The Ilizarov Method of External Fixation: Current Intraoperative Concepts
Article Outline
- Abstract
- Deformity Correction
- Trauma and Fractures
- Charcot Neuroarthropathy
- Preoperative Care
- Intraoperative Care
- Surgical Procedure
- Postoperative Care
- Conclusion
- Examination. Continuing Education Program
- Learner Evaluation. Continuing Education Program
- References
- Biography
- Copyright
Abstract
The Ilizarov method of external fixation is used to treat fractures, complex lower extremity deformities, osteomyelitis, and soft tissue contractures and to lengthen limbs. Tremendous improvements in the Ilizarov method have occurred during the past 60 years, improving intraoperative care and limb salvage management concepts. Improved instrumentation has increased the quantity and complexity of the tray systems required for these procedures. Perioperative nurses must be well versed in optimal preparation and function of Ilizarov fixation systems to ensure safe patient care during Ilizarov external fixation procedures.
Key words: Ilizarov method, external fixation, deformity correction, Charcot neuroarthropathy, fracture repair
In 1989, Stuart Green, MD, said of Gavriil A. Ilizarov, MD, “I had come across references to his work while writing a book on external fixation, but I discounted his claims of making dwarfs one and a half feet taller and correcting severe birth deformities as Russian propaganda.”1(p217) Dr Green was the first American orthopedic surgeon to visit the Kurgan All-Union Scientific Institute for Traumatology and Orthopaedics in May 1987. He had traveled to western Siberia to personally witness and study the orthopedic techniques developed by Dr Ilizarov. Beginning in 1951, Dr Ilizarov developed an external fixation method, still used today to treat fractures, complex lower extremity deformities, osteomyelitis, and soft tissue contractures and to lengthen limbs.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 In the early 1980s, Dr Ilizarov's innovative external fixation device gained popularity in Italy and France, and its use eventually spread to North America with increasing use in the 1990s.3
The Ilizarov method of external fixation for limb lengthening begins as a small, minimally invasive skin incision and removal of bone cortex (ie, corticotomy) to protect the blood supply to the comprised limb. Five to seven days later, the surgeon elongates the fracture callus using distraction osteogenesis; the limb is lengthened 0.25 mm every six hours for a total of 1 mm per day.1 The surgeon secures transosseous wires to circular external rings and applies tension to achieve fixation and stabilization of the proximal and distal bone segments (Figure 1). This method applies the tension-stress effect or law of tension-stress to stimulate growth. The Ilizarov apparatus externally stabilizes bone and its surrounding soft tissue while the tension produced stimulates active growth of osseous tissue and soft tissue through gradual traction (Figure 2).2
Figure 1.
Application of rings and transosseous wires.
Figure 2.
Radiographic interval view of limb lengthening with external fixation.
