Osteosynthesis and Trauma Care 2002; 10(4): 184-187
DOI: 10.1055/s-2002-39265
Original Article

© Georg Thieme Verlag Stuttgart · New York

Exchange of Ilizarov External Fixation by Intramedullary Nail, During Callus Consolidation Phase of Limb Lengthening: An Experimental Sheep Model

A. Papadopoulos1 , A. Karageorgos1 , M. Tyllianakis1 , E. Sourgiadaki2 , I. Tsota3 , D. Papachristou4 , E. Lambiris1
  • 1Orthopedic Department, Patras University Hospital, Rio-Patras, Greece
  • 2Department of Anesthesia, Patras University Hospital, Rio-Patras, Greece
  • 3Department of Radiology, Patras University Hospital, Rio-Patras, Greece
  • 4Department of Pathology, Patras University Hospital, Rio-Patras, Greece
Further Information

Publication History

Publication Date:
26 May 2003 (online)


Purpose: To evaluate the effectiveness of external fixation exchange by intramedullary nailing during the consolidation phase following the callus distraction phase.
Methods: In 12 skeletally mature female sheep, equally divided in two groups (group A and group B), we performed tibial shaft osteotomy and 2 cm gradual callus distraction using the Ilizarov external fixator in a 0.5 mm/12 h rate. In group A, the Ilizarov fixator was removed immediately after lengthening completion, and a static unreamed intramedullary nail was inserted. In group B, the Ilizarov device remained during the consolidation phase. The formated callus was studied, with radiographs, ultrasonograms, and triplex. All animals were sacrificed 70 days after osteotomy and bone specimens were evaluated by DEXA and histopathologic examination.
Results: In group A, all animals successfully tolerated intramedullary nailing, keeping limb alignment. All but one formed a mature callus and had entered the remodeling phase keeping callus length, before being sacrificed. One had delayed callus maturation and 0.5 cm loss of callus length, because of failed insertion of the distal locking screw in the nail. In group B, all formed mature callus too, but 2 had serious axis disorders, 3 persistent superficial pin-track infections and 1 deep infection at the same time.
Conclusions: Replacement of the Ilizarov device by static unreamed intramedullary nail during the callus consolidation phase decreases the total duration of external fixation, limits joint stiffness, pin-track infections and axial deformities, and provides protection against refracture. Our results suggest that there is no considerable difference between callus maturation in the two groups.


