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Historical Review
The Pan-Soviet Scientific Center for Traumatology and
Rehabilitation Orthopedics of Kurgan is directed by
Professor Gavriil Abramovich Ilizarov.
(Fig. 1.1: Prof. G.A.
Ilizarov has been awarded with the Lenin Prize for Medicine.
Wearing the characteristic cap of Russian surgeons he
admires the universal adaptability of his apparatus,
demonstrated on the skeleton)
 This
Institute, also known as the "V.K.N.C.-VTO,"
an acronym which has substituted for the old name of
"KNIIEKOT," is located in Kurgan, Siberia.
Professor Ilizarov, the recipient of the 1978 Lenin
Prize for Medicine, is considered a hero of Socialist
Work. As an Emeritus Professor and an Inventor Emeritus
of the U.S.S.R., he recently achieved full membership
in the Soviet Science Academy, a rare honor for a doctor
of medicine.
Ilizarov began his work more than 35 years ago in Kurgan.
His phenomenal accomplishments, only recognized in the
Soviet Union during the last 10 years, received only
scant attention in western journals. In November 1980,
Carlo Mauri, an Italian explorer, ventured to Siberia
where he was treated and cured of an infected tibial
pseudarthrosis by Ilizarov. The bridge of cordial friendship
established between Ilizarov and Mauri allowed us to
invite the Professor to the XXII Italian AO Meeting
in Bellagio, Italy, in June 1981.
(Fig. 1.2: Prof Ilizarov examines
the radiographs of his friend Carlo Mauri, who suffered
ten years from an infected nonunion of the left leg;
Fig.1.2b: In the operating room. Mauri views
the apparatus while still under spinal anesthesia; Fig.1.2c:
Only few days later, he is encuraged to walk with apparatus;
Fig.1.2d: After six months in the apparatus,
his leg is completely healed)
It was there, under the chairmanship of Professor Roberto
Cattaneo, Chief of Orthopaedics and Traumatology of
the Lecco General Hospital, that Ilizarov participated
in his first western conference. The subject of the
conference was "Prophylaxis and Treatment of Bone
Infections." Ilizarov presented three major topics:
1. "The Treatment of Open Fractures."
2. "The Treatment of Post-Traumatic Osteomyelitis."
3. "Bone Lengthening."
Our scientific curiosity was so stimulated by his presentations
during the meeting that in July 1981, Professor Cattaneo
and his associates, A. Villa, M.D., M. Catagni, M.D.
and L. Tentori, M.D., began their first clinical trials
with transosseous osteosynthesis as described by Ilizarov
using a complete set of instruments for construction
of the apparatus, donated by Ilizarov to the Lecco General
Hospital. The results were so impressive that we arranged
an educational tour of the V.K.N.C.-VTO.
After overcoming many obstacles, with the help of Mauri,
a delegation consisting of Professor A. Bianchi Maiocchi,
M.D. (Milan), Professor G. B. Benedetti, M.D. (Bergamo),
A. Villa, M.D. (Lecco) and M.A. Catagni, M.D. (Lecco)
completed the trip to Kurgan in April 1982.
 (Fig.
1.3: The first delegation of Italian physicians
visiting the KNIEKOT with Mauri (from left: Catagni,
Bianchi Maiocchi, Mauri, Villa, Benedetti))
Our stay in Kurgan allowed us to see this method applied
to all areas of orthopaedics. We were intrigued by the
evolution of Ilizarov's ideas through extraordinary
clinical observations and applied research.
Beyond the Urals, Kurgan is situated on the western
border of the immense Siberian state, some 3,000 kilometers
east of Moscow.
 (Fig.
1.4: The city of Kurgan, located just east of Ural
mountains entering Siberia, is in the middle of the
U.S.S.R.)
In this small industrial city of 250,000, Professor
Ilizarov first conceived of his method in 1951. It is
said that one patient accidentally turned the connecting
rods between rings in distraction rather than compression.
Ilizarov observed new bone formation radiographically
following this distraction. Recognizing the potential
significance of this observation, he initiated a series
of experimental work in animals.
His methodology marks the beginning of new and extremely
original scientific and practical concept which have
allowed the enunciation of new, previously unknown biologic
laws regarding bone formation, osteoinduction and tissue
neogenesis. Currently, the fundamental impetus of his
Institute is the theoretical study and practical application
of this new method of transosseous osteosynthesis in
orthopaedics and traumatology.
