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Principles of Frame Construction

Chapter · September 2012

DOI: 10.1007/978-88-470-2619-3_7

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Leonid N Solomin
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 Principles of Frame Construction
Leonid Nikolaevich Solomin
The general algorithm for the assembly of an external device
includes:
1. Identification of the objectives
2. Identification of the optimal levels for the insertion of
transosseous elements
3. Identification of the optimal transosseous elements on the
basis of safe positions and reference positions
4. Identification of the optimal levels for positioning the
external supports
5. Identification of the type and size of external supports,
corresponding to the selected transosseous elements and
their insertion levels, leaving open the possibility of mod-
ule transformation
6. Marking the selected levels and positions on the segment
for transosseous elements insertion and external support
placement
7. Transosseous element insertion, external support installa-
tion, and frame assembly
Steps 1–5 are performed during preoperative planning;
steps 6 and 7 are operative interventions. The general issues
to be considered in carrying out each step are considered in
the following.
7.1 Identification of the Objectives
Osteosynthesis in traumatology and orthopedics is a means
to reach a common aim: recovery (improvement) of the anat-
omy, function, and physiology of an injured limb. The under-
lying rationale for using an external fixation device can be
stated as:
1. To change the spatial layout of the bone fragments. Using
the specific techniques of external fixation, this can be
carried out in a “single-stage” (during surgery) or in
L.N. Solomin, M.D., Ph.D.
R.R. Vreden Russian Research Institute of Traumatology
and Orthopedics, 8 Baykova Str., St. Petersburg 195427, Russia
e-mail: solomin.leonid@gmail.com
L.N. Solomin (ed.), The Basic Principles of External Skeletal Fixation Using the Ilizarov and Other Devices,
DOI 10.1007/978-88-470-2619-3_7, © Springer-Verlag Italia 2008, 2012
7
discrete stages over a certain time within the postopera-
tive period. Resolution of the problem presupposes that
the device will be dismantled after the necessary orienta-
tion of the bone fragments has been achieved (Fig. 7.1).
2. For bone fragment fixation. the external fixation device is
used only as a fixing device; for example, after open repo-
sitioning of bone fragments and compression arthrodesis
(Fig. 7.2).
3. For the provision of (improved) limb function during
the postoperative period. To ensure limb support and
movement, the external fixation device must fix the
bone fragments with sufficient rigidity. Furthermore,
the transosseous elements must be placed so as to reduce
the risk of pin-induced joint stiffness (Fig. 7.3). The
conditions to meet these requirements are discussed in
Chap. 2.
In clinical practice, the external fixation device may have
to meet the requirements of a combination of two or more
identified problems or solve all of them in aggregate.
Therefore, a particular clinical situation often demands a
compromise solution (Chap. 3) that ensures the maximum
efficiency of all components of the external device.
7.2 Identification of the Optimal Levels
for the Insertion of Transosseous
Elements
This stage of external device assembly must be based on
knowledge of the biomechanics of bone fragment manage-
ment and fixation rigidity (Chap. 2).
In the treatment of fractures, optimal conditions for the
reduction and fixation of bone fragments are provided by an
external fixation device in which the distance between the
basic and reductionally fixing transosseous elements in the
proximal and distal modules is maximized (Chap. 2). Thus,
basic transosseous elements should be inserted as close as
possible to a joint, and the reductionally fixing wires and pins
closer to the fracture site. The requirements to ensure optimal
181
182 L.N. Solomin

Fig. 7.1 (a–d) Malunited tibial fracture. Bone

fragment dislocation is eliminated within 7 day by a b
using an external fixation device. After locked
nailing is performed, the frame is removed

c d

conditions for both bone repositioning and fixation are
satisfied by the Ilizarov device. Its assembly involves two
external supports for each bone fragment. The supports in
each module must be placed as far apart as possible. The
transosseous elements must be positioned abarticularly and
at a distance of 1–3 cm from the bone fracture line (Fig. 7.4a).
Exceptions are the osteosynthesis of intra-articular or juxta-
articular fractures.
Stabilizing transosseous elements, as a rule, are inserted
between the basic and reductionally fixing transosseous ele-
ments, as close as possible to the basic transosseous elements
(Fig. 7.4b). The maximal distance from reductionally fixing
to stabilizing transosseous elements is defined by the ability
to fix the latter using four-hole posts.
Insertion of stabilizing half-pins slantwise with respect
to the longitudinal axis of the bone allows an increase in the
7 Principles of Frame Construction
a b
Fig. 7.2 (a–c) After removal of the plates, minimal bone fragment mobility is found. As a result external fixation using a arch type frame is
performed
distance between reductionally fixing and stabilizing
transosseous elements (Figs. 7.21b, c, 7.24 and 7.25). The
greatest rigidity will be provided by a support to which a
half-pin inserted slantwise is fixed by means of a four-hole
post. This level is optimal for the insertion of a stabilizing
half-pin.
Figure 7.4d shows that for distal transosseous elements,
level VII instead of level VIII is chosen. This choice implies
that the distal bone fragment is long enough, in this case
183
longer than the example shown in Fig. 7.4a. Moreover, the
use of stabilizing transosseous elements will increase the
rigidity of the osteosynthesis, thus fulfilling one of the major
requirements of combined external fixation (Chap. 3).
In deformity correction, the need for reductionally fixing
transosseous elements and supports in frame assembly is
obviated if the spatial location of the bone fragments is
changed by mutually moving the external supports fixing
each fragment. To provide the proper rigidity needed for
184 L.N. Solomin

osteosynthesis, the maximum distance should be reached
between the basic and the stabilizing transosseous elements.
This is achieved by inserting the stabilizing transosseous ele-
ments slantwise to the longitudinal axis of the bone fragment
and then fixing them by means of a four-hole post. If the
length of the bone fragment does not allow the use of this
type of assembly, then a shorter post must be substituted.
Depending on the treated segment and the objectives of the
osteosynthesis, each module can include one or two supports
(Fig. 7.5).

