteotomies both from distal and 4. Intercalary prosthesis applications
a b c
Fig. 38.15 Osteosynthesis was performed using an intra- using an orthofix after the application of unilateral exter-
medullary nail on a man aged 22 on the femur diaphysis nal fixator. (i, j) The nail was locked from the proximal
segmental fracture which had been developed after a and distal when both femur lengths were equal. Total
motor vehicle accident. (a, b, c) Six months later, he had reunion was provided 2 months after the external fixator
applied to our clinic due to nonunion with 3.5 cm short- application. (k, l, m, n, o, p). Clinical photos of the
ness. (d, e, c) The nail was carved and a thicker nail was patients after total union (q, r)
replaced. (g, h) Then a monolocal distraction was applied
d e f
g h i j
k l m n
o p q
Monolocal oblique distraction
Fig. 38.16 The illustration of monolocal oblique distraction
a b c d
Fig. 38.17 L tibial open fracture developed on a man rected. Pseudoarthrosis was treated in 5 months using the
aged 40 due to motor vehicle accident. Plate and screws monolocal distraction technique. Patients preoperative
are used for osteosynthesis. Patient had undergone a sec- x-ray (a, b) and clinical photos (c, d). Clinical photos of
ondary operation for osteosynthesis 5 months later the patient after fixator applied. (e, f) Gradual correction
because of nonunion. Ilizarov’s external fixator was of the angulation. (g, h, i, j, k). X-ray and clinical photo
applied due to the nonunion and the angulation was cor- after treatment (l, m, n)
e f
g h i j k
l m n
Fig. 38.18 Application of the monolocal simultaneous compression and distraction using a neutral hinge
Fig. 38.19 The illustration of monolocal simultaneous compression and distraction
5. Distraction osteogenesis netic potential are expensive treatments for the

6.
Bone Morphogenetic Proteins (BMPs) developing countries [8, 9].
Applications applications One of the most popular Ilizarov method is the
intercalary bone transport. The bone defect in any
Autologous bone grafts are used for closing size could be closed without any need for graft
the pseudoarthrosis complicated with minor application. Tricortical elongation may provide
infections and defected environments. However, more quick results for excessive defects. The bone
most graft applications are limited with the fragment transport may be performed with rings
patient’s own bone stock. Therefore, closure of which are fixed with crosswise K wires or with
the large grafts cannot be performed in this man- olive wires. At least two crosswise wires must be
ner. Too much time is required for strengthening preferred if the transport will be performed with
of the autologous spongious bone grafts for rings. The trace developed due to the movement
weight bearing [8, 9]. of the wires will be healed leaving a scar [8, 9].
Bone defects resulted from open fractures are Correction is applied after transport to the pre-
contaminated environments. This is a significant viously fixed ring in cases where the internal
restraint for bone reconstructions. transport will be applied with the oblique olive
Vascular pedicled free bone grafts are fre- wires, because the required compression will not
quently used for the reconstruction of the defects be possible on the docking region. First, standard
that are larger than 6 cm. Vascular anastomosis Ilizarov is applied to all long bones. Then, corti-
and microsurgery are frequently required. The cotomy is provided with an osteotomy performed
most significant problems are the mortality in from the metaphysodiaphyseal region. The callus
donor region, reunion deficiency, and fracture tissue will be formed with the corticotomy in
risk. 7–10 days (Fig. 38.27).
In recent years, there has been a new technol- The angulation and sequencing are corrected
ogy for closing the bone defects with BMPs. At gropingly after fixing the rings perpendicular to
present, the molecules that increase the osteoge- bone in segmentary and defected pseudoarthroses.
a b c d
e f g h
Fig. 38.20 R femur distal diaphyseal fracture developed distraction applied and the system was locked after the
on a women aged 25 due to motor vehicle accident. Long limb lengths were equal. Union was provided 3 months
intramedullar nail had been used for osteosynthesis. On later after the application. Preoperative x-ray before the
follow up pseudoarthrosis with significant angulation had first operation (a), postoperative x-ray and development of
been observed at the fracture site. Ilizarov’s external fix- the nonunion (b, c, d), clinical photos of the patient before
ator was applied due to the nonunion and the angulation (g, h) and after (e) aplication of the fixator (e) and x-ray
corrected in operation. Proper hinge system was built and (f) of the patient. Correction of the angulation ( i, j, k) and
monolocal simultaneous compression and distraction x-ray (l) and clinical photos (m, n) of the patient after
technique applied. After the signitifcant callus formation fixator removal
i j k l
m n
Monolocal consecutive compression & distraction
Compression 1 cm distraction Compression Distraction until the

limb lengh is equal
and wait for the callus
Fig. 38.21 The illustration of monolocal consecutive compression and distraction. This cycle may be repeated two or
three times and rarely four times. If there is still no callus, then there must be an error on the treatment protocol
a b c d e
Fig. 38.22 A man aged 39 years with a compound tibia circular external fixator. Consecutive compression and
fracture due to traffic accident. Osteosynthesis was distraction were initiated when the proximal and distal
applied using the K wire and plastering. Nonunion was fragment axes of the tibia were overlapped and parallel
observed after 5 months. (a, b, c) We had fixed the angula- (e). Reunion was provided at the end of the fifth month
tion and translation gradually (d) and prepared for mono- and the device was removed. (f, g)
focal consecutive compression and distraction with
f g
Bilocal simultaneous compression & distraction
Bone
Corticotomy
Formation
Pseudoarthrosis Docking Site

with bone defect
Fig. 38.23 The illustration of the bilocal simultaneous compression and distraction. A medium segment is created
by transportation with corticotomy
a b c d e
Fig. 38.24 A defected pseudoarthrosis due to compound performed segment transport from the proximal metaphy-
fracture on distal tibia. Osteosynthesis had been per- seal region using Ilizarov-type external fixator. (c, d) The
formed using the monolateral fixator (a), however there defect was closed and union was provided after the suc-
was no union at the end of the sixth month. (b) We had cessful treatment. (e)
Trilocal simultaneous compression & distraction

Corticotomy
Pseudoarthrosis Docking Site

with bone defect
Fig. 38.25 The illustration of the trilocal simultaneous compression and distraction. Basically, the same principles are
applied as in bilocal but corticotomy is performed in two different levels
a b c
d e f g
Fig. 38.26 Left crus open fracture had developed on a loaded cement application. (a, b) Two corticotomies
male patient aged 50 years after a motor vehicle acci- were performed from the metaphysodiaphyseal and
dent. There had been 4 cm shortness and fistula on the supramalleolar region in our clinic with circular external
injured extremity of the patient when he was admitted to fixation. (d, e, f, g) The trilocal bone transport was
our clinic after 12 unsuccessful operations. (c) One of applied until both fragments attach to one another. The
that sessions is 12 cm bone resection and antibiotic- external fixator was removed after union (h)
The rods and rings are fixated parallel to the bone.

h The alignment must be provided in all planes, and
the length of the extremity must be as much as the
opposite side. This enables the fragment to reach
the docking region without any need for translation.
The radiographs must be taken to verify that the
connection rods are parallel to the mechanic axis of
bone. The fluoroscopy alone is not sufficient. The
frame must be prepared before the operation and
X-ray must be taken with the patient if possible.
Each of the fragments must be fixed from two
different levels for the fixation of the bone frag-
ments. A nail that is fixed too close to the fracture
line may cause a gap while docking and too far
fixing will not provide a stable osteosynthesis.
The most appropriate fixing will be 2.5 cm to the
most distal cortex.
The points to be considered about the opera-
tion are:
1. The Ilizarov frame must be prepared appropri-

ate to the technique.
2. The length of the segment: Fixing with two
Fig. 38.26 (continued) rings cannot be possible if the length is smaller
TREATMENT OF PSEUDOARTHROSIS WITH BONE DEFECTS
Fig. 38.27 The illustration of closing of a 5 cm defect on an atrophic-type tibial pseudoarthrosis. Fragment transport
= ascenseur operation
than 6 cm. Then, fixing with one ring must be 38.7 T

reatment of the Infected
applied and the second fixing must be on the Pseudoarthroses
ring with the offset.
3. The length of the defect: Internal sliding is Treatment of infected pseudoarthrosis could be
performed if the defect is larger than 8 cm, identified as unpredictable surgeries and usually
and external sliding is performed if the defect requires multidisciplinary approach. There is a
is smaller than 8 cm. An empty ring is added large scale in this field between salvage proce-
to the system to decrease the docking site dures and amputation. A vicious circle is the
problems if internal siding is performed. The main problem. Infection causes nonunions
empty ring will provide compression in dock- while nonunions intensify the infections.
ing site region. Nonunions are treated with stimulation, and
4. Docking site problems: The skin on the
infections are treated with resections in the
docking site may twist and penetrate into infected pseudoarthroses. Osteogenesis could
two fragments. Compression is continued in be stimulated when there is not a dead space or
such incidents. Delayed reunion or nonunion nonviable bone (sequestrum) at the pseudoar-
may develop if inadequate resection is per- throsis site. If there is a nonviable bone or dead
formed in docking site region. Bone graft is space, resection must be performed initially.
applied to the docking site region in such Stimulation of osteogenesis and fragment trans-
cases. port are following procedures (Figs. 38.28 and
5. Delayed maturation and ossification on regen- 38.29) [10–12].
erate: Dynamization is applied to the regener- Debridement and antibiotic treatment could
ate region and weight bearing is promoted. be sufficient for moderate level infections.
a b c d
Fig. 38.28 Male patient 48 years old with infected pseu- healed and reunion was provided 6 months after the oper-
doarthrosis on the left ankle. Fixation was performed ation. Preoperative X-ray of the patient (a) and clinical
using K wires 6 months earlier due to falling down from view (b), correction of the alignment and application of
the height, but infection had developed. Monolocal com- the circular external fixator (c, d), union of the fracture
pression was performed using Ilizarov-type external fix- after 6 months (e, f), and functional results (g) of the
ator, and osteogenesis was stimulated. The infection was patient
e f g
b c
Fig. 38.29 Ilizarov-type external fixator was applied to a obtained 4 months after the operation. Clinical view of the
male patient aged 75 years due to infected left ankle pseu- patient and dermal signs of infection (a), X-ray and clini-
doarthrosis. After resection of the nonviable and infected cal photo of the patient after the surgery (b, c), union after
bone segment at the pseudoarthrosis site, compression 4 months (d, e), and dermal healing (f)
was applied using the circular external fixator. Union was
d e f
However, more aggressive treatment is required Nonviable bone has higher predispositions
as the infected area exceeds. The advanced meth- to the infections. Therefore, more necrosis at
ods used in chronic cases are listed below: the bone refers to the wider infected tissue.
Ilizarov found that corticotomy increased the
1 . Wide debridement and rotational flaps vascularity and resolved the infection. He had
2. Filling the defects with antibiotic cement
expressed his opinion with the words below:
chains “The bacteria are burned out on distraction
3. Papineau’s open spongious graft application fire.” But this is not true for all cases. The
4. Tibiofibular synostosis method infected structures must be excised from the
5. Allograft application in antibiotic-loaded
pseudoarthrosis site. Then, internal transport
fibrin <sealand> must be performed to the following bone
6. Free vascularized bone and soft tissue
defects after resections. Monofocal treatment
transplantation alone could be adequate on hypertrophic pseu-
doarthroses with low level infections without
These methods have limits on deformity cor- sequestrum. The local blood flow will be
rections and lengthening. Ilizarov’s circular increased with stability. The fight against
external fixator enables simultaneous treatments infection will be strengthened by the increase
and permanent solutions. in blood circulation [7].
Bilocal treatment is preferred on atrophic deformity correction methods must be

pseudoarthroses if there is high level infection known. Only compression and distraction
and sequestrum formation. stress must be applied on the fracture line.
The skin must be remained open after wide Shearing forces should not be applied to the
resections in the presence of severe fistulas and fracture line.
malnutrition. A healthy dermal tissue could be 4. The type of the pseudoarthrosis: Ilizarov had
obtained by performing daily medical dressing or classified the pseudoarthroses as loose and
vacuum aspirated closure (VAC) applications. stiff type. In fact, there is not much difference
Bilocal treatment could be performed after soft between all classifications. The stiff type is
tissue coverage and the skin is healed [13, 14]. similar to hypertrophic type, and the loose
type is similar to atrophic-type pseudoarthro-
sis. Identification of the type of the pseudoar-
38.8 Points to Take throsis may also help identification of the
into Consideration etiology. The location may suggest an idea.
in Treatment Atrophic pseudoarthrosis is generally not
of Pseudoarthrosis present in the regions where the blood circula-
tion is well. The prevalence of hypertrophic
1. The vitality of the bone ends: The vitality of pseudoarthrosis is very rare in the regions
the bone ends is the main factor that may where the blood circulation is not good.
change the treatment options. If the fracture Pseudoarthrosis is frequent in one-third lower
is a wedge or comminuted, then atrophic part of the tibia because of relatively lower
pseudoarthrosis will develop because of the blood circulation. Union could be obtained
disrupted endosteal and periosteal circulation with compression in hypertrophic pseudoar-
at the same time. throsis if the defect is smaller than 2 cm.
2. The shape of the bone ends: The shapes of the Distraction could be applied for pseudoarthro-
bone ends will help to decide the type of the ses with defect larger than 2 cm. First, resec-
treatment as well. Longitudinal compression tion then compression must be applied if the
is applied to the cylindric fracture lines and shortness is smaller than 2 cm in atrophic
transverse compression to the rhomboid frac- pseudoarthroses. If the shortness or defect is
ture lines. Resection of the bone ends and then larger than 2 cm, then resection and segment
fragment transport with corticotomy must be transport is the best option.
preferred for the trocar type and trapezoid 5 . Age of the patient: Age is one of the main fac-
fracture lines. The shape of the bone ends on tors for the type of the pseudoarthrosis.
the radiographs will help to identify the type Generally, atrophic pseudoarthrosis develops
of the pseudoarthrosis. Callus is not present in in older patients with circulatory problems;
atrophic type but present in hypertrophic however, hypertrophic pseudoarthrosis devel-
types. Narrowing is present in fracture ends in ops among infants and children.
atrophic pseudoarthrosis but widening is pres-
ent in hypertrophic type. The medullary canal There is not a nonunion case in the world that
is closed in atrophic types and open in hyper- cannot be managed when you have knowledge of
trophic type. Sclerosis could be present in all Ilizarov principles. There is not any standard
atrophic types and not in hypertrophic types. and stereotyped treatment modality in
The movement more than 7° during the physi- pseudoarthrosis treatment. Each case must be

cal examination indicates an atrophic-type evaluated separately and treated as uniquely.
pseudoarthrosis. At the end of this chapter we have provided an
3. The deformity: Angulation, rotation, and algoritm which we use for the treatment of pseu-
translation may develop in fracture site, and doarthrosis in our clinic. (Table 38.2)
Table 38.2 Treatment protocol for pseudoarthrosis cases, Çakmak et. al., Istanbul University, Istanbul Faculty of
Medicine, Department of Orthopedics and Traumatology
Our clinics treatment algorithm of pseudoarthrosis
Question 1: What is Question 2: Question 3: Question 4: What type are the shapes of the fracture
the type of the Are there Are there any ends?
pseudoarthrosis? any limb length Cylinder Rhomboid Trapezoid/pencil
deformities? discrepancies shape shape tip
(LLD)?
Viable (hypertrophic) Deformity LLD Stable osteosynthesis with any fixation method
(−) <2 cm
LLD Distraction osteogenesis with Ilizarov external fixator
>2 cm (IEF)
Deformity LLD Correction of deformity and stable osteosynthesis with
(+) <2 cm any fixation method
LLD Distraction osteogenesis with Ilizarov external fixator
>2 cm (IEF)
Non-viable (atrophic) Deformity LLD Resection of Resection of Resection of the
(−) <2 cm the fragment the fragment fragment ends
after ends + ends + (transformation to the
resection longitudinal transverse 2/3 of cylinder type*** )
(a.r.) compression compression + longitudinal
(IEF) (IEF) compression (IEF)
LLD Resection of the fragment Resection of the
>2 cm ends + corticotomy + fragment ends
after segment transport (IEF) (transformation to the
resection 2/3 of cylinder type *** )
(a.r.) + corticotomy +
segment transport (IEF)
Deformity LLD Resection of the fragment ends + provision of the
(+) <2 cm (a.r.) alignment with deformity correction techniques +
monolocal compression (IEF)
LLD Resection of the fragment ends + provision of the
>2 cm (a.r.) alignment with deformity correction techniques +
segment transport (IEF)
(***Illustration of transformation of the

trapezoid or pencil tip type shape to the 2/3
cylinder shape with controlled resection +
corticotomy + segment transport)
4. Frankel VH, Golyakovsky V. Operative manual of

References Ilizarov techniques. St Louis: Mosby; 1992.
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1. Ilizarov GA. Ch.1, Historical background of transosse- Grune & Stratton; 1976.
ous osteosythesis. In: Green SA, editor. Transosseous 6. Paley D. Ilizarov treatment of tibial non-unions with
osteosynthesis. Berlin: Springer-Verlag; 1991. bone loss. Section 1. Clin Orthop Relat Res.
2. Marti RK, Kloen P. Ch.1, Evolution of treatment of 1989;241:146–65.
nonunions. In: Concept and cases in nonunion treat- 7. Ilizarov GA, Green S, editors. Transosseous osteosyn-
ment. New York: Theme; 2011. thesis. Berlin: Springer-Verlag; 1991.
3. Judet J, Judet R: L’ostognse et les retards de consoli- 8. Dagher F, Roukoz S. Compound tibial fractures with
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Congrs SICOT, 1960, p. 315. Joint Surg Br. 1991;73:316–21.
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Comparing conventional and Ilizarov methodologies. Hİ, Bilen FE. Treatment of infected nonunion of the
Clin Orthop Relat Res. 1994;301:118–23. juxta-articular region of the distal tibia. Acta Orthop
10. Cattaneo R, Villa A, Catagni M, Tentori L. Treatment Traumatol Turc. 2016;50(2):139–46. doi:10.3944/
of septic or non-septic diaphyseal pseudoarthroses by AOTT.2015.15.0147.
Ilizarov’s monofocal compression method. Rev Chir 13. Krishnan A, Pamecha C, Patwa JJ. Modified Ilizarov
Orthop Reparatrice Appar Mot. 1985;71(4):223–9. technique for infected nonunion of the femur: the
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11. Iacobellis C, Berizzi A, Aldegheri R. Bone transport J Orthop Surg (Hong Kong). 2006;14(3):265–72.
using the Ilizarov method: a review of complications 14. Inan M, Karaoglu S, Cilli F, Turk CY, Harma A.
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Chronic Osteomyelitis, Biofilm,
and Local Antibiosis 39
R. Schnettler, K. Emara, D. Rimashevskij, R. Diap,
A. Emara, J. Franke, and V. Alt
39.1 Introduction bones through skin lesions and soft-tissue necro-

ses as a result of trauma or surgery (exogenous).
Postoperative and posttraumatic infections of bones, The term osteomyelitis has achieved worldwide
soft tissues, and joints still present a large problem acceptance. From a pathologic-anatomical point
and are among the most serious complications of view, osteomyelitis can be differentiated into a
despite huge advances in the field of medicine. focal form – referred to as a bone abscess – and
Osteomyelitis is a heterogenous disease one with diffuse spread. As the treatment of bone,
regarding its pathophysiology, clinical presenta- soft-tissue, and joint infection has slowly been
tion, as well as management. changing with an evolution and renaissance in
Osteomyelitis basically means inflammation understanding the process of management the
of bone and bone marrow components. This infection, the epidemiology of the condition
could be of bacterial origin, but may also result appears to have evolved over time.
from tuberculosis or syphilis and, depending on Despite the efforts to decrease the incidence
the immune status of host, may even be of fungal of osteomyelitis, the increased survival rates in
or parasitic (echinococci, toxoplasma) origin. posttraumatic patients, especially those with
Osteomyelitis as a condition may develop as a extensive injury and bone exposure, have been
result of contiguous spread of the infectious accompanied by an increased incidence of post-
organism from adjacent soft tissues and joints, traumatic osteomyelitis. Furthermore, improved
hematogenous seeding by the bloodstream life expectancy among elderly patients with dia-
(endogenous), or by direct inoculation and colo- betes mellitus has resulted in more cases of neu-
nization into the bone. The bacteria reach the ropathy, vascular insufficiency, and the associated
local complications of soft-tissue loss, bone
R. Schnettler (*) • V. Alt destruction, and osteomyelitis [1, 2].
Justus-Liebig-University Giessen, Giessen, Germany
e-mail: Reinhard.Schnettler@chiru.med.uni-giessen.de
K. Emara • R. Diap • A. Emara 39.2 Pathophysiology, Diagnosis,
Ain Shams University Kairo, Cairo, Egypt
Classification, Pathogens,
D. Rimashevskij and Biofilm
Scientific Research Institute of Traumatology and
Orthopedics, Healthcare Ministry of Republic of
Kazakhstan, Astana, Kazakhstan Bone provides supportive tissue consisting of an
J. Franke
organic matrix and cellular elements. Osteomyelitis
Elbeklinikum Stade, Stade, Germany is because of the morphology of bone structure not

https://doi.org/10.1007/978-3-319-45675-1_39
606 R. Schnettler et al.
limited to its surface. The bone infection extends spp., Serratia spp., anaerobes as Peptostreptococcus
to all components of the bone as the cortex, mar- spp., Clostridium spp., and Bacteroides fragilis
row, periosteum, and surrounding soft tissue. group. These occasional pathogens account for
Osteomyelitis is an inflammatory process of around 25% or more of all osteomyelitis cases.
bone and bone marrow accompanied by bone Here can be seen some rare pathogens which
destruction and exclusively caused by an infect- account for less than 5% of all osteomyelitis cases.
ing microorganism. Surgical implants of foreign The mode of infection’s influence on the type of
materials as plates, nails, screws, and fixator pins infecting pathogen is evident in the predominance
as well as total joint protheses and bone cement of specific microorganism in each event. Bite
have a higher risk of infection than operative pro- wounds, both animal and human, introduce
cedures in which no foreign material is implanted osteomyelitis-causing pathogens as streptococci,
[3–5]. anaerobe bacteria, and Pasteurella multocida.
Infection occurs when a large number of organ- Decubitus ulcers and diabetic foot usually have
ism is inoculated into bone tissue. This inoculation streptococci, staphylococci, gram-negative bacilli,
can occur by several major routes, namely, hema- and anaerobic bacteria implicated in any resultant
togenous, contiguous, and direct inoculation. osteomyelitis [8].
The hematogenous route is essentially the Staphylococcus aureus is the most frequently
spread of the invading pathogen by the blood- isolated pathogen in implant-associated infection
stream and the consecutive seeding of bone by this [10]. As Staphylococcus aureus is an extracellu-
pathogen secondary to bacteremia from another lar pathogen due to its ability to colonize extra-
source of infection which is usually considered as cellular bone matrix and to form biofilm, it is
primary source [6]. proven that it can also internalize and survive
Most common pathogens involved in osteomy- within host cells acting as a facultative intracel-
elitis are Staphylococcus aureus and coagulase- lular pathogen [11–13].
negative staphylococci. The clinically most Recent experiments that have been conducted
important of which is Staphylococcus epidermidis. by us showed that Staphylococcus aureus could
It is found in up to 90% of bone infections follow- not only invade but also proliferate inside osteo-
ing intraoperative implantation of foreign material blasts [14] (Figs. 39.1 and 39.2).
like total joint prostheses and internal fracture It is known that Staphylococcus spp. showed to
devices [7–9]. Occasional other pathogens may be express high-affinity receptors (adhesins) for
isolated as streptococci, enterococci, Pseudomonas fibronectin, collagen, and laminin which are
spp., Enterobacter spp., Proteus spp., Escherichia abundant components of bone matrix. Fibronectin,
Fig. 39.1 Immunofluorescence microscopy, intracellular infection of osteoblasts (red dots), and internalization of
Staphylococcus aureus (Laboratory of Experimental Trauma Surgery, JLU Gießen)
39 Chronic Osteomyelitis, Biofilm, and Local Antibiosis 607
Fig. 39.2 Intracellular persistence and multiplication of Staphylococcus aureus (Laboratory of Experimental Trauma
Surgery, JLU Gießen)
a glycoprotein found in many body fluids and the site of inflammation as well as stimulating
connective tissue matrices, appears to be of par- osteoclastogenesis. All these factors are huge
ticular relevance to the pathogenesis of chronic contributors to the development of osteoporosis at
osteomyelitis: bacterial adherence to polymers the area of osteomyelitis [20]. Neither antibiotics
similar to the ones used in orthopedics is medi- nor leukocytes are able to penetrate and access
ated by fibronectin. The same glycoprotein has bacteria in case of formation of necrotic bone
been shown to mediate bacterial adhesion to metal sequestra or in case of hardware colonization due
plates and screws [15]. This mechanism could to their vascularity as well as biofilm formation
explain in part the ability of Staphylococcus [15]. Bacterial adhesion to the surface of implants
aureus to colonize hardware making them persis- enables them to develop a biofilm. There are two
tent foci of infection (Fig. 39.3). fundamental types of bacterial growth: planktonic
Staphylococcus aureus as a pathogen has and biofilm. Planktonic bacteria are freely float-
proven to have several mechanisms to resist host ing, single cells, while biofilm are composed of
defenses. These virulent factors, which enable microorganisms that adhere to and grow on a vari-
Staphylococcus aureus to invade and establish an ety of surfaces. The cells in a biofilm have the
infection in bone tissue, include the expression of capability of protecting themselves from host’s
wall protein A. Protein A serves as an antiphago- defense as well as antibiotics [21, 22]. A biofilm
cytic agent where it binds the Fc-reactive site of is defined as a multicellular aggregate of microor-
IgG [16]. Protein A is also considered as a micro- ganism attached to the surface and embedded in a
bial surface component recognizing adhesive self-produced extracellular matrix. The matrix
matrix molecule. Bacterial adhesions of consists mainly of polysaccharides, proteins,
Staphylococcus aureus help the pathogen adhere nucleic acids, and lipids. It has been demonstrated
to host tissue as well as implants causing conse- for many species that extracellular DNA (eDNA)
quent colonization [17]. Protein A can also bind is an important structural element and involved in
tumor necrotic factor receptor-1 [18, 19]. Another adhesion [23–26] (Fig. 39.4).
response to protein A of Staphylococcus aureus is This creates the foundation for the proliferation
the RANKL expression in osteoblasts and can of pathogens in bone tissue, on implants c overing
also stimulate the migration of pre-osteoblasts to the bone, or on total joint arthroplasty [2]. Biofilms
a b c
d1 d2 d3
e f
Fig. 39.3 Identification of Staphylococcus aureus – biofilm, (D1) FISH with Staphylococcus aureus gene-
biofilm in rats (Laboratory of Experimental Trauma
specific probe, (D2) FISH with EUB 338 probe, (D3)
Surgery, JLU Gießen), (A/B) Staphylococcus aureus DABi staining of DNA and biofilm, (E/F) Staphylococcus
DNA surrounded by biofilm, (C) polypeptidoglycan from aureus with FISH EUB 338 probe
have been of major concern in clinical settings naling is known as quorum sensing [28]. It also
because of their ability to cause persistent infec- presents with the challenge of high resilience and
tions [27]. Staphylococcus aureus and resistance to antibiotic treatment, so once the bio-
Staphylococcus epidermidis are two of the most film is formed, it becomes extremely difficult to
important biofilm- forming pathogens which eliminate the bacterial infection using conven-
makes them difficult to treat with antimicrobial tional antibiotic therapy. The combination of the
agents. The formation of biofilms on medical previous two is another challenge. Since biofilm
hardware has three major problems. First of all this resists antibiotic penetration and becomes a reser-
biofilm is considered as a reservoir of the bacteria voir of persistent infection, chronicity will develop
which can be shed into the body continuously con- and causes even more antibiotic-resistant strains to
tributing to the chronicity of the infection. Bacterial accelerate inside the biofilm [29]. Biofilm depth
cells inside the biofilm colonies communicate with can vary from a single cell layer to a thick com-
each other by a cell-to-cell signaling system utiliz- munity of cells surrounded by a thick polymeric
ing hormonelike c ompounds. This cell-to-cell sig- milieu. Structural analyses have shown that these
Fig. 39.4 Staphylococcus aureus with adherent biofilm (Laboratory of Experimental Trauma Surgery, JLU Gießen)
thick biofilms possess a complex architecture in The following are the classifications of osteo-
which microcolonies can exist. They own distinct myelitis according to symptoms, origin of infec-
pillar or mushroom-shaped structures through tion, and host factors:
which an intricate channel network runs. These
channels provide access to environmental nutri- Acute osteomyelitis has a duration of 4 weeks
ents even in the deepest areas of the biofilm [30]. and spreads from infectious focus or a second-
So in general, biofilms are difficult to eradicate ary bacteremia. Host factors are rare.
and thus deserve special attention. Chronic osteomyelitis has symptoms more than 4
Bisphosphonates have been found to increase weeks, the source of infection is posttraumatic
bacterial adhesion and biofilm formation. or postoperative spread from neighboring skin
Bacterial colonization of the hydroxyapatite ulcer and refers to the occurrence of bone
discs was significantly higher for all tested strains necrosis [33–38].
in the presence of bisphosphonates versus con- Host factors are often diabetes mellitus (arterial
trols. This could increase the susceptibility of occlusive disease).
patients on bisphosphonates especially to osteo-
myelitis or implant infection [31]. The subacute form of osteomyelitis begins
According to terminology, there are two forms gradually and differs from the acute form by a
of osteomyelitis – acute and chronic. Osteomyelitis lack of systemic disease manifestations. The
is classified into a purulent and a nonpurulent most common clinical finding is a Brodie assess.
form. On the basis of clinical findings, the puru- Although there does not exist a uniform and
lent form can be subdivided into an acute, sub- universally accepted classification system for
acute, and chronic (active and inactive) form [32]. osteomyelitis, a certain number have been

suggested to help guide therapy and to allow sis of osteomyelitis. Chronic infections are more
comparison of published results [5]. The first of likely to have polymicrobial involvement, includ-
the two major classifications was established by ing anaerobic, mycobacterial, and fungal organ-
Waldvogel in 1970 basing on three categories of ism. Specific cultures and microbiologic and
osteomyelitis: molecular biologic testing may be often required
for suspected pathogens or cases [33, 46–49].
Hematogenous − contiguous focus and osteomyeli- If the patient is suspected of having osteomyeli-
tis associated with vascular insufficiency [39]. tis, routine radiographs should be performed [5,
50]. Plain radiography usually does not show signs
Being as it is an etiological classification, it of osteomyelitis after initial infection; it may take
does not give much significance regarding the days or weeks to become evident. Typical findings
required therapeutic strategies. A hematogenous in acute osteomyelitis include nonspecific perios-
spread of pathogens is usually present in the bone teal reaction and osteolysis. Sequestra are infre-
and in the majority of cases involving children quent findings in acute osteomyelitis. Nevertheless
and adolescents between 2 years of age and skel- it is a useful first step that may reveal other entities
etal maturity. Acute osteomyelitis is referred to such as metastases or osteoporotic fractures.
as the juvenile form of hematogenous osteomy- Typical findings for chronic osteomyelitis are scle-
elitis [40–42]. rotic bone and a characteristic periosteal reaction.
The second major classification established by Sequestra appear as isolated parts of necrotic bone.
Cierny et al. in 1985 was based on the affected The Brodie abscess as a circumscribed osteomy-
part of the bone, the physiology status, and of the elitic lesion surrounded by granulation tissue in
host as well as the local environment. They clas- the metaphysics of a tubular bone is the most
sified chronic osteomyelitis into 12 groups. Four common manifestation of subacute osteomyelitis.
types of treatment and prognostic factors and Radiographically it is shown as an aggregate of
three physiologic classes are differentiated. The osteoclastic and osteoblastic characteristics [5, 38,
anatomic types of osteomyelitis are medullary, 50, 51].
superficial, localized, and diffuse, whereas the The indication for skeletal imaging by CT
patient in the three physiologic classes is classi- includes the visualization of bone fragments and
fied as an A, B, or C host [34]. The Cierny clas- sequestra and the detection or exclusion of
sification in general is of value in clinical practice osteonecrosis.
because of its ability to address the dynamic Computed tomography is the method of choice
nature of as well as add a second dimension rep- for image-guided navigation (bone biopsies and
resented in the host’s physiologic, metabolic, and aspirations/drainage of deep collections). MRI is
immunologic capabilities [43, 44]. more sensitive than CT, and it provides better
The diagnostic of osteomyelitis can be difficult information of assessing the viability of bone.
and requires the evaluation of a patient with rec- MRI can also visualize sinus tracts or abscesses.
ognition of clinical symptoms and supportive Nuclear medicine imaging of bone inflamma-
laboratory and imaging studies. Laboratory inves- tions can be helpful in diagnosing osteomyelitis.
tigations can be helpful, but generally lack speci- The goal is to detect the inflammation early and pre-
ficity for osteomyelitis. The C-reactive protein vent the development of chronic disease.
level correlates with clinical response to therapy Radionuclide bone scans employ technetium-
and may be used to monitor treatment [45]. labeled diphosphonate compounds which are into
Microbial cultures are essential in diagnosis and normal bone or bony processes depending on the
treatment of osteomyelitis. The preferred diag- metabolic activity. They are usually positive within
nostic criteria for osteomyelitis are a positive cul- a few days of the onset of symptoms. The sensitivity
ture from bone biopsy and histopathology of bone scintigraphy is comparable to MRI but the
consistent with necrosis. Superficial wound cul- specificity is poor. Other imaging modalities seem
tures do not contribute significantly to the diagno- promising but are not routinely used [50, 52–54].
39.3 Surgical Treatment proper fracture stabilization, and soft-tissue cov-

