|BIRTH CENTENARY CELEBRATIONS OF PROF G.A. ILIZAROV
|Year : 2021 | Volume
| Issue : 1 | Page : 70-74
Ilizarov – The teacher
Director, Division of Clinical Implementation and Outcome Studies, Center for Excellence in Limb Lengthening and Reconstruction, Scottish Rite Hospital for Children, Dallas Texas USA, Assistant Professor UT Southwestern Medical School, Dallas Texas USA, Honorary Professor, Ilizarov Scientific Center in Kurgan, Russia
|Date of Web Publication||30-Jun-2021|
Dr. A Cherkashin
Director, Division of Clinical Implementation and Outcome Studies, Center for Excellence in Limb Lengthening and Reconstruction, Scottish Rite Hospital for Children, Dallas Texas USA, Assistant Professor UT Southwestern Medical School, Dallas Texas USA, Honorary Professor, Ilizarov Scientific Center in Kurgan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Cherkashin A. Ilizarov – The teacher. J Limb Lengthen Reconstr 2021;7:70-4
This year we are celebrating the 100-year anniversary of Gavriil Abramovich Ilizarov, the founder and longtime director of the Kurgan Research and Scientific Institute of Traumatology and Orthopedics (KNIIEKOT as it was abbreviated then in Russian). He was also the creator of the Theory of Distraction Osteogenesis and inventor of the Ilizarov apparatus [Figure 1]. Like any extraordinary character who has changed a major field of science, the story of his life is now difficult to separate from legends and tales. In a few tales he is sometimes a demonic individual yet other times is a very generous host to the visitors of his center. However, he was much more complex than this simple dichotomy. In truth, there is no way to tell the full story and describe the man in this brief article. Instead, I'll try to share my memories on how it was to learn from him and explain how he influenced my life.
|Figure 1: Ilizarov in surgery: checking wet x-ray films done right after an osteotomy. He can often see something not obvious for others. (Photo by the author, Kurgan 1987)|
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It is an enormous honor and a privilege to write about this extraordinary person. I was never his favorite student but working under him and learning from his teachings changed my life. In fact, I was not very close to him and did not spend countless hours in his home office (or the “bunker” – as we called it then) perfecting his presentations and publications. Instead, I was grouped in with the majority of the orthopedic surgeons of KNIIEKOT, who had to fight for an opportunity to get into his office and present the patients awaiting his consultation.
Upon finishing medical school in 1983, I was offered a few choices for my future place of work. One of them was Ilizarov's hospital. It was not an obvious pick at the time: Kurgan was a small city by Russian standards, and external fixation did not seem like an attractive technique. However, the Ilizarov name was already a legend, and I wanted to learn from him [Figure 2]. Like many graduates, I was young, ambitious, and self-confident. I was looking forward to quickly learning all the Ilizarov procedures; however, I was shocked when I discovered that this remarkable man was nothing like the legend I imagined. First, the Ilizarov Method was complex and not easy to comprehend. The way Ilizarov was working, operating, and teaching was not what I expected either. Though I had met an extraordinarily gifted and powerful person, it took me years to fully understand him.
|Figure 2: I am presenting a patient to Ilizarov for postoperative consultation. (Photo courtesy of the photo archives of the Ilizarov Center, Kurgan 1991)|
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In an effort to describe his complex character, let me first say who Ilizarov was not. He was not a soft and caring person, especially towards his employees. He was not a punctual man either. Instead, he lived on his own clock, which was completely unsynchronized with the rest of his staff. He was not an eloquent speaker – his words often failed to keep up with his racing thoughts, making it difficult to follow and completely grasp what he was conveying. Subsequently, listening became absolutely necessary for success. He was neither a considerate nor patient educator, who would meticulously explain his technique and treatment steps. You would never expect him to “hold your hand” while you were attempting to learn his Method. In summary, he was tough! If you wanted to learn from him – you had to observe and listen vigilantly. You had to be present while he evaluated patients and operated. If he did not see you often – you did not exist in his world because he only recognized and talked to the doctors who were often around him.