a b

Fig. 7.3 (a, b) An optimal frame configuration for the treatment of knee-joint stiffness

a b c

Fig. 7.4 Identification of the

levels for transosseous element
insertion and for locating the
external supports in the treatment
of fractures. Optimum levels
for the insertion of basic,
reductionally fixing (a, d), and
stabilizing (b, e) transosseous
elements are shown, together with
the optimum levels for locating
the basic and reductionally fixing
supports (c, f). The basic and
reductionally fixing transosseous
elements in each module should
be placed as far apart from one
another as possible. The distance
from reductionally fixing
transosseous to stabilizing
transosseous elements should not
be <4–5 cm (i.e., the length of a
four-hole post)
7 Principles of Frame Construction 185

Fig. 7.4 (continued)

d e f

a b c

Fig. 7.5 Identification of the

levels of transosseous element
insertion and external support
location in deformity correction.
Optimum levels of insertion
of basic (a, d) and stabilizing
(b, e) transosseous elements are
shown together with the optimum
levels for support arrangement
(c, f). The distance from the
basic to the stabilizing
transosseous elements should not
be <4–5 cm (i.e., the length of a
four hole post)
186
Fig. 7.5 (continued) d e
7.3 Identification of the Optimal
Transosseous Elements on
the Basis of Safe Positions
and Reference Positions
This objective proceeds from that of the osteosynthesis. The
atlas in Chap. 5 is consulted. If one of the tasks of using
external fixation is to provide (improve) function of the adja-
cent joints, only reference positions (RPs) are used, with
those located contralateral to the bone being particularly
important; for example, 2 and 8, 3 and 9, 6 and 12. It is pos-
sible to insert a wire in the projection of these positions and
to insert a half-pin on the side of any RP. For example, if the
RPs at level V of the shoulder are 4 and 10, one can either
use the wire V.4-10 or the half-pin V,4,90 or V,10,90 (the
angle of half-pin insertion here is given arbitrarily). If there
is no contralateral position at this level, it is expedient to use
half-pins (cantilever wires).
The use of wires is more effective for repositioning bone
fragments in fractures, whereas the use of half-pins increases
the rigidity of bone fragment fixation. At the same time it
should be remembered that the use of half-pins is inappropri-
ate in the presence of marked osteoporosis.
In fracture treatment, the reductionally fixing transosseous
element should be inserted strictly in the frontal (positions
L.N. Solomin
f
3, 9) or sagittal (positions 6, 12) planes and perpendicular to
the anatomic axis of the bone fragment, as this will facilitate
bone fragment reduction. In the example shown in Fig. 7.4a,
the levels for the reductionally fixing transosseous elements
are IV and V. At these two levels, positions 3, 9 and 12 are
the RPs (Fig. 7.6a, b; Sect. 5.5). Thus, it is expedient to use
(as a choice) half-pins IV,12,90 and V,12,90 or olive wire
spokes IV,3-9 (or IV,9-3) and V,3-9 (or V,9-3) (Fig. 7.6c, d).
In the example shown in Fig. 7.4a, the levels for the basic
transosseous elements are identified: I and VIII. If possible
wires should be used as the basic transosseous elements. At
level I, the contralateral RPs are 3 and 9 (Fig. 7.7a); at level
VIII they are 2 and 8, 3 and 9, 4 and 10 (Fig. 7.7b). Thus at
level I the optimal wire is I,9-3 (Fig. 7.7c) whereas at level
VIII there is a choice between wires VIII(8-2)8-2, VIII,9-3,
and VIII,10-4 (Fig. 7.7d). However, in the external fixation
of the lower leg it is necessary to stabilize the distal
tibiofibular syndesmosis, which requires the use of wire
VIII(8-2)8-2.
To increase osteosynthetic rigidity, the reductionally
fixing and basic transosseous elements must not be placed in
the same plane. Therefore, if the basic transosseous elements
were inserted in the frontal plane (or close to it, at level VIII)
then for the reductionally fixing transosseous elements the
use of IV,12,90 and V,12,90 is recommended.
7 Principles of Frame Construction 187

a b

10 11 12 1 2 10 11 12 1 2
E39
E
E
9 3
9 3
VB35 B
VB
B Rp7
F
A
A D
8
D 4
8
4 VB36 F

C R
C
V57 V

7 6 5 7 6 5

A B C D A B C D
a.tibialis a.tibialtis v.saphena n.saphenus a.tibialis a.tibialis v.saphena n.saphenus
posterior anterior parva v.saphena posterior anterior parva v.saphena
v.tibialis v.tibialis n.cutaneus magna v.tibialis v.tibialis n.cutaneus magna
posterior anterior surae medialis posterior anterior surae medialis
n.tibialis n.peroneus profundus n.tibialis n.peroneus profundus

V,12,90
IV,12,90

c d

V,3-9

IV,3-9

Fig. 7.6 Selection of reductionally fixing transosseous elements (according to Fig. 7.7a). Reference positions at levels IV (a) and V (b). Optimum
(as a choice) use of reductionally fixing transosseous elements at levels IV (c) and V (d)

In the next step, the optimum positions for the insertion
of stabilizing transosseous elements are chosen. It is
advisable to use half-pins as stabilizing transosseous ele-
ments. To increase osteosynthetic rigidity and to allow for
possible modular transformation the stabilizing tran-
sosseous elements are ideally inserted as follows (Sect.
2.3.6, Fig. 2.24):
• In a plane located at an angle of 60° ± 10° to the plane of
insertion of a reductionally fixing transosseous element
(Sect. 2.3.6, Figs. 2.24 and 2.25)
188 L.N. Solomin

a b
11 12 1 11 12 1
2 E41 2
10 10
F4
E

Rp
Rp
9 3 9 3
VB
VB34
F8

8 8
4
4
R10 R3

V60
V40

7 6 5 7 6 5

A B C A B C D
a.tibialis a.tibialis v.saphena v.saphena
a.poplitea a.peroneus n.saphenus
posterior anterior parva magna
v.poplitea communis v.saphena
v.tibialis v.tibialis n.suralis n.saphenus
n.tibialis magna
posterior anterior
n.tibialis n.peroneus profundus
c
d