of Chronic Osteomyelitis: erage. Infection complicates fracture healing and
Local Antibiotics will lead to infected nonunion, which is a special
form of chronic osteomyelitis. It is a combination
To manage chronic osteomyelitis has always been of two severe, local, mutually potentiating com-
difficult and is a challenge for surgeons. In recent plications – instability and infection.
decades, the standard treatment for osteomyelitis Further problems such as segmental defects,
has been serial aggressive debridements, soft-tis- shortness, and angulation complicate the treatment
sue coverage, and long-term systemic antibiotics which has to start with removal of all necrotic tis-
often combined with the application of local antibi- sue, soft tissue, and bone. All foreign materials have
otics, followed by reconstruction of skeletal defects to be removed. Successful therapeutic approach is
[2, 35, 36, 38, 55–58]. The treatment of osteomy- like in tumor surgery en bloc resection.
elitis with local antibiotics has been controversial Bone reconstruction should be performed as a
[59] but has become a common practice in ortho- secondary procedure with bone grafting (defect <
pedics [60] (Fig. 39.5). 4–6 cm), whereas segmental defects (defect >
The treatment of osteomyelitis has evolved 4–6cm) should be treated by bone transport and
with the changes in antibiotic therapy and ortho- shortness with lengthening. Bone transport and
pedic technique. Prevention of osteomyelitis is lengthening involve the technique of distraction
best accomplished by aggressive, timely debride- histogenesis [56, 61–63]. Nevertheless, the
ments of open fractures, appropriate antibiotics, essential step in the treatment of chronic osteo-
myelitis is radical surgical debridement with
removal of dead bone and all foreign material
implants such as nails, plates, and prostheses
[36]. In planning the management of patients
with chronic osteomyelitis, it is mandatory to
take into consideration the morbidity and func-
tional impact that the disease is causing, the type
of host, and the magnitude of the proposed surgi-
cal procedures. Treatment is expensive and time-
consuming and may result in failure, recurrent
sepsis, continued disability, and an inability to
return to a productive role in society. The deci-
sion on reconstruction or amputation of a chroni-
cally infected limb is difficult and depends on
various factors. The treatment must be planned
individually and discussed in detail with the
patient. Therefore, patients with chronic osteo-
myelitis should be treated in specialized depart-
ments (Fig. 39.6) [56, 64, 65].
When a fracture is associated with chronic
osteomyelitis, external fixation is preferred to
obtain stability. The current recommendation for
adjunctive antibiotic therapy in the management
of chronic osteomyelitis is intravenous treatment
for six weeks. Dead space resulting from exces-
sive debridement should be filled with polymeth-
Fig. 39.5 Calcaneus infection with gentamicin-PMMA ylmethacrylate beads impregnated with
beads gentamicin (Septopal ). ®
Fig. 39.6 Therapeutic Dèbridement

regimen
gle
itig ich
ze ze PMMA chains, spacer
ch itig
glei
Sanierung des
Ggfs. Stabilisierung Weichteilschadens
3–4 Wochen
KnÖcherne Rekonstruktion
ggfs. Reosteosynthese
Entfernung PMMA bzw. Spacer
Einbringen Gentamycin Schwamm
Fig. 39.7 Gunshot injury located at the thumb
Polymicrobiality mandates use of a broad- leaving beads in situ might lead to additional
spectrum antibiotic incorporated in the PMMA problems in the long term (Figs. 39.7, 39.8, 39.9,
bead. Short-term or prolonged-term implanta- 39.10, 39.11 and 39.12) [65, 67].
tion of PMMA antibiotic beads is possible. In It is important to note that antibiotic administra-
short-term implantation, the beads are removed tion in osteomyelitis in general unless complicated
within 8 days and in long-term implantation may by another severe or potentially life-threatening
be left up to 80 days. Prolonged implantation of infection is delayed until the results of laboratory
antibiotic beads is indicated in specific patients work indicating the type of infecting pathogen are
with localized osteomyelitis, large dead space identified. The choice of antimicrobial agent has to
cavities, and marginal soft-tissue coverage and be more specific and lead to a special guided anti-
in patients with secondary surgical risks biotic therapy regime [68]. So it is essential to take
[55, 65, 66]. an intraoperative smear for identification of the
But as it is well known that in the absence of pathogen and to perform an antibiogram. Additional
sufficient antibiotic, PMMA can serve as a sub- tissue samples are taken for microbiologic and his-
stratum for bacterial colonization and could tologic examination (Figs. 39.13, 39.14, 39.15,
involve cases of antibiotic-resistant strains. Thus, 39.16 and 39.17) [2].
Fig. 39.8 Aggressive surgical debridement. Additional Fig. 39.9 Plate arthrodesis with iliac crest bone
external fixation and K-wires. Local gentamicin fleece interposition
Fig. 39.10 Infected plate osteosynthesis 4 weeks post-op. Radial flap with distal pedicle
Fig. 39.11 Surgical debridement/jet lavage/gentamicin collagen fleece. Radial flap with distal pedicle
Fig. 39.12 Clinical outcome: no infection signs 24 months post-op

Fig. 39.14 En bloc resection, external fixation stabiliza-

tion, gentamicin-PMMA beads (Septopal® implantation)
Fig. 39.13 Infected tibial plate osteosynthesis

Fig. 39.16 Change of method. Minimal invasive plate

osteosynthesis
Fig. 39.15 6 weeks post-op: autogenous bone graft (fib-

ula and iliac crest)
Fig. 39.18 Femur fracture – hematogenous osteomyelitis
Fig. 39.17 Bony consolidation, no infection signs 12

months post-op
The monosegmental transport assembly for cal-

lus distraction in defects >4–6 cm requires proxi-
mal or distal corticotomy and stepwise transport of
the segment in the defect. An additional bone graft-
ing is required when in the area of docking zone a
delayed bony healing is visible (Figs. 39.18, 39.19,
39.20, 39.21, 39.22, 39.23 and 39.24).
A disadvantage of gentamicin-PMMA beads
is that the material is non-biodegradable and its
limitation of its use to infections in which the
bacteria are sensitive to gentamicin.
Individual mixing in of several other antibiot-
ics has been described, but the mixture and
respective release characteristics of the antibiot-
ics are uncertain. A new antibiotic substitution
material based on biodegradable material such as
a combination of 55% hydroxyapatite and 48.5%
calcium sulfate (POP) manufactured as pellets
(PerOssal®) can adsorb all known antibiotics in a
Fig. 39.19 En bloc resection, external fixation stabiliza-

tion, gentamicin-PMMA beads (Septopal® implantation)
Fig. 39.21 Docking site without bone consolidation,

autogenous bone grafting, plate osteosynthesis, no infec-
tion signs 24 months post-op
Fig. 39.20 Callus distraction, proximal to distal, mono-

segmental transport 4 weeks after radical sequesterotomy
Fig. 39.22 Infected plate osteosynthesis with Fig. 39.23 Removal of implant Regazzoni external fixa-
osteomyelitis tion. supraacetabular/femoral neck/shaft. Corticotomy.
Aggressive surgical debridement removal of infected
granulation and scar tissues. Resection of avascular dead
bone till punctate bleeding on bone surface is seen. Tissue
biopsy for culture. Jet lavage irrigation local antibiotic
carrier (gentamicin-PMMA beads)
Fig. 39.24 Monosegmental
transport from distal to
proximal, bony
consolidation, no signs of
infection 24 months
post-op
watery solution. These pellets need 5 minutes to biofilm biomass was neutralized, and also the
completely absorb the antibiotic solution (Figs. killing efficacy was influenced in a positive
39.25, 39.26, 39.27, 39.28, 39.29 and 39.30). way.
The antibiotic treatment of implant-associated In conclusion, glycopeptide antibiotics were
infections and osteomyelitis remains challenging. not effective in eradicating
Biofilm-associated bacteria display a decreased S. epidermidis biofilms, but the combination with
susceptibility toward antibiotics. A recently pub- rifampicin improved the killing efficacy in vitro.
lished in vitro study [69] showed that treatment of The antibiotic substitution material based on
S. epidermidis biofilms with several glycopep- biodegradable material (PerOssal®) offers the
tides increased the total biofilm biomass and that required characteristics of a modern local antibi-
these antibiotics (vancomycin, teicoplanin, oxa- otic carrier and can successfully replace nonre-
cillin, rifampicin and gentamicin) were not effec- sorbable PMMA chains and collagen fleece in
tive in killing bacteria embedded in biofilms. selected indications especially in infections with
However, when vancomycin or teicoplanin methicillin-resistant pathogens [40].
were combined with rifampicin, the increase in
5000
Elution of gentamycin
1000
100
10
mg
Septokoll [1 cm2]
Septokoll [1 Kugel 7 mm]
1 Sulmycin Implant [1 cm2]
Perossal [1 FK 6×6 mm]
0.1
0 1 2 3 4 5 6 7 8 9 10
days
Fig. 39.25 Resorbable pellets of 51.5% nanocrystalline hydroxyapatite and 48.5% calcium sulfate (PerOssal®). All
known antibiotics in a watery solution can be added to the carrier substance
Fig. 39.26 Implant/
bone infection,
Staphylococcus
epidermidis biofilm on
implant (plate)
(Laboratory of
Experimental Trauma
Surgery, JLU Gießen)
Fig. 39.27 En bloc resection 7 cm. Tissue biopsy for cul-

ture. Jet lavage/eradicating biofilm from implant (plate).
Stable internal fixation remains in situ
Fig. 39.28 Defect filling with pellets impregnated with vancomycin and rifampicin
Fig. 39.29 Six weeks later, bone grafting (fibula autograft/cancellous bone/BMP-2)
Fig. 39.30 Four
months later,
BMP-2-implantation/
fibula and iliac crest
bone chips
implantation and
screw fixation. Fifteen
months later, no
infection signs/stable
consolidation. Patient
walks 500 m without
cane
Conclusion 11. Fraunholz M, Sinha B. Intracellular Staphylococcus

• Infection after osteosynthesis and orthope- Aureus: live-in and let die. Front Cell Infect Microbiol.
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implantation of gentamicin-polymethylmethacry-
in Warfare Surgery 40
Mustafa kürklü, Yüksel Yurttaş,
Harun Yasin Tüzün, and Mustafa Başbozkurt
40.1 E
xternal Fixation on War Modern high-energy weapons expose soft tis-
Injuries: Principles sue and bone to serious damage. Besides being the
and Applications best decision in extensive soft tissue injury, exter-
nal fixation eliminates the requirement for full
One of the most common war injuries is limb reduction. In fractures fixed with internal fixation,
injury. The mortality and morbidity rates are reported infection rates are distinctly high [3, 6].
higher for war injuries. The reported occurrence Ballistic information is important for the eval-
of gunshot wound injuries in the literature uation and treatment of these injuries. Ballistic
exceeds the incidences of motor vehicle acci- studies showed that mass, velocity, diameter,
dents, sports injuries, or industrial accidents. The shape of bullet, and distance influences the degree
number of gunshot wounds in the United States is of injury [7]. The kinetic energy that occurs at the
about one hundred thousand (100,000) per year. site of injury related with mass and velocity of
Extremity injuries constitute 70% of all cases, bullet according to E = 1/2mV2 formula. Moreover,
most frequently in lower limbs, and bone frac- route of bullet, secondary shock wave, and cavita-
tures are detected in half of the cases [1–5]. tion phenomenon influence the degree of injury.
Firearm wounds have three distinct types: low-
velocity wounds (muzzle velocity <350 m/s), inter-
M. kürklü, MD (*)
Division of Hand Surgery, Department of mediate-velocity wounds (muzzle velocity
Orthopedics Surgery and Traumatology, University of 350–500 m/s), and high-velocity wounds (muzzle
Health Sciences, Ankara, Turkey velocity > 600 m/s) [8]. In low-velocity wounds, the
e-mail: kurklumd@yahoo.com exit holes are smaller than the entry holes because
Y. Yurttaş, MD tissue stretches. Cavitation phenomenon is not seen
Department of Orthopedics Surgery because of less kinetic energy. Bullets damage tis-
and Traumatology, Private Doctor Bayram Öztürk
Hospital, Ankara, Turkey sue in their path, and cavitation phenomenon occurs
with tension; the shock wave increases harm in
H.Y. Tüzün, MD
Division of Hand Surgery, high-velocity wounds because high kinetic energy
Department of Orthopedics Surgery fracture of the bone occurs with bone loss. The exit
and Traumatology, Gulhane Research and Training wounds are larger than the entry wounds, and more
Hospital, Ankara, Turkey
soft tissue damage and necrosis are observed. It is
e-mail: tuzundr@yahoo.com
the most important difference between the high-
M. Başbozkurt, MD
velocity wounds and low-velocity wounds. Gustilo
Department of Orthopedics Surgery
and Traumatology, Private Keçiören Hospital, type 1 and type 2 open fractures may be associated
Ankara, Turkey with low-velocity wounds. High-velocity wounds
https://doi.org/10.1007/978-3-319-45675-1_40
630 M. kürklü et al.
create Gustilo type 3 open fractures. Energy trans- scan can be used in order to investigate the injury
fer is high, and particles of the bullet enter the of intra-articular fractures, vertebrae, and pelvis.
wound in shots fired at close range, which creates a If possible, a tissue culture must be taken for
different type of injury [9]. The risk of infection specific antibiotherapy. The wound should be
increases significantly because foreign bodies enter cleaned with antiseptic solutions. Tetanus prophy-
the wound and cause huge skin defect. laxis and prophylactic antibiotic with first-
Patients with firearm injuries should be generation cephalosporins should be applied to all
assessed according to general principles of patients. Dickson et al. recommended 0.5 mL teta-
trauma. First, ABC should be assessed, and then nus toxoid, 1 gr IV cefazolin, and 7 days of 500 mg
injuries of the head, thorax, abdomen, and pelvis oral cephalexin for Gustilo-Anderson type 1–2
should be explored. All of the patient’s clothes fractures. Infection is rare in this type of injury.
should be removed when they are being exam- Irrigation and debridement is often sufficient
ined. First, the patient is stabilized hemodynami- for low-velocity wounds, but if a patient has
cally, and then the injured extremity must be high-velocity wounds, debridement should be
evaluated. During resuscitation and systemic performed in the operating room. Irrigation
interventions, the wound should be closed with a should be performed with saline.
sterile dressing and splinted. The bullet entry and Aggressive irrigation and debridement is very
exit holes should be identified, and vascular and important for firearm wounds that have extensive
neurologic injuries should be investigated [10]. soft tissue damage. Necrotic tissue, contaminated
Penetrating trauma increases the incidence of subcutaneous fat tissue, bone fragments not asso-
vascular injury. Rapid diagnosis can be made ciated with soft tissue, and foreign bodies should
with a physical examination. In the presence of be removed (Fig. 40.1). Debridement must be
cold extremities, cyanosis, large hematoma, pul- conducted every 48 and 72 h. Care must be taken
satile bleeding, and loss of distal pulses, a large so as not to damage healthy tissue during irriga-
vascular injury should be considered [11]. It must tion and debridement.
be kept in mind that a distal pulse is obtained in Muscle tissue quality is assessed using the
27.3% of patients although there is main vascular classic four Cs:
injury [12]. Pulse control alone is not enough for
assessing vascular pathology. Angiography is the • Color (red or brown)
gold standard for definitive diagnosis. • Consistency (how does the muscle feel)
Distal sensory and motor examination should • Capillary circulation (does it bleed?)
be performed carefully to the injured limb. The • Contractility (responds to pinch or
findings of possible peripheral nerve injury electrocautery)
should be investigated. Electrodiagnostic studies
are not used for peripheral nerve injuries caused It should not be forgotten that soft tissue is
by blast in the early stages. Most of these injuries very necessary to heal fractures; primary closure
recover spontaneously. Omer et al. reported that should be avoided because of anaerobic infec-
70% of peripheral nerve injuries of upper extrem- tions. The wound could be closed after 5–7 days
ities recovered spontaneously [13]. or when the subcutaneous edema disappears [16].
Brien et al. reported that patients with sciatic Soft tissue reconstruction may be necessary if
and peroneal nerve injury recover 60% [14]. If there is a large defect, and help from plastic sur-
there is nerve defect, marking sutures should be geons could be requested.
done, and after closing the wound, the nerve can Foreign bodies can be present in intra-articular
be repaired through this markings [15]. There is fractures. Intra-articular foreign bodies can cause
no consensus of operation time for nerve damage joint damage, synovitis, and systemic intoxica-
at gunshot wounds. tion, so they must be removed at an early time.
Anteroposterior and lateral radiographs must Fracture should be fixed to provide the anatomic
be done to assess the bone and foreign body. A CT integrity of joint [17].
40 External Fixator Applications in Warfare Surgery 631
Fig. 40.1 Bone and

soft tissue debridement
in the gunshot injury
Ilizarov fixators apply interdependent full

rings and rods. In the proximal sections of the
joint, half rings and arcs may be used (Fig. 40.3).
The stability of the Ilizarov can be increased
depending on some factors. In order to allow for
edema, the rings have to be placed 2 cm away
from the skin. The stability is increased concur-
rently with broadening the wire diameter, reduc-
ing the distance between the rings, and putting
two rings instead of one on each bone segment. It
is necessary to tighten each ring, which contain at
least two wires, with four rods [22].
Stabilization of open or closed fractures or
Fig. 40.2 Fasciotomy applied for lower extremity gun-
shot injury unstable periarticular injuries is the current indi-
cation for the use of damage control approaches
with uniplanar fixation (Fig. 40.4). There are
In the event of clinical requirements of compart- some benefits of using external fixators such as
ment syndrome, fasciotomy should be performed. technical ease, easier wound care, decreasing
Fasciotomy is applied for lower extremity injuries infection risks, ensuring rigid fixation, minimal
more often than for upper extremity injuries bone bleeding, pain control, allowing early mobi-
(Fig. 40.2) [18]. lization, and early joint movement and facilitation
Fracture should be fixed after soft tissue of transport to a specialist center. Besides the
wound care. According to retrospective stud- major advantages, cosmetic problems, malalign-
ies, early stabilization reduces secondary ment, malunion, nonunion, and pin tract infection
injury, pulmonary complications, ARDS, inci- are the issues to be considered with external fixa-
dence of infection, and hospital length of stay tion. The external fixator (EF) can be changed in a
[17, 19]. second step with internal fixation. As being not an
An external splinting instrument is equipped ultimate instrument, definitive fixation materials
in external fixation, generally as a bar or frame can only be used after edema, soft tissues, and
attached to the bone. Usually a pin or a wire is general conditions are healed. Inefficiency in sta-
used as an interosseous anchoring system. Fixator bilizing the extremity, nerve or vessel injury, or
configurations have three categories: uniplanar, pin tract infections are some complications in
biplanar, and multiplanar [20, 21]. external fixation. A good knowledge of anatomy
Fig. 40.3 ECF fixator application in lower extremity gunshot injury
phy, osteomyelitis, premature union, delayed

union, or nonunion [20, 21].
Along with considerable arguments about pin
insertion techniques, pin placement is allowed to
be out of the zone of injury and practically farthest
from planned incisions. Crucial soft tissue man-
agement requires deciding on an anatomic site
without a large soft tissue sleeve, preparing an
adequate skin incision, spreading tissues to the
bone, employing cannulation during drill/pin
insertion with the use of protective sleeves, and
stabilizing soft tissues around the pin to prevent
motion. Even if an external fixator is employed as
a temporizing measure, pin loosening and pin tract
infection can negate the benefit of external fix-
ators. There is multifactorial cause of pin loosen-
ing and infection; nevertheless, it is important to
prevent thermal and mechanical damage at the
pin-bone interface. Local inflammation is assumed
to be because of excessive motion of the muscle
and skin around the bone so responsible for pin
Fig. 40.4 Unilateral fixator application in lower extrem- tract infections. It is considered that thermal dam-
ity gunshot injury age has a potential function in pin loosening, and
the severity of the damage is associated with maxi-
can prevent the risk of damaging neurovascular mum temperature and the sum of time that the
structures and an appropriate preoperative prepa- bone is exposed to increased temperatures during
ration can avoid contractures of soft tissue and pin insertion. Predrilling, irrigation during drilling,
joint. Late complications include chronic recur- and power insertion of the pin are the procedures
rent pin tract infection, sympathetic reflex dystro- to reduce temperatures pin insertion [23–25].
External fixators are capable of using as per-

manent method and stabile fixators that control
reduction cannot to be changed.
40.2 T
he Principles of External
Fixator Application
to the Femur
Vascular damage and a large soft tissue wound

associated with high-velocity missile and shrap-
nel injuries are indications for external fixation of
a femoral fracture. Nowadays, external fixators
as a main treatment are uncommonly observed.
Nevertheless, complication rates, along with pin
tract infection, residual loss of knee motion, and
implant failure, are significant. An intramedul-
lary nail is generally applied after wound healing
(2 weeks) (Fig. 40.5). The thigh is one of the
areas most affected by gunshots with a rate of
about 40%. The pattern of fracture and neurovas-
cular examination are both crucial in the initial
evaluation. It is important to assess and note the
present condition of the patients instantly. A hid-
den arterial bleeding, which is rarely observed, is
evaluated as normal in the initial examination.
Fig. 40.5 Femoral intramedular nail fixator application
Following the first evaluation, conventional in lower extremity gunshot injury
anteroposterior and lateral radiographs of the
femur, including the hip and knee, should be pro-
vided. In the case of a surgical delay, a balanced intervene with future prone positioning during
skeletal traction should be implemented [3, 26]. the treatment of other concurrent injuries [21].
In the application of an external fixator to the First, two pins are inserted into the distal and
femur, an object should be placed below the proximal portion. Afterwards, clamps are placed
knee in order to form a hump as preoperative on these pins. Subsequently, another two pins
preparation. The procedure continues with a are correspondingly inserted. Traction should be
knee flexion about 30°. Femoral shaft fractures implemented previous to the placement of the
are stabilized with pins (6 mm) placed anterolat- bar that is between the clamps [27]. Knee range
erally or directly lateral, both proximally and of motion (ROM) should be checked just after
distally. Two pins are inserted below or above the fixator is applied. The motion of the knee is
fracture fragments a minimum 7 mm away from usually allowed in diaphyseal fractures, yet full-
the fracture, and it is crucial that pins should knee ROM is required; however, in distal
pass bicortically. Prior to pin application, pin fractures including knee joint, tibia fixation is
points should be identified, and it should be cut often needed and knee ROM is blocked. The
about 1 cm with a scalpel. The bone is approached femoral artery, vein, and nerve are at risk during
with blunt dissection. In the placement of distal surgery, and neurovascular bundles should be
pins, avoiding the suprapatellar pouch should protected, especially during proximal pin place-
be considered. Lateral pin placement does not ment [17, 28, 29].
40.3 T
he Principles of External antibiotic therapy, early soft tissue closure, and
Fixator Application fracture stabilization are critically important.
to the Knee There is no definite evidence for the methods of
fracture stabilization; nevertheless, external fixa-
There is an anteroposterior, lateral, and oblique tion draws attention because of the minimal
view in radiographic examination of a firearm impact on the blood circulation. On the other
injury around the knee. Important information hand, it includes a number of risks such as chal-
concerning the extent and complexity of frac- lenges related to soft tissue, pin tract infection,
ture pattern is acquired through CT. Assessment and malunion [32]. Generally indicated in type
of a knee firearm injury requires specific care 3-B and 3-C tibial fractures, external fixators are
for the possibility of a neurovascular injury. very advantageous in cases that require repeated
The treatment plan is affected if the bullet pen- debridement or those with large soft tissue
etrates the knee joint; therefore, it is important defects. When permanent fixation methods
to determine the bullet trajectory. In the treat- should be delayed, external fixators can be used.
ment of a patient with a massive soft tissue It is the most preferable method for recovery
injury, application of an external fixator sur- operations with concomitant neurovascular inju-
rounding the knee should be planned initially, ries [33].
and then it should be converted into internal Following the first evaluation, conventional
fixation [3]. anteroposterior and lateral radiographs of the
With pins (5 mm) in the anterolateral femur tibia, including the knee and ankle joints, should
and the anteromedial tibia, the stabilization of be provided. CT is advantageous for proximal
distal femur fractures, tibial plateau fractures, and distal firearm injuries in assessing the feasi-
and knee dislocations is performed. To prevent bility of intra-articular bone and metal fragments
joint penetration, proximal tibia pins must be as well as articular displacement [3].
placed minimum 14 mm distal to the articular The pin placement of the tibia is anteromedial,
surface. In order to cross the knee joint, there and pins should be perpendicular to the cortex
can be make use of a single long bar or smaller and parallel to the joint line. The pins are placed
crossing bars from each segment, ensuring that on the subcutaneous anteromedial surface of the
no radiopaque clamps cover the joint line. With tibia and perpendicular to either the anteromedial
an approximately 5–15° slight flexion amount, or posterior faces of the tibial cortex. Pins, which
the fixator should be inserted, and a posterior must pass the tibia bicortically, are to be at least
splint can be applied for further stability. 15 mm from the joint surface. If the pins exceed
Postoperative bracing and early motion for this distance, the joint capsule and tendon may be
fractures with stable fixation is recommended damaged. The ankle can be fixed during the soft
[21, 30]. tissue healing. In order to prevent injury to the
anterior tibial vessels and the deep peroneal
nerve, distal pins should be placed by blunt dis-
40.4 T
he Principles of External section [3, 21].
Fixator Application One-third of the tibia extends closely under
to the Tibia the skin, which allows for the occurrence of open
tibial fractures and accompanying bone defect
Methods of treatment for open tibia fractures are more frequently. The Ilizarov external fixator is
still debatable. The reported infection rates of the most convenient method in these cases.
type 3-B fractures are about 50% [31]. In order Healing of soft tissue defect and closing the bone
to diminish infection rates, radical intervention defect with bone transfer are some advantages of
with recurrent wound debridement, intravenous the method (Fig. 40.6) [34, 35].
Fig. 40.6 Tibial ECF fixator application in lower extrem-

ity gunshot injury
Fig. 40.7 Foot frame fixator application in lower extrem-

40.5 T
he Principles of External ity gunshot injury
Fixator Application
to the Ankle and Foot
zation. Posterior to the halfway point from the
High-velocity and shotgun-induced fractures of posteroinferior calcaneus to the inferior medial
the foot should be treated immediately by stabiliz- malleolus and posterior to the one-third mark
ing with closed or open reduction, using a mini- from the posteroinferior calcaneus to the navicu-
mum of internal fixation. Internal fixation is lar tuberosity is the most secure medial calcaneus
reported in intra-articular fracture cases, in those placement [36, 37].
near vascular repairs, and in low-velocity gunshot To prevent injury to the lateral plantar and
wounds. Temporary external fixation is recom- medial calcaneal nerves, the bone should be
mended frequently, particularly including cases reached with blunt dissection. A posterior splint
with significant soft tissue or osseous loss [3, 36]. can be used to provide additional stability and
Usually the configuration, which includes a preventing equinus. In addition, supplementary
delta frame with anteromedially placed tibial pins can be located medially into the talar neck
shaft pins and a transcalcaneal pin, is applied on and cuneiforms or laterally into the cuboid or first
significantly swollen ankle and pilon fractures. metatarsal base or fifth metatarsal base. In cunei-
When compared with a half-pin, the insertion of form pin placement, the pin has to enter the dor-
a transfixation pin into the calcaneus, which is sal half of the medial cuneiform; thus, the
inserted distal and posterior to the neurovascular structures plantar to the midfoot arch are avoided
bundle, assists the fracture reduction and stabili- (Fig. 40.7) [21].
A medially located spanning external fixator good and rich vascular anastomosis; thus, we can
is able to catalyze renewal of anatomic height take pulses in nearly 50% of the patients even if
and length of the calcaneus during the definitive all of the major arteries are damaged [3, 18].
treatment. Medial to lateral in the distal tibia, Nerve injury can accompany arterial injury in the
calcaneal tuberosity, and medial cuneiform are upper extremity. If these injuries are neuropraxic or
the locations of half-pins (5 mm). A compressor- a contusion, they can recover spontaneously [3, 40].
distractor and/or laminar spreader instrument is Electrodiagnostic studies are usually not useful
applied following the bar placement to strategi- initially because these studies cannot differentiate
cally restore length as well as correct the varus between a neuropraxic lesion and more serious
and translation deformity [21, 36, 37]. injury. Even if follow-up studies at 6 weeks and 3
months demonstrate signs of early recovery, its
benefit is still very rare. The nerve exploration
ought to be considered if signs and symptoms do
40.6 Gunshot Injuries
not recovery till 3 months after injury [3, 40].
of the Upper Extremity
At gunshot wounds, the most difficult decision
to make is operating patient for neurologic deficits
40.6.1 Vascular and Nerve Injury
or determination of the time of exploration for the
in the Upper Extremity
injured nerves. There is no common concept on
timing of exploration and repair. Delayed repair
A full neurovascular examination should be per-
supporters strongly emphasize that the extended
formed. Injury to the limb may also lead to dam-
damage to the nerve is beyond the injury site. It is
age to neurovascular structures because the neural
difficult to determine the exact site of nerve dam-
and vascular structures run close to the osseous
age, which leads to inadequate resection. Extensive
structures. Upper extremity gunshot injuries can
contusions to nerve tissue in high-energy traumas
cause significant nerve damage in 50% of the
can cause epineural softening and failure of nerve
patients [3, 10].
repair. Fortunately, there is a near 70% possibility
A cold, cyanotic, pale, and pulseless limb,
of spontaneous nerve regeneration reported in
expanding hematoma, and audible bruit or a pal-
these contused nerve tissues [3, 13] (Fig. 40.8).
pable thrill, especially pulsatile bleeding, are the
Clean wounds and sharp transection is the
main symptoms of major vascular injuries caused
only indication for primary repair. The nerve
by penetrating trauma. A physical examination
ends are marked for future repair plans if imme-
can provide adequate information for diagnosis
diate repair is not considered [41].
in such injuries. There is no need to perform
angiography because it can cause delay in diag-
nosis and treatment. Early intervention with
direct pressure to the bleeding site is crucial. In
spite of the fact that the upper extremity has an
extensive collateral circulation support, applying
a tourniquet is not recommended to maintain the
perfusion of the distal limb. The upper extremity
has an extensive blood supply from collateral
arteries; thus, the incidence of limb loss resulting
from vascular trauma is quite low [3, 11, 38, 39].
Even in the event of total arterial damage in
the upper extremity, a poor but palpable pulse can
be felt. Furthermore, it has been reported that
demonstrable pulses can be found in 20% of Fig. 40.8 Radial nerve total lesion in the early period of
patients with certain angiographically deter- upper extremity high-energy gunshot injury. As shown in
mined arterial damage. The upper extremity has figure, the nerve is intact
40.6.2 Shoulder Injuries 40.6.3 Humeral Injuries
Gunshot injuries are relatively common in the Upper extremity long bone fractures are less com-
shoulder region. In some series in the literature, mon than lower extremity long bone fractures.
its incidence is reported as 9% [42–44]. Gunshot diaphyseal humeral fractures are seen as
Arterial, venous, and nerve injuries related the third most common shaft fractures. Complications
with shoulder gunshot injuries are commonly such as nerve injuries [13, 46, 47] are relatively
seen. Vascular injuries commonly accompany common in patients with gunshot wounds of the
major fractures and 15% of shoulder gunshot humerus. There is an increased prevalence of nerve
injuries have vascular injuries [9, 45]. In cases of injury related with distal humeral injuries when
shoulder gunshot injuries, foreign bodies such as compared with more proximal injuries [48–57].
clothing, bullets, the skin, and other debris are The treatment principles of gunshot humeral
driven into the joint and may cause septic arthri- fractures are controversial. Several treatment
tis. Accordingly, irrigation and debridement must methods have been introduced including fracture
be performed with arthroscopy or open surgical brace, external fixation, and internal fixation.
techniques. Also nonviable small bone fragments However, quite a few patient series of humeral
must be removed. Nondisplaced fractures can be fractures related to gunshot injuries have been
treated using conservative techniques but unsta- reported in the literature [58].
ble fractures and articular surface fractures must The fracture brace or coaptation splint can be
be treated by open reduction and internal fixation used appropriately if there is minimal soft tissue
(Fig. 40.9). Large osteochondral fragments of injury. Proximal and distal fractures are often not
articular surface can be fixed with headless suitable for this method of care [49, 55, 56].
screws or bioabsorbable pins. Neck or shaft frac- External fixation that can be used for the gunshot
tures can be fixed using plates or intramedullary injuries with open humerus shaft fractures include
nails. However, in the event of non-reconstructible large, soft tissue wounds and neurovascular injuries.
fractures, hemiarthroplasty can be considered as There are some advantages with external fixation
the treatment of choice. including limited damage to the blood supply of the
a b
Fig. 40.9 (a) Preoperative X-ray appearance of the proximal humeral intra-articular fracture due to high-energy gun-
shot injury. (b) Early postoperative plain radiograph
Fig. 40.11 Plate fixation in humeral shaft fracture in

high-energy gunshot injury
Fig. 40.10 Unilateral external fixation in humeral shaft Internal fixation for humeral gunshot fractures
fracture in high-energy gunshot injury can be performed successfully (Fig. 40.11). This
procedure enables patients to commence ROM
fracture, and it does not affect neurovascular anasto- exercise as soon as possible. Type 1 open humeral
mosis or postoperative wound care (Fig. 40.10). fracture infection rates are seen as 1.9–2.3% after
Due to the fact that there are few studies about internal fixation [3].
humeral external fixation uses for gunshot wounds,
it is difficult to calculate the results [58].
The most common complication in external 40.6.4 Forearm Injuries
fixation is pin tract infection. Although nearly
10% of patients treated with external fixators There are several studies related to gunshot
have pin tract infections, these infections respond wounds of the forearm [61–68], but a high rate of
well to systemic antibiotics [3]. Pins can also be nerve injury and compartment syndrome is seen
removed if necessary. in this region especially if accompanied by ulnar
Functional results of external fixation are and radial artery injuries [61, 64, 69].
comparable with intramedullary or plate fixation. If there is any doubt about compartment
In one study, 93.6% of patients treated with exter- syndrome, fasciotomy should be performed
nal fixation regained the full functional recovery immediately. It has been suggested that 24 h
of their upper extremities [59]. The nonunion rate close follow-up should be maintained for all
for externally fixed upper extremity fractures gunshot wounds of the forearm [70].
ranges from 5 to 62% [58]. The aim of the treatments is to provide length,
If lateral or posterior pin placement is consid- alignment, radial bowing of the forearm, soft tis-
ered to avoid damage to the radial nerve, open pin sue coverage, and vascular and neural integrity.
placement is recommended for the distal humeral Minimal soft tissue injury and non-displaced
fractures [60]. fractures of both bones can be treated through
a b
Fig. 40.12 Internal fixation to the ulnar and radial comminuted bone fracture in high-energy gunshot injury. (a)
Temporary K-wire fixation. (b) Plate fixation
conservative means. It is generally recommended tions, urgent internal fixation can be performed,
that soft tissue injuries with significant bone loss or definitive treatment can be postponed fol-
should be treated with external fixation, and then lowing the temporarily external fixator (Fig.
when the limb is stable, second-stage reconstruc- 40.13) [74]. In definitive treatment, internal
tion can be undertaken [63, 64]. However, it has fixation or hinged external fixation can be done
been reported recently that Gustilo-Anderson (Fig. 40.14). Arthroplasty can be used in the
type 3-A and 3-B open fractures have been late period in elderly patients. Arthroplasty is
treated with internal fixation after serial debride- not an effective choice for young and active
ment. Variable infection results ranging 5–41% patients [76]. Arthrodesis is a treatment option
have been reported related with high-energy gun- for severely injured joints in young patients and
shot wounds treated with internal fixation [3, 69, patients who have good bone stock with no
71, 72]. infection [77]. Elbow gunshot wounds’ compli-
Internal fixation is a good option for forearms cations are stiffness, malunion, nonunion,
with a decreased infection rate (Fig. 40.12) infection, and nerve injury [13].
because the forearm has good vascularity, and
there are numerous vascular connections in the
forearm [73]. 40.6.6 Hand Injuries
Gunshot injuries to the hand have wide spec-