Beginning in a small general hospital under Ilizarov’s
direction, research grew rapidly from a small laboratory
with a staff consisting of Ilizarov himself and two
scientific specialists. This laboratory became an operative
branch of the N.I.I.T.O. of Leningrad (1969), expanded
over the next two decades incorporating a vivarium which
housed 50 animals and a hospital with two orthopaedic
wards of 40 beds each. one for adults and one for children.
The clinics were based at Kurgan City Hospital where.
under the direction of orthopaedic traumatologists.
clinical trials had begun using the Ilizarov method
for acute trauma.
His new Institute, the V.K.N.C.-VTO, built in 1982,
is currently one of the largest research centers in
U.S.S.R.
It combines a hospital with 1200 beds and 12 operating
rooms with modern technology focused on the fields of
tissue growth and regeneration and a research department
made up of seven scientific sections comprising fifteen
research laboratories. These laboratories, each with
its own surgical suite, are equipped to conduct experimental
surgical research. There is a new vivarium which houses
400 dogs and is run by specialized maintenance personnel.
a veterinarian, and four nutritionists. There are also
separate departments in physiology. chemistry, biochemistry,
biomechanics, nuclear medicine, radiology and mechanical
engineering.
(Fig. 1.5: Entry to Ilizarov's
new hospital called the Soviet Scientific Center for
Traumatology and Rehabilitation Orthopeadics (V.K.N.C.-VTO
inaugurated in 1983) - Fig. 1.6: Typical of Siberia,
the institute is shaped like a snowflake. Each wing
houses a separate clinical service, sharing central
facilities of operating room, radiology, laboratory
and physical therapy - Fig. 1.7: Front view of
the institute)
The staff working in the Institute includes more than
1000 persons specialized in various fields, with 30
of the physicians dedicated exclusively to research.
The clinical sections of the Institute are organized
into several subspecialty areas including lengthening,
deformity correction, non-unions, hip, foot and infection.
A well-equipped polyclinic facilitates the many outpatient
procedures necessary during treatment. The twelve operating
rooms are run like efficient "assembly lines"
by hundreds of physicians trained in the various clinical
applications. Particular care is dedicated to physical
therapy, where one of the fundamental principles of
this methodology, load and motion, is practiced under
the direction of a well-qualified staff.
The Ilizarov apparatus is so versatile that its assembly
is adaptable to treat any skeletal pathology. This treatment
method is currently used by a majority of the hospitals
in the Soviet Union, where it is estimated that close
to one million patients have been
treated using this modality. In the past few years,
the use of this method has diffused beyond the boundaries
of the U.S.S.R. Italy can be considered the first western
country to begin clinical trials which started in 1981.
 (Fig.
1.8: Prof. Ilizarov during a breack in the operating
room at Lecco General Hospital, headquarters of the
Italian A.S.A.M.I.)
The impact of this method, illustrated by Ilizarov
himself at the Bellagio meeting in 1981, inspired us
to organize A.S.A.M.I., the Association for the Study
and Application of the Methods of Ilizarov (Lecco, 1982).
As its first order of business, the association, with
Cattaneo as president, organized the first course on
The Theoretical and Practical Application of Ilizarov's
Methods held in Longone al Segrino, Lecco, in June 1983.
The course was directed by Ilizarov and his assistant,
Dr. V. I. Shevtsov. There were over 300 participants
among which were two honored guests, Augusto Sarmiento,
M.D., and G. Dean MacEwen, M.D., from the United States.
In September 1983, thirty Italian specialists were
invited by the Russian Ministry of Health to attend
the First International Symposium on Transosseous Osteosynthesis
held at the V.K.N.C.-VTO Institute in Kurgan. Eight
hundred specialists from many eastern countries and
a limited number of other western specialists also attended.
In a separate monograph, I summarized the enormous amount
of scientific research and clinical trials presented
at this meeting.
In June 1984, the second instructional course was offered
at Dorga, Bergamo, Italy, under the direction of Professor
Benedetti, Chief of the "M. Rota" Institute
of Bergamo United Hospitals. Ilizarov, with the assistance
of Doctors V. I. Shevtsov and S. I. Shved, supervised
this meeting where we first presented our own results
with 600 patients treated by this method in Lecco and
Bergamo.
