The history of external fixation
Also see Historical Vignettes on How the Ilizarov Method Came to the West

The history of external fixation dates back to the late 19th century.  The history of surgical limb lengthening
dates back to the turn of the 20th century when Codivilla published the first article on this subject in the
American J. Orthop. Surg Vol 2, 1904-5. While he used a gradual traction system, his successor Putti and
others began using external fixation to lengthen limbs. Putti and others recognized that bone could be
regenerated by distraction.  Through the 1930’s, 40’s and 50’s various EF devices were developed to
lengthen limbs (Dickson 1932, Haboush 1932, Abbot 1939, Allan 1948, Anderson 1952). Even the concept
of lengthening over a nail was introduced in 1956 by Bost. All authors used distraction osteogenesis as the
means of bone regeneration. Various osteotomies were used including Z shaped.  Emphasis was placed on
minimal invasive osteotomy for better bone regeneration. Circular EF for use in fracture treatment dates back
to Bitner in the 1930’s, Mendoza 1946 and Witmosser 1949.  Ilizarov patented his device in 1951. His
methods and devices remained relatively unknown in the West until the 1980’s.  In the 1960’s and 70’s the
prevalent method in the West was the Wagner technique. This method frequently led to failure of bone
formation due to an open osteotomy, periosteal transaction, acute diastasis and 2mm per day distraction
rate. It did introduce the concept of getting the EF off early by plating at the end of the distraction phase.
The frequent disasters from the Wagner method gave LL a bad reputation that is remembered to this day.
Ilizarov deserves credit for identifying the factors that are important to bone and soft tissue regeneration
and to applying basic science to this field. Few others with the exception of Kawamura from Japan
contributed to the science of LL in those days. Ilizarov’s method reached national attention in the USSR
when he successfully repaired the infected NU of Valeri Bruml the Soviet Gold Medal High Jumper. He
remained in obscurity outside the USSR until a media campaign in 1972 in which he was described a the
Magician of Kurgan. Prof. Monticelli from Rome was asked to comment on the Soviet LL achievements.  He
assigned his assistant Renato Spinelli to research this.  Spinelli began animal experiments on physeal
distraction based on Ilizarov’s publications. He received a scholarship from the Italian Othopedic Assoc. to
visit Ilizarov. He went in 1980 and learned that corticotomy lengthening was the preferred method in Kurgan.
He published articles on this method in the Western journals. Despite Spinelli the world did not learn much
regarding Ilizarov. It was not until a serendipitous connection between an Italian photojournalist-explorer
Carlo Mauri and his orthopedic surgery friend Anglo Villa from Lecco that the Ilizarov method came to Italy.
Mauri learned of Ilizarov from a Russian physician on the Tigris expedition of Thor Heyerdahl in 1978.  He journeyed to Kurgan
and was treated in 1980.  His friends in Lecco Italy learned of Ilizarov from Mauri’s stories and pictures. They invited him to
Lecco in 1981 for an AO conference on bone infection. The Italian group voyaged to Kurgan later that year (Cattaneo, Benedetti,
Bianchi-Maiocchi, Villa, Catagni) .  In 1983 Bianchi-Maiocchi signed and agreement with the Soviet Licensing Body (Licensintorg)
to manufacture and commercialize the Original Ilizarov Fixator in Italy.  This critical event ensured a continuation of the academic
exchange between Kurgan and Western Europe. Another Italian group in Verona (DeBastiani, Aldegheri) developed an external
fixator for fracture treatment that was then adapted for LL (Orthofix).  They adapted Ilizarov’s new concepts to this monolateral
EF showing that it was not the device but the method of gradual distraction of a low energy osteotomy that was important for
bone regeneration. The Wagner device was adapted the same way and proven to regenerate bone as long as the Ilizarov
biologic principles were adhered to (Canadel, DePablos: Spain). In addition to LL, Bone Transport, NU distraction, joint
distraction and many other techniques were introduced to Western Europe because of the Ilizarov connection.  The method was
introduced to the US by Dror Paley who traveled to Italy in 1985 and then did a six month fellowship in Lecco and Kurgan in
1986.  Paley connected the Richards Company (now Smith and Nephew) to Bianchi-Maiocchi and a commercialization
arrangement for the US and Canada resulted. In 1982 the Italians founded ASAMI.  Various ASAMI’s were created in different
countries in Europe. In the US, Paley started ASAMI North America in Baltimore in 1989.  A few years later ASAMI International
was founded by Roberto Cattaneo. Its first meeting was held in New Orleans. Since the 1980’s many publications, courses and
conferences on this subject have been presented. The scientific work of the Soviets has been reproduced and expanded upon.  

In 1990 Paley began Lengthening over Nail (LON) published in 1997.  This method was used throughout the 90’s to reduce the
treatment time in EF.  Nail lengthening is not new. It dates back to Bost in 1956.  Fully implantable nail lengthening was first
reported on by Alexander Bliskunov  from Sinferopel, Ukraine in 1983. In 1990 Guichet developed the self lengthening Albizzia
nail around the same time as Baumgart and Betz developed the Fitbone motorized nail. In 1994 Dean Cole developed the ISKD
nail which is the first FDA approved fully implantable LL device.  The era of implantable LL is here and many more devices are
expected (e.g. Orthogon-Israel, Phenix-France). LL concepts have now expanded to other fields in particular cranio-maxillo-facial
surgery and spine surgery with many new innovative devices. Growth factors and pharmacologic modulation of bone healing may
play a role in the bone and soft tissue healing of limb lengthening (e.g. biphosphonates).
Dror Paley, MD, FRCSC
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