History of Medicine

Bike Spokes and a Wrong Turn Advance

Fracture Treatment

by

Roy Meals MD

     Gavriil Ilizarov, a Pole, attended medical school in Crimea and Kazahkstan during World War II and then, without any practical training, was posted to Kurgan, Siberia. This war-torn region was 1200 miles east of Moscow, far away from any established center of advanced understanding. The area was rife with wounded soldiers suffering from nonhealing, infected fractures.

     With vast need, limited resources, and no preconceptions to restrain him, Ilizarov developed an external fixation frame, which would support a tibia fracture, for instance, during healing. As others had done before, he placed pins perpendicular to the bone on both sides of the fracture site and left the pins protruding through the skin.  He then attached the pins to each other with longitudinally aligned threaded rods—the external fixator.

     By 1955, Ilizarov had become chief of trauma and orthopedics at his Siberian outpost. Because resources remained scarce, he used bicycle

Gavril Ilizarov (photo by Dr. Bernd-Dietmar
Parteke, posted on Wikipedia)

spokes for the bone-penetrating pins in his external fixators. The spokes were flimsy compared to the stout quarter-inch-diameter pins previously employed; but when tensioned, the spokes met the need and did so with minimal soft tissue injury. Ilizarov compared the complete construct to that of a bicycle wheel, where the bone was the fully-stabilized hub. The “rims” were metal rings encompassing the limb at several levels above and below the injury site, and the tensioned wires passing from hub to rim (bone to rings) were bicycle spokes. Once the spokes and rings were in place, the rings were secured to one another with the threaded rods.

   The aim of the external fixation was to hold the fractured bone ends firmly against each other. Without any motion at the fracture site, the bone-producing cells, osteoblasts, could begin to bridge the gap. This was problematic, however, when the gap was large, because osteoblasts can “jump” only so far, across a stream but not across a chasm. Ilizarov used a wrench to make daily, tiny adjustments of the rings on the threaded metal rods and could thereby slowly draw the bone ends together and close the gap. He showed the nurses how to perform this at home to close the fracture gap in almost imperceptible increments over weeks.

     One confused nurse, however, kept turning the wrench the wrong way, repeatedly distracting the bone ends rather than drawing them together. To Ilizarov’s surprise when he saw an X-ray of the patient weeks later, the slowly expanding gap was filling in with new bone. The bone-forming cells had been toiling happily, unaware that their task was ever-expanding.

     Other surgeons had lengthened limbs through external distraction but had always filled the gap in the lengthened bone with bone graft taken from elsewhere in the body, typically the pelvic rim. This necessitated additional surgery to harvest the graft and risked the development of donor site pain, disfigurement, and disability. Sometimes the gap in a bone was too big for even the largest possible bone graft to span it.

     In an ah-ha moment Ilizarov realized that by moving the bone ends apart ever so slowly (less than a sixteenth of an inch a day in six evenly spaced intervals), new bone would fill in the gap on its own. (Yank on taffy and it snaps in half. Pull on it gently and it stretches.) This slow movement between bone ends could allow lengthening of bones that had healed too short and also could correct angular and rotational deformities of fractures that had healed with misalignment. (Twist taffy slowly, it twists.) Ilizarov applied the technique widely, and his patients called him “the magician from Kurgan.” Nonetheless, the medical establishment in Moscow considered Ilizarov a quack and discounted his growing achievements and reputation.

     This began to change when Russian high jumper Valeriy Brumel injured his leg in a motorcycle accident in 1965, a year after winning the Olympic gold medal. Following 3 years of multiple and unsuccessful operations in Moscow to heal the injury, Brumel traveled to Kurgan for treatment. He recovered sufficiently to high jump 6 feet 9 inches, which was 7 inches off his world record but still quite respectable for somebody who had been hobbled by injury for years.

     Regardless of his success in treating Brumel, Ilizarov’s contributions did not receive the recognition they deserved. This was even though his center in the 1970s grew to 24 operating rooms, 168 physicians, and around 1000 beds—by far the largest orthopedic center in the world.

     Then in 1980, an Italian adventurer sought Ilizarov’s help after European doctors had given up hope of ever producing a sound leg. The mountaineer had broken his leg 10 years previously and was left with an unhealed fracture with an inch of shortening. After Ilizarov achieved bone healing and lengthening, the grateful patient called Ilizarov “the Michelangelo of Orthopedics.” On return to Europe, the patient’s result astounded the Italian doctors, who then invited Ilizarov to speak at a European fracture conference in 1981. Ilizarov gave three lectures, the first time he had presented his material outside the Soviet Union. At the end he received a 10-minute standing ovation.

                   

     In subsequent years, others have refined Ilizarov’s external fixator hardware and technique. Now many limbs with unhealed fractures, shortening, and angular or rotational deformities have been spared amputation beginning with that one patient who turned the wrench the wrong way. Anybody could do that, but Ilizarov recognized the implications and appreciated that the wrong way might be the right way. 

Sources:

Abdel‐Aal, A. M. (2006). Ilizarov Bone Transport for Massive Tibial Bone Defects. Orthopedics. 29(1):70‐74.

Aronson, J. e. (1989). The histology of distraction osteogenesis using different external fixators. Clinical Orthopaedics and Related Research. 241:106‐116.

Codivilla, A. (1904). On the means of lengthening, in the lower limbs, the muscles and tissues which are shortened through deformity. Am J Orthopedic Surgery, 2:353.

Smith, D N., Harrison. M H M. (1979) The correction of Angular Deformities of Long Bones by Osteotomy‐Osteoclasis. The Journal of Bone and Joint Surgery. 61‐B(4):410-4.

Spiegelberg B, Parratt T, Dheerendra SK, Khan WS, Jennings R, Marsh DR. (2010). "Ilizarov principles of deformity correction". Annals of the Royal College of Surgeons of England. 92 (2): 101–5.

Svetlana Ilizarov (2006). "The Ilizarov Method: History and Scope". In S. Robert Rozbruch and Svetlana Ilizarov. Limb Lengthening and Reconstruction Surgery. Boca Raton, CRC Press.