 (Fig.
1.9: Prof Ilizarov examines the devices manufactured
in Italy (Dorga, Bergamo, June 1984))
On the last day of this meeting, Ilizarov gave the
concluding "Professorial Lecture" on the "Treatment
of Nonunion" before a hall of 400 orthopaedic surgeons,
including Professor Maurice Müller, the president
of SICOT and the founder of AO International.
From 1983 to 1985, the Ilizarov method has spread rapidly
through most of western Europe as a result of the A.S.A.M.I.
organization in Italy. On February 1, 1985, Ilizarov
participated in the "Fin de semana Traumatològico-Ortopèdico"
in Spain, at the "Ramòn and Cajal"
Center, as organized by Professor J. de Palacios y Carvajal.
On February 4, 1985, in Barcelona, he also attended
the meeting, "A Day on the Indications and Methods
of the Ilizarov Technique", held at the San Rafael
Hospital and
directed by Professor Viladot. In October of that year,
the first French Course on the "Theoretical and
Practical Aspects of the Ilizarov Technique" was
held in Strasbourg, organized by M. D. B. Briot of the
"Traumatology and Orthopaedics Center" directed
by Professor I. Kempf. Later that month, other meetings
were given at the University of Milan and at the "Bambin
Gesu" Pediatric Hospital in Rome.
Many courses have since been organized in different
cities of Italy, Portugal, Switzerland, France, Spain.
Greece, Brazil and the United States. Regularly scheduled
courses for orthopaedic surgeons are currently held
at both the Lecco and Bergamo General Hospitals. In
September 1986, there was an international meeting at
the V.K.N.C.-VTO in Kurgan on the experimental, theoretical,
and clinical aspects of trans-osseous osteosynthesis.
including the first exchange of data by a group of western
surgeons. In May 1987, the third meeting on the theory
and clinical application of the Ilizarov technique was
held in Longone al Segrino near Lecco. In January 1988,
at St. Vincent. Italy, the International Congress on
External Fixation provided a forum to compare various
systems of external fixation that recognized Ilizarov's
work as an exceptional breakthrough in bone biology.
This method is now used in many western nations and,
more recently, the United States and Canada. Based on
a 1987 poll, the number of European hospitals using
the method included: Italy, 175; Spain, 80; France,
117; Portugal, 5; West Germany, 8, and Greece, 5, with
more than 6,000 cases treated.
A.S.A.M.I. groups have been founded in France. Spain,
Belgium, Portugal and Brazil to allow a joint effort
in the advancement of scientific and clinical knowledge
on this subject.
In order to document our progress, several monographs
have been published in Italian. Our first monograph,
published in 1983, the "Introduction to the Knowledge
of Ilizarov's Method in Orthopaedics and Traumatology,"
summarizes the theoretical and technical aspects of
the apparatus, the indications for use and the clinical
and experimental results from Lecco and Bergamo.
The second monograph, the Proceedings of the First
Symposium at the V.K.N.C.-VTO in September 1983, published
in 1985 as "Transosseous Osteosynthesis According
to G. A. Ilizarov - Experimental, Theoretical and Clinical
Aspects," reports the preliminary biomechanical
studies comparing the Ilizarov device to conventional
external fixators with statistical analysis of clinical
results. We subsequently published the first A.S.A.M.I.
Bulletin on the "Transosseous Osteosynthesis of
Tibial Fractures" (1985), the second Bulletin on
the "Transosseous Osteosynthesis of Fractures and
Nonunions of the Forearm" (1986) and the third
Bulletin on the "Lengthening of the Leg According
to Ilizarov's Method" (1988).
In view of a growing interest in Ilizarov's methods
among English-speaking physicians, we have attempted
to consolidate the experience of our western colleagues
based upon clinical and research principles from the
V.K.N.C.-VTO. We hope this textbook will facilitate
the understanding of this difficult method and help
all orthopaedic specialists who are about to apply it
clinically.
In writing this textbook, we thank the orthopedists
from Lecco and Bergamo, as well as numerous other colleagues,
for their cooperation in providing information and case
reports. From this clinical material, we attempted to
clarify the different methodologies used by Ilizarov
which had previously remained obscure due to language
and cultural differences. In some cases, we have introduced
helpful modifications of his techniques.
