Ovid: Chapman’s Orthopaedic Surgery

Editors: Chapman, Michael W.
Title: Chapman’s Orthopaedic Surgery, 3rd Edition
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Deborah F. Stanitski
D. F. Stanitski: Professor, Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, 29425.
Over the past decade, external fixation has gained
increasing acceptance as a surgical technique in children. The most
common applications include incidences of trauma, correction of limb
deformity, and limb-length equalization.
The numerous fixators available fall into two general
categories: circular fixators and cantilever external fixators.
Biomechanical studies have demonstrated that bone formation is enhanced
by cyclic axial micromotion and, perhaps, by limited-bending
micromotion (23). Torsion, on the other hand,
is generally deleterious to bone formation. The Ilizarov-type of
circular external fixator, which is less stable to axial loading than
are most cantilever systems but relatively resistant to torsion,
provides an excellent biomechanical environment for bone formation (42).
Another advantage of circular external fixation is that
it is applicable to patients of virtually any size from toddler to
large child, obese adolescent, or adult. The system provides
three-dimensional adjustability, allowing angulation, translation,
rotation, and lengthening when necessary. The Taylor Spatial Frame (5) now allows these parameters to be corrected simultaneously but currently has some ring-size limitations (Fig. 171.1). The traditional Ilizarov external fixator can be constructed with hinges to correct existing limb deformity (Fig. 171.2).
Circular external fixation can be used to span adjacent limb segments,
to protect potentially unstable joints, or to treat joint contractures (Fig. 171.3).
Figure 171.1.
The Taylor Spatial frame allows simultaneous correction of angulation,
rotation, length, and translation through the use of six struts and
universal ball joints.
Figure 171.2.
Preconstructed Ilizarov tibial fixator mimics the deformity and allows
gradual correction through hinges placed at the level of the deformity.
Figure 171.3. A: Preoperative photograph of a 3-year-old patient with arthrogryposis and a nearly 90° flexion deformity of the knee. B: Appearance of Ilizarov fixator affixed to the femur and tibia, spanning the knee joint with corrective hinges.
The disadvantages of the traditional circular external
fixator are its bulk, the fact that it is difficult to apply and
adjust, and that it requires multiple sites for transfixing wires. The
traditional Ilizarov external fixator uses 1.5 or 1.8 mm transfixing
tensioned wires for bone fixation, with half-pin fixation in the
proximal femur. Over the last 5 to


years, a number of surgeons have modified the originally described
techniques, substituting half-pins for some of the wires. Specifically,
in children, the traditional “medial face” tibial wire (parallel to the
medial face of the tibia) has been eliminated in favor of an
anteroposteriorly directed half-pin. Affixing half-pins to a circular
fixator permits 360° adjustability at the same time it avoids some of
the soft-tissue problems of transfixing wires.

Unilateral external fixators by contrast are easy to apply, require a limited number of pin sites, and are less bulky (33).
They are applied to only one side of the limb and require usually no
more than four to six half-pins per limb segment depending on the type
of application. Cantilever systems have some disadvantages. They can be
used only on limbs of a certain size, they have less stability to shear
stress than circular fixators, they cannot span joints easily, and
their ability to correct angulation, rotation, and translation
gradually is limited. With many current systems, significant
adjustments such as device and pin clamp exchange must be made under
general anesthesia. Some systems, including the Heidelberg (5), Orthofix (5), and EBI (5) systems, have gradual but limited correction capabilities.
In this chapter, I provide specific application recommendations. I have had more than a decade of experience


with both types of devices. The Ilizarov type of fixator remains the
more versatile device, but patient acceptance and comfort clearly favor
the monolateral fixator.

A number of cantilever devices are available in North
America for trauma or limb reconstruction applications, including the
Orthofix device (Orthofix, Winston-Salem, NC), EBI Dynafix (EBI Corp.,
Parsippany, NJ), Smith and Nephew Heidelberg fixator (Smith and Nephew,
Memphis, TN), the Hex-Fix (Smith and Nephew, Memphis, TN), and the
Synthes External Fixator (Synthes USA, Philadelphia, PA). In each case,
application requires pin clamps or pin clamp templates through which
half-pins are inserted. The choice of fixator is usually determined by
the problem to be addressed and size of the patient. The most commonly
used limb reconstruction systems are the Orthofix and EBI, with the
Heidelberg system having been recently introduced. These fixators are
lightweight devices with the ability to telescope. The technique for
insertion of the half-pins, and application of these types of fixators
is discussed in detail in Chapter 11 and specifically for the tibia in Chapter 24.
The Orthofix, available in pediatric and adult sizes, has variable body lengths (Fig. 171.4).
The short or standard length devices are used most often on children.
Orthofix has two articulating ball joints and uses tapered predrilled
half-pin fixation. The telescoping body can be unlocked once fracture
or osteotomy callus formation is evident radiographically. This
capacity theoretically allows axial loading or dynamization of the bone
facilitating callus formation and bone healing. The standard
articulated device is used for fracture management and osteotomies (16,35,40,50,53). Its ball-and-joint articulation permits approximately 30° to 35° of angulation; it can be freely rotated.
Figure 171.4. Several lengths of the Orthofix pediatric (top two) and adult (bottom 3) fixators are available.
Use the straight slide-type device or LRS (5) (Limb Reconstruction System) for lengthening (Fig. 171.5). It allows placement of more than two pin clamps when necessary for situations such as bone transport. A swivel clamp


can be substituted for straight clamps at one or both ends of the bone (Fig. 171.6);
this technique may be useful for bifocal osteotomies with acute
deformity correction or to eliminate deformity that may develop during
lengthening. A variety of angulation and rotation template clamps are
now available for more accurate multiplanar corrections (Fig. 171.7). Do not use the standard swivel clamps for lengthening; they are less stable than the standard pin


clamps. With either the standard articulated body fixator or LRS,
insert tapered predrilled half-pins through the clamp templates. Then
replace the template with the standard pin clamps and tighten them. For
fractures and osteotomies, generally two half-pins above and below the
fracture or osteotomy are adequate. The widest pin spread in the clamp
provides the best stability. For limb lengthening, use three pins
proximal to the lengthening site in the femur and tibia. Two or three
are adequate distally, depending on the size of the patient and amount
of anticipated lengthening (Fig. 171.8) (1,22,25,46,47,48).

