OT notes · Orthopaedics

Ilizarov ring fixator / LRS application (incl. limb lengthening)

Usual anaesthesia
Spinal (lower limb) or general
Position
Supine on a radiolucent table, bump under the hip so the patella faces the ceiling, C-arm from the opposite side; prone only when combined with a posterior soft-tissue procedure
Setting
elective

Operative note template for applying an Ilizarov ring fixator or a monolateral (LRS-type) fixator, with or without corticotomy for lengthening or bone transport, with a filled example for a four-ring Ilizarov frame on a closed comminuted tibial shaft fracture.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • pin and wire site infection, need to change a wire or pin
  • nerve or vessel injury from a wire or pin
  • joint stiffness and contracture (knee flexion, ankle equinus), especially with lengthening
  • delayed union, non-union, malunion
  • poor or early consolidation of regenerate (lengthening)
  • need for docking-site grafting (bone transport)
  • long time in the frame, frequent visits, frame adjustments
  • fracture after frame removal
  • skin pressure from the frame with swelling

Pre-operative details for this operation

  1. IndicationFracture (acute)Non-union / pseudarthrosisInfected non-union / osteomyelitisBone defect: bone transportLimb length discrepancy: lengtheningDeformity correctionJoint contracture
  2. Bone, side, levelfracture type or deformity (CORA, angle), defect length, discrepancy in cm
  3. Soft tissues and neurovascular statuswounds, flaps, pulses, peroneal nerve; muscle imbalance around ankle
  4. Frame plannedring sizes from the normal limb (two fingerbreadths clearance, more posteriorly), number of rings, floating ring for transport, foot plate if ankle to be spanned; frame preassembled and sterilised
  5. Planned corticotomylevel (metaphysis preferred), method, fibular osteotomy level

Anaesthesia and position

  1. AnaesthesiaSpinalCombined spinal-epiduralGeneral
  2. Positionsupine, hip bump, patella to ceiling, towel bumps under the leg; C-arm opposite side square to table
  3. TourniquetNot usedUsed for open part only

Operative findings

  1. Fracture / deformity after reductionalignment on AP and lateral, residual gap or distraction
  2. Corticotomycomplete on C-arm (gentle test of angulation / distraction not more than 2 mm), reduced at end
  3. Bone quality and bleeding at corticotomypoor bleeding may mean a longer latency

Procedure (steps)

  1. Frame typeIlizarov ring fixator (all wires)Ring fixator with wires and half pinsHybrid (rings with wires at metaphysis, half pins in shaft)Monolateral rail (LRS-type) with half pinsHexapod / spatial framenumber and size of rings or length of rail
  2. Reductionlongitudinal traction on radiolucent table; avoid excessive or prolonged traction; limited internal fixation of joint surface if needed
  3. Frame mountedframe opened (clamshell) and placed round the limb, aligned parallel to the tibial crest on AP and lateral
  4. Reference wiresproximal wire lateral to medial parallel to the knee joint (about the level of the physeal scar); distal wire parallel to the ankle joint; frame made orthogonal on C-arm; wires tensioned
  5. Wire insertion techniquewire diameter (1.5 / 1.8 / 2 mm), smooth or olive; stabbed through skin and muscle to bone at a safe angle, drilled at low speed or by hand across both cortices, tapped through soft tissue on the far side; no skin tension; attached to the ring without bending (spacers / posts)
  6. Wire and pin mapfor each ring: level, number of wires and half pins, direction (e.g. lateral-medial, anterolateral-posteromedial, fibulotibial), olive side; at least 2-3 points of fixation per ring
  7. Wire tensiontension applied to each wire (kg, as read on tensioner); olive wires used for reduction or compression
  8. Half pinsdiameter, length, site (tibia: anteromedial face within the safe arc; femur: lateral arc), predrilled, bicortical
  9. Monolateral (LRS) framenumber of pins in each clamp, pin sites, rail length, rail distance from skin (at least a fingerbreadth), compression or distraction applied at end
  10. Fibular osteotomyNot doneDone: level, oblique cut with micro-saw and saline, complete on C-arm
  11. CorticotomyNot doneOsteotome technique: anterior, medial, lateral cortices, posterior cortex drilled then completedGigli saw (proximal metaphysis only)level, incision, subperiosteal, completeness confirmed on C-arm, reduced
  12. Foot includedNoForefoot wires onlyFoot plate with calcaneal and metatarsal wiresreason (lengthening over about 1 inch, muscle imbalance, flap across ankle)
  13. Final checkAP and lateral C-arm of whole bone and joints above and below; all connections tightened; images saved