40.6.5 Elbow Injuries trum, from handguns to handmade mines. The
physical examination of tendons and vascular
Elbow injuries from gunshot wounds are rarely and neurologic condition is important in open
seen in the literature [74–76]. These injuries are wounds. Standard AP and lateral radiographs are
commonly associated with periarticular frac- obtained, and CT scans may be indicated to
tures, nerve, and vascular injuries [13, 75]. assess carpal bones and articular surfaces.
Treatment begins with irrigation and debride- Irrigation and debridement is essential in the
ment of the joint. Foreign materials and small treatment of open wounds. When joints are not
loose bone fragments must be removed and ini- involved and fractures are nondisplaced, patients
tial stabilization of distal humerus, proximal may be treated nonoperatively. If tendon or neu-
radius, and ulna must be performed. rovascular injuries accompany the injury, the
Stabilization can be achieved with a splint or patient should undergo a surgery. Stabilization
external fixator. In unstable fracture disloca- of bone may be achieved using K-wires, mini
Fig. 40.13 Double
a b
colon plate fixation in
distal humeral
intra-articular
comminuted fracture.
(a, b) Preoperative
appearance. (c)
Postoperative
appearance
c
Fig. 40.14 The salvage procedure (suspension arthro-

plasty with tensor fascia lata) in comminuted elbow frac-
ture in the late period
a b
Fig. 40.15 The third metacarpal fracture due to gunshot injuries. (a) Preoperative appearance. (b) Postoperative
appearance of the plate fixation at 6 months
plates, screw fixation, cerclage wires, and mini 17. Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati
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the management of femoral shaft fractures in poly-
tant step in hand injury treatment is early postop- trauma patients: from early total care to damage con-
erative physical therapy [78]. trol orthopedic surgery. J Trauma. 2002;53(3):452.
18. Stein JS, Strauss E. Gunshot wounds to the upper
extremity. Evaluation and management of vascular
injuries. Orthop Clin North Am. 1995;26(1):29–35.
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1995;26(1):75. 84
Limb Lengthening
41
Cengiz Şen, Yavuz Sağlam, Mehmet Kocaoğlu,
F. Erkal Bilen, and Halil Ibrahim Balci
41.1 Classic Treatment had been performed for more than a decade, dat-
ing back to Codivilla who used a Steinmann pin
Cengiz Şen and Yavuz Sağlam placed into calcaneus and using several steps of
traction after femoral osteotomy [3]. He stated
Hueter and Volkmann noted that compressive that the best results were obtained from forced
forces in bone resulted in a slowing of growth lengthening using a sudden force and by then
and that tension increased bone growth and the applying a plaster apparatus to the limb while it
formation of osseous tissue (the Hueter- is maintained in complete extension (Fig. 41.1).
Volkmann principle) in the late 1700s [1]. Wolff He reported lengthening of 3–8 cm using this
disputed this in the late 1800s, believing that technique [3].
both compression and tension resulted in bone Traditionally, orthopedists have been taught
growth stimulation [2]. Long bone lengthening that leg-length inequality greater than 2–2.5 cm
should be treated with some form of equaliza-
tion. Based on a review of the literature, it is dif-
ficult to justify this figure as an absolute above
which treatment is indicated [4]. Orthopedic sur-
geons should carefully assess the impact of leg-
C. Şen, MD (*) • H.I. Balci
length inequality in each patient, along with the
Orthopaedic and Traumatology Department, patient’s concerns regarding the inequality, to
34190 Istanbul, Turkey determine the best treatment. It is often helpful to
e-mail: senc64@gmail.com; balcihalili@hotmail.com have adolescents wear a shoe lift corresponding
Y. Sağlam, MD to 5 mm less than the actual discrepancy for a
Biruni University, Department of Orthopedic Surgery brief time to give them a sense of what correction
will provide when the need for treatment is
e-mail: yavuz_saglam@hotmail.com
equivocal [4]. This can help the surgeon and the
M. Kocaoğlu
patient decide whether shortening or epiphysio-
Department of Orthopedics, American Hospital Istanbul,
Teşvikiye Mah, Güzelbahçe Sok, desis is indicated.
34365 Istanbul, Turkey Modern techniques of limb lengthening and
e-mail: drmehmetkocaoglu@gmail.com the principles of distraction osteogenesis for bone
F.E. Bilen, MD, FEBOT heling were described by Ilizarov [5–9]. Professor
Faculty of Health Sciences, Istanbul Yeni Yuzyil Gavril Abramovich Ilizarov was born in Caucasus
University, Cevizlibag, 34010 Istanbul, Turkey
(former USSR) in 1921. Having graduated from
e-mail: bilenfe@gmail.com

https://doi.org/10.1007/978-3-319-45675-1_41
646 C. Şen et al.
Fig. 41.1 The whole

apparatus at work:
traction and the
countertraction are
applied to the two
portions of the plaster
apparatus
medical school in 1944, his first job was as a developing fracture callus after a latency period of
family doctor in the Kurgan province of Northern 5–14 days [5–9]. The tissue response to gradual
Siberia. As this was a remote area, Ilizarov largely lengthening in Ilizarov’s method was described as
worked alone and was required to perform a range “the tension-stress effect on the genesis and
of surgical procedures although his only formal growth of tissues” [6, 7]. By preserving the soft
surgical training had been a 6-month course in the tissue envelope and callotasis techniques, the ten-
military field. In 1954, he successfully treated his sion created by gradual distraction stimulates
first patient, a factory worker with a tibial non- neogenesis of the skin, blood vessels, peripheral
union [10]. During this time, he also observed cal- nerves, and muscles [4, 6, 7]. Using this method,
lus formation in a patient who had mistakenly many diseases that had previously been consid-
distracted his frame instead of compressing it, and ered untreatable were successfully treated.
he came up with the “distraction osteogenesis” To correct leg-length discrepancy, appropriate
concept in the 1950s. Valeriy Brumel, an Olympic corticotomy is crucial. With corticotomy, a lim-
champion high jumper, visited Ilizarov while he ited exposure of the bone (usually the metaphy-
had an infected distal tibia nonunion and a signifi- sis) is made, with careful preservation of the
cant leg-length discrepancy. Carlo Mauri, a well- surrounding soft tissue and periosteal integrity.
known Italian journalist and explorer, was also Ilizarov preferred dividing the bone with a small
treated for distal tibial nonunion by Ilizarov and osteotome and often completed the osteotomy
his colleagues. After both patients were healed, with a rotational maneuver [12]. Some surgeons
Ilizarov’s success was widely published, and he prefer to use a drill to make holes circumferen-
was invited to present his findings at the AO tially through the cortex, and the corticotomy is
(Arbeitsgemeinschaft für Osteosynthesefragen) completed using an osteotome [13]. Subsequent
conference in Bellagio [10]. Ilizarov introduced reports showed that the critical factor is minimi-
his technique to the Western world in 1981 [11]. zation of soft tissue injury rather than preserving
Ilizarov recommended gradual distraction intramedullary blood supply [4, 14–16]. No ini-
either across the physis (chondrodiatasis) or after tial distraction should be made after external fixa-
low-energy osteotomy, which preserved soft tis- tion of the bone segments. For tibial lengthening,
sue and the medullary canal or corticotomy (cal- the suggested site of corticotomy is at the junc-
lotasis), with no immediate displacement of the tion between the proximal metaphysis and diaph-
bone fragments and gradual distraction of the ysis, distal to the tibial tuberosity (Fig. 41.2).
41 Limb Lengthening 647
a b c d e
f g h i j k
Fig. 41.2 (a). Patient with isolated right tibia shortening early fracture callus (e, f). Bone fragments are gradually
(b). Clinical assessment of limb-length inequality using distracted, typically an optimum distraction rate of
graduated blocks. An estimation of leg-length inequality 0.25 mm, four times per day. Regenerated bone can be
can be made with the patient standing erect on sufficient seen between the ends of the distracted bone fragments (g,
graduated blocks under the shorter limb to the level of the h). The leg was placed in a cast after the consolidation
pelvis (c, d). The bone is exposed with minimal periosteal phase (until regenerated bone healing is adequate to allow
elevation and proximal metaphyseal- diaphyseal osteot- removal of the device) (i–k). The affected side was over-
omy is performed with a Gigli saw. Bone fragments are lengthened by 1 cm, limb-length inequality disappeared,
kept in place for 5–7 days of latency, thus allowing recon- and the pelvis was leveled
stitution of the local blood supply and development of
648 C. Şen et al.
a b c d e
f g h i j
Fig. 41.3 (a). Patient with right femur shortening due to between the ends of the distracted bone fragments in the
proximal early physeal closure (b, c). Distal metaphyseal- late phases of gradual distraction and early consolidation.
diaphyseal osteotomy was performed, and the femur was (i, j). After the removal of the device, limb-length inequal-
placed in a circular external fixator. (d–g). Early phase of ity disappeared and the pelvis was leveled
gradual distraction (h). Regenerated bone can be seen
Femoral lengthening corticotomies are usually usually diaphyseal and with a slower lengthening
just distal to the lesser trochanter or at the junc- rate of 0.25x2 mm/day [4, 5, 10, 17].
tion between the distal metaphysis and diaphysis Gradual distraction on the bone and surround-
(Fig. 41.3). Lengthening corticotomies of short ing soft tissues, such as muscles, nerves, vessels,
bones such as the metacarpus and metatarsus are and tendons, creates stress that can stimulate and
maintain active regeneration [18]. While the bone

is distracted by an external fixator, intramembra-
nous ossification with the formation of a new
bone regenerate can be formed [8].
Callus formation is enhanced by performing a
low-energy corticotomy to preserve blood sup-
ply and to cause less damage to the soft tissues
[8, 18]. A series of experiments were conducted
using 65 dogs to better understand the process of
distraction osteogenesis. It was shown that ideal
conditions included stable fixation, a low-energy
osteotomy followed by 5–7-day latency, and an
optimum distraction rate of 0.25 mm, four times
per day [5–7]. The distraction period continues
until the desired amount of lengthening (or the
maximal amount attainable, given soft tissue
constraints) has been achieved. Faster distraction
limits angiogenesis and cell growth, which
inhibits osteogenesis, and results in no new bone
formation in the distraction gap. Much lower
rates of distraction resulted in premature con-
solidation of bone, which prevented further dis-
traction [6, 7].
During the distraction period, regenerated
bone arises between each distracted bone surface
with a central radiolucent fibrous zone compris-
ing type I collagen. New bone trabeculae form
directly from this central collagen zone and
extend to both bone surfaces. On radiographs,
Fig. 41.4 Ilizarov’s circular external fixator is a complex
columns of type I collagen look striated in the device used either for lengthening or deformity correc-
line of distraction force and surrounded by blood tion. Frame configuration and frame stability are greatly
vessels. Following distraction, these columns impacted by the ring properties and pin configurations
remodel to form a structure similar in composi-
tion to that of the host bone, a process called con- soft tissue surrounding the distraction gap,
solidation [10, 19]. tobacco use, chronic diseases, and the direction of
Lengthening of a long bone up to 10% of its the surgical approach used [14, 16]. Specifically,
original length is well tolerated by the surround- metaphyseal osteotomies tend to heal more
ing muscles, but histologic changes occur after quickly than diaphyseal osteotomies [4, 8, 16].
lengthening of 30% [20, 21]. Temporary histo- The preservation of normal joint function can
logic changes of muscles, vessels, and nerves usu- limit clinical applications [21].
ally disappear 2 months after lengthening [22]. Ilizarov’s circular external fixator is a com-
The procedure has been successful in patients at plex device used either for lengthening or defor-
nearly every age from early childhood to adults. mity correction. The major advantages of this
The new bone that forms is usually of the same device include the ability to correct residual
quality and cross section to the local site in the angular or rotational deformities without anes-
host bone from which it is formed [6, 7]. There thetic after the operation (Fig. 41.4).
are important factors that affect the quality and Frame configuration and frame stability are
the quantity of the regenerated bone such as greatly impacted by the ring properties; rings of
patient age, osteotomy location, the amount of large diameter are less stable than smaller rings.
650 C. Şen et al.
Reducing ring diameter by 2 cm increases axial 41.2 Combined Techniques

frame stiffness by 70% [10, 23, 24]. Full rings
provide the most rigidity; partial rings and arches Mehmet Kocaoğlu and F. Erkal Bilen
are particularly helpful when working near
joints. A 2-cm space between the ring and skin
allows for possible limb swelling. The distance
41.2.1 Introduction
between the rings also affects stability [10, 24].
The term combined technique derives from the
A minimum of four connecting rods between the
combination of internal and external fixation
rings and at least two points of fixation or wires
techniques. The aim is to sum the advantages of
per ring are required [10, 24]. Lengthening
both techniques while reducing the disadvan-
frames usually gain and sustain additional stabil-
tages related to each. The first gain provided by
ity from distraction forces needed to overcome
the combined technique reduces the external fix-
the soft tissue envelope; therefore, one ring per
ation time significantly. Thus, the capacity for
segment with multiple wires in different planes
correction and lengthening remains while the dis-
should be used. Frame stability increases with
comfort, dysfunction, and noncompliance caused
increasing wire diameter and tension. Increasing
by the prolonged external fixation period are
crossing angles of wires to 90° provides maxi-
reduced. Secondly, the additional stability given
mal stability [8]. Hydroxyapatite-coated pins
by the internal fixation device prevents recurrence
have been shown to have increased extraction
of the deformity, malunion, and shortening.
torque, lower rates of loosening, and decreased
In this chapter, we describe three major com-
infection rates [25].
bined techniques, namely, lengthening over nail
The limb is maintained in the external fixator
(LON), fixator-assisted nailing (FAN), and bone
until adequate consolidation of the new bone has
transport over nail (BTON). Other, alternative
occurred after lengthening (the consolidation
techniques have also been described like length-
period), to minimize the risk of refracture after
ening and then nailing (LATN) [46] and plating
removal of the fixator. Typically, the consolida-
after lengthening (PAL) [39].
tion period is approximately twice as long as the
distraction period [4, 8, 21].
Surgeons must be familiar with the fixator 41.2.2 Lengthening Over a Nail (LON)
device, the surgical technique, aftercare, and
postoperative rehabilitation. It is important to The current LON technique was first described
closely follow the effects of lengthening on the by Raschke [45] and optimized further by Paley
bone and soft tissues. Severe complications can et al. [42].
be seen associated with limb-lengthening proce- Although the femur can be lengthened only
dures such as neurapraxia, intimal arterial or along its anatomic axis by LON technique, the
venous injury, joint contracture, and joint luxa- procedure does not lead to lateral deviation of the
tion [4, 21]. Fixators used as lengthening devices mechanical axis in the clinical setting.
must ensure stability in order to produce distrac-
tion force. Undesired movements and instability 41.2.2.1 Indications and
of the corticotomy may affect the quality of the Contraindications
newly formed bone [8, 10]. Indications:
In summary, distraction osteogenesis is a
method for regenerating bone deficiencies, cor- • Limb-length discrepancy in adults
recting limb length or malalignment. Ilizarov tech- • Constitutional short stature
nique provides stability, soft tissue preservation, • Dwarfism
adjustability, and functionality but requires great • Post-traumatic epiphyseal injury sequelae
expertise. This method provides the ability to cor- • Concomitant lengthening and deformity
rect residual deformities without removing it. correction
Contraindications: valgization. Thus, the position of the K-wire must

be checked with the C-arm on both planes, AP and
• Active infection lateral. A 5-mm cannulated drill is used over this
• Immune-compromised patients K-wire to open the entry point. Multiple drill holes
• Open physeal plate are created at the previously planned osteotomy
• Intramedullary canal diameter <8 mm level through a 0.5–1-cm incision by slow turns, in
order to prevent heat necrosis of the bone. This
41.2.2.2 Special Features also produces venting of the canal as well as inter-
of the Equipment nal grafting (Figs. 41.6 and 41.7). The medullary
In patients weighing >80 kg and requiring
increased postoperative mobility and when two
segments are lengthened simultaneously, non-
cannulated titanium nails and locking screws of
5–6 mm diameter should be used.
Guide wires that allow not only the formation of
the blocking nails but also the correct insertion of
half-pins for the distraction frame should be used.
For distraction, monolateral, circular, or
hybrid devices are options. In the femur, mono-
lateral devices are used, whereas circular or
hybrid devices may be needed for lower leg LON
and cross-lengthening procedures.
41.2.2.3 F emoral LON: Surgical

Technique
The patient is placed supine on the radiolucent
table. A radiolucent support underneath the but-
tock is used to elevate the ipsilateral hip. The
femur is checked for visualization with a C-arm
image intensifier, from the hip to the knee, prefer-
ably by the attending surgeon prior to surgery.
Sterile preparation should include the hip up to
the iliac crest. A K-wire is inserted through the
piriformis fossa percutaneously while the surgi-
cal assistant places the extremity across the unin-
volved limb (scissors position) (Fig. 41.5).
A lateral shift of the entry point on the frontal
plane will produce varization of the proximal frag-
ment, whereas a medial shift will produce its Fig. 41.6 Multiple drill hole osteotomy
Fig. 41.5 Sand
bag under the
buttock for lateral
view
652 C. Şen et al.
Fig. 41.7 Axial view of multiple drill hole osteotomy
canal is reamed by 0.5-mm increments to

1.5–2 mm more than the diameter of the planned
intramedullary (IM) nail. At this point, the osteot-
Fig. 41.8 Checking the completeness of the osteotomy
omy is completed by an osteotome, while the
guide wire remains in the medullary canal. The
completeness of the osteotomy is checked with the by initially inserting a guide wire with the aid of
C-arm by translation of the fragments (Fig. 41.8). an image intensifier: there must be enough space
The IM nail (e.g., Ortopro 4 G IM, Istanbul, between the wire and the IM nail on the sagittal
Turkey) is inserted over the guide wire, which is plane, and the wire must be perpendicular to the
then removed. Proximal locking of the nail may be IM nail on the frontal plane. Upon establishment
done either in the cephalomedullary (recon) or the of the desired position of the guide wire, both
intertrochanteric (standard) direction, with no cortices are drilled via a 3.5-mm cannulated drill
advantages of one over the other. bit, and a tapered 6-mm hydroxyapatite coated
Paley et al. [42] described three alternative con- half-pin is inserted. At this point, the half-pin is
figurations for half-pin placement (Fig. 41.9). In the checked with the image intensifier to ensure that
first, the half-pins are inserted posterior to the nail it is perpendicular to the IM nail on the frontal
both proximally and distally; in the second, they are plane (Fig. 41.10) and not in contact with the IM
inserted anterior to the nail both proximally and nail on the sagittal plane (Fig. 41.11).
distally; and in the third, they are inserted anterior to The clamp of the external fixator (Orthofix
the nail proximally and posterior to the nail distally. LRS or EBI Monorail) is used as a guide for
We prefer the posterior insertion of the half-pins insertion of the second half-pin. The distal half-
proximally and distally as this configuration places pins are inserted at the supracondylar level. The
the external fixator parallel to the nail on the sagittal femoral condyles are imaged such that they are
plane, which subsequently makes sliding over the superimposed on the sagittal view with the
nail smoother and decreases sticking of the nail. C-arm to obtain a true lateral view. Two half-
The proximal half-pins are inserted at the level pins are inserted distally in the same manner as
of the minor trochanter and posterior to the IM explained above; perpendicular to the IM nail
nail, without touching the latter. This is achieved on the frontal plane, without contact with the
Fig. 41.9 Probabilities for nail placement on the sagittal

plane
Fig. 41.10 New bone formation at the distraction site

IM nail on the sagittal plane. Holding the proxi-
mal and distal screws as joysticks, the attending
surgeon checks the distal fragment manually depict the sequences of a femoral LON proce-
for free rotation as a predictor of sliding over dure during and at the end of the treatment (Figs.
the nail. 41.12, 41.13, and 41.14).
The claws and the rail of the external fixator
are connected to the half-pins. To ensure smooth 41.2.2.4 T ibial LON: Surgical
sliding, the rail is checked with the C-arm to con- Technique
firm that it is parallel to the IM nail in the frontal The patient is placed supine on the radiolucent
and sagittal planes. The claw at one side of the table. Prior to surgery, the tibia is checked with
osteotomy is fixed, while the other side is left the image intensifier on AP and lateral views,
loose for sliding. Before the session is concluded, preferably by the attending surgeon. The lower
the acute distraction test by 0.5 cm must be per- limb is prepared in sterile fashion to the level of
formed as this will establish whether or not the the iliac crest. A 2-cm transverse incision is made
mechanism is working. If the distraction test is at the lower pole of the patella (Fig. 41.15). A
positive, then the wound dressing is applied, and conventional longitudinal section also can be
the session may be concluded. Fig. 8, 9, and 10 used.
654 C. Şen et al.
Fig. 41.11 Distance between the nail and the interfer-

ence screws
Fig. 41.13 Limb length equality by photograph
Following the subcutaneous dissection, the

paratenon and patellar ligament are split longitu-
dinally. The entry point is prepared using a 5-mm
cannulated drill, as in the standard tibial nailing
technique. The guide wire is inserted. Multiple
drill holes are created at the previously planned
osteotomy level through a 1-cm incision by slow
turns, in order to prevent heat necrosis of the
bone. This also will produce venting of the canal
as well as internal grafting. The medullary canal
is reamed by 0.5-mm increments 1.5 mm wider
than the diameter of the planned IM nail. At this
point, the osteotomy is completed by an osteo-
tome, while the guide wire remains in the medul-
lary canal. A 1-cm incision is made at the
mid-diaphyseal level of the fibula, and the fibula
is osteotomized via the multiple drill-hole tech-
Fig. 41.12 Distraction through two levels nique. The completeness of both osteotomies is
Fig. 41.15 Transverse skin incision
A wire parallel to the proximal tibial joint sur-

face is inserted posteriorly and fixed to the proxi-
mal ring of the frame. At the supramalleolar
level, another K-wire, parallel to the distal tibial
joint line on the frontal plane, is inserted posteri-
orly without touching the IM nail and fixed to the
Fig. 41.14 X-ray at the end of the treatment distal ring of the frame. Two half-pins (preferably
hydroxyapatite coated) are inserted proximally
checked with the C-arm by translation of the without touching the IM nail, one of which will
fragments. The tibial IM nail (e.g., Orthopro 4 G also fix the fibular head in order to prevent distal
IM) is inserted over the guide wire, which is then migration during lengthening. This half-pin is
removed. Proximal locking of the IM nail is done placed in the anteromedial tibia by the cannu-
in the usual manner. lated drill bit technique. Both half-pins are fixed
We prefer circular-type external fixators for to the proximal ring (Fig. 41.17).
tibial LON due to the otherwise high risk of val- Distally, an olive wire is inserted at the lateral
gization of the fragments during distraction, malleolar level parallel to the joint line to estab-
caused by the stiffness of the interosseous mem- lish tibiofibular fixation (Fig. 41.18). At this
brane. Paley et al. [42] reported similar results point, the distraction test is performed and the
when they used unilateral external fixators for procedure is concluded.
tibial LON. A frame is prepared consisting of Figures 15–17 show the sequences of a tibial
three rings: one for the proximal fragment, one LON procedure (Figs. 41.19, 41.20, and 41.21).
for the distal fragment, and one “dummy” ring in Distraction starts on day 7 at a rate of 0.25 mm
between, which is not used for fixation but for four times a day. On day 14, control roentgeno-
frame stability (Fig. 41.16). gram should be done to specify the conformity of
656 C. Şen et al.
Fig. 41.16 Tibial frame Fig. 41.17 Photographic documentation
the distraction size and regenerate lengths. yseal level, interference screws may be used on
Usually, both should be 1–2 mm less due to a each side of the IM nail to increase stability.
deflection of the transosseous elements. After the frame has been removed, the patient
is mobilized with two crutches and is allowed to
41.2.2.5 R emoval of the External bear 10% of his or her body weight (depending
Fixator on the nail type). The patient returns for follow-
The external fixator should be removed immedi- up every month until the regenerate consolidates.
ately after the desired amount of lengthening is During this period, stretching and range-of-
achieved. The extremity is sterilely prepared, motion exercises are encouraged. To decrease the
including the frame, in the supine position. The risk of nail breakage, full weight-bearing is
whole frame is draped except for the area used for allowed only when three of four cortices are con-
distal interlocking. The distal locking holes are pre- solidated, as seen on AP and lateral views during
pared using cannulated drills over the K-wire via follow-up.
the free-hand technique, and the interlocking For locking screws with a diameter of more
screws are inserted. If the insertion is at the metaph- than 5 mm and nails with a diameter of 12 mm or
Fig. 41.18 Wire application parallel to the ankle joint
Fig. 41.20 X-ray at the end of the treatment
more, the fatigue resistance of the locking nail is

usually sufficient not to limit weight-bearing
beginning at the first days after nailing.
41.2.2.6 Complications
There can be significant complications associated
with LON:
• Mechanical sticking of the distraction system

(wrong technical application), this complication
occurs especially when over-reaming of the
medullary canal has not been performed.
• Pin-tract infection.
• Delayed union/inadequate regenerate produc-
Fig. 41.19 Tibial frame before distraction tion or premature consolidation; distraction
658 C. Şen et al.
Fig. 41.21 AP and lateral x-rays at the end of the treatment
rates should be individually regulated on the

basis of patient monitoring.
• Development of stiffness of adjacent joints. Fig. 41.22 A severe multi apical lower extremity deformity
Therapeutic exercises should be instituted
during distraction and fixation periods. The thritis of the hip, knee, and/or ankle joints [30,
threat of development of a severe contracture 47, 50]. Orthopedic surgeons have utilized many
is an indication to stop the lengthening. different procedures to correct these deformities
• Breakage of a half-pin or interlocking screw to prevent secondary osteoarthritis. However,
usually arises from inadequate loading on the leg. these techniques generally result in low patient
comfort and lack accuracy. A comprehensive
A total lengthening of 6 cm, a lengthening rate technique termed “fixator-assisted nailing”
of 21.5%, and a Paley difficulty score of 8.5 are (FAN) was developed by Dror Paley in 1993 and
the critical cutoff points above which complica- was first described by Paley et al. in 1997 [42].
tions are more likely to occur [36, 43].
41.2.3.1 Indications and
Contraindications
41.2.3 Fixator-Assisted Nailing Indications include the following:
Deviation of the mechanical axis (MAD) results • Metabolic bone disease with multilevel, com-
primarily in deformities of the long bones which plex deformities (Fig. 41.22)
result in the development of secondary osteoar- • Congenital deformities around the knee joint
• Acquired posttraumatic deformities (malunions)

• Acquired hypertrophic nonunions with
deformities
• Sequelae of poliomyelitis
Contraindications include the following:
• Presence or a history of infection

• Deformities in the pediatric age (before phy- 110 mm
seal closure)
• Long bones that are sclerotic and/or are nar- 10˚
row (medullary canal <7 mm) 0.5 cm
41.2.3.2 Examination
Physical examination should include documen-
130 mm
tation of the range of motion of the adjacent
joints, muscle strength, and neurologic status.
Clinical length, alignment, and discrepancies 37˚
should be noted and then measured 1.5 cm
radiographically.
41.2.3.3 Imaging Studies 90 mm