Figure 171.5. A: Orthofix LRS slide lengtheners are available in various lengths, as well as pediatric and adult sizes for limb lengthening. B: Template clamps are placed directly on the lengthening device for parallel pin placement. C: LRS system with pin clamps in place and distraction device above the fixator.
Figure 171.6. Swivel template clamps and swivel pin clamps are available for angular correction.
Figure 171.7. A and B: A new rotation template clamp is now available to allow accurate planning and pin insertion for acute rotational corrections. C:
The new angulation template clamp can be affixed to the end of the
slide for planned acute angular correction 90° orthogonal to the plane
of the swivel clamp.
Figure 171.8. A:
Clinical appearance of a patient with Ollier’s disease after tibial
lengthening with residual varus deformity of the femur and shortening. B: AP and lateral radiographs following application of LRS system and acute correction of femoral deformity. C to E: Clinical and radiographic appearance at the conclusion of lengthening and bone consolidation.
The T-Garches device (Orthofix) is useful for gradual
correction of frontal plane deformity in the tibia—for example, in
adolescent Blount’s disease (Fig. 171.9) (59).
Small lengthenings can also be achieved with this device. A new
template clamp allows correction of acute sagittal plane deformity
before application of the device following osteotomy (Fig. 171.10).
It is not recommended for large lengthenings; the hinge may not
withstand large lengthening forces, and the device, for the most part,
accommodates only two proximal tibial pins (Fig. 171.11).
Figure 171.9. A and B: The T-Garches external fixator is ideal for correction of proximal tibial frontal plane deformity. C and D:
Clinical and radiographic appearance of a 12-year-old boy with
adolescent Blount’s disease and varus deformity of both the tibia and
the femur. E: Radiographic appearance
following osteotomy of the femur and tibia, and application of an
Orthofix external fixator to the femur and T-Garches external fixator
to the tibia. F: Radiograph following fixator removal with restoration of normal limb mechanical axis.
Figure 171.10.
The new T-Garches template clamp allows accurate pin placement for
simultaneous sagittal and frontal plane deformity correction.
Figure 171.11.
Only two pins can be placed in the proximal T-Garches fixator. This
potentially limits its use, particularly for significant lengthenings.
In applying the LRS systems, standard ball-joint fixators,



and the T-Garches, it is important to note the length of the device and
the pin spread for the particular application. Be certain, for example,
in a limb lengthening, that the device is long enough. At least 10%
extra length is needed for the tibia and 20% for the femur. The
bone-to-fixator distance is relatively large, particularly in the
femur. Thus, there is not always a 1:1 ratio between the amount of
lengthening the device can achieve (ie, number of turns) and the actual
distraction achieved in the limb. Start with some extra length in the
device to avoid running out of space.

  • In the case of fracture reduction or
    osteotomy, anticipate whether the device will need to be lengthened or
    shortened to achieve the correct bone position before determining pin
    placement. Add a supplemental pin to the fixator body if necessary for
    segmental fracture stabilization.
  • Once pins are in place, remove the
    template. Obtain provisional reduction of a fracture or positioning of
    the bone ends following osteotomy before applying the fixator.
  • Apply the fixator and tighten the pin
    clamps. Attach the reduction forceps to the clamps and fine-tune the
    bone position under image intensifier control.
The major generic difference between the Orthofix and
the Dynafix (manufactured by EBI Medical Systems) is that the Dynafix
itself is used as its own template. Tissue protectors and drill guides
are placed directly through the pin clamps. The Dynafix articulated
body fixator has mobile joints that allow angulation in the frontal and


plane and rotation through the center of the fixator (Fig. 171.12).
The snakelike configuration of the device and the multiple fixator body
joints permit translation and rotational corrections as well as
approximately 30° of angulation at each joint. As with the standard
Orthofix unit, these corrections need to be completed during surgery.

Figure 171.12. The EBI Dynafix external fixator allows angulation, translation, and rotation through its “snake-like” configuration.
The lengthening system is similar in concept to the Orthofix LRS (Fig. 171.13 and Fig. 171.14).
Both systems use pins with an external shaft diameter of 6.0 mm. The
pin clamp spacing and configuration are different between the two
devices; thus, it is impossible to exchange devices without changing
pin locations.
Figure 171.13. The EBI lengthening system is similar to the Orthofix LRS system.
Figure 171.14. Swivel clamps are available for the Dynafix lengthening system.
A device similar to the Orthofix T-Garches is also available for correction of proximal tibial deformities (Fig. 171.15).
Because the pin clamps are applied to the T portion of the device, more
than two pins can be inserted if desired. The pins may also be applied
either proximal or distal to the T allowing some longitudinal spread of
the proximal metaphyseal pins.
Figure 171.15. Like the T-Garches, the EBI T-fixator allows gradual angular correction in the proximal tibia and lengthening.
Heidelberg Fixator
Used in Europe for approximately 5 years, the Heidelberg
fixator, designed by Dr. Joachin Pfeil, has recently been introduced to
North America (Fig. 171.16). This device is yet
another cantilever system. Its proposed benefit, however, is the
ability to achieve gradual angular correction through a device called
the angulator (Fig. 171.17). Pins are inserted through a drill guide template (Fig. 171-18), which can be applied to the fixator in any plane and allows correction of oblique plane deformity or correction of deformity


that may arise during limb lengthening such as procurvatum and valgus
in the tibia. The surgeon can also apply supplemental bone screws when
necessary to enhance stability. A special clamp is also available to
allow fixation to the Ilizarov ring system (Fig. 171.19).
Experience thus far in North America is limited, but the device has
some potentially significant advantages, particularly when gradual
deformity correction is desirable. Translational correction must
nonetheless be obtained intraoperatively.