Although the original circular frame was developed for limb lengthening, the effectiveness of the Ilizarov external fixator in other orthopedic surgical applications has been broadened and widely recognized. The Ilizarov method of external ring fixation has been used for a variety of procedures such as deformity correction, trauma repair, and Charcot neuroarthropathy reconstructive surgery (Table 1).2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13
TABLE 1. Outcomes of Seven Ilizarov External Fixator Research Projects
| Author | Number of Cases | Outcome | Intraoperative Implications |
|---|---|---|---|
| Catagni et al1 | ■59 | ■All fractures healed ■30 achieved excellent results ■27 achieved good results ■1 achieved fair results ■1 achieved poor results | ■A mixture of fixators (eg, hybrid application) used ■Some internal fixation used |
| Antoci et al2 | ■10 cadaveric lower extremities (5 pairs) | ■Less vertical translation and angular displacement of the distal segment when using a foot plate in addition to external fixation | ■Multiple trays and components required, including a modified ring (eg, foot plate) |
| Mekhail et al3 | ■19 | ■Results ■2 excellent ■11 good ■4 fair ■2 poor ■Complications ■20 minor ■19 major ■Satisfaction ■18 of 19 patients satisfied | ■Removal of the external fixator requires Ilizarov system instrumentation ■Orthopedic biologic (eg, cancellous) graft is required in docking sites ■Intramedullary nails are recommended in some situations |
| Sen et al4 | ■53 (26 internal fixation and 27 Ilizarov external fixation) | ■Ilizarov fixator ■achieved better results ■achieved better alignment of the lower extremity ■prevented arthritis progression | ■Power instrumentation (eg, power saw) and osteotomes required for osteotomy |
| Sen et al5 | ■11 | ■Average improvement in clinical scores ■all patients achieved a plantigrade foot with no malalignment or malorientation ■9 achieved equal leg lengths ■11 had minor complications ■4 experienced obstacles that required surgical intervention | ■Additional surgical soft tissue procedures performed along with Ilizarov fixator application |
| LaBianco et al6 | ■45 patients (47 frames) | ■41 of 45 achieved osseous union ■8 experienced intermediate-type complications ■56 experienced minor complications | ■Multiple trays and components required |
| Tetsworth and Paley7 | ■23 patients (28 limbs) | ■Accuracy of correction increases with surgical experience | ■Additional application of ring and strut systems is needed for gradual correction |
1Catagni MA, Ottaviani G, Maggioni M. Treatment strategies for complex fractures of the tibial plateau with external circular fixation and limited internal fixation. J Trauma. 2007;63(5):1043-1053. |
2Antoci V, Voor MJ, Seligson D, Roberts CS. Biomechanics of external fixation of distal tibial extra-articular fractures: is spanning the ankle with a foot plate desirable? J Orthop Trauma. 2004;18(10):665-673. |
3Mekhail AO, Abraham E, Gruber B, Gonzalez M. Bone transport in the management of posttraumatic bone defects in the lower extremity. J Trauma. 2004;56(2):368-378. |
4Sen C, Kocaoglu M, Eralp L. The advantages of circular external fixation used in high tibial osteotomy (average 6 years follow-up). Knee Surg Sports Traumatol Arthrosc. 2003;11(3):139-144. |
5Sen C, Kocaoglu M, Eralp L, Cinar M. Correction of ankle and hindfoot deformities by supramalleolar osteotomy. Foot Ankle Int. 2003;24(1):22-28. |
6LaBianco GJ, Vito GR, Kalish SR. Use of the Ilizarov external fixator in the treatment of lower extremity deformities. J Am Podiatr Med Assoc. 1996;86(11):523-531. |
7Tetsworth KD, Paley D. Accuracy of correction of complex lower-extremity deformities by the Ilizarov method. Clin Orthop Relat Res. 1994;301:102-110. |
Deformity Correction
In a 1994 retrospective study on 28 limbs in 23 patients, Tetsworth and Paley7 determined that gradual mechanical distraction of complex lower extremity deformities could be aligned and corrected with greater accuracy by applying an Ilizarov external fixator. Furthermore, the accuracy of limb correction improved with surgical experience. In 1996, LaBianco et al,2 who successfully used the Ilizarov external fixation system instead of the traditional internal fixation method, noted that they preferred the Ilizarov system because of its stability, adaptability, and allowance of postoperative weight-bearing activities. In 2003, Vito et al4 published their findings on how to evaluate proximal, middle, and distal leg deformities preoperatively and how to correct these deformities with an external fixator. Sen et al5 used a supramalleolar osteotomy and an Ilizarov external fixator to safely and efficiently correct ankle and hindfoot deformities. They found this surgical method to be the treatment of choice for patients with limb length discrepancies and poor soft tissue conditions. Interestingly, in 1995, Lin et al6 developed a computer-assisted surgery planning system for the correction of lower extremity deformities using the Ilizarov method. The computer program provides a digitized bone deformity template to design an optimal, three-dimensional external frame.
