Stuart A. Green, MD, FAAOS


Published 12/31/2023
Stuart A. Green, MD, FAAOS

A Look into the History of Modern Limb Lengthening

First American to visit Dr. Ilizarov recounts procedure’s history

Operation Barbarossa, Adolf Hitler’s ill-fated attack on the Soviet Union, left 800,000 Russians dead and countless others wounded. Among the surviving casualties was a soldier from the city of Kurgan, Russia, who sustained a below-knee amputation that also created a 90-degree flexion deformity of his knee, fused solid in bony ankylosis. Wanting to someday don a prosthesis, the soldier sought care at his hometown veterans clinic. There, he encountered Gavriil Abramovich Ilizarov, a young surgeon who devised a plan to straighten out the flexed knee joint.

Dr. Ilizarov first performed an osteotomy across the knee’s bone mass, starting at the bend’s apex. He next applied a homemade external fixator (constructed of shovel handles) from mid-femur to mid-tibia, with turnbuckles spanning the bent knee. Instructing his patient to gradually extend the turnbuckles to straighten the limb, Dr. Ilizarov departed for a Black Sea vacation. Upon return, he planned to bone graft the resulting triangular defect between the cut bone ends. To Dr. Ilizarov’s surprise, newly formed bone filled the space, eliminating the need for a second operation. At that moment, Dr. Ilizarov realized that he had unlocked from within bone a previously unknown capacity to create new osseous tissue with appropriate conditions of soft-tissue–sparing osteotomy, a stable external fixator, a short delay to commence the healing process, and then gradual distraction of the cut bone ends at an appropriate rate and rhythm.

Development of the Ilizarov method
Over the next few years, Dr. Ilizarov extended his observations. Using the process, which he called “distraction osteogenesis,” Dr. Ilizarov lengthened stunted limbs and corrected angular, translational, and rotational long-bone deformities, using combinations of hinges and other assemblies on a circular, tensioned-wire external fixator. He named the newly formed bone “regenerate.” Dr. Ilizarov soon realized that he could eliminate skeletal defects (e.g., remaining after debridement of osteomyelitis) by elongating one side or the other of the remaining bone fragments, a technique now called “bone transport.” He published his first series of such cases in 1951.

As his fame grew, Russians from near and far came to Dr. Ilizarov for treatment, including the offspring of important government officials. Distressed by the long waitlist, the authorities enabled Dr. Ilizarov to grow his facility over the following decades. At first, the Cold War restricted knowledge of Dr. Ilizarov’s techniques to Eastern Bloc countries, especially because the Red Army realized that restorative orthopaedic surgery was useful in returning injured soldiers to active duty.

By the time Western orthopaedic surgeons were first able to visit Dr. Ilizarov in the 1980s, his Kurgan Institute had evolved into the world’s largest orthopaedic hospital, employing 360 surgeons, all using the Ilizarov method to overcome limb deformities and defects uncurable by other means. The Ilizarov apparatus, a modular, circular external fixator secured to bone with tensioned wires, was also used to eliminate hand and foot abnormalities and, by taking advantage of the neovascularization that occurs during distraction osteogenesis, cure dysvascular limb diseases as well.

Impact and expansion in the West
Modifications to Dr. Ilizarov’s apparatus by Western surgeons soon followed those early visits. For instance, I was the first American to visit Dr. Ilizarov. When applying what I learned from him, I substituted half-pins for Dr. Ilizarov’s tensioned wires in certain locations, thereby lessening the number of implant-skin interfaces and reducing muscle irritation from wire transfixion.

Charles Taylor, MD, FAAOS, of Memphis, Tennessee, devised an ingenious circular external fixator based on the hexapod Stewart Platform, used for such things as flight simulators and stomach-churning amusement park rides. Dr. Taylor’s accompanying user-friendly computer interface proved a hit with surgeons, who found rotational deformities especially difficult to correct using classic Ilizarov fixator techniques.

Meanwhile, surgeons around the world began to devise strategies to reduce the interval a patient under treatment had to spend in an external fixator, based on the observation that pin- and wire-site infections increased over time. Dror Paley, MD, FAAOS, FRCSC, for instance, lengthened limbs with a combination of an external fixator and intramedullary nail, which was locked transversely at only one end. As soon as his patient reached target length, Dr. Paley locked the nail distally and removed the frame, allowing regenerate maturation without a cumbersome external fixator.

With the goal of eliminating external fixators altogether, surgeons developed telescoping intramedullary nails for limb lengthening. Initially, such implants used internal ratchet-and-clutch mechanisms for implant elongation, but these devices proved unsatisfactory because the distraction rates depended on patient activity and were thus highly variable. Too rapid lengthening—termed a “runaway locomotive”—was both painful and dangerous.

Rainer Baumgart, MD, of Germany, created an intramedullary nail elongated by an internal electric motor, which is powered by a subcutaneous induction coil. The coil receives its energy from a similar-sized coil pressed against the adjacent skin. It is still on the market.

Today the most popular self-lengthening intramedullary nail contains a magnet-and-spindle mechanism that rotates in response to an externally applied rotating magnetic field. Working alongside biomedical engineers, I helped develop the implant from a design originally conceived for adjustable gastric band surgery, in which a spinning magnet regulates a band’s size around a patient’s stomach for appetite control. That device never made it off the workbench, but its progeny dominates the internal limb-lengthening market. The technology is being modified to allow bone transport, lengthening and compression plates, and a variety of other implants still to come.

Eighty years have passed since a Russian patient first told Dr. Ilizarov he wanted to throw away his crutches and walk again on two limbs after his amputation. That seemingly simple request spawned an entire system of orthopaedics that has benefited countless patients, both adults and children, in ways neither the veteran nor his surgeon could have possibly imagined at the time.

Stuart A. Green, MD, FAAOS, is cofounder and past president of the Limb Lengthening and Reconstruction Society; past president of the Association of Bone and Joint Surgeons; and a clinical professor of orthopaedic surgery at the University of California, Irvine. He is the son, first cousin, and father of AAOS Fellows.