Professor Iizarov dead in 1992 in Kurgan.
THE DEVELOPMENT OF
THE ILIZAROV TECHNIQUE IN NORTH AMERICA
Circular external fixation was first recognized in
North America in the mid-197Os when North American orthopaedic
surgeons who had visited the Soviet Union were exposed
to Volkov's circular Kirschner wire apparatus and some
of its applications. Following a trip to Russia, David
Fisher, M.D., who was then a resident in Orthopaedics,
designed a circular external fixator similar to the
Volkov device which utilized threaded half-pins instead
of wires under tension. For a variety of political reasons
within the Russian orthopaedic community, and due to
the fact that Kurgan was a closed city for tourism,
North American orthopaedic surgeons visiting the Soviet
Union were not exposed to Ilizarov and were only marginally
familiar with the circular apparatus that bears his
name. The possibilities of his method and the biology
that he had pioneered went unrecognized until the introduction
of these methods into western Europe by the Italians.
At orthopaedic meetings in Italy and other centers in
western Europe, North American surgeons were first introduced
to the Ilizarov method
and its possibilities. As early as 1983, such prominent
orthopaedic surgeons as Sarmiento and MacEwen were first
exposed to Ilizarov's work. Another prominent orthopaedic
surgeon, Dr. Victor Frankel, first encountered this
method at a meeting in Spain in 1984. These casual encounters
were met with great interest but were not followed by
the technique's application until several years later.
Dr. James Aronson learned of this technique in 1983
from MacEwen. Intrigued by the biological implications,
Aronson visited Lecco in 1984 as a traveling fellow
with Professor R. Bombelli. Upon returning to the United
States in 1984 as an assistant professor of orthopaedics
at the University of Arkansas for Medical Sciences in
Little Rock, Aronson initiated a series of animal experiments,
first reproducing Ilizarov's own work and then evolving
a basic biological model for distraction osteogenesis.
As the first North American to design and carry out
controlled research on this technique, he introduced
the biological concepts clinically for limb lengthening
using standard half-pin external fixators in 1985.
In 1983, Dr. Dror Paley, then a senior resident in
orthopaedic surgery, first heard about the Ilizarov
method from Bombelli, who was a visiting professor in
Toronto. Paley first visited Lecco, Italy, in 1985 on
a two-week, fact-finding voyage. He claims to have left
Lecco both very excited and very disappointed. He states
that he was very excited because this was the most exciting
thing that he had seen in all his residency. On the
other had, he left very disappointed because most other
techniques in orthopaedics one can learn in one to two
weeks. This technique he felt he could not learn in
such a short period of time. It was at this point that
Paley decided to do a fellowship in the Ilizarov technique
in Lecco and Bergamo in Italy. He returned the following
year and spent six months working, studying and training
at the hospital of Lecco and at the hospital Matteo
Rota in Bergamo and at the Institute in Kurgan. He was
invited back to spend an additional month in Kurgan,
which he did in March 1987. Following this extensive
training, he began practicing this technique first in
Toronto, Canada, then in Baltimore, Maryland, in 1987.
Together with Victor Frankel, M.D., Paley organized
the first two international conferences in North America
on the Ilizarov techniques, which were held in November
1987 in New York and in May 1988 in Washington, D.C.
Ilizarov was in attendance and delivered his basic science
and clinical lectures to an audience of many prominent
North American orthopaedic surgeons.
Another important proponent of this technique is Stuart
Green, M.D., of Los Angeles. Green had published a textbook
on the anatomical safe zones for full-pin external fixation
years before learning of Ilizarov from Paley. After
visiting Kurgan with Frankel, Green became entrusted
by Ilizarov to translate original basic science research
into English, published in Clinical Orthopaedics and
Related Research in 1989. Green's expertise in the areas
of nonunions and osteomyelitis provided an immediate
avenue for clinical application of Ilizarov's methods.
This provided North American surgeons with the first
published reports of this new method. Because of the
enthusiasm of Paley, Aronson, Green, Frankel and others,
the Ilizarov method has now gained a strong foothold
in North America. Its future will depend greatly on
the care and consideration given to it by its users.
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