Trauma and Fractures
Posttraumatic lower extremity bone defects have always challenged orthopedic surgeons in determining whether the limb is salvageable and then deciding which surgical method to recommend. Mekhail et al8 conducted a retrospective review of 19 patients with posttraumatic bone defects in the lower extremity. Treatment with internal bone transport using the Ilizarov ring external fixator in tibial fractures produced a good to excellent clinical outcome in 13 of 19 patients. Eighteen of the 19 patients reported being satisfied. Bone transport causes minimal soft tissue trauma and donor site morbidity with a gradual correction of the bone deformity. In 2001, Beals3 described application of ring fixators for specific foot and ankle fractures. He supported the use of external ring fixators as a treatment option for a complex lower extremity fracture with significant soft tissue injury.
The Ilizarov method of external fixation is also commonly used in the treatment of open fractures and multiple closed and comminuted fractures (Figure 3).9 Since the original Ilizarov external ring fixator was developed, modifications have been made to the apparatus to accommodate easier surgical application.4 In a 2004 laboratory study of 10 lower extremities, Antoci et al12 demonstrated the importance of spanning the ankle joint with a foot plate. This improved the biomechanical stability of the Ilizarov fixator construct in unstable distal tibial extra-articular and periarticular fractures. In 2007, Catagni et al9 evaluated the treatment of complex tibial plateau fractures in 59 patients. They used an Ilizarov fixation device modified by Catagni and Cattaneo,10, 11 along with limited internal fixation as needed. When combined with the proper indications, precautions, and surgical experience, the results from Catagni and Cattaneo supported the use of a modified Ilizarov method with minimal internal fixation as the treatment of choice for complex tibial plateau fractures.
Figure 3.
Radiographic interval view of multidirectional external fixation supporting an open ankle fracture with medial and lateral soft tissue injury.
Charcot Neuroarthropathy
Using an Ilizarov external fixator with certain plastic surgery techniques is an efficient and effective treatment for complex Charcot deformities of the lower limb. Diabetic patients who acquire Charcot neuroarthropathy have multiple challenges and have an increased propensity for poor bone quality, severe bone deformity, impaired wound healing and ulceration, and immune deficiency. These complications place patients with diabetes at a greater risk for surgical infection and loss of limb or life. The Ilizarov external fixation ring method offers a minimally invasive procedure with sufficient bone stabilization and soft tissue protection (Figure 4).13
Figure 4.
Application of multidirectional external fixation for a Charcot neuroarthropathic foot deformity.
Preoperative Care
Appropriate and timely surgical preparation is paramount to the success of surgical treatment. Each patient has specific needs depending on his or her condition and the type of surgery required to treat that condition. At the initial patient contact, a health care provider performs an assessment, which includes obtaining a thorough medical history and evaluating the patient's anxiety level and knowledge of perioperative coping modalities. This allows perioperative nursing staff members to communicate with the patient and explain the anticipated intraoperative and postoperative course of events. The circulating nurse then develops a nursing care plan specific to this patient and the anticipated surgical procedure (Table 2).