• An orthoroentgenogram in both planes should
be obtained according to the following
guidelines:
–– The knee should be at maximum extension,
especially in the lateral view.
–– The X-ray beam should be level with the
knee joint and taken from a distance of 3 m
Fig. 41.23 Paper-tracing to simulate the correction
so as to minimize magnification. procedure
–– One-centimeter blocks should be used to
level the pelvis in the AP view.
–– A magnification marker is used to deter- should be performed through the intercondy-
mine the size and diameter of the IM nail lar notch.
and to determine the number and level of • The diameter and size of the IM nail should be
the osteotomy(ies). determined based on the scaled AP and lateral
X-rays of the affected bone segment(s).
41.2.3.4 Preoperative Planning • Digital (Bone Ninja application developed
• Deformity analysis should be performed by Drs. Standard and Herzenberg which can
according to the deformity planning guide- be obtained at the apple appstore) or paper
lines given by Paley et al. (CORA plan- tracing should be performed to simulate the
ning method using joint orientation lines) surgery and to determine the provisional
[41, 43]. As intramedullary nails will be and final position of the bone segment,
inserted, anatomical axis planning should be according to the following factors (Fig.
performed. 41.23):
• Determination of the level(s) of the • The location of the extra, custom-made hole(s)
osteotomy(ies) should be conducted. on the IM nail should be determined.
• If the deformity is at the distal femoral • The location and the number of interference
metaphysis, retrograde IM nail insertion screws (polar) should be determined in a
660 C. Şen et al.
Fig. 41.24 C-arm
setup around the
radiolucent table
anner that increases the stability of the

m bag under the buttock to provide a lateral view
construct. of the femoral deformities.
• The incision at the entry point of the IM nail • Fluoroscopy from the hip to the ankle joint
and the osteotomy levels should be mapped should be accessible (Fig. 41.24).
out [33, 38, 41]). • If a long grid is available, it is placed under the
mattress of the patient.
41.2.3.5 Equipment and Preparation • Sterile preparation should be used prior to
Equipment: draping the entire lower extremity beginning
at the anterosuperior iliac spine.
• Radiolucent table
• Radiolucent knee support or a rolled, sterile towel 41.2.3.6 F AN for Femoral Deformity:
• Large-field fluoroscopy Surgical Technique
• Flexible intramedullary reaming system For distal femoral deformity corrections, retro-
• 6-mm conical Schanz screws grade intramedullary nailing is preferred. For
• Unilateral external fixator (EBI Monorail more proximal deformities, antegrade intramed-
System or Orthofix LRS) ullary nailing is more suitable. In the presence of
• 1.8-mm Kirschner wires (bayonet type) severe distal femoral valgus deformities (greater
• 3.5-mm cannulated drill bits than 15°), the authors recommend prophylactic
• Intramedullary nail peroneal nerve release.
Two pairs of 6-mm half-pins that are perpen-
Positioning: dicular to the anatomic axis of the femur (5–7° to
the diaphysis, and 8–10° to the knee joint line) are
• The patient is placed in the supine position on inserted proximally and distally, respectively (Figs.
the radiolucent table, and the affected hip 41.25 and 41.26). In the sagittal plane, it is crucial
should be slightly elevated using a silicone that the pins avoid any contact with the intramedul-
Fig. 41.25 Perpendicular placement of the Schanz screws Fig. 41.27 Posterior placement of the Schanz screws to
to the atomic axis of the proximal femoral segment leave space for the IM nail
the insertion of the distal Schanz screws, the patella

should be centered, facing forward to capture the true
AP view (Fig. 41.28). Determining the true sagittal
plane of the proximal portion of the femur is not
clear; however, a rotational arc and a lateral view
using the C-arm may help in estimating the true prox-
imal sagittal plane. Preoperative prone clinical rota-
tion measurements are used to determine the correct
rotation position of the upper femur relative to the
knee joint. CT scan measurements can also be used
to determine the rotation angle to correct. Osteotomies
are performed percutaneously from the lateral side of
the femur. Either multiple drill holes followed by an
osteotome or Paley’s focal dome drill guide tech-
nique can be used [43, 44]. The medial and the lateral
edges of the osteotomy are completed by an osteo-
Fig. 41.26 Perpendicular placement of the Schanz tome. If translation is needed at the osteotomy site,
screws to the atomic axis of the distal femoral segment the osteotome is inserted into the center of the oste-
otomy site and twisted such that the desired transla-
lary nail. Since the nail enters posteriorly, the distal tion is produced. Alternatively, half-pins can be used
half-pins should be based anteriorly. Proximally, as a joystick to produce the translation manually.
the nail is located anteriorly. The half-pins should Angular correction is performed by accurately
be located posteriorly at the level of the lesser tro- using an external fixator. The accuracy of the cor-
chanter (Fig. 41.27). In the presence of a rotational rection is verified by intraoperative X-rays of
deformity, the distal and proximal pairs of pins are both the anteroposterior and the lateral views
inserted in different rotational planes to each other. [49]. If the correction is not successful, the steps
A sterile inclinometer or even a smartphone in a are repeated until the intraoperative X-rays dic-
sterile bag [34] can be used to measure the rotation tate accurate correction. Before reaming, we pre-
angle between the proximal and distal pins. During fer to insert interference (blocking) screws to
662 C. Şen et al.
Alternatively, an intraoperative radiograph of the

femur can be taken and the joint orientation
angle of the distal femur measured. The fixator
can be readjusted according to the X-ray findings
until the desired correction is achieved. This
gives the correction the same accuracy as with
external fixation.
The nail is then inserted and locked stati-
cally (proximally and distally). To avoid creat-
ing a sagittal plane flexion deformity, a nail
without a bend is used for retrograde nailing.
However, if a distal sagittal plane deformity
(e.g., pro- or recurvatum) has to be corrected,
then a supracondylar nail with a bend or tibial
nail can be used, and the bent end of the nail
inserted so as to extend or flex the distal frag-
ment [38] (Fig. 41.29).
If needed, additional interference screws may
be inserted to increase stability.
The external fixator is removed at the end of the
surgery, and the incisions are closed primarily.
41.2.3.7 FAN for Tibial Deformity

Two pairs of half-pins perpendicular to the ana-
tomic axis of the tibia are inserted distally and
proximally (Figs. 41.30 and 41.31). In the sagit-
Fig. 41.28 Neutral placement of the knee (patella tal plane, it is crucial that the Schanz screws
forward) avoid any contact with the intramedullary nail.
The pins should be at the posterior aspect of the
guide the intramedullary drill and to prevent loss tibia on the sagittal plane to leave enough space
of the correction [26, 38]). for the nail (Figs. 41.32 and 41.33).
With more three-dimensional locking hole pat- As opposed to acute femoral deformity cor-
terns in third-generation locking nails, this may not rection, for acute rotation or valgus correction of
be needed. Conventional entry points are used during the tibia, the authors recommend prophylactic
the insertion of the intramedullary nail both proxi- peroneal nerve release [48]. If this is performed,
mally or distally. Intramedullary reaming produces the fibular osteotomy can be performed at the
an internal grafting effect on the osteotomy site. same level since the nerve is protected and the
After the correction is achieved with the osteotomy is performed under direct vision of the
external fixator, the alignment should be checked nerve.
before insertion of the nail. This can be accom- For FAN of the tibia, the fibula is osteoto-
plished by several ways. If a grid was inserted mized at the mid-diaphyseal level through a small
under the patient, the grid lines can be used to posterolateral incision (Fig. 41.34). Percutaneous
draw a virtual mechanical axis that can be visual- tibial osteotomy can be performed through a mini
ized intraoperatively. If the goal is a zero incision using either multiple drill holes or
mechanical axis deviation, then the grid line is Paley’s focal dome drill guide (Fig. 41.35). With
centered over the hip and ankle joints and should an osteotome, the completeness of the osteotomy
be also centered at the knee joint to form a col- is verified as described previously. The osteo-
linear Mikulicz line. If no grid is available, the tome is inserted into the center of the osteotomy
cautery cord can be used in the same manner. and twisted to create the desired amount of
Fig. 41.31 Parallel placement of the Schanz screw to the

ankle joint
Fig. 41.29 Lateral view of a bent end nail in femur
Fig. 41.32 Posterior placement of the Schanz screws to

leave space for the IM nail proximally
translation. The angular correction is maintained

through the application of a unilateral fixator.
Intraoperative X-rays of the two planes are
Fig. 41.30 Parallel placement of the Schanz screw to the required to verify if the desired correction has been
knee joint achieved. Adjustment of the fixator and repeat
664 C. Şen et al.
Fig. 41.35 Tibial osteotomy by the multiple drill hole

technique
compartment is recommended in most cases. The

Fig. 41.33 Posterior placement of the Schanz screws to nail is inserted and locked statically. If needed,
leave space for the IM nail distally additional interference (blocking) screws can be
inserted to increase stability. The external fixator
is removed and the incisions are closed primarily.
41.2.3.8 Postoperative Period

and Follow-Up
The patients are mobilized at the first postop-
erative day with weight-bearing as tolerated.
For approximately 3 weeks, ice is applied to
prevent synovitis at the knee joint; the ice also
has analgesic properties. Muscle strengthening
and range-of-motion exercises are initiated
immediately. The patients are followed clini-
cally and radiologically on a monthly basis
until bone healing is established. Clinical and
radiologic pictures of a patient with severe
lower extremities prior and after FAN proce-
dure are shown in Figs. 41.36, 41.37, 41.38,
41.39, 41.40, and 41.41ab.
Fig. 41.34 Percutaneous fibular osteotomy

41.2.4 Bone Transport Over Nail
X-rays are performed as needed to fine-tune the (BTON)
correction. Antegrade reaming over a guide wire is
performed conventionally through a mini incision. Numerous procedures for the treatment of bone
The reaming produces an internal grafting defects have been devised, including acute short-
effect. Percutaneous fasciotomy of the anterior ening and then lengthening (most suitable for
Fig. 41.37 Same patient from behind

Fig. 41.36 A patient with a severe multiapical deformity
at the lower extremities
depends on the length of the required distraction,
segmental defects up to 5 cm long), bone trans- with longer EFTs carrying a higher risk of com-
port (the best option for defects 5–12 cm in plications. The distraction phase is followed by
length), and vascularized free fibular grafting in the consolidation phase (which often lasts more
combination with transport and lengthening or than twice as long), which is difficult for the
ipsilateral fibular transport (for segmental bone patient to tolerate.
defects >12 cm). Titanium mesh cages filled with Removal of the external fixator before satis-
autograft, demineralized bone matrix, and factory consolidation has occurred is associated
allografts have also been used to reconstruct large with fracture, deformity, and shortening through
segmental bone defects. the distracted callus [40]. Older frames often
In patients with limited life expectancy, the required repeated adjustment to prevent mis-
use of a segmental prosthesis may be indicated, alignment of the docking site. The use of an IM
without having to wait for healing [52, 53]. nail together with an external fixator avoids
Bone transport with the use of an external fix- misalignment of the docking site, leading to
ator is known to be a reliable solution that leads significant decreases in the EFT and better
to successful outcomes. The time spent in an maintenance of the anatomic length and the
external fixator (the external fixation time, EFT) alignment [45].
666 C. Şen et al.
Fig. 41.38 Standing photograph of the same patient from Fig. 41.39 AP orthoroentgenogram of the same patient
the side
The BTON technique prevents the common com- Kocaoglu et al. [37] reported a mean external
plications of bone transport, such as delayed consoli- fixation index (EFI) of 13.5 days per cm in 13
dation, axial deviation, translation, and deformity patients (7 tibiae, 6 femurs) by means of the
recurrence or occurrence. This is attributed to the BTON technique.
improved construct stability provided by the IM nail. By contrast, bone transport achieved with the
Bone transport may also be accomplished Ilizarov device alone was associated with an
through the use of fully implantable IM lengthen- extended EFT (average 16.7 months) and high
ing devices, such as an internal lengthening nail EFI (average 2 months/cm) compared to the
(ISKD). Cole [32] reported a technique through BTON technique. There was also a significant
which healing of the nonunion was targeted first, difference in the EFI between smokers and
followed by lengthening with an ISKD to resolve nonsmokers (on average, 2.60 vs. 1.45 months/
a limb-length discrepancy. cm, respectively) [27].
To further reduce the EFT, bifocal or trifocal

strategies may be used. Each osteotomy helps to
shorten the overall treatment time by 0.5–1 mm/day.
41.2.4.1 Indications
and Contraindications
Indications:
• Bone defects of 5–12 cm
Contraindications:
• Vascular disease
• Diabetes mellitus
• Active infection
• Open physeal plate
• Intramedullary canal diameter <8 mm
Relative contraindications:
• Bone defect >12 cm

• Tobacco abuse
41.2.4.2 Special Features

of the Equipment
Preoperative planning is of paramount importance
for bone transport procedures. AP standing ortho-
roentgenograms and lateral plain X-rays are
obtained and studied together with IM nail tem-
plates to determine the placement of additional
holes to achieve locking of the transport segment.
Fig. 41.40 Orthoroentgenogram of the same patient after
the correction of the deformities
For femoral defect reconstructions, unilateral
external fixators are used (Orthofix LRS, Italy; EBI
Although most surgeons are cautious about Monorail, Biomet, USA) and for tibial defect
using IM nails in open fractures, the BTON tech- reconstructions circular external fixators (Ilizarov
nique was shown to be successful in the treat- or Taylor Spatial Frame, Smith and Nephew, USA).
ment of Gustilo 3b open tibial fractures [29, 35].
The transport process not only treats the bony 41.2.4.3 General Principles
defect, it also helps with soft tissue coverage. of the BTON Surgical
Management of the docking site requires spe- Technique
cific procedures. Acute shortening of the defect Surgery can be executed either “closed” or “open.”
can reduce the transport time to achieve docking. In the closed method, a nail is inserted without
The tibia and the humerus can be safely short- exposing the ends of the bone fragments. If the
ened by up to 3–4 cm and the femur by up to closed method is difficult or impossible (due to
5–7 cm. Once docking is established, straightfor- expressed sclerosis, deformities of the bone ends,
ward lengthening may be performed. or foreign bodies), the operation is performed
668 C. Şen et al.
Fig. 41.41 Photographs
a b
of the same patient after
the correction
procedure
using the open variant. This variant is indicated to allow sliding of the nail. As a rule, the longer
when the bone ends are thin or incongruent or bone fragment is used for lengthening, whether
have a reduced blood supply, as this may result in proximal or distal.
atrophic nonunion of the docking site. The next stage involves inserting the nail up to
The open method starts with processing of the the osteotomy level, followed by the osteotomy
bone ends, in which the medullary canals of the and further forward insertion of the nail. The
fragments are recanalized. It is important to osteotomy is performed using the multiple drill-
ensure adequate blood supply to the bone ends, hole technique. If the nail is inserted into a bone
confirmed with the “Paprika sign” recommended fragment that will be elongated, a diastasis at the
by Mader [31]. If needed, an additional resection osteotomy level is possible. This can be prevented
should be performed to ensure viable bone ends. by temporarily fixing the fragment using a surgi-
At the end of the bone transport process, the bone cal hook, wire, or extracortical clamp device as it
ends must be congruous. is carried through an intermediate bone fragment.
The next stage requires reaming the bone frag- However, the presence of a diastasis is not a prob-
ments. The medullary canal should be reamed lem because once the IM nail is inserted and
1.5–2 mm wider than the diameter of the IM nail locked, the fragment to be transported is fixed
either by wires or half-pins; thus, any d istraction 41.2.4.4 F emoral BTON Surgical
or diastasis through the osteotomy level can be Technique
corrected via the external fixation. Diagrams of BTON with lengthening are pro-
The nail should be locked statically (proxi- vided in Figs. 41.42 and 41.43.
mally and distally) if additional lengthening is not The patient is placed supine on a radiolucent
required following bone transport. Then the exter- table with the limbs in a scissors position and with a
nal fixator is applied; wires and half-pins should cushion placed below the pelvis on the ipsilateral
be inserted tangentially, with no nail contact. side. A standard approach (through the piriformis
Wires, half-pins, and cables can be used for fossa for antegrade nailing and through a parapatel-
the transport of intermediate bone fragments. lar 1-cm transverse incision for retrograde nailing)
Brunner et al. [28] found that the overall trans- is used for reaming the medullary canal. After the
port forces for large defects were slightly greater reconstruction, there should be sufficient nail length
than those for small defects. In the former, trans- on both sides of the regenerated bone to guarantee
port forces leveled off during bone transport
before rising again, ultimately reaching 350 N.
In patients with large defects, bifocal distrac-
tion is recommended to shorten net treatment
times. Vidyadhara et al. [51] reported an interest-
ing observation regarding bifocal distractions,
namely, that despite the same rate of distraction,
shorter fragments move faster than longer frag-
ments. This can be attributed to the attachment of
the soft tissue to the longer fragment, thereby
hindering distraction. If the segmental defect is
very large (>10 cm), trifocal transport over the
nail may be helpful to reduce the EFT and the
related problems (Oh CW et al. 2008; [51]).
Once docking is accomplished, the patient
returns to surgery for debridement (to guarantee
viable ends with maximum contact) and grafting
(to reduce the risk of nonunion or refracture at
the docking site and to shorten treatment dura-
tion). An iliac crest bone graft along with demin-
eralized bone matrix (DBM) or bone
morphogenetic protein (BMP-2) may be used for
grafting. The docking site may be compressed
acutely if the external fixator is to be removed in
the same session. Alternatively, compression
may be continued at a rate of 0.25 mm every
other day until consolidation of the docking site,
if lengthening will be continued. We prefer
autogenous posterior iliac crest bone grafting and
additionally use DBM to improve the healing
potential in all cases.
For intermediate bone fragment fixation, an
additional locking screw is inserted. The other
option is a conventional plate or monocortical Fig. 41.42 BTON technique with lengthening before
locking plate. transport
670 C. Şen et al.
Fig. 41.43 BTON technique with

lengthening at the end of distraction
(left) and following static locking of
the IM nail and removal of the
external fixator (right)
adequate stability. Thus, if lengthening is planned in Two to three half-pins are inserted both prox-
conjunction with bone transport, the IM nail must imally and distally to the osteotomy level, tak-
be longer than the length of the femur (Fig. 41.42). ing care that they do not come into contact with
In such cases, retrograde nailing is preferred the IM nail. There should be at least 1 mm of
because it allows the excess nail length to protrude free space between the half-pins and the IM nail
into the buttock until distraction has been com- to prevent medullary infection triggered by a
pleted, by which time the nail will have glided pin-site infection [36]. To insert half-pins with-
gradually to its correct position. Since the proxi- out nail contact, the cannulated drill-bit tech-
mal part of the nail features a larger diameter, the nique described by Paley et al. [43] is
proximal femur should be over-reamed in ante- recommended. A wire is inserted on the lateral
grade and the distal femur over-reamed in retro- femoral cortex, perpendicular to the IM nail, at
grade applications. An appropriately placed the level of the half-pin. The location of the wire
corticotomy is then performed percutaneously is confirmed with the C-arm. A hole is reamed
using the multiple drill-hole technique before the over the wire with the cannulated drill bit. The
IM nail is inserted. The osteotomy level is chosen half-pin can then be inserted and clearance
at least 5–6 cm away from the bone defect. Finally, between the pin and the nail confirmed with the
an IM nail (e.g., Ortopro 4 G) of appropriate size C-arm. A patient’s X-rays treated with BTON
is inserted and locked proximally, distally, or on technique are shown in Figs. 41.44, 41.45,
both sides, according to the planned distraction. 41.46, and 41.47.
Fig. 41.44 X-ray during the transport period of femoral Fig. 41.45 X-ray at the end of the transport period of
BTON procedure femoral BTON procedure
41.2.4.5 T ibial BTON Surgical performed at the appropriate level using either
Technique the multiple drill hole or the Gigli saw tech-
The standard ligament split approach is fol- nique. If there is shortening in conjunction with
lowed, and the medullary canal is over-reamed the segmental bone defect, then an IM nail of
1.5 mm wider than the planned diameter of the the eventual desired tibial length is inserted and
nail. The nail is then inserted and a three-ring left proximally proud so that it can slide distally
circular external fixator is used. It is very impor- during distraction.
tant that the longitudinal axis of the external fix- Figs. 41.48, 41.49, 41.50, and 41.51 show the
ator is parallel to the IM nail. Proximal and use of the circular device in BTON.
distal rings are fixed with one wire and a half-
pin. The fibula should be fixed to the tibia on 41.2.4.6 Postoperative Care
each end. None of the external fixation pins or Distraction is started on postoperative day 7 at
wires should come into contact with the nail. a rate of 1 mm/ day, divided into four equal
Before the IM nail is inserted, a corticotomy is increments. Range-of-motion exercises for
672 C. Şen et al.
Fig. 41.46 AP X-ray at the end of the treatment Fig. 41.47 Lateral X-ray at the end of the treatment
both hip and knee are initiated immediately, 41.2.4.7 Complications

excluding those patients with a long tibial IM There can be significant complications in BTON:
nail (in whom knee exercises should be post-
poned until the proud part of the nail enters the • Pin-tract infection (most common problem
tibia during lengthening). Full weight-bearing with all types of external fixation). Vigilant
with two crutches is started as soon as preventive maintenance is necessary to avoid
possible. the development of a deep infection with
Once distraction and lengthening are com- expansion of the IM canal.
pleted, the nail is statically locked and the exter- • Nonunion of the docking site (most common
nal fixator is removed. In patients with proximal problem except frame-related complications).
femoral osteotomy, a nonvascularized fibular Treatment: bone autografting, compression
graft can be inserted into the posteromedial dis- osteosynthesis; less often, a resection of the
traction site to provide additional support and to fragment ends.
decrease the force transmitted through the nail • Poor regenerate formation is related to an
until total consolidation occurs. improper rate of bone transport.
Fig. 41.48 AP X-ray at the beginning of tibial BTON Fig. 41.49 AP X-ray during the transport period of tibial
procedure BTON procedure
• Premature consolidation occurs when the However, lengthening procedures performed

latency period before lengthening is too long with external fixators result in decreased post-
or the rate of lengthening is too slow. operative patient satisfaction. Secondary axial
• Pin cutout during transport. This complication deformities created during limb lengthening
is more likely to occur in osteoporotic patients and regenerate fractures after the removal of
with large bone defects. the external fixators all result from the lack of
stability with external fixators. Furthermore,
increased external fixation time results in a
41.3 Motorized Nails challenging rehabilitation period and a longer
recovery period before a return to daily activi-
Cengiz Şen and Halil Ibrahim Balci ties. A number of techniques have been devel-
oped to decrease external fixation time. In
Limb lengthening by distraction osteogenesis 1956, Bost and Larsen combined the use of
is mostly performed via conventional external intramedullary nails with temporary external
fixators of either circular or monolateral types. fixators to overcome malalignment difficulties
674 C. Şen et al.
Fig. 41.50 Ap X-ray at the end of transport period of

tibial BTON technique
following external fixator application [71]. Fig. 41.51 AP X-ray at the end of tibial BTON
Lengthening over an intramedullary nail, as procedure
described by Paley et al. in 1997, provides a
significantly decreased external fixation time Western countries followed Blinskunov’s inter-
and can reduce infection rates for femoral nal lengthening idea.
lengthening cases [72]. As technological devel- Baumgart and Betz from Germany developed
opments take place, new research has focused a motorized nail in 1991, the FITBONE
on more comfortable lengthening procedures (Wittenstein, Igersheim, Germany). It was a
for patients to avoid many of the well-known fully implantable lengthening nail that worked
complications of external fixators. Implantable with an internal motor, controlled with an exter-
distraction nails are the most commonly used nal transmitter via an antenna. An external
implants to provide lengthening with internal apparel that used radiofrequency was needed to
fixation. The idea took origin from Alexander make work the internal motor [56, 57] (Figs.
Bliskunov from the Ukraine. He described his 41.52 and 41.53).
telescopic lengthening nail technique in 1983 Guichet and Grammont developed a tele-
[54, 55]. He derived a lengthening mechanism scopic nail in 1994 known as the Albizzia
by a connector between the pelvis and femur. (Depuy, Villerbuane, France), which was later
The rotational motion of the femur produced modified and released as the Betzbone and the
lengthening of the intramedullary nail. The nail Guichet. It was the first telescopic nail used for
is used just as in the Ukraine, but research from lengthening. It needed 20 degrees of rotation,
Fig. 41.52 External remote control to activate lengthen-

ing mechanism. İt is controlled by the mechanical sound
listened by patient
and 15 rotations were needed for 1 mm of

lengthening [58–60]. Using the same concept
of lengthening by rotation through the callus,
Cole developed a double-clutch mechanism to
cause distraction, the intramedullary Skeletal
Kinetic Distractor (ISKD) (Orthofix Inc.,
McKinney, TX). Only 3–9 degrees of rotation
was required for lengthening. “Runaway nail”
or “runaway lengthening” was a frequent com-
plication because lengthening was so easy to
activate. Rapid distraction caused nerve and
vascular complications and also poor bone
quality at the distraction site [61–63].
Arnaud Soubieran from France developed the
Phenix nail. The Phenix had a mechanism acti-
vated by a large external, handheld magnet. By Fig. 41.53 Anthena that is placed subcutaneously to
rotating the magnet around the leg, an internal detect radiofrequency in fitbone system
crankshaft mechanism in the nail was rotated.
This leads to traction on a wire pulley, which
caused distraction of the nail. Rotating the magnet Unilateral lengthening with an intramedul-
in one direction led to lengthening, whereas rotat- lary nail can be performed for congenital defor-
ing it the other way led to shortening [58–60]. mities, post-traumatic shortening, and
Ellipse Technologies (Ellipse Technologies, limb-length discrepancies. Bilateral lengthening
Irvine, CA) developed the PRECISE nail with a is mostly for dysplasia such as achondroplasia,
team of surgeons headed by Dr. Stuart Green. hypochondroplasia, and constitutional short stat-
Ellipse used the same mechanism that they had ure (patients under the fifth percentile for
developed for their spinal growing rod called “the height). Increasing height in normal-statured
MAGEC System.” The mechanism is activated by individuals (patients > fifth percentile) is referred
an external remote control (ERC) device. It took to as “cosmetic stature lengthening,” which also
7 min and 210 revolutions to achieve 1 mm of became popular with the development of intra-
lengthening. Facing the ERC 1 direction causes the medullary lengthening devices [68]. The reason
nail to lengthen, whereas facing it in the other direc- for the popularity of the lengthening with intra-
tion would go in the reverse (shortening) direction medullary devices is the fewer complications
[64, 65]. The PRECISE nail 1 and 2 was popular- compared with the classic Ilizarov apparatus
ized in the United States of America (Fig. 41.54). [69, 70] (Fig. 41.55).
676 C. Şen et al.
Fig. 41.55 Unilateral lengthening of the post-traumatic

short femur because of distal physeal arrest
Fig. 41.54 Precice 2 nail, with trochanteric entry. X-ray Distraction speed depends on the bone and diag-
during the distraction period nosis. With the femur, we prefer to start distrac-
tion with a rate of 1 mm/day in 4 times. But for
Intramedullary lengthening, although comfort- the tibia, we prefer 0.75 mm/day distraction 3
able and makes lengthening much more easy for times. In tibial cases, we start with 1 mm/day dis-
patients and the physician, should only be used by traction to prevent early consolidation, and at the
surgeons who are experienced about the Ilizarov first follow-up check, we decrease the rate to
principle. Many problems that can be solved by 0.75 m/day. In congenital cases, we also prefer
experienced surgeon can become problematic in 0.75 mm/day for femur lengthening. As men-
the hands of others. We want to discuss some of tioned, X-ray follow-ups are important to have an
the problems that can be seen during the proce- idea about the consolidation of the regenerate. By
dure. Poor regenerate formation/nonunion is not decreasing the speed, one can increase the quality
exclusive to intramedullary nails that fail to main- of the regenerate. To have an idea about the regen-
tain safe rate control, but, rather, this remains a erate quality in the early weeks, one needs experi-
well-known complication for all limb-lengthening ence about the basic lengthening technique.
procedures. Many reasons can be found for poor Another well-documented problem with
regenerate. Problems about osteotomy, stability implantable lengthening nails is the difficulty
of fixation, infection, metabolic problems about with distraction. Kubiak and colleagues attrib-
the patients can all cause poor regenerate. We fol- uted this to impingement and friction. Soft tissue
low up patients every 2 weeks after the operation releases contractures and joint dislocation but
during the distraction period and do not start dis- can also decrease the need for power to lengthen
traction before the fifth day after the operation. the bone segment.
One of the main problems with distraction distraction part should be on the female rod side
nails is that they are straight nails attempting to and as much as possible away from the distal part
lengthen a curved femur. It causes an important of the female rod. The limitation on that point,
problem, especially in the femur. Over-reaming especially in the femur, is the amount of lengthen-
to fit the nail intramedullary and diaphyseal locking designed for the patient. Straight nail fixation
ing of the nail may cause fractures that can limit is not from metaphysis to metaphysis in an ana-
the success of the procedure. We suggest to tomically curved femur. An osteotomy that is too
choosing the correct entry point to long bones to proximal can cause varus deformity, and one that
prevent over-reaming and controlled weight- is too distal can cause instability in the telescopic
bearing until consolidation. The patient should rod system during lengthening. Preoperative
understand that the nail should be removed. planning and selection of the osteotomy site are
Lengthening with intramedullary nails causes important. Mechanical failure is seen in all
lengthening over anatomic axes. It is especially designed implants especially with early weight-
problematic in femoral lengthening. It causes val- bearing and difficult cases. Appropriate engineer-
gus deformation that correlates with the lengthening adjustments to improve product design and
ing goal of the extremity. For example, in case of new implants will decrease complications.
5 cm lengthening in a femur, we will have 5-degree The degree of pain is much more less with
valgus deformity in the frontal plan. Preoperative internal devices. With the use of magnetic remote
planning can prevent extreme valgus deformity. controlled devices, problems with pain have
Compressive forces caused by the soft tissues are decreased considerably. Devices that work with
substantial enough to limit lengthening in intra- rotational movement on the callus can cause pain.
medullary lengthening devices [65]. External fixa- Patients should be informed accordingly. Muscle
tion or a combination of the external fixation with contraction and nerve entrapment especially
internal fixators as plates and intramedullary nails around the knee should be evaluated preopera-
do not have such problems. The force produced by tively. The fibular nerve becomes more problem-
the nail magnet should overcome the soft tissue atic, especially with valgus problems. This type
forces. Therefore, we suggest early soft tissue of pain has been notably absent from reports on
release in cases of lengthening with an implant- FITBONE and PRECISE 1 and 2 [65].
able intramedullary nail. In cases of the lengthen- Pulmonary and fat embolism can be seen with
ing with external fixators, we prefer to make the intramedullary devices. Intramedullary devices
release during the lengthening period when we are 10 or 12.5 in diameter. Therefore, we have to
have the tightness [66]. ream until 14. Especially in cases of bilateral
Mechanical failure of implantable nails can be lengthening, reaming of both the femur and tibia
divided into two groups: mechanical failure of the can become problematic. We suggest drilling the
distraction mechanism and breakage of the integ- osteotomy site and open the small holes (ventila-
rity of the nail. We should always be ready for tion holes) before reaming. This has two advan-
mechanical failure because they are technology- tages: first, it decreases intramedullary pressure
dependent devices [67]. Therefore, we suggest and prevents intramedullary products to enter the
visualizing the distraction of the device and bone venous system and, second, internal grefonage
in the operating room and then finishing the oper- takes place because lengthening takes place from
ation. The second reason for mechanical failure is the osteotomy side.
the breakage of the integrity of the nail. They are Another problem that prevents use of intra-
telescopic nails that enter one another; one male medullary nails is the growth plate issue. Many
rod advances distally over the female rod. The congenital cases need lengthening during the
telescopic system becomes instable as lengthen- open physis. Therefore, external fixators continue
ing goes on, and the amount of contact between to be important devices for the first one or two
the female and male rods decreases. The osteot- lengthenings for these patients. If we can reach
omy site becomes an important predictor for sta- the amount of length that of one implantable
bility in such telescopic rods. The osteotomy and lengthening nail fitted inside the long bone in the
678 C. Şen et al.
adolescent period, we can continue lengthening Accelerated physiotherapy enabled by motor-

more comfortably for these patients. The trochan- ized intramedullary nails leads to early progress
teric entry nail system gives us the opportunity to toward normal joint range of motion (ROM).
start the nail around the 12–14 years of age. Therefore, motorized intramedullary nails may
However, in the case of tibia, we suggest waiting be an appropriate method for the treatment of
until closure of the physis. limb-length discrepancies. Patient selection is of
In the event of risk of joint dislocation, we pre- paramount importance for a successful outcome.
fer to use external fixators because we can pass the The application of this method requires surgical
joint, especially the knee, with a hinge and fix both experience and technical knowledge (Fig. 41.56).
bones. In this way, we can prevent dislocations. Cost is a major consideration. The intramedul-
Physicians who use intramedullary lengthening lary lengthening devices, especially new ones,
devices without securing the knee or hip joints, are very expensive. Insurance providers consider
especially in congenital cases such as proximal intramedullary lengthening as costly compared
focal femoral deficiency, should be very experi- with the classic Ilizarov technique. In the future,
enced about the distraction osteogenesis and should the cost of implants will decrease, and many of
be careful to follow up the lengthening process. surgeons will be able to undertake lengthening
Nail breakage; bone fracture at the end of the worldwide. However, the basic principles of dis-
locking screw; deep infection; pulmonary and fat traction osteogenesis and information about com-
embolism because of intramedullary reaming; plications should be studied and viewed with
peroneal nerve injury; knee, ankle, and hip flex- training programs to prevent catastrophic results.
ion contractures; and joint subluxations are other The distraction mechanism of the nail may not
complications that can be encountered with function properly during surgery or during the
intramedullary lengthening devices [68–70].
distraction phase. At this point, the surgeon must
Physical therapy and bracing are important to be familiar with other lengthening techniques
prevent contractures. Lengthening for stature [71–73]. The device, the surgeon, and teamwork
without these measures may lead to significant with the physiotherapist is important for good
stiffness and contractures of joints [70]. results.
Fig. 41.56 Clinical view of the 20-year-old male patient. Femoral lengthening of 5.5 cm is performed with intramedul-
lary lengthening device (precice 2). Full range of motion at knee joint during distraction and consolidation phases
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67. Burghardt RD, Herzenberg JE, Specht SC, et al.