I,3-9

VIII,3-9

VIII,4-10

(VIII,8-2)VIII,8-2

Fig. 7.7 Choice of basic transosseous elements (according to a). Reference positions at levels IV (a) and V (b). Optimum reductionally fixing
transosseous elements at levels IV (c) and V (d)

• At an angle of 120° ± 10° to the longitudinal axis of the
proximal bone fragment and 70° ± 10° to the longitudinal
axis of the distal bone fragment
• At a distance provided by the use of four-hole posts
In the example shown in Fig. 7.4b, there are two levels
for stabilizing transosseous elements: II and VII. At level II
the half-pin II,2,120 fulfills the above-mentioned require-
ments (Fig. 7.8c), and at level VII the half-pin VII,2,70
(Fig. 7.8d).
In deformity correction, the displacement of one tran-
sosseous module against the other is used. Thus, the basic
and stabilizing transosseous elements should provide the
maximal rigidity of osteosynthesis. As noted in Sect. 7.2, the
distance between basic and stabilizing transosseous elements
in each module should be maximized (Fig. 7.5). Generally,
basic transosseous elements are inserted in the frontal or sag-
ittal (or close to them) planes and perpendicular to the longi-
tudinal axis of the bone fragment. This allows monitoring of
7 Principles of Frame Construction 189

a b
11 12 1 2 11 12 1
10 10 2
E
E36

F
9 3
9 3
Rp
VB39
VB
Rp9
R8
8
F7 4
8 4
R7

R
7 V55 5
6 V

7 6 5
A B C D E A B C D
a.tibialis n.peroneus a.tibialis v.saphena v.saphena a.tibialis a.tibialis v.saphena v.saphena
posterior superficialis anterior parva magna posterior anterior parva magna
v.tibialis n.peroneus v.tibialis n.cutaneus n.suralis v.tibialis v.tibialis n.suralis n.saphenus
posterior profundus anterior surae medialis posterior anterior
n.tibialis n.tibialis n.peroneus profundus

c d

II,2,120
VII,2,70

Fig. 7.8 Choosing stabilizing transosseous elements (according to Fig. 7.7b). Reference positions at levels II (a) and VII (b). Optimum stabilizing
transosseous elements at levels II (c) and VII (d)

the basic support. The stabilizing transosseous elements
should be inserted as follows:
• In a plane located at an angle of 60° ± 10° to the insertion
plane of the basic transosseous elements (Sect. 2.3.6,
Figs. 2.24 and 2.25)
• At an angle of 120° ± 10° to the longitudinal axis of the
proximal bone fragment and 70° ± 10° to the longitudinal
axis of the distal bone fragment
The basis for selecting levels for the insertion of tran-
sosseous elements in order to correct a lower leg deformity
190 L.N. Solomin

a b 12 c 12

II,2,120
9 3
9 3
III,3-9

6
6

d 12 e 12 f 12
V,12,120
IV,12,70 VI,4-10

3
9 39 9 3

6
12 6 6
g

VII,2,70
9 3

Fig. 7.9 (a–g) Options for basic (c, f) and stabilizing (b, d, e, g) transosseous elements