TABLE 2. Nursing Care Plan for a Patient Undergoing an External Fixation Procedure
| Diagnosis | Nursing interventions | Interim outcome statement | Outcome statement |
|---|---|---|---|
| Risk of impaired skin integrity | ■Transports according to individual needs by ■assessing mobility limitations and adapting the plan of care to address mobility impairments ■performing or directing the patient's transfer ■maintaining the patient's body alignment during transfer ■applying safety devices correctly and in a timely manner ■ensuring an adequate number of properly trained personnel for safe transfer ■Evaluates for signs and symptoms of skin and tissue injury as a result of transfer or transport by ■assessing the patient for correct anatomic alignment by checking the position of arms, legs, torso, and head and neck ■visually inspecting skin for areas of redness, bruising, abrasion, compression, and/or pressure related to transport ■assessing the patient's pain or discomfort level using an approved pain scale | ■The patient is free from signs and symptoms of injury related to transfer/transport on discharge from the OR. | ■The patient is free from signs and symptoms of injury related to transfer/transport. |
| Risk of perioperative positioning injury | ■Identifies physical alterations that require additional precautions for procedure-specific positioning ■Verifies presence of prosthetics or corrective devices ■Positions the patient by ■selecting positioning devices based on patient's identified needs and the planned surgical or invasive procedure ■ensuring that devices are readily available, clean, free of sharp edges, padded as appropriate, and in working order before placing the patient on the OR bed ■modifying the OR bed as necessary before attaching positioning devices ■assessing the patient while he or she is awake for level of consciousness, perception of pain, mobility impairments, and presence of skin conditions ■adapting the positioning plan to accommodate limitations ■rechecking the patient's body alignment and extremities, the safety strap, and all padding if repositioning occurs ■removing positioning devices cautiously after surgery while maintaining the patient's body alignment and homeostatic status ■Evaluates for signs and symptoms of injury as a result of positioning | ■The patient is free from pain or numbness associated with surgical positioning. ■The patient's pressure points demonstrate hyperemia for less than 30 minutes. | ■The patient is free from signs and symptoms of injury related to positioning. |
| Risk of injury | ■Confirms the patient's identity before the surgical or invasive procedure and verifies the surgical procedure, the surgical site, and laterality ■Implements protective measures before the surgical or invasive procedure ■Applies safety devices ■Implements protective measures to prevent skin/tissue injury due to mechanical sources ■Performs required counts ■Uses supplies and equipment within safe parameters ■Records devices implanted during the surgical or invasive procedure ■Maintains continuous surveillance ■Evaluates for signs and symptoms of physical injury to skin and tissue | ■The patient's skin condition, other than incision, is unchanged between admission and discharge from the OR. ■The patient is free from unplanned retained objects after surgery. | ■The patient is free from signs and symptoms of injury caused by extraneous objects. |
| Risk of infection and knowledge deficit regarding wound care | ■Assesses susceptibility for infection ■Implements aseptic technique ■Classifies the surgical wound ■Performs skin preparations ■Protects the patient from cross-contamination ■Minimizes the length of the invasive procedure by planning care ■Initiates traffic control ■Administers prescribed prophylactic treatments ■Encourages deep breathing and coughing exercises ■Administers care to the wound site ■Monitors for signs and symptoms of infection ■Assesses knowledge regarding wound care and phases of wound healing ■Provides instruction about wound care and phases of wound healing ■Evaluates responses to instruction about wound care and phases of wound healing | ■The patient is afebrile and free from signs and symptoms of infection. ■The patient verbalizes signs and symptoms of wound infection to report immediately to the surgeon at the time of discharge. ■The patient and family members demonstrate the correct technique for applying a wound dressing at the time of discharge. | ■The patient is free from signs and symptoms of infection. ■The patient demonstrates knowledge of wound management. |
| Anxiety and compromised family coping | ■Notes sensory impairments ■Identifies barriers to communication ■Determines knowledge level ■Assess readiness to learn, identifies psychosocial status, and assesses coping mechanisms ■Explains the expected sequence of events ■Implements measures to provide psychological support ■Provides status reports to family members ■Elicits perceptions of surgery ■Evaluates the psychosocial response to the plan of care and to instructions | ■The patient verbalizes the sequence of events to expect before and immediately after surgery and states realistic expectations regarding recovery from the procedure. | ■The patient demonstrates knowledge of the expected responses to the surgical or invasive procedure. |
| Impaired physical mobility, ineffective therapeutic regimen management, and knowledge deficit regarding the rehabilitation process | ■Provides instruction based on age and identified need ■Identifies expectations of home care by ■assisting the patient and family members to identify and achieve realistic, measurable goals to attain desired outcomes ■explaining safety and comfort home care measures appropriate for the procedure, such as ■resting frequently for limited periods during early recovery ■having a family member in the home when taking the first shower ■rolling to the side of the bed and then using one's arms to elevate to a sitting position when getting out of bed for the first few times ■sitting in the car seat, then rotating one's legs into the vehicle ■taking pain medication as ordered with food and fluids and notifying the health care provider if pain persists or worsens ■using a handrail when descending stairs and not driving a mechanized vehicle (eg, car, motorcycle, scooter) until released by the surgeon ■Evaluates the environment for home care ■Evaluates the response to instruction | ■The patient and family members verbalize realistic expectations regarding rehabilitation after surgery. ■The patient describes the prescribed rehabilitation regimen to follow immediately after discharge from the facility. | ■The patient participates in the rehabilitation process. |
After explaining the surgical intervention and answering the patient's questions, the surgeon obtains the patient's written consent for the surgical procedure and, cooperatively with the patient, marks and initials the correct surgical site. After assessing the patient particularly regarding anesthetic health, the anesthesia care provider discusses anesthetic modalities with the patient. Although general anesthesia is an option, many patients undergo regional anesthesia (ie, sciatic, femoral, popliteal, saphenous, ankle) with IV sedation (ie, monitored anesthesia care) for limb surgeries. This combination anesthetic approach allows for analgesia and acute pain management.
