S T A N F O R D M E D I C I N E
Volume 16 Number 4, SUMMER 1999
the magician from kurgan
If the father of modern limb- lengthening techniques hadn't won acclaim for treating a famous Russian athlete, his ideas might never have made it out of Siberia.
IN THE 1950S PEOPLE BEGAN FLOCKING TO GAVRIEL ABRAMOVICH ILIZAROV, MD, FROM ALL OVER RUSSIA, HOPING THAT THE MAN KNOWN AS "THE MAGICIAN FROM KURGAN" COULD CURE THEM OF AILMENTS THAT HAD FLUMMOXED OTHER HEALERS. BUT UNTIL 1967, THE RUSSIAN MEDICAL ESTABLISHMENT DEEMED ILIZAROV -- THE INVENTOR OF MODERN LIMB LENGTHENING -- A QUACK. FOR NEARLY TWO DECADES, HIS TECHNIQUES REMAINED BURIED IN KURGAN, WESTERN SIBERIA, IN THE TINY, TWO-STORY, WOODEN HOSPITAL FOR WAR INVALIDS.
Ilizarov (1921-1992) developed his limb-lengthening technique somewhat by accident, while practicing in medically underserved Western Siberia, where many of his patients were World War II veterans suffering from compound gunshot fractures. To heal these difficult fractures, he developed an innovative technique, one that eventually proved successful for lengthening bone. He cross-inserted two to three thin, flexible wires (originally, he used bicycle spokes) through the broken bone above the fracture site, and two to three wires below the fracture site. The wires transected both the fractured bone and the soft tissue. He secured the ends of the upper set of wires to one metal ring encircling the limb and the ends of the lower set of wires to another metal ring (picture two bicycle wheels perpendicular to the limb, one wheel above the fracture, one below). After positioning the bone fragments by manipulating the wires and rings, he anchored the two metal rings to each other via external rods running the length of the limb. Strong, yet flexible, the apparatus accommodated body weight and motion, stimulating the growth of new cells between bone fragments.
In the early 1960s, Ilizarov discovered that his apparatus offered a new way to lengthen bone. One of his patients, a veteran with a short stump of tibial bone, asked Ilizarov to elongate the stump. Intending to lengthen the tibia by grafting on a piece of bone, he set out to create a sufficient gap in the tibia to accommodate the graft. He inserted pins in the bone, cut the bone in half between the two sets of pins without disturbing its blood supply, and then attached rings and rods as if treating a fracture. He showed the patient how to lengthen the vertical, expandable rods, instructing him to push apart the two pieces of tibial bone one millimeter daily.
Shortly after the patient created a sufficiently wide gap in the bone, Ilizarov went on vacation. When he returned one month later, he found the patient waiting for him near the hospital entrance, wearing the apparatus Ilizarov forgot to remove before his trip. An X-ray revealed that this was a serendipitous lapse: There was no gap in the tibia. To Ilizarov's surprise, newly formed bone tissue had filled it.
Ilizarov's "Tinker-Toy"-like apparatus proved to be significantly safer and more effective than older techniques. Its many thin, flexible wires enmeshed within a three-dimensional frame render it stable and flexible, and they equally distribute tension throughout the limb. This allows the patient to use the limb even when there is a wide gap in the bone, stimulating a strong bone union, says Todd Lincoln, MD, a Stanford pediatric orthopedic surgeon who employs Ilizarov's technique at Lucile Packard Children's Hospital at Stanford. In addition, Ilizarov's pins cause little tissue damage, and the apparatus' numerous interchangeable components give it unprecedented versatility.
In contrast, the pre-Ilizarov techniques, developed in the early part of this century, relied on crude devices and rigid pins. For example, a doctor performing a commonly used older technique made a cut in the middle of a bone and around its circumference, but didn't create a gap between the two halves. Then he drilled one thick, rigid pin into, but not through, the bone above the cut and a second thick, rigid pin below the cut. To widen the cut in the bone to achieve greater length, he anchored the pins to an elongating bar, or a clumsy traction device, extending along the length of the leg. Such devices accommodated little movement, so patients were required to either lie in bed for weeks or im mobilize the leg in a plaster cast. More often than not, this lack of movement slowed or prevented healing. In addition, the thick, rigid pins caused significant tissue damage and increased the risk of bone infections and bone deformities. Perhaps the greatest weakness of these early devices was that they could be used only for lengthening, while the Ilizarov effectively treats a variety of orthopedic problems, says Lincoln.
Though Ilizarov's technique was an obvious improvement over the limb-lengthening strategies of his day, it took decades to catch on. One problem was that his early papers were published exclusively in Russian language journals, rarely available outside the Soviet Union. Another, more formidable, obstacle was the fact that Ilizarov wasn't a member of the medical elite, at an institution in Moscow or Leningrad. Vladimir Golyakhovsky, MD, an orthopedist at the Hospital for Joint Diseases in New York, N.Y., tells of his encounter with Ilizarov in Russia in the mid-1960s in his article "Gavriel A. Ilizarov: 'The Magician from Kurgan,' " published in the Bulletin of the Hospital for Joint Diseases Orthopaedic Institute, Volume 48, Number 1, 1988. According to Golyakhovsky, at the time a young physician based in Moscow, the medical establishment viewed Ilizarov as a provincial quack but its leaders decided the tales of his magical bone-lengthening technique bore investigation. So, they sent Golyakhovsky, who came back extolling Ilizarov's technique. But according to Golyakhovsky, his superiors remained unmoved until soon after, when in 1967 they learned that Ilizarov had successfully treated Olympic champion high jumper Valery Brumel, who had fractured his left tibia and fibula in a motorcycle accident.
That success catapulted Ilizarov to national prominence, and the government finally gave him funds to build an orthopedic hospital in Western Siberia. Shortly thereafter, converts began spreading his technique throughout Europe. In the early 1980s, Ilizarov's ideas arrived on these shores. According to Lawrence Rinsky, MD, a professor of functional restoration, Stanford orthopedists did one of the first Ilizarov procedures in the United States.
Ilizarov made two long-lasting contributions, says Rinsky: showing that bone could lengthen one millimeter daily and developing the Ilizarov apparatus. Independent research has confirmed Ilizarov's observation that lengthening a bone one millimeter daily is optimal, and his device remains the most widely used system for limb-lengthening by virtue of its unmatched versatility. "With the Ilizarov, you can correct and lengthen in all planes, even broaden a too-thin bone," says Rinsky.
The Ilizarov does have its drawbacks, however. "Constructing an Ilizarov pre-operatively takes a lot of time -- about four hours -- and invariably I'll have to change it at least once during surgery," says Lincoln. As a consequence, less technically demanding apparatuses are slowly replacing the Ilizarov, says Rinsky. These newer devices, called monolaterals or hybrids, incorporate many of Ilizarov's ideas, like micromotion capabilities to encourage healing, but require less work from both doctor and patient. -- CK