Figure 171.16.
The Heidelberg fixator has been recently introduced to North America.
Similar to other systems, it has several pin clamp types. Lengthening
occurs through the body of the fixator itself.
Figure 171.17. The Heidelberg “angulator” allows gradual deformity correction following lengthening.
Figure 171.18. Pins are introduced through a hand-held template that matches the pin clamp.
Figure 171.19. A special Heidelberg clamp allows fixator attachment to the Ilizarov ring system.
The Hex-Fix can be used to stabilize pediatric long-bone
fractures definitively and in osteotomies in small children or children
with particularly small bones, as in the skeletal dysplasias. I prefer
to use it for proximal femoral fractures or fractures in very small
children (those younger than 4 to 5 years of age) in whom stable
fracture fixation is desired. The device can accommodate predrilled or
self-drilling (eg, Schanz) half-pins of 4, 5, or 6 mm. There are
several types of pin clamps available that accommodate one or two bone
pins (Fig. 171.20). The single pin clamps
permit flexible pin spacing. The clamps also allow some angulation and
rotation, enabling multiplanar half-pin fixation on a cantilever device.
Figure 171.20.
The Hex-Fix is particularly useful for fracture fixation in small
children. Four, five, or six millimeter pins may be introduced through
the pin clamps, which act as their own template. They are available as
single or double clamps as shown. Pins and pin clamps are secured using
the universal tool.
Generally, insert two pins proximally and distally to
the fracture or osteotomy; pin spacing is dependent on the individual
situation. There is no limit to the number of pins that can be used
other than the ability to put the pin clamps on the bar. The actual bar
on which the pin clamps are assembled is available in several lengths,
the shortest being 8 inches. Although a distractor unit is available
for lengthening, I have no experience using this device for limb


The most commonly used circular external fixator is the
Ilizarov apparatus. This device is applicable to all limb segments in
both the upper and the lower extremities and can be used for deformity
correction of both bone and soft tissue, and for limb lengthening (3,5,6,7,8,9,10,11 and 12,15,17,19,20 and 21,24,27,29,30 and 31,32,38 and 39,41,42,43,44 and 45,51,56,57 and 58,61,62 and 63).
Acute trauma applications in the child are limited. It is used most
commonly for segmental bone loss, in which it can be used for bone
transport (11).
In children, the Ilizarov device is applied most
commonly to the femur or the tibia. The standard tibial fixator
consists of one or two rings proximally and distally depending on the
size of the patient. The standard tibial wire “formula” calls for the
insertion of four wires proximally and distally (Fig. 171.21) (26).
These wires are either 1.5 or 1.8 mm in diameter. Use 1.5 mm wires in
the tibia of smaller children, and 1.8 mm wires in the femur and the
tibia of heavier children. At each end of the bone, place two “olive”
wires and two smooth wires. Generally, place the olive wires
transversely in the frontal plane, one olive from the medial and one
from the lateral aspect of the bone. Transfix the fibula and tibia with
a smooth wire, both proximally and distally. Finally, place two wires


anterolateral to posterolateral (one proximal and one distal), parallel
to the medial border of the tibia. When bifocal—proximal and distal
tibial osteotomies—are planned, use another ring fixed to the
mid-diaphysis by two wires (Fig. 171.22).
These wires are often two olive wires, or an olive wire and plain wire,
depending on the direction or nature of the deformity.

Figure 171.21. A and B: Transverse “Olive” wires are first placed on the most proximal and distal rings. C and D: Two additional olive wires are placed from the opposite direction on the two middle rings. E and F:
Smooth wires are placed from the lateral aspect of the leg, parallel to
the medial face of the tibia both proximally and distally. G and H: Two smooth wires are placed through the proximal and distal fibula, transfixing the tibia.
Figure 171.22. Bifocal treatment for deformity or lengthening requires an additional middle ring with two-wire or wire and half-pin fixation.
Many modifications have been made to this standard wire
“formula” in recent years, generally the substitution of half-pins for
wires (discussed in Chapter 32).
In children, I prefer a largely “wired-based” circular
fixator. Because the standard medial face tibial wire can often
interfere with the pes anserinus tendons, I substitute a half-pin for
this wire, leaving the remaining wires as described earlier (Fig. 171.23).
In the tibia, the addition of an extra ring in the diaphysis allows
bifocal treatment. It is useful for patients with deformities at more
than one level (Fig. 171.24), when extensive lengthening is necessary, and in bone transport (Fig. 171.25).
Figure 171.23. A half-pin is often substituted for the traditional Ilizarov medial face wire and affixed to a Rancho cube.
Figure 171.24. A and B:
Standing and lateral teleoroentgenograms of a patient with Ollier’s
disease and a 13 cm limb-length inequality with bifocal tibial
deformity. C and D: The Ilizarov external
fixator with bifocal application was used for gradual correction of the
proximal and distal deformities as well as 8 cm of lengthening. E: Radiographs at the conclusion of tibial consolidation.
Figure 171.25.
Tibial radiographs of a 16-year-old boy who presented following a
pedestrian motor vehicle accident with 6 cm of missing bone. Antibiotic
cement beads were used as a spacer, and external fixation was applied
using a Synthes external fixator. B: The
Ilizarov apparatus was applied over the Synthes fixator, which was then
removed. A proximal osteotomy was performed and bone transport was
initiated to restore the defect. C: Radiographs at the conclusion of bone transport. D: Radiographs following fixator removal.
For femoral fixation I prefer an Italian modification
using partial rings proximally, as compared with the original Russian
technique, which uses full rings for both the proximal and distal
thigh. My technique is as follows.
  • Generally, I use four wires distally—two 1.8 mm olive wires and two plain wires fixed to one or two rings (Fig. 171.26).
    Figure 171.26.
    Schematic drawing of the Italian modification of standard Ilizarov
    fixation of the femur. Note that proximal fixation is achieved using
    half-pins. An empty middle ring is used to facilitate angular or
    rotation correction as well as lengthening. Distal fixation is
    traditional through four 1.8 mm transfixing wires.
  • Connect these rings to an empty diaphyseal ring via lengthening rods or hinges depending on the application.
  • Achieve proximal fixation by half-pin,
    rather than by wire fixation. Determine the diameter of the half-pin by
    the size of the child.
  • Connect the distal rings to the proximal thigh fixation through oblique supports.
  • Attach the proximal half-pins to one or two “arches,” depending on the size of the patient.
  • P.4370