is shown in Fig. 7.5c. The apex of the deformity is located
in the middle third of the tibia. Levels II, III, and IV are
optimum for the proximal bone fragment, and levels V, VI,
and VII for the distal bone fragment (Fig. 7.9a). Cross-
sectional cuts through the lower leg (Sect. 5.5) show the
transosseous element options at the corresponding levels.
The above-mentioned conditions define the choice of
transosseous elements, as shown in Fig. 7.9b–d for the
proximal bone fragment, and Fig. 7.9e–g for the distal bone
fragment.
In the opinion of some authors, situations in which tran-
sosseous elements pass through more than two or three acu-
puncture points on different meridians or cross one meridian
two or three times should be avoided [80, 85, 103]. However,
the use of transosseous elements as stimulators at biologi-
cally active points should not be ruled out [83, 104].
7 Principles of Frame Construction
7.4 Identification of the Optimal Levels
for Positioning the External Supports
The requirements to ensure optimal conditions for bone repo-
sitioning and for fixation are satisfied by the Ilizarov device.
Its assembly involves two external supports for each bone
fragment (one support for a short fragment, as an exception).
In fractures, the basic supports must be located in imme-
diate proximity to the basic transosseous elements, with
reductionally fixing supports placed between reductionally
fixing and stabilizing transosseous elements (Fig. 7.4c, f).
In addition, the distance between an external support and
the external end of the transosseous element should be
4–5 cm, i.e., equal to the length of a standard four-hole post
(Fig. 7.10a). Thus, the maximal length of a bone fragment
for one support is 8–10 cm (Fig. 7.10b). For longer bone
fragments it is necessary to use two supports (Fig. 7.10c).
a b
5 cm
10 cm
Fig. 7.10 Determination of the necessary number of supports in frac-
tures. Stabilizing transosseous elements must be fixed at a distance of
4–5 cm from the reductionally fixing support (a). For bone fragments
191
In deformity correction, the basic support is also located
in the immediate proximity of the basic transosseous ele-
ments. The distance from a support to the external end of the
stabilizing half-pin should be 4–5 cm (length of a four-hole
post) (Figs. 7.5c and 7.11a). If the rigidity of an osteosynthe-
sis must be increased by using additional stabilizing tran-
sosseous elements, inserted at a greater distance from the
basic support, then another support, as a stabilizing support,
is required (Figs. 1.4, 7.5f and 7.11b).
Note: For a very long bone fragment it is always possible
to fix the stabilizing half-pins by means of a four-hole post
placed above and under the support. However, this will not
always provide the osteosynthetic rigidity needed to fulfill
the requirements for combined (hybrid) external fixation
(Sect. 3.5). These situations necessitate the use of an addi-
tional stabilizing support to which extra stabilizing tran-
sosseous elements can be fixed.
>10 cm
with lengths of up to 10 cm, one support can be used (b – distal mod-
ule). For bone fragments longer than 10 cm, two supports are used
(a – proximal module, b – both modules)
192
Fig. 7.11 In deformity
correction, the distance from the
a b
basic transosseous elements to
the stabilizing half-pins should
be maximal. If the distance from
a support to the half-pins allows
their fixation by means of a
four-hole post, then one support
is used (a – both modules; b –
distal module only). If this is not
the case, then two supports are
used: one stabilizing and one
basic (b – proximal module)
7.5 Identification of the Type and Size
of the External Supports Corresponding
to the Selected Transosseous Elements
and Their Insertion Levels While
Allowing for Module Transformation
If it is necessary to use wires, the support should be circular
or semicircular. If only half-pins are fixed, the support can be
of any type: circular, semicircular, sectorial (arch) or mono-
lateral. Figure 7.12 shows the most frequently used closed
and open external supports.
To minimize the frame configuration it is advisable to use
sectoral, semicircular, and monolateral supports. However
there is a direct correlation between the type of support, on
the one hand, and the reduction of the bone fragment and the
rigidity of the osteosynthesis, on the other. Use of a closed
(circular) external support provides both optimal conditions
for tensing wires and a greater choice of positions and angles
for half-pin insertion. It also facilitates bone fragment reduc-
tion and increases osteosynthetic rigidity. Therefore if the
objective of an osteosynthesis is a two- to three-plane bone
fragment reduction or deformity correction with the subse-
quent fixation of rigid bone fragments, then the initial frame
configuration should be assembled on the basis of circular
L.N. Solomin
and semicircular supports. Further on, this arrangement can
be minimized using modular transformation.
However, rings often cannot be used, for example at lev-
els 0, I, and II of the upper arm and upper leg. It is inappro-
priate to use closed basic supports when they mechanically
obstruct movement of the adjacent joint.
To enable modular transformation, all transosseous ele-
ments of the given support should be fixed to one part of it
(Fig. 7.13). Figure 7.14 shows the supports intended for
modular transformation. If the device is intended only for the
fixation of bone fragments, it can initially be semicircular,
sectorial, or monolateral.
The diameter of the external supports is selected taking
into account the circumference of the sector at every inser-
tion level of the transosseous elements. The choice of the
standard size should allow for both a probable increase in the
circumference by 4–6 cm due to soft-tissue edema and for
soft-tissue displacement relative to the repositioning of the
bone fragments.
The minimally recommended distance from the skin to
the external support is not the same for the different seg-
ments and sides of a segment. As a rule, the distance on a
dorsal surface of the segment should be 1.5- to 2-fold greater
than that on a ventral surface.
7 Principles of Frame Construction 193

Fig. 7.12 Main types of external support (From [26])

Due to anatomic and inter-individual variations, the cir- supports of the maximum standard size for the particular sit-
cumference of the segment will differ at every level. Hence, uation. In the former case, the rigidity provided by the struc-
there are differences in the diameter of the supports at every ture is reduced due to the need for connection plates in the
level (Fig. 7.15); alternatively, the device is assembled from completed device, such that its installation becomes more
194 L.N. Solomin

Fig. 7.13 (a) Fixing transosseous

elements to one part of a support
a
allows modular transformation (MT).
(b) In this case MT is impossible, as
the wire is fixed to various parts of a
ring

a b

Fig. 7.14 (a–d) External supports c d

allowing modular transformation
7 Principles of Frame Construction 195

Fig. 7.15 In assembling the

frame using supports of various
diameters, connection plates
should be used. A bend in the
connecting rods is inadmissible

complicated; however, the dimensions of the device are a

reduced. It is easier to assemble the device from supports of
the same standard size as this provides more freedom for
manipulations; however, the device is bulkier. The rigidity of
bone fragment fixation inevitably decreases due to the
increase in the diameter of some of the supports.
Thus, in every situation a reasonable compromise must be
reached based on the priorities of: (a) provision of greater rigid-
ity of the osteosynthesis; (b) minimization of the dimensions of
the external frame; (c) the need for greater freedom for chang-
b
ing the spatial orientation of the fragments; and (d) provision of
maximum possible motion of the joints. For example, in joint
arthrodesis (joint fusion), the possible locations for transosseous
element insertion are extended by using safe positions. In con-
trast, for mobilization of a joint using external fixation tech-
niques, the device should be assembled on the basis of
transosseous elements inserted in the projection of RPs.
It must again be emphasized that the number of tran-
sosseous elements and external supports inserted should pro-
c
vide an adequate rigidity of fixation for each bone fragment.
An external fixation construct-rigidity test is described in
Chap. 36. All frame assemblies for combined external
fixation presented in Part II of this book correspond to this
requirement.
To reduce the surgical intervention time, the external
structure (the frame of the device) should be pre-assem-
bled and then sterilized, either as a whole or in separate
modules, together with any necessary additional
equipment.