Closure, drains and dressing

  1. Corticotomy / open woundslayers, suture
  2. Wire and pin sitesskin released where tented; dressing sponges held against skin with clips; material used to soak them
  3. Wire endscut and bent or capped
  4. Distal neurovascular status and skin clearance from rings at end

Specimens and implants

  1. Rings / railnumber, sizes (full / 5/8 / half), make; rods and connecting parts
  2. Wiresnumber, diameter, smooth / olive, make, lot
  3. Half pins / Schanz pinsnumber, diameter, length, make, lot, sticker
  4. Tissue sentNoneBone / tissue for culture and HPE (non-union, infection)
  5. C-arm images saved

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevation and neurovascular watchan unusually painful wire may be through a nerve: inform senior
  2. Pin and wire site caresponges left till the 2-week visit, then daily shower with soap and water; report new pain, redness or discharge at a site
  3. Weight bearing and exercisesweight bearing in the frame as allowed; active knee and ankle exercises to prevent contracture
  4. Latencydays before distraction starts (usually 5 days to 3 weeks; 7-20 days in tibia, per bone and patient)
  5. Distraction prescriptionrate (mm/day) and rhythm (e.g. 0.25 mm four times a day); which rods or struts; patient and relatives taught
  6. No NSAIDsduring distraction and consolidation
  7. X-rayscheck X-ray; then every 1-2 weeks during distraction for length, alignment and regenerate
  8. Watch forequinus, knee flexion contracture, skin pressure from rings with swelling
  9. Follow-upfirst visit date; frame adjustment plan

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. G.B., 35 years, road traffic accident. Closed comminuted fracture of the distal third of the right tibia with fibula fracture at the same level. Contused, blistered skin over the anteromedial leg. Definitive treatment with an Ilizarov ring fixator planned.

Case details

Date: 05/09/2026. Trauma list. OT 2.

In OT 13:30. Spinal 13:40. Start 14:00. End 16:10.

Surgeon: Dr A. (consultant). Assistant: Dr B. (3rd-year resident, Orthopaedics), who placed the distal wires and tensioned the frame.

Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Closed comminuted distal-third tibia fracture right with poor anteromedial skin. Ilizarov frame chosen to avoid an incision through contused skin.

Pre-op: dorsalis pedis and posterior tibial pulses palpable, sensation normal, toes moving. Compartments soft.

Frame preassembled from left leg measurements: four full rings (160 mm) joined by four threaded rods, two fingerbreadths clearance, sterilised.

Consent in Hindi including long frame time and pin-site problems. Right leg marked. WHO checklist done. Inj cefazolin 2 g IV at 13:50.

Anaesthesia and position

Spinal anaesthesia. Supine on radiolucent table, bump under right hip, patella to ceiling. No tourniquet. C-arm from left side.

Painted with povidone-iodine from mid-thigh to toes and draped.

Procedure

Longitudinal traction: alignment within 10 degrees on C-arm.

Frame opened on one side, placed round the leg, reassembled and aligned parallel to the tibial crest on AP and lateral.

Proximal reference wire 1.8 mm, lateral to medial, parallel to the knee joint at the level of the physeal scar. Distal reference wire 1.8 mm, parallel to the ankle joint above the physeal scar. Frame made orthogonal on C-arm. Both wires tensioned and fixed.