  • Introduce wires or half-pins on the
    diaphyseal ring for bifocal application to the femur. Although bifocal
    lengthening is not recommended, proximal angular or rotational
    osteotomy can be performed acutely (Fig. 171.27), combined with distal deformity correction and lengthening.
    Figure 171.27. A and B:
    Preoperative photographs and teleoroentgenogram of a 6-year-old boy
    with congenital shortening of the femur, fibular hemimelia, and a
    three-ray foot. C: The Ilizarov technique
    was used for bifocal application. Acute rotational correction was
    performed proximally. Elimination of distal femoral valgus and
    subsequent lengthening was done distally. D and E: The photographs demonstrate symmetric internal and external rotation at the conclusion of treatment. F: Radiographs demonstrate excellent healing of both femoral and tibial lengthening sites.
Circular fixation allows almost limitless modification
of the fixator. During lengthening, adjacent joints are at risk for
progressive contracture, subluxation, or dislocation. The risk of
dislocation is particularly significant in the case of congenitally
short limbs, such as the ankles associated with fibular hemimelia,
knees or hips in the congenital short femur, and proximal femoral focal
deficiency (PFFD). Pre-existing contracture due to trauma, burn, or
infection may warrant use of circular fixation for gradual correction
of deformity with combined femoral and tibial lengthening. Consider
prophylactic incorporation of the foot or tibia in tibial or femoral
lengthening, respectively, at the beginning or if there is any
indication of subluxation or progressive contracture as lengthening
proceeds. Consider extending the fixator to the pelvis when the hip is
at risk for subluxation (Fig. 171.28). I
recommend fixation of the foot at the initial surgery in any patient
undergoing tibial lengthening who has fibular hemimelia or a
pre-existing equinus contracture. Comprehensive release of the foot can
be maintained with foot fixation and combined with tibial lengthening (Fig. 171.29).
Figure 171.28. A:
Radiographs of an 11-year-old girl with a painless fibrous
pseudarthrosis of her right hip and a projected limb length inequality
of 9 cm. B and C: Radiographs demonstrate
Ilizarov fixation of the femur with extension of the fixation to the
pelvis to protect the potentially unstable hip. D and E:
Radiographs at the conclusion of lengthening demonstrate excellent
consolidation of the bone and no disruption of the hip joint.
Figure 171.29. A and B:
Clinical appearance and radiographs of a 2 1/2-year-old girl with
hemisacral agenesis, recurrent club foot deformity, and a leg-length
inequality. C and D: An open soft-tissue
release of the foot was combined with gradual correction of residual
foot deformity and tibial lengthening using the Ilizarov technique. E: Clinical appearance at the end of treatment.
  • Try to use two metatarsal olive wires and two calcaneal olive wires.
  • In the forefoot, introduce the medially
    based olive wire through the first and second metatarsals and the
    lateral wire through the two lateral metatarsals. Fix them to an arch,
    tensioned no more than 50 to 80 kg. Place the wires in this fashion to
    avoid flattening the forefoot arch and preclude weight bearing on wires.
  • Introduce one calcaneal wire from the medial side and one from the lateral side, usually diverging no more than 45° (Fig. 171.30).
    Figure 171.30.
    A variety of options are available for foot fixation using the Ilizarov
    technique. I prefer hindfoot fixation through the calcaneus using
    opposing olive wires and forefoot fixation, with the lateral olive wire
    transfixing the two lateral metatarsals and the medial Olive wire
    transfixing the two medial metatarsals.
  • Fixation of both the hindfoot and
    forefoot avoids midfoot deformity and forefoot equinus, which can
    result from tension on the long toe flexors during lengthening.
  • Once the distraction phase has been
    completed, remove the foot fixation, allowing the ankle and foot to
    regain motion while the tibial lengthening site consolidates. If
    prophylactic circular fixation has been applied to the tibia during
    femoral lengthening, remove it once femoral




    distraction has been completed as long as there is no significant concurrent contracture of the hip.