Before transferring the patient into the OR, the circulating nurse confers with the surgeon, anesthesia care provider, and other perioperative team members regarding pertinent assessment results. The circulating nurse and scrub person then perform the counts. The circulating nurse ensures that the OR setup for an Ilizarov procedure is complete, which includes obtaining several surgical tables and ensuring that all instrument trays and supplies and a fluoroscopy unit (C-arm) are ready and placed in the OR (Table 3), before bringing the patient into the room on the OR stretcher.
TABLE 3. Perioperative Equipment and Supply Needs for the Ilizarov Method of External Fixation1, 2
| Preoperative | Intraoperative | Postoperative |
|---|---|---|
■All properly packaged and sterilized equipment as requested ■Appropriately positioned and prepared radiolucent OR bed (eg, with kidney brace) ■Necessary positioning aids ■Skin and tissue protectors to accommodate the patient's size and weight ■Arm boards ■Padding for extremities and bony prominences ■Hip roll ■Sufficient instrument tables (eg, typically 3 or more back tables and 2 Mayo stands) ■Radiology equipment: ■Fluoroscopy unit (C-arm) ■Lead aprons and thyroid shields for every perioperative team member ■Preoperative images (radiology technologist will provide) ■Medications and solutions ■Antibiotics for IV and irrigation prophylaxis ■Platelet-rich and platelet-poor plasma ■Topical hemostatic agents ■Pathology and culture supplies dependent on the specific procedure ■Orthopedic biologic bone and tissue grafts as requested by the surgeon and prepared according to the vendor's written instructions ■Thromboembolic disease stocking and sequential compression device for the nonoperative lower extremity ■Indwelling urinary catheter kit depending on the anticipated length of the procedure | ■Monopolar electrosurgical unit and grounding pad ■Bipolar electrosurgical unit ■Pneumatic tourniquet unit and appropriate sizes of tourniquets ■Fluoroscopy unit ■Basic orthopedic, plastic, and neurosurgery trays ■Ilizarov fixation instrumentation system, usually 4 to 12 trays ■Rings ■Wires ■Pins ■Rods ■Struts ■Plates ■Arches ■Tensiometers and wire/pin cutters ■Connecting components (eg, hinges, posts, nuts, bolts, clamps, washers, sockets) ■Utility trays (eg, wrenches, pliers, drivers) ■Steinman pins: large and small ■Osteotomes ■Power driver/saw system, corresponding batteries, and choice of saw blades ■Sutures: absorbable and nonabsorbable ■Dressings ■Povidone iodine solution ■Silver dressings ■Specialty absorbent dressing ■Gauze ■Rolls and wraps | ■Extra dressing supplies ■Povidone iodine solution ■Silver dressings ■Specialty absorbent dressing materials as requested ■Gauze ■Rolls, wraps ■Extra tools from the Ilizarov system (eg, wrenches, rings) ■Regional anesthesia for augmentation ■Local anesthetics ■Pumps ■Catheters |
1Zgonis T, Stapleton JJ, Jeffries LC, Girard-Powell VA, Foster LJ. Surgical treatment of Charot neuropathy. AORN J. 2008;87(5):971-986. |
2Hay BK, Karas CB. A teaching plan for external fixation. AORN J. 1981;34(3):424-426. |
Intraoperative Care
After transporting the patient into the OR from the preoperative area, the circulating nurse helps the patient move onto the OR bed. The circulating nurse then positions the patient to include securing the safety strap, assisting with placing anesthesia monitoring devices, padding bony prominences with protective devices, assisting with tourniquet application, and placing the C-arm. The circulating nurse initiates the surgical time out with active participation of all team members. This includes audible confirmation of the patient's identity, procedure, surgical site, and laterality. After induction of anesthesia, the circulating nurse performs the surgical site prep, after which the surgeon and scrub person drape the surgical site.