Despite all this, he was a gifted and entirely “self-made man.” Nothing was given to him – he had to fight for everything. Starting from his childhood days, he had to catch up with his peers since he started school late. Nonetheless, he finished his entire education in just a few years and later was accepted into medical school. During the Second World War, his medical school was evacuated from Crimea to Kazakhstan. The years that followed were extremely difficult, and he had to learn a lot by himself. After graduation, he was sent to the remote and vast region of Kosulino located in West Siberia. In Dolgovka village, he was the only doctor around for many miles. He was even flown by an airplane to reach patients located in remote areas, often for an emergency treatment. In Dolgovka, he was a general practitioner, a general surgeon, and a plastic surgeon. Ilizarov had to learn trauma and orthopedic surgery on his own out of necessity, and he never had a mentor to help him learn. Instead, his mentors were books and his own practice. This experience molded his perception of education, meaning he expected this same level of dedication from others – you have to earn your knowledge. It was in this remote village, where he struggled to treat severe fractures along with posttraumatic and orthopedic conditions with very limited resources, that he got the idea of an external fixation apparatus. This idea later became the Method and the external fixation system. He was very proud of his creations and often over-protective of his inventions. He realized very early on the power of his treatment technique, and just like any powerful tool, it could cause extensive damage if not used properly. As a result, Ilizarov wanted to ensure the proper use of it. He disclosed his new method of treatment with well-recognized orthopedic surgeons of the time but was only met with mockery. Ilizarov was deemed by others as a developer of “a locksmith's approach to surgery” and was offered “to perfect” his ideas under someone else's name. Unsurprisingly, he was very cautious about protecting his name and was careful to share the new developments. This was his “child,” and like any inventor, he had to be sure it would be properly mastered. From the early days he faced the dilemma of sharing his inventions with other surgeons, as well as protecting patients from severe complications reported by others.
All of this is clear and understandable now – but at that time it seemed like a very harsh and unfriendly environment. Many young surgeons could not bear it and quickly left without a proper understanding of Ilizarov's personality and his Method. KNIIEKOT was not for everyone. Despite all of this, the ability to work with people was one of Ilizarov's strengths, and like everything else, he did it in his own way. Yes, he was tough. Yes, he had high standards. However, he would recognize the people who were willing to work hard and earn their education. He would integrate them into his team and help them achieve their goals. We all had our ambitions, shortcomings, and limitations, but he was willing to work around them if one was willing to be part of his team. Ilizarov built the team which, under his leadership, fine-tuned the Method and the device that has been shared with the rest of the world. The Ilizarov method today is not the creation of a single person but a result of the work of many talented individuals.
From the very beginning, talented surgeons and other specialists tolerated his tough personality to be a part of something really big. I truly regret that in this short paper I cannot mention all of the great people who helped grow the Method of Ilizarov to its current state. I only have room to write about those with whom I was close and who helped me understand Ilizarov. Some individuals were already legends by the time I joined the team. There is a list of books about Ilizarov at the end (unfortunately all in Russian – I hope I can see the time when they will be translated in English), where more great names are mentioned. I never met Ilizarov's first student and colleague, Dr. Anatoly Kaplunov, but I have heard a lot about his work with Ilizarov and input into the overall development of the Method. Of course, I also read his brilliant book, which unfortunately was published after Ilizarov's death and long after I left the Ilizarov Center. If only I had access to such knowledge when I was still there because it would have helped me avoid quite a few troubles and better understand the Shef (“ШeФ” as we called Ilizarov in Russian. The term was first introduced by Kaplunov and cannot be translated exactly to English; it is something between a boss, chief and patron). In the early 1960s, Kaplunov was joined by four other young doctors: Valentina Gracheva, Anatoly Devyatov, Valeria Trokhova and Lidia Popova. These were the first five who tremendously helped spread the knowledge about the Method. It was during this time when the first orthopedic surgeons from all around the USSR started to come to Kurgan to learn this new treatment modality. Later on, I personally learned a lot from Valeria Trokhova, who I can proudly name as my mentor. She was the one who shared her knowledge and told me some “funny stories from the past.” Very energetic, completely open, and always willing to answer any of my questions, she helped me better understand the Shef and helped me learn more from Ilizarov.
There were many others, but I would like to thank Dr. Sergey Shved – who helped me better understand trauma and the possibilities of external fixation in severely damaged tissues. He is also one of the greatest educators of the Method and longtime chair of the department of continuing education. There are many surgical tips and tricks I've learned from Valery Maltsev – who is now working in Milan, Italy. He was a director of the department of hip pathology, where I first started my orthopedic career. That was until the second department for hip pathology was formed, where Ilizarov appointed me as a director. My very good friend and colleague Alexander Kirienko is also now working in Milan, Italy. Kirienko has done a lot to spread the knowledge of the Method and teach surgeons from countries all over the world on how to apply the frame and manage deformity correction and lengthening. His book, Ilizarov Technique for Complex Foot and Ankle Deformities, is one of the bestsellers about the Ilizarov technique and a must-have for foot and ankle surgeons.