7.6 Marking the Selected Levels Fig. 7.16 (a–c) Dividing the femur into eight standard levels to desig-
nate the levels of support placement
and Positions on the Segment
for Transosseous Element Insertion
and External Support Placement
7.7 Transosseous Element Insertion,
The scheme of segment division into levels is shown in Fig. External Support Installation,
4.1. During surgery for this purpose, a special swiveling and Frame Assembly
device and a sterile marker are used (Fig. 7.16). In case of an
acute injury, this stage is carried out after reconstruction of The procedure for transosseous element insertion and the
the limb axis and rough elimination of the displaced frag- specific features of frame assembly depend on the segment
ments by means of skeletal traction on the orthopedic exten- being operated upon, the type of pathology, and the goals of
sion table. osteosynthesis.
196
In fractures skeletal traction or distraction devices should
be applied before the external fixation procedure is per-
formed. The algorithm for transosseous element insertion,
external support installation, and frame assembly is as fol-
lows (Figs. 7.26 and 2.4.11):
• Insertion of the basic transosseous elements
• Frame assembly
• Distraction to form a gap between bone fragments
• Insertion of reductionally fixing transosseous elements
• Bone fragment reduction
• Insertion of stabilizing transosseous elements to
increase osteosynthetic rigidity and to enable modular
transformation
• Elimination of the gap between bone fragments
In deformity correction, the algorithm is as follows
(Fig. 7.34):
• Insertion of basic and stabilizing transosseous elements
into the proximal bone fragment
• Assembly of the proximal transosseous module on the
basis of only a basic support or using two supports: basic
and stabilizing
• Insertion of basic and stabilizing transosseous elements
into the distal bone fragment
• Assembly of the distal transosseous module on the basis
of only a basic support or using two supports: basic and
stabilizing
• Connection of the proximal and distal transosseous
modules by means of a unified (Sect. 2.2) or universal
(Chap. 17) unit
• “Bone” one : osteotomy, bone grafting, etc. (if necessary)
The features of each stage of mounting an external fixator
are discussed in the following.
When transosseous elements pass through the flexion sur-
face of a segment, the adjacent joint is placed in the extension
a b
Fig. 7.17 (a) The wire is inserted using a slow-speed drill. (b) Excessive pressure upon a wire and its bend are inadmissible
L.N. Solomin
position and vice versa (Fig. 2.3). It is not always possible to
place the limb in the specified position during the insertion of
transosseous elements while operating under conditions of
skeletal traction on an orthopedic extension table. In such
cases, before the wire is inserted through the extension sur-
face of a segment, the skin is displaced (manually or with the
help of a special hook) towards the adjacent joint. When
using only RPs for transosseous element insertion, there is no
need to perform these manipulations.
For the insertion of wires, discontinuous boring at the
maximum rotational speed of the drill (850 rpm), cooling
the wire with an alcohol-impregnated gauze tampon, and
regulating (up to 20 N ) the axial pressure on the wire are
advised. After the guiding end of the wire passes the second
cortical plate, the drill should be disconnected; further inser-
tion of the wire through the soft tissues is achieved using
gentle hammer strikes on the base of the wire. If a wire with
an olive stop is used, a puncture of 2–3 mm should be made
in the skin. The guiding end of the wire should not be pulled
in an attempt to insert the stop to the bone; rather, the punch-
ing technique is used. To insert a spiral stop as far as the
bone, the wire is pulled at the guiding end with simultane-
ous rotation of the curvature in the soft tissue (Fig. 7.17).
For half-pin insertion in a bone, a 0.5 cm incision is made
after a channel has been formed in both cortices by means of a
drill. Thermal damage to the bone is prevented by interrupted,
slow-speed drilling and cooling of the drill in a damp gauze
napkin. The use of a tissue protector sleeve will also help to
shield the surrounding soft tissue from mechanical damage.
Half-pins with a drill on the directing end obviate the need
for a channel for half-pin insertion [2]. They should be used
carefully, especially in patients with osteosclerosis. If there
is no forward movement of a half-pin when the distant cortex
is drilled, then upon rotation within the nearby cortex the
7 Principles of Frame Construction
c d
Fig. 7.17 (continued) (c) Through soft tissue outside the second cor-
tex, a wire is inserted using only a hammer. (d) A 2- to 3-mm incision
is made using a wire with an olive stopper. (e) Pulling sharply to sub-
merge the olive stopper until the bone is inadmissible. (f) For an inser-
tion until a bone corkscrew stopper is reached, a wire is pulled at its
197
sharp end with simultaneous rotation. (g) After wire insertion, disc
clips for the fixation of gauze napkins are stringed along the device.
(h) Disc clips on the sides of the wire stopper should have visible dif-
ferences in shape, color, etc. (i) Industrially made disc clips for gauze
napkin fixation
198
Fig. 7.18 (a) Placement of the
drill sleeve on the bone (e.g., at a
position 9) and then changing the
angle in the transversal plane to
approach position 8 is a grave
error. (b) The drill sleeve is
inserted in the projection of
position 8
screw part of the half-pin will destroy the thread previously
made in the cortex, thus immensely weakening fixation of
the half-pin in the bone.
The insertion of a conical half-pin should be done
fluoroscopically because its partial return following a too
deep insertion into the bone will lead to its destabilization.
Half-pins with a cortical and spongy thread should be
inserted in the diaphyseal and metaphyseal parts of the bone,
respectively. The plane in which the half-pin is inserted must
correspond to the position in which the transosseous element
is to be inserted (Fig. 7.18).
Continuing with the tasks of an osteosynthesis, the half-
pin is inserted perpendicular to the longitudinal axis of the
bone fragment or at an angle distinct from 90° (usually 70°
L.N. Solomin
or 120°). For insertion of a half-pin at any set angle, the spe-
cial conductor (Table 1.2, Fig. 7.19) is used.
For insertion of a half-pin at an angle of 90°, the “control-
ling device for bone fragment reduction and support orienta-
tion” (Table 1.2, Figs. 7.20 and 7.33) can be used. The use of
intraoperative fluoroscopy facilitates this step.
The half-pin should be inserted through both cortical lay-
ers. The exceptions are when the main vessel or a nerve con-
tacts the bone. However, in all cases the screw of the half-pin
should be hidden within the bone to prevent breakage of the
half-pin (Fig. 7.21).
Insertion of a half-pin through the center of the bone’s
breadth is limited by needles inserted subperiosteally
(Fig. 7.22).
7 Principles of Frame Construction 199

a b

Fig. 7.19 A special drill sleeve is used to insert a half-pin at a specified
angle to the longitudinal (anatomic) axis of the bone fragment. (a) A
sleeve placed at 90°: in the fixator, the calibrated wire is fixed at the
mark indicating the location of the sleeve at the necessary angle. (b) A
sleeve placed at 70°: when drilling is started, the sleeve is inclined until
the calibrated wire leans against the bone
Fig. 7.20 For insertion of a half-pin at an angle of 90° to the longitu-
dinal axis of a bone fragment (Table 1.2) both wires of the special
device are immersed until the bone. The half-pin is inserted parallel to
the wires of the device. If the fragment is short, the length of one of the
wires is altered according to the diagram and in accordance with the
bone’s relief

