Ilizarov Frames - a clever use of bicycle wheels

Professor Roger M Atkins, Consultant Orthopaedic Surgeon, University Hospitals Bristol

Gavril Abramovitch Ilizarov was a Russian surgeon in the last century. He worked in Kurgan in Siberia, starting his clinical career shortly after the second world war. He was faced with a large number of war casualties with un-united fractures, who he was unable to treat with the primitive equipment available to him. Ilizarov made two huge contributions. He devised his fine wire circular frame and he put forward the concept of distraction osteogenesis. Ilizarov stated that he invented his external fixator after seeing the spokes and hub of a wheel on a horse drawn cart. That may be so but the Ilizarov type fine wire circular frame was first described in Vienna by Witmoser in the 1930's. Witmoser's frame did not meet with the support of Bohler, who was the senior surgeon of the trauma hospital in Vienna, and was not taken up.

Ilizarov was certainly an avid journal reader and it may be that he knew of Witmoser's article in Arch. Lang. The influence may of course have been subconscious. The Ilizarov frame consists of a series of rings connected together by struts to form cylindrical ring blocks. These blocks are attached to segments of a limb by pairs of tensioned fine wires crossing at a right angle (or as near as possible to it). Between the ring blocks, hinges are placed which allow a focus of activity, for example a fracture, non-union or deformity, to be treated. Ilizarov's second insight was the development of distraction osteogenesis. Traditional orthopaedic surgery has relied on compression and excision to treat problems of fracture healing and deformity. Ilizarov stumbled on the concept that distracting a fracture will cause bone to form so opening the way for leg lengthening. How Ilizarov happened on this concept is not clear.

The tale is told that one of his patients misunderstood Ilizarov's instructions concerning tightening his frame and instead of compressing the fracture, turned the nuts in the wrong direction and lengthened the fracture site. Ilizarov noticed that bone formed in the distraction gap and realised that gentle distraction would cause bone to form. After this insight, the rise of the Ilizarov method is something of a fairy tale. Ilizarov originally practiced in a small country clinic without anaesthetists or in-patient beds. For his early patients, he would draw his proposed frame and the patient would ask the local blacksmith to produce the parts. Ilizarov applied the frame under local anaesthetic. Ilizarov published his early results at Russian meetings but his concepts were rejected by the medical establishment. Valerie Brumel was a Russian Olympic high jump gold medallist who was injured in a motor cycle accident, suffering a compound distal tibia fracture. Despite the best efforts of the Russian medical establishment, the fracture went on to an infected non-union and was advised to have an amputation. Brumel heard of Ilizarov and in desperation visited him. Ilizarov used his apparatus to cure the non union and eradicate the infection. After this success, Ilizarov stock rose rapidly in Russia.

The All Russia Institute for Reconstructive Orthopaedic Surgery was built in Kurgan, which rapidly expanded until it had 26 operating theatres and was the largest orthopaedic unit in the world and a massive research program was started. Ilizarov's fame however was confined to the Soviet Union. His work was unknown outside Russia. Carlo Mauri was an Italian mountaineer and explorer, who was born in Lecco, a small town in Northern Italy on the shores of lake Como. He broke his leg in an accident and despite the best efforts of Italian medicine, ended up with an infected non-union. Despite this, he took part in Thor Heyerdahls Ra expedition. Valerie Brumel was also a member of that expedition and famously but possibly apocryphally said I think I may know a man who can help you. Mauri was cured of his infected non-union by Ilizarov and returned to lead many expeditions. He died in Lecco in 1982. After his treatment by Ilizarov, Mauri showed his healed non-union to the Italian doctors who had failed to cure him and Ilizarov was invited to Italy to lecture by Luigi Cattaneo, the chief orthopaedic doctor in Lecco and Renato Bombelli from nearby Busto Arsizio. Invited to speak for a few minutes, Ilizarov entranced his audience (and wrecked the conference) by speaking for over two hours. There followed academic exchanges and Maurizio Cattani (confusingly Cattaneos junior partner) learned Ilizarov's techniques and turned Lecco into an international centre for Ilizarov's methods.

The Italian surgeons knew Frank Navarra, the development director of a small American orthopaedic manufacturer based in Memphis, called Richards (subsequently taken over by Smith and Nephew) and they showed Ilizarov's work to him. He became convinced that Ilizarov's frame had potential and commenced very delicate negotiations to acquire the rights. Ilizarov was however a cold war warrior and mistrusted the USA. Eventually he visited Memphis and signed over some of the rights to development of the frame to Richards (and apparently emptied the hotel minibar into his case). Smith and Nephew began the long task of developing Ilizarov's concepts and adapting them for a Western surgical environment.

The story so far may be partly apocryphal but whether Ilizarov knew of Witmoser's frame or even had prior knowledge from some lost text of the possibility of distraction osteogenesis, there can be no doubting the genius of this man who would entertain children with magic tricks to distract them from their medical treatment. Charlie Taylor was a young orthopaedic surgeon in Memphis and he and I separately realised that the Ilizarov hinge system was not optimal. It was difficult to use and inaccurate and there were many deformities which could not be readily addressed. We both researched improved hinge systems and patented them. However he had a secret card up his sleeve: his father was a professor of engineering and his brother owned an engineering company. His father realised that we needed a Gough Stewart hinge (the device which runs flight simulators) and his brother constructed it. Much iteration later and we have the Spatial frame. Along the road, we have developed hydroxyapatite coated half-pins, novel pinsite dressings and a new mathematics to run the frame.

Bristol has led innovation in Ilizarov frame surgery. We have developed new treatments for individual syndromes, such as Blount's disease. We have innovated in general deformity correction by devising the CHAOS concept. We have undertaken basic research into fracture anatomy, for example in tibial pilon fractures, using this basic knowledge to invent new treatments. This has resulted in Bristol being the largest and academically most productive unit in Europe. We now having a regular visiting surgeon program and run an annual international masterclass.