71. Bost FC, Larsen LJ. Experiences with lengthening
Mechanical failure of the intramedullary skeletal of the femur over n intramedullary rod. J Bone Joint
distractor in limb lengthening. J Bone Joint Surg Br. Surg Am. 1956;38-A:567–84.
2011;93:639–43. 72. Paley D, Herzenberg JE, Paremain G, Bhave

68. Catagni MA, Lovisetti L, Guerreschi F, et al.
A. Femoral lengthening over an intramedullary nail.
Cosmetic bilateral leg lengthening: experience of 54 A matched-case comparison with Ilizarov femo-
cases. J Bone Joint Surg Br. 2005;87:1402–5. ral lengthening. J Bone Joint Surg Am. 1997;79:
69. Novikov KI, Subramanyam KN, Muradisinov SO,
1464–80.
et al. Cosmetic lower limb lengthening by Ilizarov 73. Dinçyürek H, Kocaoğlu M, Eralp IL, Bilen FE,

apparatus: what are the risks? Clin Orthop Relat Res. Dikmen G, Eren I. Functional results of lower
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lengthening using the PRECICE intramedullary 42–9.
lengthening nail. Tech Orthop. 2015;30:167–82.
Joint Contractures
42
Levent Eralp
42.1 Knee Flexion Contractures imaging, and exclusively angiography or angio-

graphic computerized tomography, particularly
Knee contractures could be devastating and can in posttraumatic cases.
result in bigger energy expenditure during the
gait cycle. Most contractures are because of the
congenital syndromes and due to trauma sequela. 42.2 Soft Tissue Correction
When evaluating sagittal knee deformity, it is with External Fixators
important to distinguish dynamic contracture,
due to tight hamstrings, from fixed flexion defor- Severe flexion contractures of the knee are a main
mity, which may or may not include tight ham- difficulty in functional ambulation and weight
strings, depending upon the etiology. bearing. Gradual correction of the deformity has
Many surgical procedures have been described been reported previously using various external
to treat fixed flexion knee deformity: lengthening fixators [3, 7, 9, 20]. Several authors have used an
of the hamstrings, posterior capsulotomy, epi- Ilizarov circular fixator [3], a monolateral fixator
physiodesis of the distal femoral growth plate, [9], a hinged distraction apparatus [20], or com-
femoral and tibial osteotomies, femoral shorten- puter software-based fixators.
ing, or arthrodesis [1, 18, 25]. Soft tissue release Lengthening of the distal tendon of the quad-
may be complicated by peroneal palsy, knee sub- riceps in adults is undesirable as it will result in
luxation, hyperextension, skin necrosis, and restricted active extension of the lower leg.
recurrence [9]. Besides, external fixation allows a gradual
It is essential to comprehend that handling increase in flexion of the lower leg to the neces-
knee joint stiffness is rather a complicated prob- sary angle in the postoperative period.
lem, and it is not always possible to solve it by
merely external fixation [11]. Preoperative exam-
ination includes electromyography, ultrasonogra-
42.3 Surgical Technique
phy, computed tomography, magnetic resonance
with Ilizarov Circular Fixator
One of the conditions for successful external fix-

L. Eralp, Prof. MD ation for knee joint contracture is to use the refer-
Istanbul University, Istanbul Faculty of Medicine, ence positions for the insertion of transosseous
Department of Orthopedic Surgery and
Traumatology, Istanbul, Turkey elements. The second mandatory condition of
e-mail: drleventeralp@gmail.com configuration of the device for increasing knee

https://doi.org/10.1007/978-3-319-45675-1_42
684 L. Eralp
joint ROM is the installation of axial hinges

strictly according to an axis of rotation of a knee
joint (Fig. 42.1).
Along with it, there is a widely accepted opin-
ion that movements in a knee joint have more
complex trajectory than it can be provided by the
one-axial hinges. The trajectory of movements in
a knee joint can be presented as superposition of
points on certain segments of arches of a circle of
femoral bone condyles and segments on condyles
of a tibial bone. Due to a difference of radiuses,
lengths of arches of condyles of femoral bone
and segments of tibia condyles movement in a
knee joint are carried out on several trajectories
with change of the centers of rotation. Thus, the
trajectory of movement in a knee joint represents
a complex curve, which is different for external
and internal condyles (Fig. 42.2). This provides a
rotational component of moving [13]. Therefore,
the use of the devices having the virtual hinge, for
example, hexapods, is prospective for knee joint Fig. 42.2 Hinges of external fixator to correct knee flex-
stiffness treatment. ion deformity are placed at the center of rotation of the
knee
If patellofemoral synostosis or fibrous union of
the patella with the femoral bone has occurred,
open or arthroscopic mobilization is required. and function of the injured extremity is the prior-
Extension stiffness of the knee joint is frequently ity in planning the rehabilitation of the patient
present together with a nonunion, deformity, (Fig. 42.3).
defect, or shortening of the femur in clinical prac- Arthrolysis and myolysis can be performed in
tice. Simultaneous restoration of the anatomy a single step with open adaptation of the trans-
posed and basic bone fragments.
After closed operations the knee joint is stabi-
extension lized in the position achieved by maximum elimi-
nation of the stiffness. However, to reduce pain
we have to reduce the position in the joint
achieved by the end of the operation by 30–50%.
trajectory of the axis
It often happens that after open arthrolysis and
myolysis, to avoid excessive skin stretching, the
skin is taken in with the knee joint flexed less
flexion
than what was achieved during the operation. To
reduce the risk of soft tissue necrosis after sur-
gery, the knee joint is stabilized in a position that
ensures good blood supply to the wound edges. If
there is a marked cicatricial process occurring in
the area of the knee joint, the knee is stabilized in
a position close to full extension.
A diastasis of 5–6 mm is created between the
Fig. 42.1 Trajectory of the flexion – extension axis joint surfaces in two or three stages. It is important
of the knee joint to note that due to the flexure of the transosseous
42 Joint Contractures 685
Fig. 42.3 Clinical view of knee flexion contracture caused

by soft tissue scar
elements, the amount of separation on hinges will Fig. 42.4 Correction of the knee flexion contracture of
not correspond to the joint space. Therefore, the patient Fig. 42.3
effectiveness of the distraction should be monitored
radiographically. Radiographic monitoring of the eratively), extension starts at the same rate. The
installation of the axial hinges is also necessary. same is done for flexion stiffness. When the full
On the second or third day after closed osteosyn- cycle of flexion–extension is completed, it is
thesis and after arthroscopic release, gradually repeated. The repeat cycle usually takes less time.
increasing flexion (extension in the presence of After 10–15 cycles of passive flexion and exten-
extension stiffness) of the lower leg starts by means sion, the time for a full cycle is reduced to several
of a swivel hinge at an average rate of 2–6° per day minutes. Passive movements are then supple-
in four to six stages. The rate is reduced if pain mented by the development of active movements.
occurs or if there are signs of irritation of the great For this the arms of the swivel hinge are discon-
vessels and nerves (Fig. 42.4). The manipulations nected. Over 3–7 days, a gradual transition is
must not cause any pain. The evaluation as to made to the priority development of active move-
whether the amount of movement of the swivel ments. The device for the development of move-
hinge causes no pain must be made in the morning. ments can be removed after the patient can
After flexion of the lower leg to an angle of achieve flexion–extension of the knee joint in
120° has been achieved (or less if planned preop- 10–20 min.
686 L. Eralp
42.4 Surgical Technique External fixation has been used for gradual
with Monolateral Fixator correction, both with and without simultaneous
soft tissue release [7, 9].
The monolateral fixators for knee contractures Herzenberg et al. described the use of an early
consist of laterally based rails fixed to the femur monolateral device in two patients in a review of
and tibia and connected to each other by a hinge their experience with correction of knee contrac-
which is centered over the center of rotation of tures using circular external fixation [5, 9].
the knee. A minimum of two pins is necessary in Theoretically, correction with external fixation is
both the femur and tibia. The femoral pins may more controlled and efficient than acute correc-
be put on multiple pin clamps so as the coverage tion of these deformities. In vivo canine studies
of the whole segment of the femur, but the tibial have shown that slow gradual correction appears
pins are placed within one clamp in the distal to elongate and stimulate histogenesis within ten-
tibia. A distractor is placed posteriorly between dons during bone lengthening [6, 8]. Blood ves-
the rails, as well as a separate distractor attached sels and neural structures have been shown to
anteriorly between the hinge and tibial pin proliferate and elongate during lengthening [2].
clamp. The anterior distractor is opened at the Similar changes should occur in soft tissue struc-
end of the procedure to a subjective sensation of tures during correction of joint deformities.
increased soft tissue tension as felt by the opera- Some recurrence may be noted in the follow-
tive surgeon [4, 15]. up period. It appears that in most patients, similar
Once full extension is achieved clinically and results were reported by Herzenberg et al.; the
radiographically, the fixator is left in place for overall joint motion was essentially unchanged at
approximately 4 weeks. The device is then the end of follow-up but was in a more functional
removed under anesthesia, and the extremity is arc at the end of treatment [9].
placed in a long leg cast in full extension for Major knee flexion deformity is disabling, and
approximately 4 weeks. Long leg braces are used acute correction of flexion knee contracture with
full time. These are locked in extension except soft tissue release, osteotomy, or both may lead to
for knee range of motion and strengthening exer- serious complications [2]. Soft tissue release may
cises during therapy sessions. Standing and walk- be complicated by peroneal palsy, knee sublux-
ing are allowed as tolerated. ation, hyperextension, skin necrosis, and recur-
Historically, initial surgical management rence [9].
has included releases and lengthenings of the
hamstrings and posterior capsule if necessary
[15, 17]. However, such management is often 42.5 Surgical Technique
difficult, since simple soft tissue releases are with Software-Based
often insufficient to obtain adequate extension. Hexapodal Systems (HS)
Serial extension casting, with and without
simultaneous soft tissue release, may be effec- The applying of HS technique is different from
tive in mild situations. Complications includ- the Ilizarov system. The virtual hinge of the knee
ing fracture, physeal injury, and posterior knee joint is determined by the software. Software of
subluxation, as well as peroneal nerve injury, computer-assisted frame enables to calculate any
have been reported [8, 10, 15]. It seems the movement trajectory of one fixator support refer-
development of complications after acute cor- ring to the other, and the fixator construction
rection is unpredictable. Ilizarov’s law of ten- allows providing the exact movement of these
sion stress [12, 14] has been advocated using supports [24].
the circular external fixator to treat these sorts In clinical practice, some posttraumatic condi-
of deformities, as gradual controlled traction tions may result in extension contracture of the
on living tissues creates stresses that stimulate knee joint or aggravating of the present extension
regrowth of these tissues. contracture. In such cases, it is also advisable to
use a software-based frame instead of a standard External fixation is used when dorsal flexion
hinge assembly. The frame will provide a wider of the foot by 25–30° was not achieved after
range of movements if the distal ring of the frame lengthening of the Achilles tendon. The foot is
on the tibia is at an angle of 60° to the bone. fixed by the device for 1–2 weeks, after which the
hinge system is used.
42.6 A
nkle Flexion Contractures
(Equinus Contractures) 42.7 Elbow Flexion Contractures
The device is assembled from two transosseous The first stage of the external correction of
modules fixing the lower leg and foot. The mod- chronic flexion contracture of the elbow
ules are connected by a hinge system. involves installation of a double-support mod-
The most frequent posttraumatic etiology for ule based on a ring and a two-thirds ring on the
persistent flexion stiffness is the consequence of shoulder. The support is based on wires or may
breaking the rules concerning plaster immobili- be a hybrid device. The second module fixing
zation. If relative shortening of the gastrocnemius the forearm can also be a wire or hybrid wire/
muscle or marked osteoporosis is accompanying, half-pin device. A hinge-distraction system is
the external fixation operation is performed mounted between the modules. One of the con-
simultaneously with lengthening of the Achilles ditions for successful external fixation for stiff-
tendon. In stiffness emerging after intra-articular ness in the elbow joint is to use the reference
fractures of the ankle joint, after a previous infec- positions for insertion of transosseous elements
tious process (provided there are no contraindica- [19, 23, 24]. The second necessary condition of
tions), arthroscopic release can be performed in the frame assembly for elbow joint stiffness
one stage at the same time as installation of the elimination is installation of axial hinges
external fixation device. strictly according to an axis of rotation of an
The procedure starts with mounting the tran- elbow joint, through the midpoint of lateral
sosseous module on the lower leg. A module condyle (Figs. 42.5 and 42.6).
based on a closed half ring is mounted on the foot. A diastasis of 2–3 mm is created between the
The imaginary biomechanical axis of the ankle joint surfaces. Using a swivel hinge, gradually
joint (rotational axis) passes under the medial increasing flexion of the elbow joint starts at an
malleolus, through the center of the trochlea of average of 2–6° per day in four to six stages. The
the talus, and comes out under the top of the lat- flexion rate must be reduced if pain occurs or if
eral malleolus [16]. there are signs of irritation of the great vessels
By means of swivel hinges, gradual extension and nerves. The manipulations must not cause
of the foot is started at an average of 2–6° per day any pain. The evaluation as to whether the amount
in four to six stages on the second or third postop- of movement of the swivel hinge causes no pain
erative day. The rate is reduced if pain occurs or must be made in the morning. Only after a night
if there are signs of irritation of the great vessels without analgesia should an increase in the rate
and nerves. The manipulations must not cause of joint movement be recommended [20, 22, 24].
any pain. After extension to an angle of 15–20° The procedure for using external fixation
has been achieved, the foot is stabilized for devices presented is intended for patients with
3–5 days. After that, flexion is started, its rate stiffness with no bone component, with congruent
being limited only by the occurrence of pain. joint surfaces (Figs. 42.7, 42.8, 42.9, and 42.10).
After a full cycle of flexion–extension is com- In patients with posttraumatic intra-articular
pleted, it is repeated. The repeat cycle usually elbow joint fusion, who suffer from the disease
takes less time. After 10–15 passive flexion and over 1 year, the following method is used. At the
extension cycles, the time for a full cycle is beginning, cup-and-ball (hinged) osteotomy of
reduced to several minutes. area of joint fusion using medial and lateral
688 L. Eralp
Fig. 42.5 Radiological
view of external fixator
construction built to
correct the equinus
contracture caused by soft
tissue. Attention to the
hinges placed at the
center of the trochlea of
the talus
Fig. 42.7 Clinical view of elbow contracture
Fig. 42.6 Monoplanar external fixation application to

upper extremity to correct the elbow flexion contracture.
Hinges strictly placed according to an axis of rotation of
an elbow joint, through the midpoint of lateral condyle
Fig. 42.8 Circular external fixator application to correct

elbow contracture
References
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ment of flexion contracture of the knee in myelome-
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extension medial rotation osteotomy to correct knee
flexion contracture and lateral rotation deformity of
tibia after polio. J Pediatr Orthop. 1991;11(5):646–51.
3. Damsin JP, Ghanem I. Treatment of severe flexion
deformity of the knee in children and adolescent
using the Ilizarov technique. J Bone Joint Surg Br.
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4. DelBello DA, Watts HG. Distal femoral extension
osteotomy for knee flexion contracture in patients
Fig. 42.9 Hinges are placed at the midpoint of lateral with arthrgryposis. J Pediatr Orthop. 1996;16:122–6.
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Jones S, Bell MJ. Joint distraction and reconstruc-
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6. Ebraheim NA, Saddemi SR, De Troye RJ. Results
of Judetquadricepsplasty. J OrthopTrauma. 1993;7:
327–30.
7. Gillen II JA, Walker JL, Burgess RC, et al. Use
of Ilizarov external fixator to treat joint pterygia.
J Pediatr Orthop. 1996;16:430–7.
8. Heydarian K, Akbarnia BA, Jabalameli M, Tabador
K. Posterior capsulotomy for the treatment of severe
flexion contractures of the knee. J PediatrOrthop.
1984;4:700–4.
9. Herzenberg JE, Davis JR, Paley D, et al. Mechanical
distraction for treatment of severe knee flexion con-
tractures. Clin Orthop. 1994;301:80–8.
10. Hosny GA, Fadel M. Managing flexion knee defor-
mity using a circular frame. Clin Orthop Relat Res.
2008;466:2995–3002.
11. Ilizarov GA, Makushin VD, Gerasimov PI, Desjatnik
EG. The treatment of stiff joints of the femur and
lower leg associated with angular displacement of
bone fragments with use of Ilizarov’s closed tech-
nique (methodological recommendations). Kurgan:
RSC “RTO”; 1979.
12. Ilizarov GA. Clinical application of the tension-stress
effect for limb lengthening. Clin Orthop Relat Res.
1990;250:8–26.
Fig. 42.10 Achieve of the extension at the end of
13. Iwaki H, Pinskerova V, Freeman MA. Tibiofemoral
correction
movement 1: the shapes and relative movements of
the femur and tibia in the unloaded cadaver knee.
approaches is performed. The ends of humeral J Bone Joint Surg. 2000;82–B:1189–95.
and elbow bones should be processed by mills. At 14. Kornilov NV, Karptsov VI, Novoselov KA, et al.
Comparative analysis of one- and two-stage methods
this procedure, the humeral condyles turn into a of surgical treatments of femur pseudoarthrosis and
semicylindrical form, and incisura trochlearis malunions associated with knee joint contractures. In:
ulna gets an elliptic one. Thus, a resection of the Kornilov NV, editor. Planned surgical interventions (pre-
ends of a humeral bone and ulna should be operative examination and patient preparation, compli-
cations, outcomes). Saint Petersburg: RNIITO; 1992.
0.5–1 cm. Development of new elbow joint 15. Mooney III JF, Koman LA. Knee flexion contractures:
movement is carried out by means of hinged Soft tissue correction with monolateral external fixa-
frame (Solomin, Tuncay Springer kitap). tion. J South Orthop Assoc. 2001;10(1):32–6.
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16. Oganesyan OV, Ivannikov SV, Korshunov AV. The 21. Shevtsov VI, Nemkov VA, Sklyar LV. The Ilizarov’s
restoration of shape and function of the ankle apparatus. Biomechanics. Kurgan: Periodika; 1995.
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Shevtsov VI, Makushin VD, Kuftyrev
BINOM; 2003. LM. Pseudoarthrosis, long bone defects of the upper
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1 8. Phillips WE, Audet M. Use of serial casting in quences of damage to the elbow joint with applica-
the management of knee joint contractures in tion of the Ilizarov device (dissertation). Kurgan: RSC
an adolescent with cerebral palsy. Phys Ther. “RTO”; 2004.
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The Treatment of Complications
in Ilizarov Technique 43
Mustafa Uysal
Complications may emerge as undesirable and major complications, according to the require-
unexpected situations during treatment. In some ment of surgery for treatment [2]. Complications
cases, they become a barrier to reach the target, were classified as mild, moderate, and severe,
so they adversely affect the course of treatment. and risk factors were classified as high and low
How much a complication affects the outcome of by Dahl [3]. Caton graded complications as
treatment is closely related with the severity of groups 1–3 according to their severity [4, 5].
complications. Popkov investigated them as related with bone
The Ilizarov technique is likely to have a and joint or infectious and neurovascular [6].
higher complication rate because most cases are Paley described a classification including all
complicated and have long periods of treatment, kinds of difficulties and graded them as problem,
which can create the wrong perception that the obstacle, and complication [7]. Problems repre-
Ilizarov technique is too difficult to perform. sented difficulties that required no operative
However, it is logical to accept the risk of compli- intervention to resolve, while obstacles repre-
cations alongside the wide range of opportunities sented difficulties that required operative inter-
provided by Ilizarov’s device. vention. Complications were a more severe form
The awareness of complication risks, skills, of difficulty that could not be solved during
and knowledge to treat complications are basic treatment.
requirements for this technique. Otherwise, Complications can be encountered in all
even simple problems can lead to serious com- phases of treatment including planning, applica-
plications, which negatively affect patient tion, and follow-up. They can start at the begin-
satisfaction. ning of surgery or several weeks after frame
Many classifications have been described to removal.
understand complications since the first attempt The classification of complications according
of limb lengthening by Codivilla in the nine- to their occurrence period:
teenth century [1]. Complications can basically
be divided into two groups, such as minor and 1. During the frame application:
1.1 Neurovascular injury
1.2 Compartment syndrome
1.3 Incomplete osteotomy
M. Uysal, MD
Sakarya University, School of Medicine, Department
of Orthopedics and Traumatology, Sakarya, Turkey
e-mail: mstfysl@hotmail.com

https://doi.org/10.1007/978-3-319-45675-1_43
692 M. Uysal
2. When the frame is on the patient: 43.1.2 Compartment Syndrome

2.1 Pin tract infection
2.2 Joint contracture Compartment syndrome can occur after insertion
2.3 Joint subluxation of too many pins and wires through an extremity
2.4 Neurologic symptoms with extensive soft tissue damage, which causes
2.5 Early union increasing compartment pressure as well as direct
2.6 Deformity vascular injuries. Osteotomy may increase com-
2.7 Pain partment pressure alone. Fasciotomy can be per-
2.8 Extremity edema formed after the injury of large vessels or prolonged
2.9 Implant failure bleeding in suspicious circumstances. In some
2.10 Delayed consolidation critical situations, the extremity can be monitored
3. After frame removal: by frequently measuring compartment pressure.
3.1 Residual deformity
3.2 Refracture
3.3 Contracture 43.1.3 Incomplete Osteotomy
When osteotomy is not completed in all parts of

43.1 During Frame Application the cortex, distraction cannot be achieved in the
distraction phase. It is more often seen corticoto-
43.1.1 Neurovascular Injury mies by drilling and caused some trouble such as
pain and prolonged treatment period. Treatment
Neurovascular injuries can be encountered dur- is generally to complete the osteotomy.
ing pin insertion as well as during osteotomy or Translation between bone fragments has to be
corticotomy procedures. Surgeon should know checked after osteotomy is completed.
transactional anatomy well to avoid neurovascu-
lar injury. A surgical plan has to be made for
insertion of pins and wires using a surgical atlas 43.2 W
hen the Frame Is
for application before surgery. Safe zones should on the Patient
be defined for each extremity. The most common
vulnerable structures are the radial nerve in the 43.2.1 Pin Track Infection
distal arm and proximal forearm, fibular nerve
around fibular neck, and anterior tibial artery in It is the most common complication of external
proximal tibia. Fistula formation can occur after fixators [8–11]. The rate is reported up to 96%
an artery and vein are injured together. Local in some series in literature [9]. It progresses
compression on extremity usually stops bleeding, from outside to inside as a skin irritation, cellu-
but close monitoring of circulation must be fol- litis, and subcutaneous, deep, and bone infec-
lowed during the postoperative period. Wires tion. Pin tract infection is closely related with
should be pushed forward through soft tissues factors such as wire tension, tethered skin by
gently without drilling after insertion of cortical wire, and thickness of soft tissue between skin
bone in order to avoid heat necrosis and local and bone [12]. It is generally triggered by the
trauma. Motor functions should be preserved micro-movement of skin around the wire or pin
during anesthesia, and then reflex muscle con- (Fig. 43.1).
traction can be observed in case of neurologic Careful dressing with compression padding
injury to make wire position change possible. over the skin to avoid excessive movement can be
Sometimes, direct protection of nerves with tiny applied around wires and pins. Tethered skin
dissection in small incision is helpful to avoid around wires and pins should be avoided during
neurologic injury, such as radial nerve dissection the surgical procedure. If necessary, release of
and protection in the distal arm. skin with a small incision using a lancet is advised
43 The Treatment of Complications in Ilizarov Technique 693
Fig. 43.1 Grade 2 pin tract infection

Fig. 43.2 The tension effect of gastrocnemius and ham-
string muscles
[8]. Early diagnosis and intervention is important
in treatment, so patients should be informed
about pin care and warned about infections. All Additionally, if the wire fixation is made through
kinds of infection stimulate pain and negatively tendinous structures, the accommodation of mus-
affect the physical therapy period. cles becomes difficult.
Pin track infection was simply classified in Flexion contractures occur in knee, ankle, and
three grades by Paley [7]: interphalangeal joints in the lower extremities
and elbow, wrist, and phalanx in upper extremi-
Grade 1: Soft tissue inflammation. This can be ties. Muscles that bridge two joints show more
resolved in a couple of days with attentive resistance than muscles with one joint because of
care with antiseptic solution and compressive the fiber length (Fig. 43.2). As a consequence,
dressing around the pin. Wire tension should knee and ankle joint contractures are seen more
be checked. frequently because of the effect of hamstring and
Grade 2: Soft tissue inflammation but bone tissue gastrocnemius muscles [7, 13]. It is advised to
is not yet affected. One-week antibiotherapy is adjust maximal muscle length during the fixation
generally sufficient. around joints.
Grade 3: Bone infection. Treatment is more dif- Physical therapy has major role in avoiding
ficult. Removing the pin or wire and local contractures [14, 15]. Passive tensional move-
debridement is necessary. ment is the most common treatment regime.
Tension effective in a way must be applied to
muscles passing two joints. Application of a
43.2.2 Joint Contractures brace to hold the knee joint in extension and
ankle joint in 90° flexion is helpful to prevent
The lengthening capacity of bone tissue is greater advancing contractures [16]. If contractures
than muscles and ligaments, which have high exceed 40°, the joint is included in the frame con-
resistance to stretching. Joint contractures are struction, and progressive correction is applied.
one of the main problems after lengthening due The lengthening rate can be decreased or tempo-
to incompliance of flexor muscles with increased rarily stopped when contractures occur.
bone length. However, the structure of muscles Especially when lengthening over 6 cm in the
responsible for antagonistic movement is different. tibia, proximal and distal joints should be
The joint is forced to move in flexion position. included in the frame construct and released in
694 M. Uysal
Fig. 43.4 Femoral lengthening was planned in a patient

who has congenital short femur. The knee joint was fixed
during lengthening against the risk of subluxation due to
Fig. 43.3 Frame is extended temporarily to the ankle knee instability
joint to avoid contracture
the consolidation period [7] (Fig. 43.3). There is

another optional method. Lengthening 10 mm
more than required and then compressing is help-
ful to relieve soft tissue tension.
Nevertheless, small surgical procedures such
as tenotomy, tenoplasty, and myotomy are helpful
in the prevention of contracture. The most fre-
quently performed procedures are release of rec-
tus femoris, fascia lata, sartorius, and hamstring
muscles for femoral lengthening and achilloplasty
for tibial lengthening. Contractures are one of the
major factors that decrease patient satisfaction;
therefore, precautions should not be neglected.
43.2.3 Joint Subluxations
The most common cause of joint subluxation is

patients who are prone to joint instability [17]. Fig. 43.5 Proximal tibia-fibular diastasis after deformity
Congenital diseases such as proximal femoral correction
focal deficiency and fibular hemimelia have high
risk for instability. It is seen most commonly in with distraction and translation should be
the knee joint but also in hip and ankle joints attempted using fixator components. Soft tissue
[17]. When joint contracture is neglected, asym- release can be added if required.
metric contraction force of muscle is responsible In the event of acetabular roof insufficiency (if
for subluxation [18]. In femoral lengthening, CE angle is below 20°), surgery to increase cov-
hamstring muscles pull the tibia backward, espe- erage must be planned to prevent hip subluxation
cially when the knee is in flexion, which results before femoral lengthening.
in knee subluxation. If there was any risk for Any proximal or distal diastasis between the
instability, the joint could be included in the tibia and fibula must be evaluated as subluxation
frame (Fig. 43.4). In treatment, gradual reduction (Fig. 43.5). A transfixation wire passing from the
fibula to tibia is helpful for prevention of diastasis rate or callotasis under general anesthesia can be
and subluxation. Open reduction can be neces- done in treatment; otherwise, open corticotomy
sary in cases of severe subluxation. should be reapplied.
43.2.4 Neurologic Symptoms 43.2.6 Reoccurrence of Deformity
The neurologic response to bone lengthening is Asymmetric forces on fracture or corticotomy

another limitation for the lengthening rate. As a site may cause deterioration of limb alignment in
result of excessive extension on nerve fibers, the time. The most frequent causes are insufficien-
first symptom usually appears as neuropraxia cies in fixation of segments and wire tension. The
and may transform to paralysis if it is not recog- risk of deformation increases with the amount of
nized at an early stage. The red flag symptoms lengthening. There is a predisposition to varus
are pain and hyperesthesia followed by hypoes- and procurvation for the proximal femur, valgus
thesia and loss of strength [19]. Therefore, and procurvation for the proximal tibia, and varus
examination of sensory and motor function is and procurvation for the distal tibia in the conse-
very important for early diagnosis. When the quence of anatomic features. If a screw or olive
symptoms appear, lengthening should be stopped wire is positioned against the force creating the
or slowed down. The peroneal nerve or tarsal deformity, some problems can be avoided. In
tunnel should be released as a precaution before addition, rings in the distal femur and proximal
excessive corrections because the peroneal and tibia can be placed in 5–10° slope to the frame,
posterior tibial nerves are the most commonly which is in the opposite direction of the defor-
affected nerves. mity. Adjusting the frame to asymmetric com-
Neurologic symptoms due to stress on nerve pression or distraction can solve deformities up
fibers usually cause no serious neurologic dam- to 5°, but larger ones need frame revision.
age if they are recognized at an early stage, but Deformities of more than 10° are treated by
stress symptoms have the potential to result in replanning the deformity and attaching hinges to
serious complications. Permanent neurologic the frame (Fig. 43.6).
damage is a serious complication because addi-
tional surgical procedures such as release of
contractures or tendon transfers may be 43.2.7 Pain
necessary.
Although pain is not a serious problem with cur-
rent surgical approaches and analgesia protocols,
43.2.5 Early Union it is a very common symptom and may be alone
or associated with other problems. Pain usually
Early union is consolidation of bone tissue before occurs with periosteal stress, muscle spasms,
its planned time. It generally occurs when the contractions, and soft tissue inflammation trig-
latent period takes a long time. The recommended gered by wires. Patients express themselves in
latent period for children is 5 days and 7 days for different ways because pain severity is subjec-
adults. It can be extended depending on the tive. Pain affects the progress of treatment, espe-
patient. The femur and tibia are the most com- cially in lengthening [20]. Restriction in range of
mon locations for early union. Neurologic symp- motion, contractures, and circulatory disorders
toms, pain, and contractures may cause early can also cause pain. Appropriate pain medication
union because of decreasing the lengthening rate. according to personal pain threshold should be
Open osteotomy is an option instead of corticot- started immediately. If there was no relief from
omy in order to prevent early union. Pain that pain, the reason should be investigated. Reflex
results from overload on wires during distraction sympathetic dystrophy should be kept in mind in
is a primary symptom. Increasing the lengthening case of excessive pain and swelling.
696 M. Uysal
Fig. 43.6 After the deformity has progressed more than 30° during lengthening, revision with hinge system has been
included to the frame
43.2.8 Extremity Edema
This usually occurs early during surgery depend-

ing on the surgical trauma. Later, it is caused
by venous stasis due to immobility of extremity.
Inappropriate ring diameter may cause local
compression, which results in edema in the
extremity. Frame revisions are required rarely.
Elevation of the limb is advised, and a supportive
dressing is applied as much as possible. Edema
resolves after frame removal.
43.2.9 Implant Failure