12
a b

9 3

Fig. 7.21 (a) The half-pin should be passed through both cortices. (b) The exceptions are when the main vessel or a nerve contacts the bone

Before inserting a half-pin in metaphyseal bone, a canal is
made in the nearby cortex using a 3–4 mm awl (Fig. 7.22).
For insertion of a pin in diaphyseal bone (Figs. 7.23, 7.24,
and 7.25), a canal is formed with a diameter corresponding
to the standard size of the pin and in relation to the bone tis-
sue density. The canal diameter is 2.7 mm for a 4-mm half-
pin, 3.8 mm for a 5-mm half-pin, and 4.8 mm for a 6-mm
half-pin. In patients with osteoporosis, the diameter of the
canal must be 0.1–0.2 mm less. Use of a surgical drill with a
stopper (Table 1.2) requires the addition of a tissue protector
sleeve (Table 1.2). Bayonet drills (Table 1.2) are approxi-
mated to the bone by puncturing the soft tissues. Insertion of
a pin without a self-tapping guiding end must be preceded by
thread formation in the bone using a tap.
200 L.N. Solomin

After the transosseous elements have been inserted, pre-
sterilized gauze-wad fixators are strung on them using plastic
or rubber discs 10–15 mm in diameter for wires and
20–25 mm in diameter for half pins. Fixators placed on the
side of the stopper of the wires must be distinguishable by
color, shape, etc.
Mounting of the frame of the device starts with the basic
supports. The use of an image intensifier facilitates their
two-plane orientation at an angle of 90º to the longitudinal
axis of the bone fragment. In addition, the method shown in
Fig. 7.26 can be used.
The external supports are oriented relative to the bone in
the horizontal plane (“centering” of the external supports
relative to the soft tissues) according to the individual fea-
tures of every segment. This information is presented in the
respective chapters of this book.

a b

c d

e f

Fig. 7.22 Inserting a half-pin in metaphyseal bone at an angle of 90°. of the controlling device for bone fragment reduction and support ori-
(a) Finding the anterior and posterior cortices. The third wire is inserted entation. (e) Formation of a channel in the nearby cortical plate. The
at a level of the top of the greater trochanter of the femur. (b) A 4–6 mm awl is placed parallel to the wires of the device. (f) Insertion of half-pin
incision is made. (c) Formation of the soft-tissue channel. (d) Placement parallel to the wires of the device
7 Principles of Frame Construction 201

g h

Fig. 7.22 (continued) (g) The half-pin is inserted perpendicularly to the longitudinal axis of the bone. (h, i) A disc clip, either prepared during
the operation (h) or industrially made (see Fig. 7.17i), is put on the half-pin

Wires and, especially, half-pins should not be bent in
fixing either one to the external supports of the device. If
the external end of a transosseous element is located at a
certain distance from the support, gasket washers or posts
(brackets) should be used (Figs. 7.27 and 7.28). An excep-
tion to this is when elastic deformation of transosseous
elements is used intentionally; for example, in the reposi-
tioning of bone fragments or to increase the rigidity of the
osteosynthesis.
If the half-pin is not inserted perpendicular to the ana-
tomic axis of the bone fragment, it is fixed to the support
using two posts, male and female, or two male posts. If two

a b

Fig. 7.23 Inserting a half-pin in diaphyseal bone at an angle of 90°. (a) Finding the anterior and posterior cortices. (b) A 4–6 mm incision is made
202 L.N. Solomin

c d

Fig. 7.23 (continued) (c) Formation of the soft-tissue channel. (d) A
calibrated wire is fixed in the position providing sleeve placement at an
angle of 90° (see Fig. 7.19a). (e) Insertion of the tissue protector sleeve
with a trocar and its disposition such that the calibrated wire rests
against the bone. (f) The trocar is removed, the drill is entered, and the
first cortex is drilled. (g) After the drill is set against the second cortex,
nuts are screwed at a distance from the sleeve equal to the thickness of
the second cortex (2 mm). (h) After channel formation in the second
cortex, the screwed nuts rest against the sleeve, preventing further
movement of the drill
7 Principles of Frame Construction 203

i j

k l

Fig. 7.23 (continued) (i) Inserting the half-pin through both cortices. bayonet drill parallel to the wires of the device. (l) The half-pin is
(j) The disc clip is placed on the half-pin. (k) Insertion of a half-pin at inserted parallel to the wires of the device, i.e., perpendicular to the
an angle of 90° using the controlling device for bone fragment reduc- longitudinal axis of the bone fragment (see Fig. 7.20)
tion and support orientation. The bone channel is made by focusing a

a b

Fig. 7.24 Inserting a half-pin in diaphyseal bone at an angle of 120° protector sleeve and placing it such that the calibrated wire rests
(as in Fig. 7.19b). (a) A calibrated wire is fixed in the position pro- against a bone
viding sleeve placement at an angle of 120°. (b) Inserting the tissue
204 L.N. Solomin

c d

Fig. 7.24 (continued) Formation of the channel in both cortices (c) Half-pin insertion at an angle of 120° followed by placement of the disc clip (d)

a b

Fig. 7.25 A half-pin is inserted by means of an adapted sleeve (Table After incision of the soft tissues, the bayonet drill is entered into the
1.2) when the support is already mounted. (a) Finding the anterior and bone and a channel in both cortices is formed. (e, j, k) Insertion and
posterior cortices. (b, c) Inserting the adapted sleeve in the hole of the fixation of a half-pin
post. (c, f) Entrance of the bayonet drill into the adapted sleeve. (d, g–i)
7 Principles of Frame Construction 205

e f

g h

i j

51.43

Fig. 7.25 (continued)