The circulating nurse is responsible for traffic management to minimize the potential for infection. This is particularly complex because of the large number of tables and Ilizarov system trays required for these procedures (Figure 5, Figure 6). Depending on the specific surgical procedure, the radiology technologist has to move the C-arm frequently in and out of the surgical field to obtain different views (Figure 7). This poses numerous challenges when there are many tables and surgical staff members in the room. During Ilizarov procedures, it is not uncommon for team members to inadvertently drop components on the floor or have wires tear or puncture holes in the drapes or fluoroscopy unit cover. Fortunately, the Ilizarov trays come with numerous duplicate components to minimize the need to resterilize contaminated items.
Figure 5.
External fixation components on one of the OR back tables.
Figure 6.
Assembly and preparation of the external fixation apparatus.
Figure 7.
Use of the fluoroscopy unit.
Surgical Procedure
In most Ilizarov procedures, the surgeon evaluates and radiographically maps the surgical site in all three planes (ie, sagittal, frontal, transverse) of deformity or fracture pattern. Every surgical team member must wear a lead apron and shield throughout the procedure. The surgeon may prebuild the frame before the procedure or build it during surgery. The surgeon applies the Ilizarov external fixator by placing transosseous wires across the proximal and distal ends of the deformity and fracture site. Typically, these wires are longer than standard Kirschner wires and usually are 1.8 mm to 2.0 mm thick. Using tension, the surgeon secures the transosseous wires to the ring frames via nuts and bolts. The surgeon connects each ring segment to the next segment with rods, graduated rods, struts, and hinges. This process of assembling the rings can be simple and speedy or complex and time consuming depending on what the surgeon wants to achieve and the magnitude of the deformity. When the surgeon has applied the entire fixator system, gradual or acute correction can be achieved.
The surgeon, scrub person, and circulating nurse apply a bulky postoperative dressing (eg, flat gauze, roll gauze) (Figure 8). They elevate the patient's extremity on a pillow or pillows after transferring the patient to a postoperative stretcher. The anesthesia care provider and circulating nurse then transport the patient to the postanesthesia care unit.
Figure 8.
Application of the postoperative protective dressings. Note that perioperative team members are wearing appropriate lead aprons and thyroid shields.
Postoperative Care
The postanesthesia care unit nurses monitor the patient's vital signs, including pain, and also monitor the patient for compartment pressures if the surgeon considers the limb at risk for compartment syndrome. When the patient is comfortable, he or she is allowed to be mobile on a walker or crutches. Postoperative weight bearing is dependent on pathology, patient compliance, and fixator configuration.
The Ilizarov fixation device is applied externally, so occasionally some components may become loose or fall off the apparatus (eg, during patient transport or positioning). Having an extra set of tools and components from the Ilizarov system is not essential, but it can be useful in these rare situations. Typically, hospitals in which a large number of these procedures are performed have extra components and tools in separate sterile packs. Some wires may be prominent or protrude sharply, so it is advisable to have extra dressing materials in the postanesthesia care unit.