Fig. 43.7 Failure in K-wires resulting in wire breakage
Implant failure usually results from overloading
wires or pins. Metal fatigue is the main reason.
The weakest site is located near the bone or the 43.2.10 Delayed Consolidation
frame. The physician should suspect sudden-onset
pain and check the wire tension. Roentgenogram This is rarely seen in young and healthy patients.
is helpful for diagnosis (Fig. 43.7). System stabil- There are some risk factors such as metabolic
ity should be reevaluated after the removal of the diseases, malnutrition in the short latent period,
broken parts. If necessary, new wire and pin inser- smoking, lengthening over 4 cm, traumatic corti-
tion can be achieved. cotomy, earlier operations in the same area, frame
Fig. 43.8 Insufficient regeneration in consolidation phase
instability, and acute correction of deformities

concomitant with lengthening [21].
Delayed consolidation is encountered more
commonly in diaphyseal bone than metaphyseal Fig. 43.9 Refracture line in humerus after frame removal
bone due to the lack of blood circulation. Diagnosis
is possible with observation of insufficient regen-
before frame removal [24]. Frame dynamiza-
eration in roentgenograms (Fig. 43.8). Distraction
tion with loosening of connection rods between
is slowed down or stopped. Patients may be
rings can provide a secure consolidation phase.
encouraged to walk with weight bearing. A con-
Brace application prevents deformity progres-
secutive compression-distraction regime is
sion in case of realizing it in earlier phase. A
another option in treatment [22]. If any regenera-
brace must be applied in every child with con-
tion can be induced, grafting is necessary with
genital disease as a precaution.
autogenous bone [23].
Axial deformities of 5 mm are acceptable, but
larger discrepancies are evaluated as complica-
tion [25]. A discrepancy of more than 20 mm is a
43.3 After Frame Removal major complication and mostly needs secondary
surgical intervention.
43.3.1 Deformity
Residual deformities can occur due to resilient 43.3.2 Refracture

bone immediately after frame removal. The rea-
sons are generally lack of complete bone healing Displacement of bone edges or stress fracture can
due to a short consolidation time. There is a risk be seen as refracture in the healing site (Fig. 43.9).
of fracture in that area. The appearance of at least Osteoporosis due to disuse atrophy or reflex sym-
three cortexes of bone should be checked in pathetic is a predisposing factor for refractures.
anterior-
posterior and lateral roentgenograms These can be treated with cast or brace application,
698 M. Uysal
risks in surgery. If patients are made aware of the

estimated treatment period before surgery, they
accept and accommodate difficulties easier during
the treatment. Patients should be warned about
signs of some major problems and asked to con-
sult as much and as soon as possible with the hos-
pital in case any problems occur. Physicians
should see the patient regularly in clinic, and the
patient should be able to visit physicians when-
ever desired. Educational documents including
written and visual explanation about the postop-
erative period may facilitate accommodation of
patient. Patient cooperation is a major component
Fig. 43.10 “Judet quadricepsplasty” performed to
increase range of motion due to knee stiffness related with in surgical success. For example, although it is
lengthening procedure well known that smoking increases complications
in patients with and Ilizarov external fixator [26],
but sometimes they need surgical fixation. if the patient continues to smoke, it suggests the
Deformities of more than 1 cm in length and 5° in patient does not show cooperation. Whatever pre-
angulation are major complications [7]. cautions are taken, avoiding complications some-
times cannot be possible. Experience provides
43.3.3 Joint Stiffness avoiding complications and allows the ability to
respond early to them. It was shown that there was
Joint stiffness is characterized by decreasing a negative ratio between experience of surgeon
almost all range of motion. Contractures that are and complication rate [3].
neglected and not corrected when the frame is on The benefits of the Ilizarov technique, which
the patient may advance to joint stiffness until the has been used for a long time with high rates of
end of treatment. Arthrofibrosis, muscle contrac- success, are unquestionable. The success of the
tures, and chondral damage may also be seen Ilizarov technique requires knowing how to
with stiffness. Chondral damage is a serious struggle with complication as much as being
complication and negatively affects patient familiar surgical application techniques.
satisfaction. Treatment options include distrac-
tion of the joint and extensive soft tissue release
(Fig. 43.10). References
1. Codivilla A, The classic. On the means of lengthening,
43.4 How to Avoid Complications in the lower limbs, the muscles and tissues which are
shortened through deformity. 1905. Clin Orthop Relat
Res. 2008;466(12):2903–9.
Success in deformity surgery requires teamwork. 2. Velazquez RJ et al. Complications of use of the
The team includes the doctor, patient, patient’s Ilizarov technique in the correction of limb deformi-
relatives, physiotherapist, radiologist, and per- ties in children. J Bone Joint Surg Am. 1993;
sonnel responsible for wound care and dressing. 75(8):1148–56.
3. Dahl MT, Gulli B, Berg T. Complications of limb
Coordination between them carries high impor- lengthening A learning curve. Clin Orthop Relat Res.
tance, and this should be established before 1994;301:10–8.
surgery. 4. Caton J. Traitment des inegalites de longeur des mem-
Patient’s cooperation is also a very important bres inferieurs et des sujets de petite taille chez l'enfant
et l'adolecent. Rev Chir Orthop. 1991;77
factor in achieving a good result. The patient must (suppl.1):31–80.
be enlightened about surgical procedures, and 5. Vargas Barreto B et al. Complications of Ilizarov leg
they must give informed consent for the probable lengthening: a comparative study between patients
with leg length discrepancy and short stature. Int 16. Kocaoglu M et al. Complications encountered during
Orthop. 2007;31(5):587–91. lengthening over an intramedullary nail. J Bone Joint
6. Popkov A. Erors and complications of operative Surg Am. 2004;86-A(11):2406–11.
lengthening of the lower extremities in adults by the 17. Jones DC, Moseley CF. Subluxation of the knee as a
Ilizarov method. Vestn Khir Im I Grek. 1991;1:113–9. complication of femoral lengthening by the Wagner
7. Paley D. Problems, obstacles, and complications technique. J Bone Joint Surg Br. 1985;67(1):33–5.
of limb lengthening by the Ilizarov technique. Clin 18. Suzuki S et al. Dislocation and subluxation during
Orthop Relat Res. 1990;250:81–104. femoral lengthening. J Pediatr Orthop. 1994;14(3):
8. Eralp L et al. A review of problems, obstacles and 343–6.
sequelae encountered during femoral lengthening : 19. Young NL et al. Electromyographic and nerve con-
uniplanar versus circular external fixator. Acta Orthop duction changes after tibial lengthening by the
Belg. 2010;76(5):628–35. Ilizarov method. J Pediatr Orthop. 1993;13(4):473–7.
9. Antoci V et al. Pin-tract infection during limb 20. Young N, Bell DF, Anthony A. Pediatric pain patterns
lengthening using external fixation. Am J Orthop. during Ilizarov treatment of limb length discrepancy and
2008;37(9):E150–4. angular deformity. J Pediatr Orthop. 1994;14(3):352–7.
10. Eldridge JC, Bell DF. Problems with substan-
21. Kenawey M et al. Insufficient bone regenerate after
tial limb lengthening. Orthop Clin North Am. intramedullary femoral lengthening: risk factors
1991;22(4):625–31. and classification system. Clin Orthop Relat Res.
11. Garcia-Cimbrelo E et al. Ilizarov technique results 2011;469(1):264–73.
and difficulties. Clin Orthop Relat Res. 1992; 22. Kocaoglu M et al. Management of stiff hypertrophic
283:116–23. nonunions by distraction osteogenesis: a report of 16
12. Green SA, Ripley MJ. Chronic osteomyelitis in pin cases. J Orthop Trauma. 2003;17(8):543–8.
tracks. J Bone Joint Surg Am. 1984;66(7):1092–8. 23. Wagner H. Operative lengthening of the femur. Clin
13. Damsin JP, Ghanem I. Treatment of severe flexion Orthop Relat Res. 1978;136:125.
deformity of the knee in children and adolescents 24. De Bastiani G et al. Limb lengthening by callus distrac-
using the Ilizarov technique. J Bone Joint Surg Br. tion (callotasis). J Pediatr Orthop. 1987;7(2):129–34.
1996;78(1):140–4. 25. Burghardt RD et al. Mechanical failure of the

14. Acharya A, Guichet JM. Effect on knee motion of Intramedullary Skeletal Kinetic Distractor in limb
gradual intramedullary femoral lengthening. Acta lengthening. J Bone Joint Surg Br. 2011;93(5):639–43.
Orthop Belg. 2006;72(5):569–77. 26. McKee MD et al. The effect of smoking on clinical
15. Herzenberg JE et al. Knee range of motion in iso- outcome and complication rates following Ilizarov
lated femoral lengthening. Clin Orthop Relat Res. reconstruction. J Orthop Trauma. 2003;17(10):
1994;301:49–54. 663–7.
Postoperative Rehabilitation
44
Arman Apelyan
Distraction osteogenesis is a safe method to cor- soleus. During rest, it is important to keep the
rect leg length discrepancy. It reduces the risk of knee in extension and ankle in dorsal flexion. The
deep infections, bone healing problems, mal- use of a dynamic or a static brace to maintain
union, or nonunion and avoids complications these positions prevents range of motion loss. It
such as internal fixation failure. On the other is generally possible to resolve knee flexion con-
hand, the range of motion and muscle strength tracture, but it is hard to resolve equinus deformi-
decreases at the proximal and distal joint of the ties. With intensive physical therapy, it will be
lengthened bone. Fixation with pins and wires possible to get the ankle neutral position. In
causes adhesions between bones, soft tissues, and recent years, the fixation of ankle with a pin facil-
the different layers of soft tissues because the itates the rehabilitation. After the removal of
lengthening process affects the soft tissues and external fixator, the rehabilitation for ankle stiff-
cartilage. As a result, joint and connective tissue ness and muscle weakness will start to reach full
stiffness in the surrounding muscle develops [15]. range of motion.
The main problems of limb lengthening are The bone deformity develops during lengthen-
muscle and joint stiffness. The duration with fixing phase. The axial deviation develops due to
ator, amount of lengthening, and pins or wires imbalance of soft tissues surrounding the bone
that pass through the tendons reduce the range of during bone distraction. Pin side infections, hip
motion. The lengthening over nail technique and knee joint instability, knee joint stiffness, and
shortens fixator use duration. The pins and wires axial deviation are most common problems on
allow for the short time with this technique. After femoral lengthening. Pin side infections are seen
the removal of the fixator, full range of motion is often because of soft tissue bulk around the bone.
available in a short time. Knee joint subluxation develops due to pull of
Joint contracture and axial deviation are the hamstrings on the tibia. Tibia will subluxate pos-
two problems most seen on tibial lengthening. teriorly on the femur. Use of dynamic knee exten-
Aside from pin infections, ankle equinus and sion brace will decrease the risk of subluxation.
knee flexion contractures develop in tibia length- During the femoral lengthening, it is impor-
ening due to tension in the gastrocnemius and tant to maintain the knee range of motion. During
the lengthening, knee flexion decreases. Knee
flexion exercises should be done to prevent joint
A. Apelyan, MSc Pt stiffness. Knee extension exercises also should be
Kinemed Physical Therapy and Rehabilitation Center, done to prevent the knee joint subluxation. Joint
Istanbul, Turkey
e-mail: aapelyan@hotmail.com

https://doi.org/10.1007/978-3-319-45675-1_44
702 A. Apelyan
muscles. The wires and pins are passing through

these muscles to fixate the bone, whereas one
third of the tibia is under the skin and not sur-
rounded with muscles [15].
The amount of lengthening and the period
with external fixator affects the range of motion.
The period with external fixator decreases range
of motion. In some cases the loss of range of
motion restrain to reach the goal of lengthening.
To decrease the daily lengthening rate or stop
lengthening permanently, increasing the physio-
therapy sessions is an alternative option. The
advantage of lengthening over nail is the removal
Fig. 44.1 Knee subluxation seen on femoral lengthening
by a fully implantable lengthening nail. View of the of the external fixator and locking of the nail at
depression of proximal tibia and the flexion contracture of the end of the lengthening. The pins and wires
the knee passing through the muscles are removed. As a
result, less scar and arthrofibrosis occur. After
removal of external fixator range of motion and
strength are recovered. During femoral lengthen-
ing, knee extension contracture occurs because of
resistance of quadriceps. During tibial lengthen-
ing, knee flexion contractures occur because of
resistance of gastrosoleus [9].
On forearm lengthening, mostly on radial
lengthenings, it is important to keep wrist stabil-
ity. A stability problem on the elbow is not com-
mon. During radial and on one bone forearm,
lengthening the elbow, fingers, and the wrist
tends to go in flexion contracture. To prevent
Fig. 44.2 On femoral lengthenings it is important to these complications, intensive physiotherapy and
stretch the adductor muscles to prevent hip subluxation the use of extension braces are important. The
due to adductor tension diameter of the forearm bones are small, and sur-
rounding muscles tend to narrow the regenerate
stiffness, arthrosis, and knee subluxation develop bone formation on large lengthenings. To reduce
due to insufficient rehabilitation [18] (Figs. 44.1 the daily lengthening rate will resolve the prob-
and 44.2). lem. Ulna is acting as a support to radius during
During femoral and tibial lengthening, knee lengthening, and it prevents the axial deviation.
range of motion decreases because of the mus- The most common complications on different
cles traversing double joint through the knee reviews are pin infections, deformity after the
joint. On tibial lengthening, the tibialis anterior removal of external fixator, radial nerve injury,
muscle can’t accommodate to daily 1 mm rate of and loss of wrist range of motion.
callus distraction. As a result, the new contractile Humeral lengthening done for extremity dis-
materials that will maintain optimum length of crepancy is unilateral and for short stature is bilat-
sarcomere along the muscle fibers will be insuf- eral. During lengthening, soft tissue- and
ficient. The range of motion is affected more on bone-related complications are common. The
femoral lengthenings than tibial lengthenings complications are seen during surgery or during
because a large part of femur is surrounded with lengthening process. Stability and axial deviation
44 Postoperative Rehabilitation 703
problems are not common on humeral l engthening. In recent years, limb lengthening with fully
On the humeral lengthenings, if the osteotomy implantable nails are alternative to external fix-
level is on the distal of deltoid tuberosity of the ators. It is more comfortable for patients and there
humerus, the shoulder range of motion won’t be is less complication risk. It allows patients to have
affected. It will affect the elbow range of motion. good cosmetic results and quick rehabilitation
A dynamic extension brace will prevent elbow because there aren’t pin-related problems. The
flexion contracture. Most of complications are studies showed that the patients regain hip, knee,
soft tissue related. Bone-related complications are and ankle range of motion easier. The fully implant-
not common. Generally humeral bone healing is able lengthening nails are good treatment options
easier [18] (Fig. 44.3). to resolve extremity discrepancy. During lengthen-
ing, the complications seen are muscle weakness
and range of motion restrictions. After operation,
Segment
lengthened Problem soft tissues Problems
the physiotherapy starts with strengthening of
Tibia Gastrocnemius Knee flexion,
quadriceps, hamstring, and gastrocnemius mus-
equinus cles. Good physiotherapy will resolve muscle
Plantar fascia Cavus weakness and range of motion problems. This sys-
Toe flexors Toe flexion tem is more comfortable for patients. It allows
Femur Long hamstrings Knee flexion daily living activities and increases sleeping qual-
contracture ity, and there is no pin side infection; consequently,
Quadriceps Knee extension the patient feels less pain [12, 13] (Fig. 44.4).
contracture
Intramedullary skeletal kinetic distractor
Iliotibial band Tendency for
(ISKD) system allows lengthening with 3–9
posterior
translation and degrees of rotation along the long axe of the
external rotation bone. If the distraction is too fast, weight bearing
of proximal tibia and range of motion will be restricted. In ISKD
Humerus Long biceps Elbow flexion systems, the most common problem is to set the
contracture
lengthening rate. In Fitbone system, the patient
Forearm Finger flexors İP and DİP flexion
contracture
activates and controls the system by a transmitter.
MP joint It allows the telescopic nail to elongate. It is eas-
extension ier to control the amount of lengthening on
contracture Fitbone system [8, 11].
Fig. 44.3 Achondroplastic patient with bilateral humeral Fig. 44.4 It is easy to use CPM machine for patients with
lengthening on postoperative first day while writing with pen a fully implantable femoral lengthening nail
704 A. Apelyan
44.1 Progressive Weight Bearing is more than 15% of the length of the bone, or the
period between operation and lengthening is shorter
The external fixator system allows patients to full than 7 days, there is a higher risk of refracture [1, 6,
weight bearing after the operation. When length- 11, 14, 22].
ening is finished, on consolidation phase the In our clinic, we do dry needling in some cases
patient gives full weight without carrying devices when the bone healing process is slow. We use
like crutches. dry needling technique to stimulate bone regen-
The combined method, intramedullary nail eration (Figs. 44.6, 44.7, and 44.8).
and external fixator, allows full weight bearing
during lengthening. After the removal of exter-
nal fixator and locking the nail, patients are not
allowed to full weight bearing. When it is uni-
lateral, the patient will walk with partial weight,
and if it is bilateral, the patients are allowed to
walk only for transfers: 10 feet in one time or 50
feet daily to walk [21].
The patients will be able to walk with full
weight when the x-rays show two mature cortices
on the new bone regeneration level. The patients
should progress from two crutches to one and to
none. The x-rays should show three mature corti-
ces on the new regenerated bone level to remove
the external fixator when there is no intramedul- Fig. 44.6 The stimulation of callus regeneration by dry
lary nail [24] (Fig. 44.5). needling technique on tibial lengthening when bone heal-
On ISKD system, we teach the patients to ing is insufficient
give 15 kg weights to operated side. On Fitbone
technique, the patient is allowed to give 20 kg or
20 % of his weight during lengthening. Patient
will give full weight on consolidation phase.
The risk of refracture depends on the etiology. In
congenital cases when the amount of lengthening
Fig. 44.5 Weight bearing exercise by a weighing machine Fig. 44.7 X-rays before dry needling
Fig. 44.9 Dynamic finger extension brace to prevent

flexion contracture of fingers caused by metacarpal
lengthening
Fig. 44.8 X-rays after dry needling
44.2 Dynamic Splinting
Contracture is the joint stiffness due to the short-

ening of connective tissue. Dynamic splinting
keeps the joint at the most extended position and
prevents the contractures and provides the elon-
gation of soft tissues (Figs. 44.9 and 44.10).
Dynamic knee splint custom knee device Fig. 44.10 The facilitation of metacarpophalangeal joint
(CKD) is a custom-made brace with hinges. The extension by Kinesio taping
resistive band crossing the hinges produces pro-
longed duration and slow stretch. The flexible
fiber cast allows the patient to take on and out the
brace and to use it permanently. CKD is a custom-
made and cost-effective dynamic brace compared
to the other classic dynamic splints (Fig. 44.11).
Regarding the needs of patients, the use of CKD
for knee flexion contracture or for flexion deficits is
possible. We also use it for elbow contractures after
the removal of external fixator. When the patient is
with external fixator, we can add the brace to exter-
nal fixator with hinges [4, 7, 16, 23].
The fully implantable lengthening nails allow
the use of custom braces easily during lengthening
phase to keep knee joint on extension to prevent Fig. 44.11 The application of CKD to prevent knee flex-
knee subluxation. ion contracture on femoral lengthening
706 A. Apelyan
44.3 Nerve Injuries test before operation and then test on lengthening
phase, and we compare the results.
Nerve injuries are the most common complica- The studies show that nerve injuries happen on
tions seen during lengthening. Acute lengthen- 0.7–30% of limb lengthenings. Most of the nerve
ings often are cause of neurogenic pain and injuries develop on bifocal tibial lengthening. Nerve
nerve palsy. Nerve injuries develop rarely on injuries tend to develop on simultaneous femoral
gradual lengthenings but it takes parts. The nerve and tibial lengthenings more than single femur or
injuries develop right after the operation or dur- single tibia lengthenings. The risk of nerve injury is
ing the distraction process. The nerve injuries high for the lengthening patients with skeletal dys-
after operation are due to the surgical trauma by plasias. According to the lengthening extremity,
wires, drilling and osteotomy instruments, or to tibial nerve, fibular nerve, ulnar nerve, radial nerve,
the indirect stretch of acute correction. The or median nerve injuries are seen. PSSD is a precise
cause of the nerve injuries that develops during method comparing to the other electrodiagnostic
distraction is not as clear. Nerve injury is a con- tests to measure nerve injury. These results allow us
traindication to continue lengthening. To con- to adjust the lengthening rate and the amount of
tinue lengthening will damage the nerve and lengthening [5, 17, 20]
cause permanent nerve injury. Paresthesia and
weakness are the signs of nerve injuries.
Generally the first symptom is hyperesthesia 44.4 Positioning
along the sensory nerve and continues with hyp-
esthesia. Paresthesia and muscle weakness are The starting point to rehabilitation is to teach
late symptoms of distraction. Standard nerve patients to correct positioning of the operated
tests, near nerve transmission test, EMG, and extremity on rest. Dynamic and static splints help
NCS are applied. In addition to these tests, MRI, the patients to position. For tibia lengthenings,
CT, and ultrasound are also done. In recent years, the correct position is knee extended and ankle
the use of Pressure-Specified Sensory Device on dorsal flexion. For femoral lengthening
(PSSD) is common. patients, the knee and hip should be in extension
We use two-point discrimination test in clinics and the hip in abduction; for forearm lengthen-
(Fig. 44.12). We compare the lengthening side ings, the wrist is extended, fingers in anatomical
with the unaffected side by two-point discrimina- position; for humeral lengthenings, the elbow is
tor. When it is a bilateral lengthening, we do the extended [3] (Fig. 44.13).
Fig. 44.12 Two-point discrimination testing to measure Fig. 44.13 Patient with femoral lengthening lied in prone
peroneal nerve injury that occurred on tibial lengthening position to keep the knee and hip on extension while at rest
44.5 Passive Stretching maintain range of motion during lengthening to

and Strengthening prevent contractures. If contractures develop, it
will be hard to regain range of motion on distrac-
The cause of the muscle weakness is disuse and tion phase. It is important to do intensive therapy
joint effusion related to reversible partial reaction to prevent contractures (Figs. 44.14, 44.15, 44.16,
of degeneration and reflexive neurogenic and 44.17).
inhibition. For the lower extremities, on the postopera-
Patients start on the first postoperative day tive first day, patients start by mobilization with
strengthening and stretching exercises. Patients walker then continue with two crutches. Before
are encouraged to do exercises by themselves. discharging, we teach patients stair climbing
Home exercise program is given to patients. The and give them home exercise program, and we
loss of range of motion is important for lengthen- take them to outpatient treatment. We start
ing patients. Rehabilitation program is focused to strengthening and range of motion exercises,
cycle ergometer, CPM, resistive exercises, and
walking exercises and use some physical ther-
apy modalities.
Fig. 44.14 On femoral lengthening, stretching the knee

to get knee flexion while the hip is on extension
Fig. 44.16 Ankle dorsal flexion stretch on prone position

while the knee is on extension
Fig. 44.15 It is important to keep pelvic tilt while stretch- Fig. 44.17 Ankle range of motion exercises for patients
ing hip flexors with external fixator
708 A. Apelyan
44.6 Heat Therapy During lengthening, pain causes loss of range

of motion. Cold therapy is a modality to control
Collagen tissues are stiff with tension. Collagen pain. Cold packs, ice whirlpools, ice massage, or
tissues are more elastic when heated. Heating and cold sprays are different applications of cold
stretching together are more effective to elongate therapy to manage pain. 15 min of cold therapy is
connective tissues. Often heating is used before enough to desensitize. It reduces the pain that
stretchings to prevent musculoskeletal injury. occurred in stretching and helps for the healing.
Before stretching, superficial heating, espe-
cially hot pack treatment, is used during
15–20 min with towels to the muscle that should 44.9 Hydrotherapy
be stretched. Heating increases circulation,
increases the temperature of muscle and tissues, Hydrotherapy use especially for bilateral external
and decreases spasm. Stretching must be done fixator patients or for unilateral femur and tibia
right after heating [2]. patients prevents muscle weakness and improves
active range of motion. The buoyancy of water
compensates the fixator weight and eases muscle
44.7 Massage strengthening. The weight of fixators is heavy to
carry and makes it hard to do exercises for chil-
Joint mobilization, massage, and tractions are dren. The buoyancy of water eases movement of
manual therapy methods applied in rehabilita- extremity. It is suggested to do pool therapy with
tion. Massage increases flexibility and coordina- high chlorine level to prevent infections when
tion, increases pain threshold, and decreases external fixator is on. With the fully implantable
neuromuscular sensitivity. Massage stretches the intramedullary lengthening systems, it is easy to
muscles, extends the fascia, and mobilizes soft perform hydrotherapy because there are no pin
tissue adhesions. Massage applied before stretch- side infections or skin care problems [3].
ing increases range of motion. Myofascial relax-
ing techniques and joint mobilization techniques
take significant part of the rehabilitation [19]. 44.10 Advanced Rehabilitation
When external fixator is on, it is easy to do range

44.8 Electrical Stimulation of motion exercises but when it is off or it is a
lengthening with fully implantable intramedul-
Combining electrical stimulation with exercises is lary nail. We should be careful for exercises.
an effective technique for muscle strengthening. Especially in the first 6 weeks, we should not
The muscle strengthening stimulation pro- give torsion to the new regenerated bone level.
gram should be high enough to develop on mus- Brace application for the first 6 weeks will pre-
cle 60% of maximum voluntary isometric vent refracture. Closed chain exercises are safe
contractions. Pulse period should be close to and should be given before open kinetic chain
duration needed for chronaxie (300–600 μs). exercises. While stretching, we should stabilize
Pulse per second should be 70–80 hz. On-time the proximal bone by distal and give force to the
period should be 10–15 s; off time should be 50 s. proximal part of the distal bone. We should not
The patient should be instructed to contract his force too much while stretching.
muscles when stimulation is on. Total treatment Especially in the first 4–6 weeks, we should
should be three sets of ten contractions. not give standing exercise, squat, or some
A medium frequency biphasic stimulation stretches on standing position. In advanced stages
machine is preferable. After the operation, TENS on consolidation phase, treadmill, bicycle, step-
application to decrease pain can be done. During per, and resistive exercises, stretches on standing
rehabilitation, TENS will decrease pain [10]. position, and also proprioception exercises on
7. Finger E, Willis B. Dynamic splinting forknee flexion con-

tracturefollowing total knee arthroplasty: a case report.
Cases J. 2008;1(1):421. doi:10.1186/1757-1626-1-421.
8. Hankemeier S, Pape HC. İmproved comfort in limb
lengthening with the intramedullary skeletal kinetic dis-
tractor. Arch Orthop Trauma Surg. 2004;124:129–33.
9. Herzenberg J, Scheufele L. Knee range of motion in
isolated femoral lengthening. Clin Orthop Relat Res.
1994;301:49–54.
10. Hooker D. Electrical stimulating currents. In: Prentice
W, editor. Therapeutic modalities in rehabilitation.
Mc Graw Hill: New York; 2005.
11. Kenawey M, Krettek C. İnsufficent bone regenerate
after intramedullary femoral lengthening. Clin Orthop
Relat Res. 2011;469:264–73.
12. Krieg A, Lenze U. Intramedullary leg lengthening
Fig. 44.18 Patient with external fixator walks on tread- with a motorized nail. Acta Orthop. 2011;82:344–50.
mill without crutches on consolidation phase 13. Krieg A, Speth B. Leg lengthening with a motor-
ized nail in adolescents. Clin Orthop Relat Res.
2008;466:189–97.
defected foot or hand exercises should be done 14. Launay F, Younsy R. Fracture following lower limb
lengthening in children. Orthop Traumatol Surg Res.
(Fig. 44.18). 2013;99:72–9.
Rehabilitation is a teamwork; the team con- 15. Maffulli N, Ubaldo N. Changes in knee moton follow-
sists of patient, family, physical therapist, and the ing femoral and tibial lengthening using the ilizarov
orthopedic surgeon. Regular follow-ups and apparatus. J Orthop Sci. 2001;6:333–8.
16. McGrath M, Mont M, Siddiqui A. Evaluation of

patient attendance to treatment will provide suc- custom device fort he treatment flexion contractures
cessful results. aftertotal knee arthroplasty. Clin Orthop Relat Res.
2009;476:1485–92.
17. Noqueira M, Paley D, Bhave A. Nerve lesions associ-
ated with limb lengthening. J Bone Joint Surg Am.
References 2003;08:1502–10.
18. Paley D, Kovelman H. İlizarov technology. In:

1. Baugmart R, Burklein D. The management of leg Stauffer R, editor. Advances in operative orhopaedics.
lenght discrepancy in Ollier’ s disease with a fully St. Louis: Mosby; 1993.
implantable lengthening nail. J Bone Joint Surg Br. 19. Prentice W, Lehn C. Therapeutic massage. In: Prentice
2005;87:1000–4. W, editor. Therapeutic modalities in rehabilitation.
2. Bell G, Prentice W. İnfrared modalities. In: Prentice Mc Graw Hill: New York; 2005.
W, editor. Therapeutic modalities in rehabilitation. 20. Rozbruch R, Fryman C. Use of ulrasound in dedec-
New York: McGraw-Hill/Medical Pub. Division; tion and treatment of nevre compromise in case of
2005. humeral lengthening. HSS J. 2011;7:80–4.
3. Bhave A. Fizyoterapi ve rehabilitasyon, İlizarov cer- 21. Rozbruch SR, Kleinman D. Limb lengthening and
rahisi ve prensipleri. Çakmak M, Kocaoğlu M, edi- then insertion of an intramedullary nail. Clin Orthop
tors. doruk grafik: İstanbul; 1999. Relat Res. 2008;466:2923–32.
4. Bhave A, Baker E. Custom knee device fort he treat- 22. Sinqh S, Lahiri A. The results of limb lengthening by
ment of knee flexion contractures after İSKD femoral callus distraction using an extending intramedullary
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Psychiatric Evaluation of Patients
Using External Fixators 45
İrem Yaluğ Ulubil
Table 45.1 Defects necessitating limb-lengthening

45.1 Introduction surgery
Traumatic Fractures (injuries due to firearms or
External fixators (external stabilizing devices) traffic accidents), posttraumatic
are used in skeletal muscle trauma or for neces- sequel, malunion, etc.
sary limb reconstruction to fix congenital defects. Congenital Idiopathic, congenital diaphyseal
This technique, also known as the Ilizarov aclasis, congenital hip dislocation,
method, has been developed to rehabilitate seri- congenital equinovarus, etc.
Syndromic Blount syndrome, Ollier syndrome,
ous skeletal and soft tissue defects in both chil-
Perthes syndrome, and
dren and adults [1]. neurofibromatosis
The method has been developed by the Oncological Tumors
Russian orthopedist, Dr. Gavriil Ilizarov primar- Rheumatic Juvenile chronic arthritis etc.
ily to treat nonunion of bones. In time it has been Infectious Osteomyelitis, septic arthritis, polio,
used for lengthening of arms and legs in children etc.
with achondroplasia (a type of dwarfism). The
Ilizarov device consists of metal rings, rods,
wires, and screws. The device is mounted onto surgery using the Ilizarov method can be consid-
the bone externally by cutting through the bone ered. Using this method in people with achondro-
cortex. A week after osteotomy, in order to ben- plasia, leg elongation of 40–50 cm has been
efit from the bone healing properties of osteo- achieved after 3–4 sessions of surgery [3, 4].
blasts, the screws of the device are turned a Besides limb lengthening, the method can also be
quarter of the way for every day, every 6 h, thus used for conditions needing limb reconstruction
slowly lengthening the bone ends millimetrically. due to traumatic fractures (Table 45.1) [5, 6].
If the device is used for a bone lengthening, it
stays on the body for 5–6 weeks for every centi-
meter of extension [2, 3]. 45.2 Psychiatric Significance
When the difference of length between the two
legs is equal to or greater than 4 cm, leg-lengthening Due to its long, complicated, and risky nature,
this procedure is very stressful for the patient,
patient’s relatives, and sometimes for the health
İ.Y. Ulubil, Prof., MD professionals. The applications carry high risk of
Acıbadem University School of Medicine,
Istanbul, Turkey
e-mail: dryalug@yahoo.com

https://doi.org/10.1007/978-3-319-45675-1_45
712 İ.Y. Ulubil
complications (infections around the screws and psychiatric responses may be observed in caregiv-
other areas, pain, recurrence, joint stiffness, bone ers who will provide care to patients living with an
dislocation and fractures, early or late union of external fixator for a period of time. This situation
bones, flexion deformity, foot deformities, nerve may negatively impact the patient’s treatment,
and vein problems, etc.). Seventy percent of the decrease the quality of care, and may cause the
patients experience complications such as infec- patient to not comply with rules about cleaning the
tion or late recovery [3–5]. areas around the screws, resulting in extreme
The application of the Ilizarov circular external anger, sensitivity and thoughts of guilt, along with
fixator poses challenges in performing everyday a depressed outlook, and avoiding regular controls
tasks; it hinders the ability of the individual to take of the fixator. In patients who will have an external
care of their basic physical needs and disrupts the fixator treatment, conditions such as mental retar-
functionality of the patient. This results in psycho- dation, psychotic disorder, impulse control disor-
logical reactions. It may also result in psychoso- der, chronic psychiatric conditions that might be
cial and physical responses from the patient’s triggered by stressed (schizophrenia, bipolar dis-
relatives and healthcare providers [4, 7–9]. In order, major depressive disorder, etc.) personality
addition, the duration of the procedure, coupled disorder, and alcohol and/or substance abuse
with the possibility of the extension of the process should be accounted for before the treatment in
due to complications, uncertainty of prognosis, order to evaluate whether or not they will interfere
may affect the response of the patient and the with the treatment. If deemed necessary, psychiat-
patient’s caregivers. While the device is mounted, ric help should be sought.
in order for physical activity to continue, trained Before the procedure, careful attention should
nurses/caretakers are needed for daily and weekly be paid to communicate to the patient and the
care of the screws. During this time, even simple patient’s relatives, the various challenges and the
activities are challenging; the patient might need requirements of the treatment, as well as ensuring
help with personal hygiene and self-care [1, 10]. that they are motivated and are psychologically
In caregivers who provide care to patients (e.g., resilient. Sufficient multidisciplinary support
caregivers for plegic patients) unable to go on with should be provided [3].
their daily lives, psychiatric symptoms and disor- In determining suitability of patients, it is
ders such as anxiety, depression, anger control important to do background research on the
issues, somatization problems, sleep difficulties, patient’s personal and family psychiatric history
and interpersonal problems are observed. Similar for alcohol and substance abuse (Table 45.2).
Table 45.2 Suggestions for evaluation prior to surgery