206
a b
c d
Fig. 7.26 Frame assembly in fractures. After the basic transosseous
elements are inserted, a basic support is mounted, generally perpen-
dicular to the respective bone fragment. In this case, the controlling
device for bone fragment reduction and support orientation can be used
(Table 1.2). One of the calibrated wires is removed from the device; the
two remaining wires are withdrawn for an equal distance and then
L.N. Solomin
inserted as far as possible into the diaphyseal part of the bone fragment.
If the fragment is short, the length of one of the wires is altered accord-
ing to the skiagram in accordance with the bone’s relief (a). The support
is placed parallel to the wires of the device: first in the frontal (b) and
then in the sagittal (c) planes. The specified device also allows control
over the orientation of the proximal (d) and distal
7 Principles of Frame Construction 207

e f

Fig. 7.26 (continued) (e) reductionally fixing supports. Proximal and fragment reduction (h). The final step is insertion of the stabilizing tran-
distal modules are connected by threaded rods (f). A 4–6 mm distrac- sosseous elements, elimination of the diastasis, and dismantling of the
tion for diastasis is done (g). Next, the proximal and distal reductionally skeletal traction (i)
fixing elements are inserted followed by consecutive two-plane bone
208 L.N. Solomin

a b

c d

Fig. 7.27 (a) A half-pin is inserted perpendicularly to the anatomic
axes of the bone fragment (parallel to the device support) and close to
the support. It is fixed with an L-shaped clamp. (b) The half-pin is
inserted perpendicularly to the anatomic axes of a bone fragment (par-
allel to the device support) and at some distance from the support. It is
fixed with a female post. (c) The half-pin is not inserted perpendicularly
to the anatomic axes of the bone fragment (non-parallel to the device
support) and at some distance from the support. It is fixed with a male
post and the L-shaped clamp or (d) male and female posts (or two
female posts). Bending of a half-pin to a support is forbidden! If neces-
sary, washers should be used
7 Principles of Frame Construction 209

a b

Fig. 7.28 (a) A wire is located at a some distance from a support. (b) Wires must not be bent to fix them to the external supports of the device. If
the external end of a transosseous element is located at a certain distance from the support, posts (c) or gasket washers (d) should be used

female posts are used, the half-pin cannot be removed with-
out dismantling the support. The half-pin can also be fixed
using an L-shaped clip (Fig. 7.28).
The basic variants of wires tensioning are shown in
Figs. 7.29, 7.30, 7.31, and 7.32.
The protruding ends of the wires are cut off at a distance
of 30–40 mm from the outer edge of the support and are bent
over. Repeated bending of the free ends of the wires should
be avoided as subsequent straightening of the wires (to restore
the tensile force for repositioning) may be necessary and the
wire may fracture at the point of curvature (Fig. 7.29e).
In deformity correction, transosseous modules fixing the
proximal and distal bone fragments are not parallel to one
another. Consequently, they are connected by one- or two-
plane hinges (Fig. 7.34). The branches of the hinges must be
coaxial with the respective bone fragments. Skewness and
bending of the hinge jaws towards one another are
inadmissible. In cases in which angular deformity is to be
eliminated with time, the subsystem includes three hinges:
two axial and one swivel. Axial hinges are located strictly in
parallel on the opposite sides of external supports. The axis
of rotation of a pair of axial hinges is determined according
to the tasks of the osteosynthesis. The swivel hinge is placed
on either the concave or the convex side of a deformity. It is
also possible to place two hinges on the concave side and two
hinges on the convex side of a deformity. More detailed
information about Ilizarov and universal hinges is given
in the sections devoted to deformities of the long bones
(Chaps. 16 and 17).
After installation of the device is completed, movements
in adjacent joints are performed with the maximum possi-
ble amplitude. If soft-tissue tension is present, the skin and,
if necessary, the fascia are cut, displaced relative to the
transosseous element, and sutured (Fig. 7.35). If an incision
210
a b
c d
Fig. 7.29 Tensioning wires by means of a standard wire tensioner. (a)
Slight fixing of the wire using a wire fixation bolt. (b) The wire is cut
off at a distance of 3–4 cm from the fixing bolt of the wire tensioner. (c)
Correct placement of the wire tensioner: the nut of the wire fixation bolt
>3 cm is necessary, then the transosseous element should
be reinserted.
The frame and skin are carefully cleaned of blood. The skin
where a transosseous element emerges is covered with dressings
of 4–6 cm2 impregnated with 70% ethyl alcohol (Chap. 34). A
control radiograph taken in the operating room is obligatory.
L.N. Solomin
is located in the center of the wire tensioner. (d) Otherwise, it will be
difficult to tighten the nut of the wire fixation bolt. (e) After tensioning
and fixings the wire to a support, its free end is bent to the support,
avoiding bending at an angle of 90º
By means of special positioning of the patient in the bed
or through the use of attachments to the external fixation
device, the joints are placed in the position specific for every
segment depending on the pathological condition that neces-
sitated surgical intervention. The external structure is cov-
ered with a cotton cover (Chap. 34).
7 Principles of Frame Construction 211

a a

c
c

Fig. 7.30 (a) A lever wire tensioner can be substituted for a standard
wire tensioner when use of the latter is complicated or impossible. (b)
Fixing a wire with the lever wire tensioner. The arms of the tensioner
are brought together and the wire is fixed to the support. (c) Removal of
the wire tensioner; the end of the wire is bent to the support

Fig. 7.31 (a) Tensioning a wire by means of turning a post (general

scheme). (b) The post is inclined inwards at an angle of 15–20º and a
wire is fixed to it. (c) The post is held with a flat-nose pliers and the nut
fixing the post is turned. (d) The post is in a vertical position; the wire
is tensed
212 L.N. Solomin

