The origins of callus distraction can be traced back to the early 1900s. Although Codivilla (1) is most commonly cited as the first surgeon to address a shortened limb by distraction and traction concepts, the contributions of several other pioneers from this era cannot be overlooked (2,3). Codvilla performed an oblique osteotomy of the femur that was then lengthened by placing a sudden and intense pull on a steel rod inserted through the calcaneus. The correction was then maintained by a plaster cast that incorporated the steel bars until healing occurred. If greater lengths were needed, the process was repeated at later intervals.

Steinmann (2) modified this technique by placing his newly developed Steinmann pin through the distal tibia as opposed to the calcaneus. Correction was secured by applying traction with weights to the extremity. Freiberg (2) placed a steel rod through the posterior process of the os calcis and connected it to a traction screw via a heavy picture wire. A spring-loaded scale was used and served as a dynamometer. Forces as high as 45 kg were often needed to achieve the desired length. Any subsequent lengthening that was needed was performed without anesthesia. All of these procedures were quite traumatic and poorly tolerated by the patients.

In 1913, Magnunson (3) attempted to improve this technique by making it simpler and less risky for patients. He executed a Z-osteotomy of the femur and separated the two fragments by traction and countertraction with weights. Once the desired length was obtained, a plug was placed between the bone ends and the weights were removed. The bony fragments were fixed with absorbable ivory screws. Despite what appeared to be an excellent attempt at improving patient morbidity, all patients were greatly traumatized, and one patient died. The frustration and disappointment resulting from these complications resulted in surgeons abandoning the techniques of callus distraction for a short period of time.

Interest in bone lengthening via traction increased again in the late 1920s and early 1930s. In 1927, Abbott (4) described a procedure that, with some modification, became a popular operation in the United States. He was the first to use the tibia as his target tissue for lengthening. Following osteotomy of the fibula and insertion of Steinmann pins in the proximal and distal ends of the tibia, the tibial osteotomy was performed and the distraction apparatus applied. He cautioned against correcting over 5.08 cm of deformity. Abbott also performed a lengthening to the Achilles tendon as part of his correction. Carrell (5) was concerned about forward angulation of the fragments secondary to the bowstring action of the tightened leg muscles. He attempted to offset these forces by placing a third pin in front of the fragments. Unfortunately, this led to significant skin damage in adjacent areas and proved to be unsuccessful. Brockway and Fowler (6) used an off-center pin on the proximal end of the osteotomy to try to address the potential angulation problem. Two pins were inserted on each side of the osteotomy and the more distal of the two proximal pins was placed slightly more anterior. Some surgeons preferred Kirschner wires (K-wires) to Steinmann pins (7,8).

Haboush and Finkelstein (8) were the first to emphasize the importance of maintaining the periosteum at the level of the osteotomy. The sleeve of periosteum that was preserved resulted in a quicker deposition of callus and more rapid healing. Bosworth (9) also advocated the Abbott technique and suggested a delay of 10 days between execution of the
osteotomy and the initiation of lengthening. He was also one of the earliest surgeons to report positive results with few complications.

In 1934, Putti (10) described a femoral osteotomy that was gradually lengthened over an 18- to 21-day period. He designed an apparatus that allowed for traction and countertraction forces to be applied during the lengthening period. With this technique, he typically achieved between 6.35 and 10.16 cm of length.

Despite these efforts to improve the success of the procedure and to reduce patient morbidity, complications persisted and leg lengthening through traction techniques became unpopular again in the late 1930s. Compere (11) stated that all surgeons performing leg lengthening procedures had encountered some degree of complication. He divided complications into three broad categories: (a) overstretching, (b) interference of blood supply to the fragments, and (c) insufficient fixation of the fragments.

Following World War II, there was a renewed interest in leg-lengthening procedures. The emphasis during this era was placed on trying to develop better means of fixation. Attempts were made to not only improve the strength of fixation but to make the devices less traumatic. Allan (12) created an apparatus that allowed the K-wires used for fixation to be placed in stirrups and clamped in a carrier. One of the pairs of wires was fixed while the other was capable of moving in a direction away from the stationary counterparts. Allan also advocated leaving the periosteum intact while performing an oblique osteotomy. He recognized the importance of preserving as much soft tissue as possible around the lengthening site. Once the desired length was obtained, he secured the position with screws. Allan’s modification was also short lived owing to a variety of complications that arose.