Each wire stabbed through skin and muscle to bone at a safe angle, drilled across both cortices at low speed, tapped through on the far side. Skin not tented. Wires fixed to rings without bending, using posts where needed.

Ring 1 (proximal tibia): reference wire plus oblique medial-to-lateral wire under the ring. Ring 2 (proximal diaphysis): lateral-to-medial wire plus one 6 mm half pin on the anteromedial face. Ring 3 (distal diaphysis): two crossed olive wires. Ring 4 (distal tibia): reference wire plus fibulotibial wire.

Residual lateral displacement of the main distal fragment corrected with one of the ring 3 olive wires: tension applied before the wire was secured, pulling the fragment towards the tensioner, reduction checked on C-arm, then wire secured on the olive side. Residual gap closed.

All wires tensioned with the wire tensioner; tension values written on the frame chart. All nuts tightened.

C-arm AP and lateral of whole tibia with knee and ankle: alignment restored, no distraction at fracture. 8 images saved.

Closure

No wounds. Wire and pin sites dressed with sponges held against the skin with clips.

Wire ends cut and bent. At end: pulses palpable, toes pink and moving, rings clear of skin all round.

Specimens and implants

Four 160 mm full rings, four threaded rods, posts and bolts. Seven 1.8 mm wires (2 olive, 5 smooth). One 6 mm half pin 150 mm. Make and lot as on packets; stickers in case sheet and implant register.

No specimen. 8 C-arm images saved.

End of procedure

Estimated blood loss 50 ml. Count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 80/min, BP 120/76 mmHg.

Post-op orders

Right leg elevated on pillows. Pulses, toe movement and sensation 2-hourly for 24 h. Inform on call if any wire site is unusually painful.

Sponges to stay till review at 2 weeks. Then daily bath with soap and water.

Knee and ankle active exercises from POD 1. Partial weight bearing in frame with walker as pain allows.

Check X-ray right leg AP and lateral in frame on POD 1.

Follow up in clinic at 2 weeks.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 05/09/2026, 16:30.

Must document for this operation

  • A wire and pin map: level, direction, type and diameter at each ring. Anyone adjusting, retensioning or removing a wire later needs to know what is where, and which wire may be near a nerve.
  • Wire tension at the time of application. A loose wire is the usual cause of wire-site pain and infection; the recorded value is the baseline for retensioning.
  • Corticotomy level, method and that it was complete. An incomplete corticotomy stops even distraction; the regenerate is judged against this record.
  • Latency, distraction rate and rhythm, and who was taught to turn the frame. Rate and rhythm decide the quality of the regenerate; errors here are a common cause of failure.
  • Whether the foot was included and why. Equinus is common with tibial lengthening and is easier to prevent than to treat.
  • Ring sizes and component list with lot numbers. Needed for frame changes, stock, and implant traceability.

Common mistakes in these notes

  • Writing 'Ilizarov applied' with no ring count, wire map or tension.
  • No note of whether a corticotomy was done and confirmed complete.
  • Distraction plan left for 'later' with no written latency or rate.
  • Not recording the neurovascular status after each wire in a difficult zone.
  • No instruction about NSAIDs for a lengthening or transport.

Indian practice and paperwork

  • Record batch and serial numbers of wires, half pins and frame parts in the case sheet, implant logbook and discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))
  • Used wires and pins removed at frame removal are metallic body implant waste and go in the blue puncture-proof container. (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines)

Sources

  • Chapman MW, James MA, eds. Chapman's Comprehensive Orthopaedic Surgery. 4th ed. Jaypee Brothers; 2019, Ch 52, Ilizarov techniques (Lowenberg D, Githens M), e-book PDF pp. 1012-1015, 1026-1036.
  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 59, Fractures of the lower extremity: Ilizarov external fixation, Technique 59.11, pp. 2603-2606.
  • Seligson D, Mauffrey C, Roberts CS, eds. External Fixation in Orthopedic Traumatology. Springer; 2012, Ch 10, External fixation of long bones (Beck D, Benson CD), pp. 143-161.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Implantation of internal fixation devices: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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