Q = 157 kg Q = 136 kg Q = 91 kg Q = 68 kg
b

a b c d
c

Fig. 7.32 (a) Wire tensioning by turning the wire fixation bolt. (b) The (b, c) or loosen (b, d) the bolt. The maximum tensile force of the wire
maximum possible tensile force on the wire depends on the moment is greater if a wire tensioner is used (b, a, b). [26, 27]. (c) Wire tension-
acting on the bolt and resulting from the wire’s tensile force to tighten ing with the help of a traction clip

a b

Fig. 7.33 To reduce the number of radiographs in a patient undergoing fracture location, the wires are inserted until they touch the bone frag-
fracture reduction, a device to determine the quality of the repositioning ment. The third wire is then inserted until it touches the other fragment
is used (Table 1.2). Neighboring calibrated wires are withdrawn for the (a). If a precise reduction has been achieved, the marks of all the cali-
same distance and fixed on a plate. At the minimum distance from the brated wires will be at the same level (b)
7 Principles of Frame Construction 213

a b c

d e

Fig. 7.34 Frame assembly in deformity correction. Assembly of the supports is in one plane, then one-plane hinges are used. (d, e) If the
proximal (a) and distal (b) transosseous modules. (c) Connection of the angle between supports is in two planes, two-plane or universal hinges
proximal and distal modules by a reductional unit. If the angle between (Table 1.2, item no. 15) are used
214 L.N. Solomin

Fig. 7.34 (continued) (f) for osteotomy

(if it is necessary) modules temporarily f g
should be separated. (g) After osteotomy,
the modules are re-connected

a b

Fig. 7.35 (a) The transosseous element presses on the soft tissues. The skin and fascia are dissected (b), the soft tissues are released (c), and the
wound is closed (d)
7 Principles of Frame Construction
7.8 Ilizarov Method of Corticotomy
In Part II, methods for the repair of long bone defects and the
correction of deformities are based on Ilizarov corticotomy
together with osteoclasis (Figs. 7.36 and 19.12). For this pur-
pose, the rods connecting the device supports proximal and dis-
tal to the contemplated corticotomy area are disassembled, i.e.,
the modules by which the proximal and distal bone fragments
are to be fixed are separated. Then, through an incision, the adja-
cent and lateral cortical plates are dissected with a narrow 5-mm
osteotome. The proximal and distal modules are rotated and
flexed manually in opposite directions to fracture the remain-
ing part of the cortical plate. At the Russian Ilizarov Research
Center, this type of bone destruction has been shown to result in
the formation of a distraction regenerate. The threaded rods are
reinstalled in the apertures from where they were removed.
If a bone is sclerosed, in order to avoid its splitting,
five or six 2-mm channels arranged like a fan (Fig. 26.2)
a b
c d
Fig. 7.36 Ilizarov method of corticotomy. (a) Frame mounting. (b)
The proximal and distal modules are separated. The surgeon should
record the sites of the joining connecting rods and supports as well as
215
should be made prior to corticotomy. Table 7.1 shows the
positions (Sect. 4.3) optimal for corticotomy execution.
The positions for the forearm bones are shown for the mid-
dle position of a segment: between supination and prona-
tion. As noted in the table, when the main vessels and
nerves are adjacent to a bone, osteotomy should be done
“openly” (using a surgical approach) in order to avoid their
damage.
An osteotomy of fibular bone is shown in Fig. 15.1. The
techniques used in the epimalleolar approach, by means of a
Gigli’s saw, are presented in Sect. 16.8.
After corticotomy, one or two stitches are placed in the
wound. A cutaneous circular bandage should not be used. To
reduce the hematoma volume, a compression sling-like ban-
dage is applied for 1–2 h. Five to eight layers of sterile fabric
dressing are used to cover the wound area and are fixed with
a bandage wrapped tightly on half-pins mounted on the
device (Fig. 7.37).
the lengths of all connecting rods. A small (5–7 mm) incision is made
for chisel insertion. (c–e) A corticotomy is performed
216 L.N. Solomin

f
e

Fig. 7.36 (continued) (f) Osteoclasis is carried out by consecutive flexion in the frontal and sagittal planes. (g) Fluoroscopic control. (h) The
modules are re-connected by rods; the device is stabilized
7 Principles of Frame Construction 217

Table 7.1 Recommended positions for corticotomy of long bones

Levels Bones, positions, notes
Humerus Ulna Radius Femur Tibia
I – 9, 10 – 9, 11, 12 3, 4
Protection of the
n. ulnaris
II 11 4, 5, 6 9, 10 1, 12 3, 4
Protection of
vessels and nerves
III 11 4, 5, 6 1, 11, 12 1 3, 4
Protection of the n. radialis
IV 9, 10 4, 5, 6 1, 12 1 3, 4
Protection of the n. radialis
V 9, 10 4, 5, 6 1, 12 1 3, 4
Protection of the n. radialis Protection of the a.v. tibialis ant.
and n. peroneus profundus
VI 9 4, 5, 6 1, 12 1, 2 4
Protection of the n. radialis and
a. profunda brachii
VII 9 4, 5, 6, 7 1, 12 3, 4 1, 2
Protection of the n. radialis, a. Protection of the a.v. Protection of the a.v. tibialis ant.
collateralis radialis, n. ulnaris poplitea and n. peroneus profundus
and a. collateralis ulnaris
VIII – 4, 5, 6, 7 1 3, 4 1, 2
Protection of the Protection of the a.v. Protection of the a.v. tibialis ant.
vessels and nerves poplitea and n. tibialis and post.

Fig. 7.37 After corticotomy to

reduce the hematoma volume, a
compression sling-like bandage is
applied for 1–2 h. A specially
prepared small elastic sling with
fixing hooks can be used (From
[26])

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