Psychiatric Determining and stabilizing any illnesses that might prohibit surgery, providing additional
symptoms interventions if necessary, and evaluating the adaptability skills of the patient and the patient’s
family for long-term treatment
Patient education Group sessions with patients who have received the treatment before, setting realistic goals and
prior to surgery expectations
Pain management Administering the appropriate dosage of analgesics
Family support Evaluating the support system of the patient, determining other family stressors
Adaptation Evaluation of the patient and the patient’s family for their adaptation and accord with
directions, continuity in treatment and controls, etc.
Treatment goals Ensuring that the patient, the patient’s family, and the healthcare team have the same goals and
expectations from the treatment
Effective factors Evaluation of factors such as school, work, siblings, etc. that might affect long-term treatment
and providing support for new arrangements
Sleep hygiene Learning about sleeping habits prior to surgery and making suggestions for sleep hygiene and
habits in accordance with age
Cited from Richard et al. (2015) [17]
45 Psychiatric Evaluation of Patients Using External Fixators 713
Despite the fact that studies on the psychoso- [9]. The literature on this topic is predominantly
cial effects of external fixator use have proved to about the child and adolescent population. This is
be inconsistent, it is observed that patients expe- due to the fact that the external fixator treatment
rience psychiatric problems during and after fix- was initially used for leg lengthening in syn-
ator use. Yıldız et al. (2005) demonstrated that in dromic illnesses during childhood. Its use among
patients undergoing the external fixator treat- adults was adopted later, and there have not been
ment, SCL-90-R scale for somatization, interper- many studies evaluating the psychiatric effects on
sonal sensitivity, depression, anxiety, anger and adults.
hostility, paranoid thoughts, additional symp- In a study conducted by Martin et al. (2003),
toms, and general symptoms were significantly coping mechanisms of adolescents receiving the
higher than the control group. These patients external fixator treatment were studied. It was
have also expressed frequent sleep problems. determined that adolescents prior to the treatment
Adaş et al. (2015) [18] suggested that these were most likely to engage in emotional regula-
patients might in addition have reduced sexual tion (e.g., increase in expression of emotions)
functionality. and were least likely to engage in problem-
These psychiatric symptoms observed in the solving and acceptance. After treatment, during
patient may cause disruptions in the patient’s the early stages, they were most likely to engage
daily tasks, resulting in the reduction of the qual- in emotional regulation and used coping mecha-
ity of treatment as well as the success of the treat- nisms such as wishful thinking, cognitive restruc-
ment. Hospital stay might be extended due to turing, social support (family and peer support),
noncompliance with treatment and complications problem-solving, and acceptance and used these
and challenges faced by the healthcare team. mechanisms with equal frequency. After the
Studies have shown different results for psy- removal of the device, emotional regulation,
chiatric symptoms. While Ramaker et al. (2000) social support, and cognitive restructuring mech-
showed that the procedure does not cause signifi- anisms were employed. As part of these coping
cant psychological problems, Ghoneem et al. mechanisms, peer support in adolescents has
(1996) demonstrated that most patients exhibit been highlighted as an important factor for the
normal psychological symptoms. Hrutkay and adjustment period. During longer hospital stays,
Eiler (1990) on the other hand showed that 63.6% more flexible visitation hours or more privacy for
of the patients exhibited a temporary condition the patient is recommended. Engaging in group
such as adjustment disorder, and Yıldız et al. sharing sessions with other adolescents who have
(2005) showed that 52.4% of the patients exhib- received this treatment before and keeping video
ited at least one psychiatric symptom. diaries have been suggested as beneficial to the
The most common symptoms were anger and process.
hostility, which were exhibited in 37.5% of the The parents of children and adolescents under-
patient population. Due to the limiting effects of going external fixator treatment might also expe-
the device on the daily life of the patient, it might rience psychosocial difficulties. Niemala et al.
pose challenges in interpersonal roles and might (2007) evaluated 27 children patients and their
cause unconscious conflicts to resurface. Loss of parents altogether. They studied the patients and
autonomy, feelings of restriction, and depen- their families for anxiety, depression, self-
dence on others might be triggering anger. Anger confidence, cognitive skills, maladaptive symp-
in turn might interfere with interpersonal rela- toms, behaviors, and defenses. Self-confidence in
tionships. The patient might develop maladaptive the patient group was significantly lower than that
defenses in response to the challenges of the of the control group prior to treatment. Depression,
treatment. Over time these defenses might cause anxiety, aggressive behavior, attention problems,
the patient to become less resilient, make it more and externalization score lowered after the treat-
difficult to find a solution, eventually result in ment. One year after the treatment, permanent
depression, anxiety, and interpersonal sensitivity mental health issues were not observed. When
714 İ.Y. Ulubil
parents of patients are taken into consideration, it tact. Lee-Smith et al. (2001) state that screws that
is observed that they experience high anxiety, they are anchored to the bone might cause a direct and
have difficulty coping with the pain and chal- obvious humiliation in the perception of the
lenges their children face during the treatment, patient’s body image. In this process, the patients
and they are psychosocially and practically bur- have a very active and big responsibility in alter-
dened with the various requirements of the treating their body image. Body image perception and
ment (time-wise, economic, and physical). Some self-respect are reported to be closely correlated.
parents with high adaptation skills expressed that Therefore a patient experiencing a change in their
accepting the difficulties and overcoming the perception of their body might also experience
challenges associated with the treatment enriched loss of self-respect, further exacerbated by the
their lives. loss of control due to their dependence on others
Other studies have determined that depressive [10–14].
symptoms continued in very few patients after Patients having to live with the device might
the removal of the device. Moraal et al. (2009) draw attention in public. While some patients can
[15] followed the patients long-term after the cope with this well, others avoid going to public
treatment and showed that self-sufficiency and places. Societal labeling is one of the difficulties
self-confidence in the patients were within the these patients face [9–12].
normal range, although lower when compared to Ramaker et al. (2000) state that sleep prob-
the normal population; quality of life compared lems are the most widespread psychiatric symp-
to pretreatment had improved for the patients. tom observed during the external fixator
During the application of the external fixator, treatment. Yıldız et al. (2005) specify that 32.5%
when scores for lack of self-confidence, depres- of the patients experienced sleep problems. They
sion, and anxiety are taken into account, children attribute this to pain and restrictions on mobility
exhibit a better overall mental health profile than caused by the device.
adults [3, 4]. Ramaker et al. (2000) in their study There are few studies looking at the impact of
evaluated children and adolescents for their aca- external fixator use on sexual activity in adults. In
demic success. They demonstrated that during a study conducted on the effect of external fixator
treatment, children had reduced academic suc- treatment in males who received the treatment in
cess but after treatment, they were able to achieve their lower extremities, 89% had sexual func-
the same level of academic success that they had tional difficulties; however, these were not per-
prior to treatment. They did not find a significant manent. They have mentioned that these sexual
difference for their social activities and commu- functional difficulties could have been a result of
nication with friends during treatment. While eat- physical, psychological, and social constraints.
ing habits and appetite were not significantly It can be assumed that living with a device that
different during treatment in their study, Hrutkay does not belong to a person’s body can be a dif-
et al. (1990) showed loss of appetite during ficult process. In studies conducted with patients
treatment. receiving prosthetics after a lower extremity
Perception of body image is shaped by per- amputation, psychosocial factors have been
sonal history of defects, whether or not they are shown to have significance during the patient’s
congenital or later acquired in life as well as cul- acceptance of the prosthetic. Anxiety, depres-
tural values and norms that define the ideal body sion, and body dysmorphia influence the use of
image. A person’s perception of normal might be the prosthetic. It has been suggested that in addi-
related with whether or not that person would tion to rehabilitation, psychiatric support and
decide to opt for a leg-lengthening operation or evaluation will help increase the chance of suc-
fixing of a defect. After the device is mounted, cess in prosthetic use [19–21].
the person might experience changes in percep- Adaptation to the use of an external fixator
tion of their body image [16]. They might try to device takes a long period of time, patient support
hide the device with clothes or avoid social con- groups, educational classes, and physiotherapy
45 Psychiatric Evaluation of Patients Using External Fixators 715
groups might help the patient during this long mental health? an interim report one year after sur-
gery. J Pediatr Orthop. 2007;27:611–7.
treatment time. Parental evaluation and support is
7. Ghoneem HF, Wright JG, Cole WG, Rang M. The
crucial, especially for children at high psychoso- Ilizarov method for correction of complex deformi-
cial risk due to high parental anxiety, separation ties. Psychological and functional outcomes. J Bone
of parents, or economic difficulties [6, 10]. Joint Surg Am. 1996;78(10):1480–5.
8. Hrutkay JM, Eilert RE. Operative lengthening of the
Despite all the difficulties, complications and
lower extremity and associated psychological aspects:
chance of failure in the treatment, most of the the children’s hospital experience. J Pediatr Orthop.
patients have expressed that they would still 1990;10(3):373–7.
choose to have the treatment again. Ghoneem 9. Yildiz C, Uzun O, Sinici E, Atesalp AS, Ozsahin
A, Basbozkurt M. Psychiatric symptoms in
et al. (1996) showed 87% and Ramaker et al.
patients treated with an Ilizarov external fixator.
(2000) showed 67% of the patients would still [Article in Turkish]. Acta Orthop Traumatol Turc.
undergo the treatment again. According to the 2005;39:59–63.
data obtained by the patient feedback, it is possi- 10. Santy J et al. The principles of caring for patients
with Ilizarov external fixation. Nurs Stand.
ble that effective patient and family training and
2009;23(26):50–5.
support groups have contributed to these results. 11. Limb M. Psychosocial issues relating to external
Patients who might have had low self-esteem fixation of fractures. Nurs Times. 2003;99(44):
prior to treatment might have increased self- 28–30.
12. Limb M. An evaluation survey of self-concept issues
esteem after positive results from the treatment.
in adult clients undergoing limb reconstruction proce-
In conclusion, some psychiatric symptoms are dures. J Orthop Nurs. 2004;8(1):34–40.
exhibited in patients receiving the Ilizarov exter- 13. Cash TF, Pruzinsky T. Body images: development,
nal fixator treatment as well as the relatives of deviance and change. NY: Guilford Press; 1990.
14. Lee-Smith J. Pin site management. Towards a consen-
these patients. Therefore, psychiatric states of
sus part 1. J Orthop Nurs. 2001;5:37–42.
these cases should be taken into consideration 15. Moraal JM, Elzinga-Plomp A, Jongmans MJ, et al.
during evaluation. Long-term psychosocial functioning after Ilizarov
limb lengthening during childhood. Acta Orthop.
2009;80(6):704–10.
16. Coglianese DB, Herzenberg JE, Goulet JA. Physical
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Index
A B
Abduction deformity, 454 Bed rest, 197, 360, 362, 369
ACA. See Angulation correction axis (ACA) Bilateral Pauwels valgization osteotomy, 369, 370
Achterman-Kalamchi classification, fibular hemimelia, Biofilm, 608
494, 496 antibiotic-resistant strains, 608
Acute angulation technique, 112–122 bisphosphonates, 608
Acute osteomyelitis, 608, 609 cell-to-cell signaling, 608
ADAM frame, 555 in clinical settings, 608
ADTA. See Anterior distal tibial angle (ADTA) definition, 607
Adult stem cells (ASC) formation of, 608
bone callus phase, 24 structural analyses, 608
cartilage callus phase, 23–24 Biplanar deformity. See Oblique plane deformity
hematoma phase, 21 Birch classification, fibular hemimelia, 494, 497
inflammation phase, 21–23 Bisector line, 340–341
Angulation correction axis (ACA), 281–283 Blumensaat’s line, 267, 268, 302, 303
Angulation-translation deformity. See Translation- Bolts
angulation deformity central, 100
Ankle brachial index (ABI), 107 connection, 30
Ankle deformity rotations, 42
classification, 413 wire fixation, 30, 31
distal tibia Bone clamp, 3
on frontal plane, 414–426 Bone deformity, 473–477
on sagittal plane, 426–431 Pennig II Dynamic Wrist Fixator, 487–488
equinus deformity, 431–434 periarticular application, 488–489
with extremity shortness, 437, 438 rehabilitation, 693
flexible hybrid frame method, 438–439 soft tissue contractures treatment, 489
Ilizarov method, 413, 434–437 transarticular application, 489
percutaneous subtotal tenotomy, 434 Bone formation, in embryo. See Embryonic stem cell (ESC)
Ankle flexion contractures, 679 Bone morphogenetic protein (BMP), 19
Anterior distal tibial angle (ADTA), 271–272, 303, 305 Bone transport over nail (BTON), 656–659
Anterior external fixator, 205, 207–209 complications, 664–665
Arbeitsgemeinschaft für Osteosynthesefragen (AO), 130 contraindications, 659
Arches, 27–29 femoral, 661–664
ASC. See Adult stem cells (ASC) indications, 659
a-t osteotomy, 92–93 postoperative care, 663–664
Atrophic pseudoarthrosis, 570 preoperative planning, 659
defected pseudoarthrosis, 570 surgery, 659–661
fragmented type, 569–570 tibial, 663, 665–666
torsion wedge type, 569, 570 Bowing deformity. See Diaphyseal deformity, of tibia
Avascular necrosis Brodie abscess, 609
risk of, 90 BTON. See Bone transport over nail (BTON)
after treatment, 376, 549 Bushes and washers, 32, 33

https://doi.org/10.1007/978-3-319-45675-1
718 Index
C Clinodactyly, 463–464
Çakmak guide, 205, 206 Closed-wedge hinges, 51
Calcaneus Closed wedge osteotomy, 90–91, 384
dorsiflexion deformity of, 441 Combined deformity, 330. See also Rotation-angulation
osteotomy, 448 deformity
Camptodactyly, 462 Compartment syndrome, 676
Carpal bones, 469 Complex elbow dislocation, 169–170
Casting disease, 189 Compression hinge, 52
C-clamped external fixator, 207 Computed tomography (CT), 130
Center of rotation of angulation (CORA), 339, 340, 342, deformity, 243
344–346 rotation deformity, 327
closing wedge osteotomy, 90, 91 Computer-assisted fixators. See also Ilizarov external
diaphyseal deformity, of tibia, 404, 405, 407 fixator (IEF)
dome osteotomy, 93 ADAM frame, 555
external fixator, 100 deformity ring, 556
frontal plane deformity, tibia, 300, 301 vs. Ilizarov external fixators, 558
multiapical deformity, 285, 286, 289, 291, 292 Ortho-SUV fixator, 554, 555
open wedge osteotomy, 91, 92 rotation-angulation deformity correction, 332–335
procurvatum deformity, 429–430 rotation deformity correction, 330
recurvatum deformity, 426–427 TL-Hex system, 555
valgus deformity, 423, 424 translation-angulation deformity correction, 320, 325
varus deformity, 419 treatment, 560
Central deficiency, 462 after frame removal, 562
Cervical coxa vara. See Coxa vara deformity correction, 561
Charney external fixator, 395 postoperative X-ray, 562
Chronic osteomyelitis, 606 procurvation and varus deformity, 559
surgical treatment, local antibiotics spatial frame, 559
aggressive surgical debridement, 611 weight bearing, 561
autogenous bone graft, 611, 613 TSF, 554
BMP-2-implantation/fibula and iliac crest bone two-finger rule, 555, 556
chips implantation, 612, 617 X-ray, 556–558
bone grafting, 611, 617 See also Ilizarov external fixator (IEF)
bone reconstruction, 610 Congenital coxa vara. See Coxa vara
bony consolidation, 611, 614, 615 Congenital fibular deficiency
callus distraction, 611, 614 Achterman-Kalamchi classification, 496
clinical outcome, 611, 612 Birch classification, 494
defect filling, 612, 616 Coventry classification, 496
en bloc resection, 610, 613, 614, 616 Paley classification, 494, 498
external fixation, 610 Congenital pseudoarthrosis, of tibia, 527–531
gentamicin-PMMA beads, 610, 611, 613–615 Congenital tibial deficiency, 506
gunshot injury, thumb, 611 Congenital upper limb deformity
hematogenous osteomyelitis, 609, 614 camptodactyly, 462
minimal invasive plate osteosynthesis, 611, 613 central deficiency, 462
monosegmental transport, 614, 615 clinodactyly, 463–464
morbidity and functional impact, 610 macrodactyly, 464
plate arthrodesis, iliac crest bone interposition, polydactyly, 464
611, 612 radial deficiency, 461–463
radial flap, distal pedicle, 611, 612 syndactyly, 462
radical surgical debridement, 610 synostosis, 464
therapeutic regimen, 610, 611 transverse deficiency, 462
symptoms, 608 ulnar deficiency, 462, 463
Cierny and Mader classification system, 609 Connection bolts and nuts, 30, 31
Circular external fixator (CEF) Contractures. See Knee joint contractures
anatomic structures, 83 Cosmetic stature lengthening, 667
fixation, 85–86 Coventry and Johnson classification, fibular hemimelia,
knee arthrodesis, 400 494, 496
open book injury, 210 Coxa valga deformity, 373–374
proper Ilizarov frame, 84 Coxa vara deformity
reduction, 206, 208 acquired reasons, 368
Index 719
bilateral Pauwels valgization osteotomy, 369, 370 high-energy mechanisms, 129

compensatoire valgus deformity, 369, 371 Ilizarov circular external fixator fixation, 133–134
compressive forces, 369 locking and LISS plates, 133
congenital reasons, 368 treatment
conservative approaches, 369 goals, 131–132
developmental, 367 Ilizarov CEF fixation system, 134–141
external fixators, 369 surgical methods, 132–134
Fairbank classification, 368 wedge plates, 133
fibrous dysplasia, 370, 372 Distal femur deformity
Hilgenreiner-physeal angle, 369 circular-type external fixator, 377, 378
incidence, 367 CORA, 379
lateral proximal femoral angle, 367 deviation in mechanical axis, 377
medical examination, 368 knee flexion contracture case, 380
osteogenesis imperfect, 370, 372 mechanical lateral femoral distal angle, 377
proximal focal femoral deficiency, 370 monoplanar external fixators, correction with, 379
rickets, 370, 372 open-up osteotomy, 377, 378
subtrochanteric osteotomy, 369, 370 supracondylar femur extension osteotomy, 380
treatment goal, 369 Distal forearm fractures, 184–186
valgization osteotomy, 369, 372 Distal hinges, 55–57
X-ray view, 367, 368 Distal radius fractures
C-reactive protein, 609 classifications, 168, 169
Custom-made hinges, 47 elbow fracture-dislocations, 169–171
external fixation, 169, 170
external fixator use, 167
D functional anatomy, 167–168
Deformity, 689 hinged external fixator application, 171
definition, 461 treatment, 168
normal anatomy, 241 Distal system
radiologic imaging applications to femur, 73–75
block sizes, 242, 243 application to tibia, 78–79
CT, 243 connections, of distal block, 63
EOS, 244 guide ring, 62–63
orthoroentgenogram, 243 support ring, 62
patella positioning, 242 Distal tibia deformity
plain radiographs, 242 on frontal plane
scanogram, 243 mechanical axis, of lower extremity, 414, 415
teleroentgenogram, 242–243 valgus deformity, 422–426
reoccurrence of, 687, 688 varus deformity, 416–422
standard values, 241 on sagittal plane
treatment, 490–491 procurvatum deformity, 429–431
Degenerative arthropathy, 383 recurvatum deformity, 426–429
Developmental coxa vara. See Coxa vara Distraction interposition arthroplasty, 171–172
Diaphyseal deformity, of tibia Distraction osteogenesis, 3, 7, 693
CORA, 404, 405, 407 advantages, 384
D-shaped deformity, 404 consolidation phase, 11
fixator-assisted plating, 404, 406 external fixator devices, 11
frontal plane deformity after Ilizarov’s mistake, 11
tibia valga, 407–408 stem cells
tibia vara, 403–407 ASC, 21–24
oblique plane deformity, 404 definition, 12
O-shaped deformity, 404, 405 ESC, 13–21
osteosynthesis, 404, 405 niches, 13
sagittal plane deformity proliferation and differentiation
genu recurvatum deformity, 408, 409 processes, 12, 13
procurvatum deformity, 408, 410 symmetrical and asymmetrical
Distal femoral fractures division, 12, 13
anatomy, 129–130 temporary histopathological changes, 12
classification, 130, 131 Dome osteotomy, 93
clinical evaluation, 130, 131 D-shaped deformity, of tibia, 404
720 Index
Dual-axis hinges, 57 hand injury, 631, 633

Dynamometric tension device, 42 humeral injury, 629, 630
Dystrophic pseudoarthrosis, 569 knee, 626
shoulder injury, 629
tibia, 626, 627
E vascular and nerve injury, 628
Elbow flexion contractures, 679–381 Extremity edema, 688
Elbow flexion deformity, 471–472
Elbow joint contracture, 473–477
Embryonic stem cell (ESC) F
appendicular skeleton, 20 Fairbank classification, coxa vara, 368
BMP, 19 Familial hypophosphatemic rickets, 543
chondrocytes, 19–20 FAN. See Fixator-assisted nailing (FAN)
daughter cells, 13–14 Femoral condyles
discs, 15 level of, 213
embryonic development, 16–17 proximal tibial joint surface, 259
EMT, 15 tibia plateau, 259
epiblasts and hypoblasts, 14–15 Femoral deformity
epigenetic transformation, 14 coxa valga, 373–374
external cell groups, 14 coxa vara
mesenchymal and cartilage tissues, 20 acquired reasons, 368
MET, 18 bilateral Pauwels valgization
metalloproteinase, 16 osteotomy, 369, 370
neural tube development, 15–16 compensatoire valgus deformity, 369, 371
paraxial-intermediate-lateral mesoderm, 19 compressive forces, 369
Sonic Hedgehog (Shh) genes, 19 congenital reasons, 368
transforming growth factor, 19 conservative approaches, 369
vascularization, 16 developmental, 367
Epithelial-mesenchymal transition (EMT), 15 external fixators, 369
Equinus deformity, 431–434 Fairbank classification, 368
causes, 432 fibrous dysplasia, 370, 372
clinical categories, 432 Hilgenreiner-physeal angle, 369
clinical measurement, 432–433 incidence, 367
definition, 431 lateral proximal femoral angle, 367
with extremity shortness, 437, 438 medical examination, 368
radiography measurement, 433, 434 osteogenesis imperfect, 370, 372
ESC. See Embryonic stem cell (ESC) proximal focal femoral deficiency, 370
External fixation, 3 rickets, 370, 372
angular deformity correction, 98, 99 subtrochanteric osteotomy, 369, 370
circular fixator, 99, 100 treatment goal, 369
femoral apparatus, 99, 100 valgization osteotomy, 369, 372
four-ring apparatus, 99, 100 X-ray view, 367, 368
gradual deformity correction, 96–97 distal femur deformity, 377–380
proximal femur defects, 357 slipped capital femoral epiphysis, 374–377
rotation and translation, 101–104 Femoral fixation levels. See also Femur diaphysis
two-ring apparatus, 99, 100 fractures
varus deformity, 102 at eighth level, 217–219
External fixator (EF), 384 at fifth level, 216, 217
coxa vara, 369 at first level, 213, 215
development, 703 at fourth level, 215, 216
femur diaphysis fractures (see Femur diaphysis half rings, 213, 214
fractures) Italian femoral arches, 213, 214
IEF (see Ilizarov external fixator (IEF)) at second level, 215
knee arthrodesis, 397–398 at seventh level, 216, 218
limb lengthening, 703 at sixth level, 216, 217
psychiatric significance, 703–707 by Solomin, 213, 214
warfare surgery, 621–625 at third level, 215, 216
ankle and foot, 627–628 Femoral notch, 246, 247
elbow injury, 631–633 Femoral osteotomy
femur, 625 fixed flexion deformity of knee, 391
forearm injury, 630–631 varus deformity, of knee, 384
Index 721
Femur diaphysis fractures. See also Femoral Scythe osteotomy, 438–439

fixation levels Focal dome osteotomy, 93
frame for 1/3 distal Foot deformity
building frame, 221 classification, 441
operation technique, 221–222 frontal plane deformity
postoperative period, 222 valgus deformity of heel, 451–452
frame for 1/3 medial varus deformity of heel, 450–451
building frame, 221 horizontal plane deformity
categories, 221, 222 abduction deformity, 454
operation technique, 221–222 metatarsus adductus, 452–455
postoperative period, 222 multiplanar deformity
frame for 1/3 proximal adduction of calcaneus, 457
building frame, 219–220 cavus, 457
operation technique, 219–221 clinical photos, 458–460
postoperative period, 221 correction, 458
Fibronectin, 606 definition, 454
Fibular anlage excision, 499, 502 equinus, 457
Fibular hemimelia etiology, 454, 456
acetabular orientation operations, 496 forefoot adduction, 457–458
Achterman-Kalamchi classification, 494, 496 supination, 457
Birch classification, 494, 497 treatment, 456–458
characterization, 494 varus, 457
clinical and radiological manifestations, 502–504 V osteotomy, 458
complications, 500–501, 504–505 sagittal plane deformity
conservative treatment, 495 pes calcaneus, 449–450
Coventry and Johnson classification, 494, 496 pes cavus, 441–447
embryonic development, 493 pes planus, 447–449
etiology, 494–495 Forearm deformity
foot-ankle X-rays, 495 after surgery, 487
Ilizarov frame application and deformity correction, classification, 480, 481
497–505 complications, 487
knee X-ray, 495 principles, 481–487
lengthening osteotomy, 496 Forearm fractures
lower extremity orthoroentgenography, 495 distal forearm fractures
Paley classification, 494 galeazzi fracture, 186, 187
pathologic anatomy, 493–494 middle-distal 1/3 ulna fractures, 184
physical examination, 495 mistakes and complications, 186
preoperative graphs and clinical manifestation, 501 monteggia fracture, 186
preoperative surgical evaluation, 496 postoperative follow-up, 186
SUPERankle procedure, 496, 499 1/3 radius fractures, 184, 186
supramalleolar osteotomy, 496 ulna fractures, 186
surgical treatment, 496–497 middiaphyseal fractures
Fixator-assisted nailing (FAN), 346, 349 anatomic considerations, 181–183
contraindications, 651 1/3 radius fractures, 183
equipment, 652 ulna fractures, 183, 184
for femoral deformity, 652–654 proximal fractures
imaging study, 651 olecranon fractures, 177–180
indications, 650–651 1/3 radius fractures, 180–181
physical examination, 651 ulna fractures, 181
positioning, 652 X-ray
postoperative period and follow-up, 656–660 after Ilizarov external fixator, 187
preoperative planning, 651–652 after treatment, 188
for tibial deformity, 654–656 preoperative, 187
Fixator-assisted platin, 94–95 Frames
Fixed flexion deformity (FFD) applications to femur
distal femur, 306, 307 check, 74–76
of knee, 391 distal system, 73–75
sagittal plane deformity, 391 proximal system build, 71–73
Flexible hybrid frame method, ankle deformity application to tibia
complications, 439 check, 79–81
correction, 439 distal system, 78–79
722 Index
Frames (cont.) G
intermediate system, 77–78 Galeazzi fracture, 186, 187
proximal system, 76–77 Ganz-type fixators, 205, 207
build, 84–85 Gartland type III supracondylar fractures, 190
during operation, 64–68 Genu recurvatum deformity, 408, 409
before surgery, 69–70 Genu valgum deformity, 71, 297, 332, 403, 548–550
distal system Genu varum, 403
connections, of distal block, 63 deformity, 384, 385
guide ring, 62–63 Gigli saw technique, 73, 384, 556, 639, 663
support ring, 62 Gigli wire, 35
foot in, 87 Gunshot injury
principles, 59 bone and soft tissue debridement, 622, 623
proximal system lower extremity
connections, of proximal block, 61–62 ECF fixator application, 623, 624
proximal main support ring, 59–60 fasciotomy, 623
pushing/pulling ring, 60–61 femoral intramedular nail fixator application, 625
rotation deformity correction, 328 foot frame fixator application, 627
system connections, 63–64 tibial ECF fixator application, 626, 627
Frontal plane deformity, 377 unilateral fixator application, 623, 624
femoral axis upper extremity
anatomic axis, 247, 248, 250 elbow injury, 631–633
femoral head center determination, 245–247 forearm injury, 630–631
joint orientation lines, 250, 251 hand injury, 631, 633
LDFA, 252, 253 humeral injury, 629, 630
LPFA, 251 shoulder injury, 629
mechanical axis, 247, 250 vascular and nerve injury, 628
MNSA, 252 Gustilo-Anderson classification, 227, 228
MPFA, 251–252
femur
anatomic planning, 297–300 H
MAD, 295, 296 Half hinges, 46
mechanical planning, 296–298 Half rings, 27, 28
tibia, 298 Hardware
CORA, 300, 301 a-t osteotomy, 92–93
DMA, 299, 301 closing wedge osteotomy, 90–91
MPTA, 300, 301 dome osteotomy, 93
PMA, 299, 301 external fixation
tibial axis angular deformity correction, 98–99, 101
anatomical axis, 248, 249 circular fixator, 99, 100
distal joint center determination, 248, 249 femoral apparatus, 99, 100
joint orientation lines, 250 four-ring apparatus, 99, 100
LDTA, 252, 253 gradual deformity correction, 96
mechanical axis, 248, 249 rotation and translation, 101–104
MPTA, 252, 253 two-ring apparatus, 99, 100
tibia valga, 407–408 varus deformity, 102
tibia vara, 403–407 factors, 89
valgus deformity of heel IMN, 96–99
clinical features, 451 lever arm principle, 105
definition, 451 opening wedge osteotomy, 91–92
diagnosis, 452 order of correction, 104–105
etiology, 451 patient age, 89–90
treatment, 452 plate fixation, 94–96
varus deformity of heel Head-neck line, 260, 261
clinical features, 450–451 Heat therapy, 700
definition, 450 Hexapodal systems (HS), 235–236, 678–679
deformity diagnosis, 451 Hilgenreiner-physeal angle, 369
etiology, 450 Hindfoot equinovalgus deformity, correction, 499
technique, 451 Hinges
treatment, 451 benefits, 45
Full rings, 27, 28 build, 45
Index 723
custom-made, 47 Ilizarov external fixator (IEF), 45. See also Computer-

half hinges, 46 assisted fixators
plates, 46–47 diaphyseal and metaphyseal fracture (see Tibial
polyaxial, 47 fracture)
posts, 46 pediatric fracture
correction speed with, 57–58 advantages, 189–190
correction time with, 58 complications, 193
dual-axis, 57 femur, 191–192
position, 85 humerus, 190–191
bisector line, 49–52 indications for, 189
distal, 55–57 postop care, 193–194
for osteotomy, 282 tibia, 192–193
principles, 48–49 stimulation of osteogenesis, pseudoarthrosis
proximal, 52–54 monolocal consecutive compression and
treatment, translation-angulation deformity distraction, 574, 593–594
correction, 318–325 monolocal longitudinal compression, 571,
Hip deformity 574–576
anteroposterior x-rays, 351, 352 monolocal longitudinal distraction, 574,
distal compensatory osteotomy, 351, 353 582–586
hip arthrodesis, 355, 356 monolocal oblique compression, 572, 579–581
Ilizarov frame, 351–352 monolocal oblique distraction, 574, 587–589
preoperative planning, 351 monolocal simultaneous compression and
proximal femur defects, 357–360 distraction, 574, 589–592
proximal osteotomy, 352, 353 monolocal transverse compression, 571–572,
Hip malorientation test 577–579
head-neck line, 260, 261 Ilizarov’s method
LDTA, 260–265 ankle deformity, 413, 434–438
trochanter-head line, 260 calcaneal wires, 436, 437
Horizontal plane deformity equinus deformity, 435–436
abduction deformity, 454 Ilizarov rigid frame illustration, 434, 435
metatarsus adductus, 452–455 K-wire applications, to tibia, 434–435
Humeral external fixator application technique, 173–175 medium tibial ring fixation, 435
Hydrotherapy, 700 metatarsal heads, wires on, 436–437
Hyperextension (HE) deformity, 306, 307 midtarsal region, wires on, 436
Hypertrophic pseudoarthrosis proximal ring, 436
elephant foot, 568–569 Schanz screw fixation, 435
horse hoof, 569 application history, 6
oligotrophic type, 569 complications
Hypophosphatasia after frame remove, 689–690
infants, 549, 551 awareness, 683
pathology, 549 classification, 683–684
TNSALP, 549 delayed consolidation, 688–689
treatment, 551 early union, 687
Hypovolemic shock, 200, 203 extremity edema, 688
during frame application, 684
implant failure, 688
I joint contractures, 685–686
Ilizarov applications joint subluxations, 686–687
CEF, 85–86 neurologic symptoms, 687
frames, 84–85 pain, 687
hinges, 85 pin track infection, 684–685
including adjacent joint, 87 reoccurrence of deformity, 687, 688
K-wires, 83–84 risk factors, 688–689
osteotomy, 87 routine lengthening, 7–10
rehabilitation, 87–88 Turkish ASAMI, 8
Schanz screws, 83–84 X-rays, 7
soft tissue, safety of, 86–87 Ilizarov-type external fixators
Ilizarov classification arches, 27–29
loose-type pseudoarthrosis, 570, 571 bushes and washers, 32, 33
stiff pseudoarthrosis, 570–572 connection bolts and nuts, 30, 31
724 Index
Ilizarov-type external fixators (cont.) transfixation, 37, 38