  • Perform osteotomy of long bones for
    deformity correction or lengthening through a 1 to 1.5 cm incision,
    with minimal periosteal stripping generally using a sharp, thin ¼-inch
  • Predrill the bone with a 2.7 mm or 3.2 mm
    drill to avoid crack propagation from the osteotomy into the adjacent
    half-pins, which could considerably weaken fixation.
  • Avoid large incisions with subperiosteal
    exposure of the bone and insertion of retractors to minimize scarring
    and promote bone healing.
  • There is no need to make a true
    “corticotomy” as described by Ilizarov, because the periosteal blood
    supply is more critical than the endosteal supply. Furthermore, the
    endosteal blood supply usually re-establishes itself within a matter of
    days following osteotomy.
Circular external fixation is used to correct foot deformity (32) by one of three approaches: (1) correction by distraction alone; (2) soft-tissue release and tendon lengthening combined with distraction; and (3)
osteotomy and distraction. The choice of method depends on the child’s
age and whether the deformity is bony alone or combined with
soft-tissue contractures. Ilizarov originally described correction of
all soft-tissue deformity through closed distraction or “bloodless”
surgery (28,32). This
situation may present itself in the child younger than 4 to 5 years old
with a multiply operated club foot in poor position. In my experience,
an attempt at correction by closed distraction alone may be
unacceptably painful and, owing to the scar stiffness, may result in
wire cut-out thorough osteopenic bone. In this situation, perform a
conventional comprehensive release first, followed by fixation of the
foot and tibia with appropriate hinge placement and subsequent gradual
correction (Fig. 171.31). This surgery avoids the problem of wire migration.
Figure 171.31. A and B:
Clinical and radiographic appearance of a girl with fibular hemimelia
and a four-ray equinovarus foot following two previous attempts to
correct her foot deformity. C:
Comprehensive foot release was combined with gradual independent
correction of the forefoot and hindfoot deformities and tibial
Apply this technique only to stiff feet in poor position, the goal being to produce a plantigrade foot.
The distraction rate in soft-tissue corrections is
limited by patient discomfort, skin tension, and the tolerance of
neurovascular structures. Slight overcorrection is recommended due to
soft-tissue elasticity which can cause rebound following apparatus
removal. Once correction has been achieved, maintain the fixation an
additional 6 to 8 weeks. Use orthotics after the removal of the fixator
to maintain the correction.
Tibial fixation should span the leg with two rings. A
total of four wires, or two wires and two half-pins, are adequate
fixation in the tibia because there is no tibial osteotomy. The number
of wires in the foot and complexity of the apparatus depends entirely
on the nature of the deformity.
With bony deformity in the older child, osteotomy is usually necessary (Fig. 171.32).
The nature of the deformity determines the location of the osteotomy.
If the hindfoot is neutral and the problem is midfoot cavus or
supination, use a midtarsal osteotomy. Hindfoot fixation can be neutral
with respect to the tibial fixation. Place hinges between the hindfoot
and forefoot, centered over the apex of the deformity. A hindfoot that
is not in neutral may be addressed in one of two ways. If cavus exists
with hindfoot deformity, use a V-shaped osteotomy to address the
hindfoot and midfoot independently. Additional fulcrum wires are
necessary, usually in the midfoot and talus to ensure that correction
occurs through the osteotomy and not


joint distraction. If the midfoot and forefoot are relatively neutral
with respect to one another and the hindfoot is the problem, use a
crescent-shaped osteotomy. Perform the osteotomy from the lateral side
through the calcaneus and neck of the talus. Place wires superior and


inferior to the osteotomy with appropriate hinge location to avoid translation of the foot during correction.

Figure 171.32. A and B: This nearly skeletally mature boy with fibular hemimelia has a fixed deformity of his foot and limb shortening. C:
An open crescentic osteotomy was performed through the talus and
calcaneus with resection of the deforming tight fibular anlage. D: Lateral foot radiograph at the conclusion of correction. E: Radiographs following fixator removal.
Circular external fixation can be used to correct joint contractures in children due to trauma (Fig. 171.33),
infection, and burns. Unfortunately, to date, most surgeons’ long-term
experience has been disappointing. As with conventional soft-tissue and
capsular release, the recurrence rate is high despite prolonged periods
of posttreatment bracing. Furthermore, as with conventional surgery,
depending on the duration of the deformity and the nature of the
articular cartilage, the surgeon’s goal may be limited to reorienting
rather than increasing the arc of motion. The joints most commonly
involved in the pediatric patient are the knee and ankle. The usual
deformities are knee flexion and ankle equinus contractures.
Figure 171.33. A:
A lawnmower accident resulted in a severe flexion deformity of this
knee. Open posterior release achieved no improvement in knee position,
and the Ilizarov external fixator was applied to the femur and tibia
with hinges at the approximate center of rotation of the knee. B: Appearance at the conclusion of correction.
In the knee, the rate of correction is usually limited by the neurovascular bundles, in particular the sciatic nerve.


Apply circular fixation to span the adjacent femur and tibia to provide
an efficient lever arm. Hinges must be located as close to the center
of rotation of the knee joint as possible to avoid joint compression or
subluxation. After obtaining correction, depending on the preoperative
range of motion, use the hinges to assist in moving the knee during
physical therapy. At the ankle, center the hinge placement over the
center of the talar dome to avoid anterior subluxation of the talus in
the ankle mortise.

In general, it is easier to apply cantilever fixation
than circular fixation to the upper extremity. At present, circular
fixation is optimal for complex deformities that cannot be corrected
acutely (Fig. 171.34). It is also useful if the wrist needs to be spanned, for example, in lengthening of radial or ulnar club hand (12,37). Metacarpal wires can be fixed to a half-ring and attached to the forearm fixation (10,12,37,49,64).
Figure 171.34. A and B: Clinical and radiographic appearance of 6-year-old girl with a right radial club hand and no history of prior intervention. C:
The ulna was centralized through an open procedure and the wrist
stabilized with a transfixing Kirschner wire. Lengthening of forearm
was then undertaken. D: The ulna was lengthened by more than 89%.
Cantilever fixation can be combined with circular
fixation of the forearm, and the two methods can be used independently
for deformities such as those associated with multiple hereditary
exostosis (Fig. 171.35). In general, half-pin
fixation is easier and safer to apply to the forearm than transfixing
wires. The fact that the ulna is subcutaneous throughout its length
makes half-pin fixation





Half-pins can be attached in a multidirectional fashion to rings if
desired. Two half-pins proximal and distal to the osteotomy site are
enough for deformity correction or lengthening.