  • 1 Aquerreta J D, Forriol F, Canadell J. Complications of bone lengthening.  Internat Orthop. 1994;  18 299-303
  • 2 Aronson J. Temporal and spatial increases in blood flow during distraction osteogenesis.  Clin Orthop. 1994;  301 124-131
  • 3 Baumgart R. et al .Intramedullary nailing in callus distraction. Orthopäde 1996
  • 4 Bost F C, Larsen L J. Experiences with lengthening of the femur over an intramedullary rod.  J Bone Joint Surg [Am]. 1956;  38 567-584
  • 5 Brunner U. et al .Treatment of defects of the long bones using distraction osteogenesis (Ilizarov) and intramedullary nailing. Theoretic principles, animal experiment, clinical relevance. Unfallchirurg 1990; 93: 244 - 250
  • 6 Carrington N C. et al .Ilizarov bone transport over a primary tibial nail and free flap: a new technique for treating Gustilo grade 3B fractures with large segmental defects. Injury 2000; 31: 112 - 115
  • 7 Caton. et al .Progressive limb lengthening with a centromedullary nail versus external fixator: experimental study in sheep. Rev Chir Orthop Reparatrice Appar Mot 2001; 87: 237 - 247
  • 8 Cauchoix J, Rey J C, Héripret G, Cotrel Y, Morel G. L'allongement du fémur dans le traitement des inégalités de longueur des membres inférieurs. Description d'une technique d'allongement extemporané.  Rev Chir Orthop. 1963;  49 193-203
  • 9 Danziger M B, Kumar A, DeWeese J. Fractures after femoral lengthening using the Ilizarov method.  J Pediatr Orthop. 1995;  15 220-223
  • 10 De Bastiani G, Aldegheri R, Renzi-Brivio L, Trivella G. Limb lengthening by callus distraction (callotasis).  J Pediatr Orthop. 1987;  7 129-134
  • 11 Eyres K S, Bell M J, Kanis J A. Methods of assessing new bone formation during limb lengthening: Ultrasonography, dual energy X-ray absorptiometry and radiography compared.  J Bone Joint Surg [Br]. 1993;  75 358-364
  • 12 Fink B, Krieger M, Strauss J M. et al . Osteogenesis and its influencing factors during treatment with the Ilizarov method.  Clin Orthop. 1996;  323 261-272
  • 13 Fischgrund J, Paley D, Suter C. Variables affecting time to bone healing during limb lengthening.  Clin Orthop. 1994;  301 31-37
  • 14 Franke J, Simon M, Hein G. Ilizarov-Techniken zur Beinverlängerung: Probleme und Ergebnisse.  Orthopäde. 1992;  21 197-209
  • 15 Green S A. Postoperative management during limb lengthening.  Orthop Clin North Am. 1991;  22 723-734
  • 16 Hamanishi C, Yasuwaki Y, Kikuchi H. et al . Classification of the callus in limb lengthening: Radiographic study of 35 limbs.  Acta Orthop Scand. 1992;  63 430-433
  • 17 Hyodo A. et al .Bone transport using intramedullary fixation and a single flexible traction cable. Clin Orthop 1996; 325: 256 - 268
  • 18 Ilizarov G A. Transosseous Osteosynthesis. Theoretical and Clinical Aspects of the Regulation and Growth of Tissue. Vol. 1. Berlin, Springer Verlag 1991; pp. 3-62
  • 19 Ilizarov G A. Clinical application of the tension-stress effect for limb lengthening.  Clin Orthop. 1990;  250 8-26
  • 20 Kojimoto H, Yasui N, Goto T. et al . Bone lengthening in rabbits by callus distraction: The role of periosteum and endosteum.  J Bone Joint Surg [Br]. 1988;  70 543-549
  • 21 Kristiansen L P, Steen H. Lengthening of the tibia over an intramedullary nail, using Ilizarov external fixator. Major complications and slow consolidations in 9 lengthenings. Acta Orthop Scand 1999; 70: 271 - 274
  • 22 Lee and Huang .Femoral lengthening: callotasis with Ilizarov external fixator alone and with intramedullary locking nail. J Formos Med Assoc 1997
  • 23 Lin C C. et al .Limb lengthening over an intramedullary nail. An animal study and clinical report. Clin Orthop 1996; 330: 208 - 216
  • 24 Maffulli N, Hughes T, Fixsen J A. Ultrasonographic monitoring of limb lengthening.  J Bone Joint Surg [Br]. 1992;  74 130-132
  • 25 Markel M D, Wikenheiser M A, Morin R L. et al . Quantification of bone healing: Comparison of QCT, SPA, MRI, and DEXA in dog osteotomies.  Acta Orthop Scand. 1990;  61 487-498
  • 26 Nutton R W. Early dynamic bone-imaging as an indicator of osseous blood flow and factors affecting the uptake of 99mTc hydroxymethylene diphosphonate in healing bone.  J Bone Joint Surg [Am]. 1985;  67 763-770
  • 27 Orbay J L, Frankel V H, Finkle J E, Kummer F J. Canine leg lengthening by the Ilizarov technique: A biomechanical, radiologic, and morphologic study.  Clin Orthop. 1992;  278 265-273
  • 28 Paley D. et al .Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. JBJS 1997
  • 29 Paley D. Current techniques in limb lengthening.  J Pediatr Orthop. 1988;  8 73-92
  • 30 Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique.  Clin Orthop. 1990;  250 81-104
  • 31 Riemer B L, Butterfield S L. Comparison of reamed and nonreamed solid core nailing of the tibial diaphysis after external fixation: a preliminary report.  J Orthop. Trauma 1993;  7 279-285
  • 32 Simpson. et al .Leg lengthening over an intramedullary nail. JBJS Br 1999
  • 33 Stanitski D F, Bullard M, Armstrong P, Stanitski C L. Results of femoral lengthening using the Ilizarov technique.  J Pediat Orthop. 1995;  15 224-231
  • 34 Steen H, Fjeld T O, Bjerkreim I. et al . Limb lengthening by diaphyseal corticotomy, callus distraction, and dynamic axial fixation: An experimental study in the bovine femur.  J Orthop Res. 1988;  6 730-735
  • 35 Wasserstein I. Twenty-five year’s experience with lengthening of shortened lower extremities using cylindrical allografts.  Clin Orthop. 1990;  250 150-153
  • 36 Wheelwright E F, Court-Brown C M. Primary external fixation and secondary intramedullary nailing in the treatment of tibial fractures.  Injury. 1992;  23 373-376
  • 37 Yasui N, Kajimoto H, Sasaki K. et al . Factors affecting callus distraction in limb lengthening.  Clin Orthop. 1993;  293 55-60
  • 38 Young J WR, Kostrubiak I S, Resnik C S, Paley C. Sonographic evaluation of bone production at the distraction site in Ilizarov limb-lengthening procedures.  AJR Am J Roentgenol. 1990;  154 125-128

Dr. Andreas X. Papadopoulos

Orthopedic Clinic · Patras University Hospital · 26504 Rio-Patras · Greece

Phone: +30/6 10/99 95 55

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