full rings, 27, 28 wire tensioners, 38
Gigli wire, 35 Klein’s line, 375
half rings, 27, 28 Knee arthrodesis
K-wire, 33 Charney external fixator, 395
L-type connectors, 33 circular external fixator, 400–401
omega rings, 27, 28 external fixators, 397–398
posts, 30 goals, 395
5/8 rings, 27, 28 intramedullary nailing, 395
rods, 29 monoplanar fixators, 398
Schanz screws, 34 patient preparation, 398–399
square sockets, 32 post implant removal, 396
telescopic rods, 29–30 surgical techniques, 399–400
threaded socket, 32 TKA infection, 395–396
translation rotation device, 34 unilateral external fixator, 396–398, 400
universal socket, 30 unilateral fixators, 397–398
wire fixation bolts, 30, 31 X-ray views, 397
wire tensioner, 35 Knee deformity
wrenches, 34 high tibial osteotomy, 383, 384
IMN. See Intramedullary nailing (IMN) malalignment due to
Implant failure, 688 knee joint line deformity, 387, 389–391
Inclination technique, 42 ligamentous laxity, 387–389
Infantile coxa vara. See Coxa vara sagittal plane deformity, 391–393
Intercondylar tubercles, 248 monocompartment osteoarthritis, 383
Intermediate system, 77–78 postoperative care, 387
International Transosseous Osteosynthesis Symposium, 4 preoperative planning
Intramedullary nail-assisted correction, 346, 347 center of rotation angulation, 385, 386
Intramedullary nailing (IMN), 96–99 genu varum deformity, 384, 385
with cage technique malorientation and malalignment tests, 384
bone defects, 122 stress radiographs, 384
indications, 123 tibial osteotomy, 384
prereconstruction care, 124–125 Knee flexion contractures, 675
timing of surgery, 123–124 Knee joint contractures
knee arthrodesis, 395 ankle flexion, 679
Intramedullary skeletal kinetic distractor (ISKD), 695 elbow flexion, 679–681
knee flexion, 675
soft tissue correction, with external fixators, 675
J surgical technique
Joint contracture, 473 HS technique, 678–679
Joint line congruence angle (JLCA), 257–258 with Ilizarov circular fixator, 675–677
Joint stiffness, 690 with monolateral fixator, 678
Knee joint deformity, 387, 389–391
Knee subluxation, 693
K
Kirschner wire (K-wire), 33
application L
at ankle region, 39, 41 Lateral distal femoral angle (LDFA), 252, 253
features, 84 Lateral distal tibial angle (LDTA), 252, 253, 260–265
hand perforators, 39 Lateral ligamentous laxity, 387
joint movement and extremity function, 39 Lateral proximal femoral angle (LPFA), 251
joint positions, 39, 40 L connectors, 73, 84, 85, 219–222
skin positions, 40 LDTA. See Lateral distal tibial angle (LDTA)
stability, 38 LEAP. See Lower Extremity Assessment
tendon perforations, 39 Project (LEAP)
threaded half-pins, 41, 42 Lengthening over a nail (LON)
transfixation, 39 complications, 649–650
biomechanical features, 83–84 contraindications, 643
olive, 37–38 equipment features, 643
rotation deformity correction, 329, 330 external fixator, 648
tensioning, 40–42 femoral, 643–647
Index 725
indications, 642 MPTA, 257

tibial, 645–648 valgus deformity, 257, 258
Lever arm principle, 105 varus deformity, 257
Ligamentous laxity, 387–389 Mangled Extremity Severity Score (MESS), 108
Limb lengthening Maquet osteotomy, 345
classic treatment Masquelet technique, 111
callus formation, 641 MAT. See Malalignment test (MAT)
circular external fixator, 641 Mechanical axis, of lower extremity, 414, 415
clinical assessment, 638–639 Medial neck-shaft angle (MNSA), 252
corticotomy, 638 Medial proximal femoral angle (MPFA), 251–252
distraction osteogenesis, 638, 642 Medial proximal tibial angle (MPTA), 252, 253
femoral lengthening corticotomy, 640 Mesodermal epithelial transition (MET), 18
frame configuration and stability, 641–642 MESS. See Mangled Extremity Severity Score (MESS)
orthopedists, 637 Metabolic bone disease
plaster apparatus, 637, 638 avascular necrosis, 549
combined techniques clinical characteristics, 541
BTON, 656–666 drug-induced rickets, 543
FAN, 650–656 hypophosphatasia
LON, 642–650 infants, 549, 551
external fixators, 703 pathology, 549
motorized nails TNSALP, 549
axial deformity, 665 treatment, 551
cost, 670 nutritional rickets
implantable distraction nails, 666 biochemistry parameters, 543
intramedullary, 668 physis elongation, 542
with intramedullary nails, 669 treatment, 543
joint dislocation, 670 prematurity rickets, 543
mechanical failure, 669 renal osteodystrophy
physiotherapy, 670 angular deformity, 547–550
PRECISE nail, 667 medical treatment, 547
pulmonary and fat embolism, 669 orthopedic treatment, 547
unilateral, 667 physis, 542, 543
rehabilitation, 693 prevalence, 544, 546
LON. See Lengthening over a nail (LON) SCFE, 549
Longitudinal bisector line, 340, 341 vitamin D-resistant rickets
Low-dose stereoradiography, 244 ankle varus deformity, 543, 544
Lower Extremity Assessment Project (LEAP), 109 long bone deformity of lower extremity, 542, 543
LPFA. See Lateral proximal femoral angle (LPFA) medical treatment, 543–544
L-type connectors, 33 orthopedic treatment, 544–547
Metaphyseal osteotomy/elevation, 389–391
Metatarsus adductus, 452, 454, 455
M clinical features, 452
Macrodactyly, 464 closed treatment, 454
MAGEC system, 667 defintion, 452
Malalignment test (MAT) diagnosis, 452
femoral condyles malpositioning, 259 open treatment, 454
hip MOT Middiaphyseal fractures, 181–184
distal tibial joint orientation line, 260–265 MNSA. See Medial neck-shaft angle (MNSA)
head-neck line, 260, 261 Monocompartment osteoarthritis, of knee, 383
trochanter-head line, 260 Monoplanar fixators, 398
JLCA, 257–258 Monteggia fracture, 186
valgus deformity, 258 Moses circles, 246
varus deformity, 258 MPFA. See Medial proximal femoral angle (MPFA)
knee joint luxation, 259 MPTA. See Medial proximal tibial angle (MPTA)
LDFA, 255–257 Multiapical deformity
valgus deformity, 257, 263 anatomic and mechanical axis, 289
varus deformity, 256, 263 CORA identification, 289, 291–293
MAD, 255 LDFA, 288–293
valgus deformity, 255, 256 LDTA, 287
varus deformity, 255, 256 malalignment test, 290, 291
726 Index
Multiapical deformity (cont.) MESS, 108

MPTA, 286, 287, 289, 293 salvage, 110
O-leg deformity, 290, 291 with soft tissue defects, 112–122
open-wedge osteotomy, 287, 288, 292, 293 vascular injury, 107–108
right tibial deformity, 290 Open-up focal dome osteotomy, 387
solution CORA, 285, 286, 288, 291, 292 Open-wedge hinges, 50
varus deformity, 289–291 Open-wedge osteotomy, 91–92
Multiplanar deformity ACA, 282
adduction of calcaneus, 457 a-t type, 92
cavus, 457 bone contact, 92
clinical photos, 458–460 deformity fixation with, 287, 288
correction, 458 translation present with, 427
definition, 454 in varus deformity, 420
equinus, 457 Orthopedic Trauma Association (OTA), 227, 228
etiology, 454, 456 Orthoroentgenogram, 243, 295, 651, 658, 659
forefoot adduction, 457–458 Ortho-SUV fixator, 554, 555
supination, 457 O-shaped deformity, of tibia, 404, 405
treatment, 456–457 Ossa carpi, 469
varus, 457 Ossa digitorum manus, 469–470
V osteotomy, 458 Ossa metacarpi, 469
Osteomyelitis, 605
acute, 608, 609
N categories of, 609
Neglected hip dislocation, 353, 354 chronic (see Chronic osteomyelitis)
Neglected hip dysplasia, 351 CT, 609
Nerve injury, 698 definition, 606
Neurovascular injury, 684 host factors, 608
Non-bridging external fixator, 169 infected plate osteosynthesis, 615
microbial cultures, 609
MRI, 609
O nuclear medicine imaging, 609
Oblique plane deformity plain radiography, 609
ACA, 281–283 Staphylococcus aureus (see Staphylococcus aureus)
after treatment, 283 Osteoporosis, 541
apical direction of angulation, 277, 279 Osteotomy, 87
magnitude, 279 ACA
Paley's graphic method, 279–282 definition, 340
during treatment, 282 longitudinal bisector line, 340, 341
of tibia, 404 transverse bisector line, 340, 341
types, 277 angulation correction axis
uniplanar angular deformity, 277, 278 definition, 340
Olecranon fractures longitudinal bisector line, 340, 341
surgical technique, 178–180 transverse bisector line, 340, 341
type 1, 177, 178 center of rotation of angulation, 339, 340
type 2, 177, 178 incomplete, 684
type 3, 178 level and shape, 341
O-leg deformity, 290, 291 rules
Olive K-wires, 314, 317 close-up osteotomy, 342, 343
Olive wire, 37–38 description, 339, 341
tension, 42 dome osteotomy, 345–349
Omega rings, 27, 28 focal dome osteotomy, 343–344
Open book fractures, 202, 208–210 neutral wedge osteotomy, 342, 343
Open fractures open-up osteotomy, 342
IM nailing, with Cage Technique variables, 341
bone defects, 122 terminology, 339
indications, 123 OTA. See Orthopedic Trauma Association (OTA)
prereconstruction care, 124–125
timing of surgery, 123–124
reconstruction methods P
amputation, 109 Pain, 687
bone defect, 110–111 Paley classification
Index 727
congenital femoral deficiency, 526–527 Pes planus

fibular hemimelia, 494 definition, 447–448
Paley’s graphic method, 279–282 etiology, 448
Paley translation-rotation device, 329–331 treatment, 448–449
PDFA. See Posterior distal femoral angle (PDFA) Physiologic genu varum, 403
Pediatric fracture, IEF Pin site care, 472
advantages, 189–190 Pin track infection, 684–685
complications, 193 Plates
femur, 191–192 fixation, 346–348
humerus, 190–191 hinges, 46–47
indications, 189 technique, 94–96
postop care, 193–194 Polyaxial hinges, 47
tibia, 192–193 Polydactyly, 462
Pelvic fracture Posterior distal femoral angle (PDFA), 270, 271, 302, 304
anatomy, 197, 198 Posterior proximal tibial angle (PPTA), 271
biomechanics, 199 Procurvatum deformity, 408, 410
clinical evaluation, 199–200 clinical appearance, 429, 430
external fixator CORA determination, 429–430
circular fixators, 205, 206 diagnosis, 429, 430
resuscitation phase, 206–207 frame preparation, 431
Schanz screw, 204 hinge replacement, 431
tamponade effect, 204 osteotomy options, 430–431
tubular fixators, 205 Proximal focal femoral deficiency (PFFD)
vertically unstable injury, 207–210 Aitken classification, 521–522
incidence, 297 circular-type external fixator, 522
injury types, 199 complications, 525–526
radiologic evaluation description, 520
inlet X-ray, 200 diagnosis, 520
open pelvic fracture, 201 distraction osteogenesis, 520
outlet X-ray, 200, 201 Grammont procedure, 523
sacroiliac joint fracture dislocation, 201 Langenskiold procedure, 523
Tile classification, 202–203 lengthening of femur, 524
treatment, 203 MRI, 522
Percutaneous subtotal tenotomy, ankle Paley classification, of congenital femoral deficiency,
deformity, 434 524–525
Perthes disease (PD) SUPER hip procedure, 522, 523
arthrodiastasis, 362 SUPER knee procedure, 523
complete bed rest and Snyder brace, 360 Van Nes rotationplasty, 526
flexion-extension exercise and resting, Proximal hinges, 52–54
362, 363 Proximal system
hip distraction, 362–364 applications to femur, 71–73
Ilizarov-type external fixator, 362 application to tibia, 76–77
joint distraction, 360 connections, of proximal block, 61–62
K-wire, 361 pushing/pulling ring, 60–61
open iliopsoas tenotomy, 361 support ring, 59–60
patient positioning, 361 Proximal tibial fractures
percutaneous adductor tenotomy, 361 anatomy, 142, 143
physiologic hip range of motion, 360 AO/OTA classification, 145, 146
Shenton line restoration, 362 classifications, 142
Steinmann pin, 361 diagnosis, 148
Pes calcaneus, 449–450 imaging methods, 148–150
Pes cavus mechanism of injury, 142, 143
classification, 445 open tibia fracture classification, 145
clinical features, 442 physical examination, 148
complications, 447 posterior shearing fracture, 145, 147
definition, 441–442 Schatzker classification, 142, 144–145
etiology, 442 treatment
frame build, 445–446 conservative, 150–151
radiologic features, 442–443 surgical, 151–156
treatment, 445, 447 Tscherne closed fracture classification, 147–148
types, 443–444 Tscherne open fracture classification, 145, 147
728 Index
Pseudoarthrosis Recurvatum deformity, of knee, 391–393

biologic factors, 567, 568 Refracture, 689–690
fragments, elongation of Rehabilitation, 87–88
bilocal simultaneous compression and distraction, advanced, 700–701
574, 582, 594, 595 bone deformity, 693
trilocal simultaneous compression and distraction, dynamic splinting, 697
582, 595–597 electrical stimulation, 700
Ilizarov classification femoral lengthening, 693–694
loose-type pseudoarthrosis, 570, 571 heat therapy, 700
stiff pseudoarthrosis, 570–572 humeral lengthening, 694–695
mechanic factors, 567, 568 hydrotherapy, 700
Paley classification, 571, 573 ISKD, 695
stimulation of osteogenesis, IEF joint contracture, 693
monolocal consecutive compression and knee subluxation, 693
distraction, 574, 593–594 limb lengthening, 693
monolocal longitudinal compression, 571, massage, 700
574–576 nerve injury, 698
monolocal longitudinal distraction, 574, passive stretching and strengthening, 699
582–586 physiotherapy, 695
monolocal oblique compression, 572, 579–581 positioning, 698
monolocal oblique distraction, 574, 587–589 progressive weight bearing, 696–697
monolocal simultaneous compression and Renal osteodystrophy
distraction, 574, 589–592 angular deformity, 547–548
monolocal transverse compression, 571–572, medical treatment, 547
577–579 orthopedic treatment, 547
treatment, 597–601 physis, 547, 548
autologous bone grafts, 590 prevalence, 544, 546
delayed maturation and ossification, 598 Renal tubular acidosis, 543
docking site problems, 598 Rickets
Ilizarov frame, 597 coxa vara, 372
length of the defect, 598 nutritional, 542–543
length of the segment, 597, 598 O-leg deformity, 290, 291
treatment modalities, 582, 590 renal osteodystrophy, 544, 546–549
tricortical elongation, 590 vitamin D-resistant, 543–544
vascular pedicled free bone grafts, 590 Rods, 29
Weber and Cech classification correction using, 329
atrophic pseudoarthrosis, 569–570 reduction with, 317, 319, 320
hypertrophic pseudoarthrosis, 568–569 rotation deformity correction, 329
Pubic diastasis, 200 telescopic, 29–30, 61, 74, 205, 208
threaded, 61, 63, 66, 67, 72, 74
Rotation-angulation deformity, 330
Q computer-aided fixator, correction with, 332–335
Quorum sensing, 608 multiapical tibial deformity, 332, 336–338
Rotation deformity
acute correction, 328
R correction techniques
Radial deficiency, 461–463 computer-assisted fixators, 330
Rancho swivel, 191 frames, 328
Range of motion (ROM), 625 K-wires without olive, 329, 330
during femoral lengthening, 693, 694 Paley translation-rotation device, 329–331
Judet quadricepsplasty, 690 rods, 329
postoperative care, 387, 663–664 CT, 327
restriction in, 687 definition, 327
Recurvatum deformity level of osteotomy, 327, 328
CORA identification, 426–427 physical examination, 327
diagnosis, 426 X-rays, 327
frame preparation, 428, 429 The Russian Ilizarov Scientific Center for
hinge positioning, 428, 429 Restorative Traumatology and Orthopedics
osteotomy options, 427–428 (RISC RTO), 4
Index 729
S Simple elbow dislocation, 169

Sagittal plane deformity Slipped capital femoral epiphysis (SCFE), 368, 375, 376,
Blumensaat’s line, 302, 303 547, 549
femur avascular necrosis, 376
anatomic axis, 267–269 classification, 375
crossing point, 303–305 fixed external rotation contractures, 377
hip rotation center, 267, 268 HLA-DR4 phenotype, 375
knee rotation center, 267, 268 obesity and endocrinopathies, 375
mechanical axis, 267, 268 prophylactic pinning, 375
orientation line, 270 proximal femur osteotomies, 377
PDFA, 270, 271, 302, 304 pubertal ages, 374
lower extremity, 301, 303 on right hip, 375
mechanical axis, 272–273 valgization and extension osteotomy, 376
malalignment due to, 391–393 Solution CORA, 285, 286, 288, 292
pes calcaneus, 449–450 Square sockets, 32
pes cavus Standard tension device, 42
classification, 445 Staphylococcus aureus
clinical features, 442 bacterial adhesions of, 607
complications, 447 biofilm (see Biofilm)
definition, 441–442 identification of, 607
etiology, 442 internalization of, 606
frame build, 445–446 intracellular persistence and multiplication of, 607
radiologic features, 442–443 protein A, 607
treatment, 445, 447 Staphylococcus epidermidis, 606, 607, 612, 613, 616
types, 443–444 Stem cells
pes planus ASC
definition, 447–448 bone callus phase, 24
etiology, 448 cartilage callus phase, 23–24
treatment, 448–449 hematoma phase, 21
soft tissue problems, 306–307 inflammation phase, 21–23
tibia definition, 12
ADTA, 271–272, 303, 305 ESC
anatomic axis, 270 appendicular skeleton, 20
crossing point, 304, 306 BMP, 19
mechanical axis, 269 chondrocytes, 19–20
orientation angles, 303, 305 daughter cells, 13–14
orientation line, 270, 271 discs, 15
PPTA, 271, 303, 305 embryonic development, 16–17
procurvatum deformity, 408, 410 EMT, 15
recurvatum deformity, 408, 409 epiblasts and hypoblasts, 14–15
Sagittal plane malalignment test (MAT) epigenetic transformation, 14
distal femur, 273, 274 external cell groups, 14
extension malalignment, 273 mesenchymal and cartilage tissues, 20
flexion malalignment, 273 MET, 18
knee joint, 275 metalloproteinase, 17
proximal tibia, 275 neural tube development, 15–16
Salvage procedure, 633 paraxial-intermediate-lateral mesoderm, 19
Scanogram, 243, 295, 545. See also Orthoroentgenogram Sonic Hedgehog (Shh) genes, 19
SCFE. See Slipped capital femoral epiphysis (SCFE) transforming growth factor, 19
Schanz screws, 34. See also Kirschner wire (K-wire) vascularization, 17
application niches, 13
in distal radius fractures, 169 proliferation and differentiation processes, 12, 13
features, 84 symmetrical and asymmetrical division, 12, 13
biomechanical features, 83–84 Subtrochanteric osteotomy, coxa vara, 369, 370
positioning of, 83 SUPERankle procedure, 496, 499
Schatzker classification, 142, 144–145 SUPER hip procedure. See Systematic Utilitarian
Schatzker type 5 tibia fracture, 317, 318 Procedure for Extremity Reconstruction
Scythe osteotomy, 438–439 (SUPER) hip procedure
Severe SCFE, 375 Symphisis diastasis, 207
730 Index
Syndactyly, 462 Ilizarov frame application, 511–514

Synostosis, 464 knee disarticulation, 510, 511
Systematic Utilitarian Procedure for Extremity prosthetic fitting, 510
Reconstruction (SUPER) hip procedure, Tibial pilon fractures
522, 523 anteroposterior radiographs, 156, 157
AO-type external fixator, 158, 159
classifications, 156
T lateral radiographs, 156, 157
Taylor spatial frame (TSF), 554 orthopedic examination, 156
Teleroentgenogram, 242–243 Ruedi–Allgower classification, 156, 158
Telescopic rods, 29–30 surgical technique, 160–163
Threaded socket, 32 transfixation wires and Schanz screws, 158, 160
Tibia treatment, 158
ADTA, 271–272, 303, 305 Tibia valga, 407–408
anatomic axis, 270 Tibia vara, 403–407
bowing of, 403 (see also Diaphyseal deformity, Tissue-nonspecific alkaline phosphatase gene
of tibia) (TNSALP), 549
congenital pseudoarthrosis of, 527–536 TL-Hex system, 555
crossing point, 304, 306 Total knee arthroplasty (TKA), 395–396
diaphyseal deformity (see Diaphyseal deformity, of Transfixation wires, 37, 38
tibia) Translation-angulation deformity, 313
mechanical axis, 269 with computer-assisted fixators, 320, 325
orientation angles, 303, 305 with hinge treatment, 318–324
orientation line, 270, 271 Translation-angulation hinges, 313–316
PPTA, 271, 303, 305 Translation-compression hinges, 53, 56
procurvatum deformity, 408, 410 Translation deformity
recurvatum deformity, 408, 409 description, 309
Tibial fracture direction, 310, 311
classification, 227–228 frontal plane translation, 309, 310
hexapodal systems, 235–236 level, 313
incidence, 227 magnitude, 311, 312
lengthening and shortening, 235, 236 oblique plane translation, 309, 311
metaphyseal and diaphyseal, 231–235 Paley’s graphical method, 311–313
post-op follow-up, 236 reduction techniques
treatment olive K-wires, 314, 317
external fixators, 228–229 rod-plate system, 317, 319
frame preparation, 229 washers and rods, 317, 320
operating room preparation, 230 sagittal plane translation, 309, 311
operation, 230 Translation-distraction hinges, 53, 55
wound healing, 235 Translation hinges, 52, 53, 55, 313
Tibial hemimelia Translation rotation device, 34
anatomy, 506–507 Transverse bisector line, 340, 341
complications, 516–519 Transverse deficiency, 462
congenital hypoplasia, 507, 509 Trochanter–head line, 260
foot centralization surgery, 515–516 Tscherne soft tissue classification, 227, 228
incidence, 506 Turkish ASAMI, 8
type 1, 507, 508
type 2, 507, 508 U
type 4, 507, 509 Ulnar deficiency, 462, 463
severe deformity with diastasis, 510 Uniapical deformity, 285–287
tarsal coalitions, 506 Unilateral external fixator, knee arthrodesis, 396–398,
trans-articular knee amputation, 506 400
treatment Universal socket (U-type hinges), 30
amputation, 510, 511 Upper extremity trauma
Brown procedure, 511, 514 diaphyseal humeral nonunion, 172–174
corticotomy, 511 distal radius fractures
early through-knee amputation, 511 classifications, 168, 169
foot ablation, 510 elbow fracture-dislocations, 169–171
Index 731
external fixation, 169, 170 Coleman test, 417

external fixator use, 167 CORA identification, 419
functional anatomy, 167–168 diagnosis, 418–419
hinged external fixator application, 171 dome osteotomy, 420, 421
treatment, 168 etiology, 416
distraction interposition arthroplasty, 171–172 fixation degree, 422
humeral external fixator application technique, hinges and motor unit positioning, 420, 422
173–175 Ilizarov method, 420, 421
Upper limb deformity open-wedge osteotomy, 419, 420
bone deformity, 473–477 pre-op clinical image, 416, 417
Pennig II Dynamic Wrist Fixator, 487–488 right distal tibia, 416
periarticular application, 488–489 of heel
soft tissue contractures treatment, 489 clinical features, 450–451
transarticular application, 489 definition, 450
bones of hand, 469 deformity diagnosis, 451
etiology, 461–464 etiology, 450
fixator type, 470, 471 technique, 451
forearm bones, 467–469 treatment, 451
forearm lengthening of knee
distal 1/3, 479 clinical and radiologic appearance,
distal radioulnar level, 480–487 384, 386
head of radius level, 477–478 femoral osteotomy, 384
indications, 477
level of proximal 1/3, 478
middle 1/3, 479 W
humeral lengthening, 469–470 Warfare surgery, external fixator applications
humerus, 465–467 ankle and foot, 627–628
shoulder junction bones, 464–465 external splinting instrument, 623
surgical technique femur, 625
bilateral humeral lengthening, 471–472 firearm wounds
complications, 472–473 aggressive irrigation and debridement, 622
K-wire, 470 high-velocity wounds, 621–622
postoperative care, 473 low-velocity wounds, 621, 622
Schanz pin insertion, 471, 472 mediate-velocity wounds, 621
treatment, 490–491 resuscitation and systemic interventions, 622
knee, 626
lower extremity gunshot injuriy
V ECF fixator application, 623, 624
Valgization osteotomy, coxa vara, 369, 372 fasciotomy, 623
Valgus deformity, 377 unilateral fixator application, 623, 624
causes, 422 mortality and morbidity rates, 621
CORA identification, 423, 424 tibia, 626, 627
diagnosis, 423 upper extremity gunshot injury
dome osteotomy, 424 elbow injury, 631–633
etiology, 422 forearm injury, 630–631
fixation degree, 424 hand injury, 631, 633, 634
of heel humeral injury, 629, 630
clinical features, 451 shoulder injury, 629
definition, 451 vascular and nerve injury, 628
diagnosis, 452 Washers and rods, translation deformity correction,
etiology, 451 317, 320
treatment, 452 Weber and Cech classification
hinges and motor unit positioning, 424–426 atrophic pseudoarthrosis, 570
level of osteotomy, 424 defected pseudoarthrosis, 570
translation, posterior appearance of, 422 fragmented type, 569–570
Van Nes rotationalplasty, 520 torsion wedge type, 569, 570
Varization derotation osteotomy, 373 hypertrophic pseudoarthrosis
Varus deformity elephant foot, 568–569
ankle deformity, 377, 414, 415 horse hoof, 569
causes, 416 oligotrophic type, 569
732 Index
Wind swept deformity, 547, 550 Y

Wire fixation bolts, 30, 31 Y osteotomy, 448
Wire tensioner, 35, 38
Wire tensioning techniques, 42
Wrenches, 34 Z
Wrist bridging fixator, 169, 170 Z-osteotomy, 351, 353

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Basic Techniques

Cengiz Şen Melih Cıvan

ISBN 978-3-319-45673-7 ISBN 978-3-319-45675-1 (eBook)

Library of Congress Control Number: 2017963053

© Springer International Publishing Switzerland 2018

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Florida, USA Dror Paley, MD, FRCSC

Dr. Gavril Abramovich Ilizarov coined the term “distraction osteogenesis” in

We hope this book will have a humble contribution to our colleagues

I started my resident training in 1973 in Istanbul University, Orthopedics and

Istanbul, Turkey Mehmet Çakmak

Part I External Fixator Applications for Complex Fractures

14 Role of External Fixators in Pelvic Fracture Treatment������������ 197

Part II Ilizarov Approach in Deformity Surgery

17 Introduction to Deformity Analysis and Planning���������������������� 241

31 Diaphyseal Deformities of the Tibia �������������������������������������������� 403

Part III Ilizarov Approach in Postraumatic Complications

Turgut Akgül Istanbul University, Istanbul Faculty of Medicine, Department

Mehmet Erdem University of Sakarya, Department of Orthopedic Surgery

Reinhard Schnettler Justus-Liebig-UniversityGiessen, Germany

© Springer International Publishing Switzerland 2018 3

Fig. 1.1 Prof. Dr.

Fig. 1.2 RF Ministry of Healthcare (2015), The Russian ilizarov.ru/index.php/about-center/center-today

Fig. 1.4 Prof. Dr.

Cherkez-Zhade, with more than 300 participants,

Fig. 1.6 22 years after the first lengthening procedure,

Fig. 1.7 Ilizarov’s only

Fig. 1.8 Prof. Dr. Mehmet Çakmak with the statue of

Fig. 1.9 Prof. Dr. Mehmet Çakmak with Dr. Schevstov

9. Ilizarov GA. In: Green SA, editor. Historical back-

© Springer International Publishing Switzerland 2018 11

Symmetrical Cell Division Asymmetrical Cell Division

Fig. 2.1 Illustration of the symmetrical and asymmetrical division

Adult Stem Cell Embrionic Stem Cell

In adults and fetus following organogenesis 2.1.1 E

Trophectoderm Late Blastocyst 2 disc shape

Fig. 2.3 Illustration of early embryonic differentiation

16th Day Primary

Fig. 2.5 Illustration of the neural tube development

Intermediate Chorda- Paraxial Lateral Mesoderm

Notochord Splanchnic Somatic Extra-

Sclerotome Myotome Dermatome

Fig. 2.7 Illustration of the mesenchyme segmentation and somite formation

Summary 2.2.2 Inflammation Phase

4 . Antigen Presenting Cells (APC) 2.

References 6. Nurse P. Cyclin dependent kinases and cell cycle

3.1 Rings 3.1.3 5/8 Rings

3.1.4 Omega Rings

© Springer International Publishing Switzerland 2018 27

Fig. 3.4 5/8 ring

Fig. 3.1 A whole ring

Fig. 3.5 Omega rings

Fig. 3.2 Half ring

Fig. 3.6 Italian femoral arch

Fig. 3.3 Carbon fiber half ring

Fig. 3.7 Carbon fiber Italian femoral arches in different

Fig. 3.9 Top-to-bottom threaded, cannulated, and slotted

Fig. 3.10 Graduated type telescopic rod

As mentioned before, rods are threaded bar-type

Fig. 3.12 Curved plate

Fig. 3.14 Thinner female (left) and male (right) hinges

Fig. 3.13 A male (top) and a female post

Florida, USA Dror Paley, MD, FRCSC

Istanbul, Turkey Mehmet Çakmak

14 Role of External Fixators in Pelvic Fracture Treatment�� 197

17 Introduction to Deformity Analysis and Planning�� 241

31 Diaphyseal Deformities of the Tibia �� 403

Summary 2.2.2 Inflammation Phase

3.1 Rings 3.1.3 5/8 Rings

3.1.4 Omega Rings

3.2.7 Threaded Socket

3.2.9 Bushes and Washers

3.2.10 L-Type Connectors

3.3.1 Kirschner Wire

Fig. 3.32 Top-to-bottom, trocar-pointed, bayonet-

3.3.2 Schanz Screws

3.4.1 Translation Rotation Device 3.4.2 Wrenches

3.4.4 Gigli Wire

4.3 Application of the K-Wires

Skin positions are important in K-wire crossing 4.4 Tensioning of K-Wires

4.4.2.2 Inclination Technique

5.2.4 Polyaxial Hinges

5.2.5 Custom-Made Double-Axis

5.3 Positioning of Hinges deformity. A malpositioned hinge for opening a

5.3.2 Hinges on the Bisector Line

Fig. 5.26 (a, b) Illustration of the translation-compression hinge and working principle

deformity is corrected. Translation occurs are called “translation-compression hinges.”

5.4 Dual-Axis Hinges

5.5 Correction Speed

6.1.1.2 Pushing/Pulling Ring

6.1.1.3 Connections of the Proximal

6.1.2.3 Connections of the Distal Block

6.1.3 System Connections