Figure 171.35. A and B:
Radiographs and clinical appearance of a 16-year-old girl with multiple
hereditary exostoses with forearm shortening and deformity. C and D:
Circular fixation was applied to the radius around a small Orthofix LRS
fixator for gradual correction of radial deformity and ulnar
lengthening. E and F: Clinical and radiographic appearance of the forearm at the conclusion of treatment.
The humerus is the most easily lengthened long bone (Fig. 171.36) (10).
Perform osteotomy distal to the deltoid insertion. Two half-pins
proximal and distal to the osteotomy or lengthening site are adequate
in the arm. Insert the most distal pin just proximal to the olecranon
fossa. The next most proximal pin must avoid the path of the radial
nerve. Place it with open technique.
Figure 171.36. A and B:
Clinical appearance and radiographs of 13-year-old boy with 10 cm of
right humeral shortening due to septic growth arrest of the proximal
humerus at the age of 2 years. C and D: Radiographs at the conclusion of distraction and following consolidation.
At present, open fracture is the most clear-cut indication for external fixation of pediatric long-bone fractures (4,14,16,34,35,47,50,53,55,60).
Depending on the size of the limb segment, apply a four-pin fixator
(Hex-Fix, Orthofix, Dynafix) after irrigation and debridement of the
open wound. Locate the fixator to minimize interference with subsequent
wound management such as local or free flaps and skin grafts. In the
case of segmental bone loss, circular fixation can be used to transport
bone for definitive bone reconstruction of bone loss.
Multiple trauma, particularly if combined with a
concurrent severe closed head injury, is a strong indication for
fixation of major long bone fractures in the pediatric patient. Those
patients who require frequent computed tomography (CT) scans, magnetic
resonance imaging (MRI) studies, or the operations for treatment of
their associated injuries are more easily managed with stable fracture
fixation. Traction or spica casts make this difficult, and spica casts
may interfere with management of abdominal or chest trauma. Patients
who experience spasticity or who are uncooperative following head
injury are best managed with rigid stabilization of their long-bone
fractures. Even in the very young child, small cantilever unilateral
external fixators, such as the Hex-Fix, can be adapted to long-bone
fractures, particularly of the femur and tibia.
Operative management of isolated femoral diaphyseal
fractures using external fixation has become accepted in patients older
than 5 to 6 years of age (14,22,34,35,50,52,55).
Immediate spica treatment is still preferred in small children, and
older adolescents may be treated with intramedullary rodding. Current
literature supports operative treatment of this intermediate age group
between age 5 and 11 to 12 years, reporting excellent results with
external fixation decreasing hospitalization, promoting early patient
mobilization and return to school, decreasing psychosocial family
stress, with an acceptable complication rate (2,4,14,16,34,50,52,53,55). A recent report (18)
also demonstrated a clear cost savings when compared with traditional
skeletal traction followed by spica-cast immobilization. The major
concern when using external fixation in these fractures is the risk of
refracture. The incidence of refracture can be minimized by early
weight bearing, early fixator dynamization, and mobilization of the
knee. Anecdotal reference is made by some to suggest that the most
common fracture pattern susceptible to refracture is a transverse
diaphyseal fracture. In my experience, the most important factors in
refracture are a stiff knee and lack of weight bearing during fracture
Ipsilateral concomitant fracture of both the femur and
the tibia produces a floating knee. Operative stabilization of both the
tibia and the femur are indicated. Depending on the skeletal maturity
of the patient, intramedullary fixation of the femur, using either
reamed or flexible implants, can be combined with external fixation of
the tibia. In the younger child, external fixation can be applied to
both the femur and the tibia. It allows rapid mobilization of the
patient, motion of the knee and ankle, and normal shoe wear. Weight
bearing can be initiated as soon as patient can tolerate it in most
Although they are relatively rare in children, unstable
pelvic fractures, particularly open-book type fractures of the pelvis,
can be treated with external fixation as in the adult (52). Posterior disruptions can be addressed by internal fixation and combined with an anterior fixator (see Chapter 17). For more details on the treatment of pediatric fractures, see Chapter 164.
Each reference is categorized according to the following
scheme. *, classic article; #, review article; !, basic research
article; and +, clinical results/outcome study.
+ 1. Aldegheri R, Renzi-Brivio L, Agostini S. Callotasis Method of Limb Lengthening. Clin Orthop Rel Res 1989;241:137.
+ 2. Alonso JE, Horowitz M. Use of the AO/ASIF External Fixator in Children. J Pediatr Orthop 1987;7:594.