Other authors tried to improve on the type of fixation used to stabilize the osseous fragments. McCarroll (13) used a slotted plate with traction, whereas Bost and Larsen (14) proposed use of an intramedullary rod to hold the alignment as traction was applied.

In an effort to improve success rates and reduce patient morbidity, alternative techniques were investigated. Several surgeons (15,16) attempted epiphyseal growth plate stapling with modest results. However, there was still a need for a more effective, yet less complicated procedure owing to the limited amount of correction that could be obtained through epiphyseal stapling. This led Anderson (17), in 1952, to return to bone lengthening through traction. He performed the correction in two stages. The first stage consisted of a fibular osteotomy and a slotting technique of the distal fibula under an osteoperiosteal flap of the adjacent tibia. Once it was confirmed that there was no continuity to the fibula (approximately 6 weeks later), the tibial lengthening was started. Several surgeons modified this technique further in an effort to accomplish the correction in one stage. Coleman and Noonan (18), Gross (19), and Mitchell (20) all provided immediate fixation of the fibula to the tibia, along with executing the tibial osteotomy and assembling the distraction frame.

Agerholm (21) modified the osteotomy design by making it zigzag in effort to increase stability to the osseous fragments. Kawamura (22) made an important addition to Anderson’s technique by performing the osteotomy through the cortex only in an attempt to preserve the nutrient vessels and endosteal tissue. These developments during Anderson’s era mark the beginning of positive progress that continued over the next 30 years.

Modern day advancements in the science of callus distraction for bone lengthening actually began with the work of Wagner (23) in the early 1970s. Although his suggestions of sectioning the periosteum at the level of the osteotomy and his choice of a mid-diaphyseal location are points of controversy, Wagner made many positive contributions. He recognized the importance of slow gradual lengthening versus sudden extreme corrections. His device allowed for 1.5 mm of lengthening per complete revolution, which was executed with one full turn daily. Wagner also noted the importance of maintaining function to the limb and advocated partial weight bearing with the frame in place to allow joint motion to be preserved. This was a definite improvement over the Anderson device, the latter of which required the patient to be confined to bed. Furthermore, Wagner’s device was smaller and lighter, with a simpler method of elongation. He employed a unilateral frame with 6-mm Schanz pins. This device is very similar to the modern day external fixators (Fig. 1).

The final era in the development of callus distraction is that dominated by the concepts of Ilizarov. Ilizarov (24) began working on and publishing his ideas on bone transport as early as the 1950s in Russia. However, owing to the political climate of that time and difficulties in translation, it was not until many years later that individuals in other countries noted his work. He felt strongly about preserving the contents of the intramedullary canal during osteotomy to improve osteogenesis and decrease consolidation time. However, the actual significance of this aspect of the technique remains a controversial issue. He also expanded the understanding regarding the timing of initiating the lengthening and the rate of subsequent distraction. A delay of 5 to 7 days following osteotomy was recommended to allow for better consolidation (25). He also showed that a lengthening of 1.5 mm per day, as proposed by Wagner, is dangerous and can lead to ischemic changes. Ilizarov believed that slower, more frequent lengthening would allow for better osteogenesis and elongation of soft tissues.

These ideas are very important and have shaped our understanding of today’s science of callus distraction. Ilizarov was also a proponent of early mobilization and weight bearing, and actually prescribed participation in calisthenics for his patients while they were still in their frames.

Although these contributions changed the course of bone lengthening as a science, it was actually Ilizarov’s fixator that led to his notoriety. He popularized the concept of a ring fixator with multiple transfixation pins to stabilize the osseous fragments. By fixing each of the segments at more than one level, he was able to increase bending stiffness, but because of the flexibility afforded by the smaller size wires (1 to 2 mm), axial loading resulted in some motion. This axial movement has been thought to be very beneficial for osteogenesis in the lengthening gap. Hence, here lies the wisdom in early weight bearing following execution of the osteotomy. This continues to be one of the most popular methods used to distract and lengthen bone. This device is discussed and demonstrated in detail in Chapter 4.

Once the concepts of callus distraction were understood at the histologic level, the next stage was to choose a set of distraction parameters that would provide for the quickest and most efficient means of bone consolidation. Important parameters to consider included osteotomy versus corticotomy, level of osteotomy, latency period, amount and rate of distraction, and the ossification period.