When the patient is mobile, the nurse discharges him or her from inpatient care. The surgeon orders radiographs at periodic intervals until radiologic evidence of union occurs: intervals of three weeks, six weeks, three months, and every six months thereafter. As signs of union are noted, the patient may discontinue the use of crutches in favor of a cane.
Conclusion
The Ilizarov method of external fixation involves important preoperative, intraoperative, and postoperative considerations. It is crucial to identify available treatment options and choose the most favorable treatment for the patient depending on his or her complex orthopedic condition. Perioperative team members must understand the patient's deformity and have an organized surgical plan in place for the selected fixation method.
The Ilizarov method of external fixation is not a novelty in the world of orthopedic surgery. It has been performed for many decades in a variety of ways with different systems. All external fixation frames are not necessarily equal because of the vast number of components. Proper preparation, therefore, cannot be generalized. Attention to detail and proper perioperative management can result in improved health and quality of life for the patient.
Examination. Continuing Education Program
The Ilizarov Method of External Fixation: Current Intraoperative Concepts
PURPOSE/GOAL
To educate perioperative nurses about the use of the Ilizarov method of external fixation to treat a variety of orthopedic conditions.
OBJECTIVES
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QuestionsThe behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
Learner Evaluation. Continuing Education Program
The Ilizarov Method of External Fixation: Current Intraoperative Concepts
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References
- . Ilizarov orthopedic methods (Innovations from a Siberian surgeon). AORN J. 1989;49(1):215–230
- . Use of the Ilizarov external fixator in the treatment of lower extremity deformities. J Am Podiatr Med Assoc. 1996;86(11):523–531
- . Applications of ring fixators in complex foot and ankle trauma. Orthop Clin North Am. 2001;32(1):205–214
- . Use of external fixation to correct deformities of the lower leg. Clin Podiatr Med Surg. 2003;20(1):119–157
- . Correction of ankle and hindfoot deformities by supramalleolar osteotomy. Foot Ankle Int. 2003;24(1):22–28
- . Computer-assisted surgery planning for lower extremity deformity correction by the Ilizarov method. J Image Guid Surg. 1995;1(2):103–108
- . Accuracy of correction of complex lower-extremity deformities by the Ilizarov method. Clin Orthop Relat Res. 1994;301:102–110
- . Bone transport in the management of posttraumatic bone defects in the lower extremity. J Trauma. 2004;56(2):368–378
- . Treatment strategies for complex fractures of the tibial plateau with external circular fixation and limited internal fixation. J Trauma. 2007;63(5):1043–1053
- . Management of fibular hemimelia using the Ilizarov method. Orthop Clin North Am. 1991;22(4):715–722
- . The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop Relat Res. 1992;280:143–152
- . Biomechanics of external fixation of distal tibial extra-articular fractures: is spanning the ankle with a foot plate desirable?. J Orthop Trauma. 2004;18(10):665–673
- . Surgical treatment of Charcot neuropathy. AORN J. 2008;87(5):971–986
- . Ilizarov external fixation (Surgical principles, nursing implications). AORN J. 1990;51(6):1530–1545
- . External fixation: option for fractures. AORN J. 1981;34(3):417–423
Daniel K. Lee, DPM, FACFAS, is an assistant clinical professor of orthopaedic surgery, Department of Orthopaedic Surgery, School of Medicine, University of California San Diego. Dr Lee has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Elizabeth Thu Anh Duong, BS, is a medical student at Eastern Virginia Medical School, Norfolk, VA. Ms Duong has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Douglas G. Chang, MD, PhD, is an assistant clinical professor, Department of Orthopaedic Surgery, School of Medicine, University of California San Diego. Dr Chang has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/ce. The contact hours for this article expire March 31, 2013.
PII: S0001-2092(09)00933-8
doi:10.1016/j.aorn.2009.11.064
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