+ 3. Armstrong PF, Bell DF, Rajacich N. The Ilizarov Technique. In: Malcolm Menelaus, ed. The Management of Limb Discrepancy. London: Churchill Livingstone, 1991:161.
+ 4. Aronson J, Tursky EA. External Fixation of Femur Fractures in Children. Pediatr Orthop 1992;12:157.
+ 5. Bell DF. Treatment of Adolescent Blount’s Disease Using the Ilizarov Technique. In: Balderston RA, ed. Operative Techniques in Orthopaedics, Vol 3, No 2. Philadelphia: W.B. Saunders, 1993:149.
+ 6. Bell DF. Treatment of Post-traumatic Sequelae by the Ilizarov Technique. In. Letts M, ed: Management of Pediatric Fractures. London: Churchill Livingstone, 1993:711.
+ 7. Bell DF, Armstrong P, Paley D. Extensive Two-level Limb Lengthening. Early Results Utilizing the Ilizarov Technique. J Bone Joint Surg 1990;72-B:538.
+ 8. Bell
DF, Boyer MI, Armstrong PF. The Use of the Ilizarov Technique in the
Correction of Limb Deformities Associated with Skeletal Dysplasia. J Pediatr Orthop 1992;12:283.
+ 9. Cattaneo
R, Catagni M, Johnson EE. The Treatment of Infected Nonunions and
Segmental Defects of the Tibia by the Methods of Ilizarov. Clin Orthop Rel Res 1992;280:143.
+ 10. Cattaneo
R, Villa A, Catagni MA, Bell DF. Lengthening of the Humerus Using the
Ilizarov Technique. Description of the Method and Report of 43 Cases. Clin Orthop Rel Res 1990;250:117.
+ 11. Cattaneo R, Villa A, Catagni MA, Tentori L. Limb Lengthening in Achondroplasia by Ilizarov’s Method. Int Orthop 1988;12:173.
+ 12. Catagni MA, Szabo RM, Cattaneo R. Preliminary Experience with Ilizarov Method in Late Reconstruction of Radial Hemimelia. J Hand Surg 1993;18A:316.
! 13. Chao E, Hein T. Mechanical Performance of the Standard Orthofix External Fixator. Orthopaedics 1988;11:1057.
+ 14. Clinkscales
CM, Peterson HA. Isolated Closed Diaphyseal Fractures of the Femur in
Children. Comparison of Effectiveness and Cost of Several Treatment
Methods. Orthopaedics 1997;20:1131.
* 15. Dal Monte A, Donzelli O. Tibial Lengthening According to Ilizarov in Congenital Hypoplasia of the Leg. J Pediatr Orthop 1987;7:135.
* 16. DeBastiani G, Aldegheri R, Renzi-Brivio L. The Treatment of Fractures with a Dynamic Axial Fixator. J Bone Joint Surg 1984;66B:538.
* 17. DeBastiani G, Aldegheri R, Renzi-Brivio L, Trivella F. Limb Lengthening by Callus Distraction (Callotasis). J Pediatr Orthop 1987;7:129.
+ 18. Doane
RM, Stanitski DF, Stanitski CL. Treatment Cost of Isolated Femoral
Shaft Fractures in Children. External Fixation Versus Traction.
Submitted to Journal Pediatric Orthopaedics.
+ 19. Eldridge JC, Bell DF. The Correction of Severe Growth Abnormalities Following Purpura Fulminant Using the Ilizarov Technique. Orthop Trans 1992–1993;16:861.
+ 20. Fabry G, Lammens J, Van Melkebeek J, Stuyck, J. Treatment of Congenital Pseudarthrosis with the Ilizarov Technique. J Pediatr Orthop 1988;8:67.
+ 21. Ghoneem HF, Wright JG, Cole WG, Rang M. The Ilizarov Method for Correction of Complex Deformities. J Bone Joint Surg 1996;78A:1480.
+ 22. Glorion
C, Pouliquen JC, Langlais J, et al. Femoral Lengthening Using the
Callotasis Method. Study of the Complications in a Series of 70 Cases
in Children and Adolescents. J Pediatr Orthop 1996;16:161.
! 23. Goodship AE, Kenwright J. The influence of induced micro-movement on the healing of experimental tibia fractures. J Bone Joint Surg 1985;67B:650.
+ 24. Grill F. Correction of complicated extremity deformities by external fixation. Clin Orthop Rel Res 1989;241:166.
+ 25. Guidera KJ, Hess WF, Highhouse KP, Ogden JA. Extremity Lengthening. Results and Complications with the Orthofix System. J Pediatr Orthop 1991;11;90.
# 26. Hamdy RC, Stanitski DF. A Visual Presentation of Ilizarov Tibial Lengthening. The Journal of Orthopaedic Techniques 1995;3:55.
+ 27. Huang SC, Kuo KN. Differential Lengthening of the Radius and Ulna Using the Ilizarov Method. J Pediatr Orthop 1998;18;370.
# 28. Ilizarov GA. The Principles of the Ilizarov Method. Bull Hosp Jt Dis 1988;48:1.
# 28. Ilizarov GA. The Tension-Stress Effect on the Genesis and Growth of Tissues. Part I. Clin Orthop 1989;238:249.
* 30. Ilizarov GA. The Tension-Stress Effect on the Genesis and Growth of Tissues. Part II. Clin Orthop 1989;239:264.
* 31. Ilizarov GA. Clinical Application of Tension-Stress Effect for Limb Lengthening. Clin Orthop 1990;250:8.
+ 32. Ilizarov GA, Shevtsov VJ, Kuzmin NV. Method of Treating Talipes Equinocavus. Ortop Travmatol Protez 1983;5:46.
+ 33. Kamegaya
M, Shinohara Y, Shinada Y. Limb Lengthening and Correction of
Angulation Deformity. Immediate Correction by Using a Unilateral
Fixator. J Pediatr Orthop 1996;16;477.
+ 34. Kirschenbaum D, Albert MC, Robertson WW, Davidson RS. Complex Femur Fractures in Children. Treatment with External Fixation. J Pediatr Orthop 1990;10:588.
+ 35. Klein W, Pennig F, Brug E. Dynamic Axial Fixation for Femoral Fractures in Children. Presented at the International Congress. Evolution of External Fixation. June 1990, Montpellier, France.
+ 36. Knapp DR, Price CT. Correction of Distal Femoral Deformity. Clin Orthop Rel Res 1990;255:75.
+ 37. Lammens
J, Mukherjee A, Van Eygen P, Fabry B. Forearm Realignment with Elbow
Reconstruction Using the Ilizarov Fixator. A Case Report. J Bone Joint Surg 1991;73B:412.
! 38. Lavini
F, Renzi-Brivio L, deBastiani G. Psychologic, Vascular and Physiologic
Aspects of Lower Limb Lengthening in Achondroplastics. Clin Orthop Rel Res 1990;250:138.
+ 39. Miller LS, Bell DF. Management of Congenital Fibular Deficiency by Ilizarov Technique. J Pediatr Orthop 1992;12:651.
+ 40. Noonan KJ, Price CT. The Pearls and Pitfalls of Limb Lengthening and Deformity Correction via Unilateral External Fixation. Iowa Orthop J 1996;16:58.


# 41. Paley D. Current Techniques of Limb Lengthening. J Pediatr Orthop 1988;8:73.
+ 42. Paley D, Catagni M, Argnani F, et al. Treatment of Congenital Pseudarthrosis of the Tibia Using the Ilizarov Technique. Clin Orthop Rel Res 1992;280:81.
! 43. Paley D, Fleming D, Catagni M, et al. Mechanical Evaluation of External Fixators Used in Limb Lengthening. Clin Orthop Rel Res 1990;250:50.
+ 44. Plawecki S, Carpentier E, Lascombes P, et al. Treatment of Congenital Pseudarthrosis of the Tibia by the Ilizarov Method. J Pediatr Orthop 1990;10:786.
+ 45. Pouliquen
JC, Coelin JD, Langlais J, Pauthier F. Upper Metaphyseal Lengthening of
the Tibia by Callotasis. Forty-seven Cases in Children and Adolescents.
J Pediatr Orthop 1993;2B:49.
+ 46. Pouliquen
JC, Gorodischer S, Vernevet C, Richard L. Femoral Lengthening in
Children and Adolescents. A Comparative Study of a Series of 82 Cases. Fr J Orthop Surg 1989;3:162.
+ 47. Price CT. Limb Lengthening for Achondroplasia. Early Experience. J Pediatr Orthop 1989;9:512.
# 48. Price CT. Metaphyseal and Physeal Lengthening. Instr Course Lect 1989;38:331.
+ 49. Price CT, Cole D. Limb Lengthening by Callotasis for Children and Adolescents. Early Experience. Clin Orthop Rel Res 1990;250:105.
+ 50. Price CT, Levengood G, Zink W. The Treatment of Pediatric Fractures with Dynamic External Fixation. Techn Orthop 1989;4:74.
+ 51. Rajacich R, Bell DF, Armstrong PF. Pediatric Application of the Ilizarov Method. Clin Orthop Rel Res 1992;280:72.
+ 52. Reff
RB. The Use of External Fixation Devices in the Management of Severe
Lower Extremity Trauma and Pelvic Injuries in Children. Clin Orthop Rel Res 1984;188:22.
+ 53. Scavenius
M, Ebskov LB, Sloth C, Torholm C. External Fixation with the Orthofix
System in Dislocated Fractures of the Lower Extremities in Children. J Pediatr Orthop 1993;2:161.
+ 54. Schlenzka D, Poussa M, Osterman K. Metaphyseal Distraction for Lower Limb Lengthening and Correction of Axial Deformities. J Pediatr Orthop 1990;10:202.
+ 55. Shih HN, Chen LM, Lee ZL, Shih CH. Treatment of Femoral Shaft Fractures with the Hoffman External Fixator in Prepuberty. J Trauma 1989;29:498.
+ 56. Stanitski DF. Treatment of Deformity Secondary to Metabolic Bone Disease with the Ilizarov Technique. Clin Orthop Rel Res 1994;301:38.
+ 57. Stanitski DF, Bullard M, Armstrong P, Stanitski CL. Results of Femoral Lengthening Using the Ilizarov Technique. J Pediatr Orthop 1995;15:224.
+ 58. Stanitski DF, Shahcheraghi H, Nicker DA, Armstrong PF. Results of Tibial Lengthening Using the Ilizarov Technique. J Pediatr Orthop 1996;16:168.
+ 59. Stanitski
DF, Srivastava P, Stanitski CL. Correction of Proximal Tibial
Deformities in Adolescents Using the T-Garches External Fixator. J Pediatr Orthop 1998;18:512.
+ 60. Tolo V. External Skeletal Fixation in Children’s Fractures. J Pediatr Orthop 1983;3:435.
+ 61. Trivella GP, Brigadoi F, Aldegheri R. Leg Lengthening in Turner Dwarfism. J Bone Joint Surg 1996;78B:290.
+ 62. Velazquez
RJ, Bell DF, Armstrong PF, et al. Complications Using the Ilizarov
Technique in the Correction of Limb Deformities in Children. J Bone Joint Surg 1993;75A:1148.
* 63. Vilarrubias
JM, Ginebreda I, Jimeno E. Lengthening of the Lower Limbs and
Correction of Lumbar Hyperlordosis in Achondroplasia. Clin Orthop Rel Res 1990;250:143.
+ 64. Villa A, Paley D, Catagni MA, et al. Lengthening of the Forearm by the Ilizarov Technique. Clin Orthop Rel Res 1990;250;125.
! 65. Young
NL, Bell DF, Anthony A. Paediatric Pain Patterns During the Ilizarov
Treatment of Limb Length Discrepancy and Angular Deformity. J Pediatr Orthop 1994;14:352.
! 66. Young
NL, Davis RJ, Bell DF, Redmond DM. Electromyographic and Nerve
Conduction Changes after Tibial Lengthening by the Ilizarov Method. J Pediatr Orthop 1993;13:473.

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