When I just joined the KNIIEKOT, Dr. Petr Shaglanov was the current chief of staff. On top of being a very good anesthesiologist, he was also a great politician. He would be the one to warn me that my rare attempts to outsmart Ilizarov had failed miserably and that Shef is again waiting for me in his office to “teach” me the right way of doing things. Once, in 1991, I tried to speed up the process of working on Ilizarov's talk for his trip to Austria for an orthopedic meeting (where I was going with him as his assistant) and decided to type his talk on the computer. However, Ilizarov would only recognize typewriter copies and would count them to be sure none were missing. Computer copies were impossible to count and control. It was a tedious job to re-write and retype them after each correction by him in the typewriter. So, I took one of the copies and started entering it into a computer instead. In less than thirty minutes, Dr. Shaglanov called and said that Shef had noticed the missing copy, and it would be better for me if I went and presented myself for the “execution” before being called upon…?
The Ilizarov apparatus and external fixation system would not appear how it does today without the great input of Dr. Igor Kataev. His brilliant mind and engineering skills helped introduce many new parts and improvements to the Ilizarov system. He was appointed by Ilizarov as a head of the patenting department (there was one in the KNIIEKOT!). Dr. Kataev unfortunately had to leave the institution after sharing his knowledge with Dror Paley without Ilizarov's approval (see JLLR 2018: Volume 4, Issue 2).
Another great team player, Vladimir Shevtsov, became the head of the Center after Ilizarov passed on. While in this position, he did a lot to continue Ilizarov's legacy. He kept the Center running and organized regular international training courses to continually spread the knowledge that Ilizarov created. He also traveled around the world, presenting the treatment results of thousands of patients and new achievements of the Center.
If there ever was a favorite student of Ilizarov, at least at the time I was there, that was my longtime colleague and dear friend, Dr. Mikhail Samchukov. He spent more hours every day working with Ilizarov than he ever got to spend with his own family. Mikhail was helping the Shef prepare his talks and publications, and he was able to listen and understand Ilizarov the way I had never mastered. After Dr. Samchukov left Kurgan and joined the Texas Scottish Rite Hospital for Children in Texas, he worked with Dr. John Birch to establish the Limb Reconstruction Center. I believe Dr. Samchukov's contribution to sharing the knowledge of the Method is impossible to overestimate. Not only does he continually popularize Ilizarov's surgical techniques – he is also the one who drives the development of external fixation techniques to the new frontier, further developing the Method. From the very early days in the KNIIEKOT, we were both actively involved in training Russian and foreign surgeons coming to the Center. We were always trying to make these events not only very educational but also equally entertaining. Much like the hunting trip in 1988, when the first group of English-speaking surgeons come to Kurgan to partake in the International Course offered by the Center [Figure 3]. Mikhail was tasked by Ilizarov to help Dr. Stuart Green with the book he edited. Both Mikhail and I were working on sorting and selecting slides from Ilizarov's vast collection to be included as illustrations to this amazing work of Stuart [Figure 4]. Ilizarov would not trust anyone but Mikhail to handle the slide collection.
|Figure 3: First International Course in KNIIEKOT. Education was always a lot of fun! Here on the hunting trip from left to right: Dr. S. Green, Mr. A. Lukianov (Trauma manager at Richards Medical Co. at that time), D. Paley, E. Sochnev (Deputy director for international affairs of the KNIIEKOT). Note: no wild animals were harmed during this hunting… (Photo by the author, Kurgan 1988)|
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|Figure 4: I am discussing external fixation complications with Dr. Stuart Green when he was invited by Ilizarov to edit his book. Mikhail Samchukov and I were appointed by Ilizarov to help Dr. Green select appropriate illustrations from vast collection of patient slides, photos and x-rays. We were also tasked to catalog what was given away… (Photo courtesy of the photo archives of the Ilizarov Center, Kurgan 1990)|
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By the 1980s, the Ilizarov name become known far beyond the USSR. Many patients from all around the globe came for consultations and to be operated on by Ilizarov. The waiting line for an admission to the KNIIEKOT grew and exceeded many years. Ilizarov could not attend to and operate on every patient, so a good majority of the surgeries were performed by the doctors on his team. However, if any patient insisted on being treated by Ilizarov himself, that request was always granted. On his surgical and consulting days, he had to attend to dozens of patients. After a thorough examination, any “Ilizarov patient” had to be presented to the Shef for a personal consultation. You, as the treating physician, would request for an Ilizarov appointment. In return, you would get a time slot and may wait hours in line with other surgeons before finally getting in. The number of patients there were to consult did not matter, each one would get enough time and attention from Ilizarov. Sometimes these consultations would continue far beyond midnight. When the consultation started, every surgeon who had patients to present could observe Ilzarov as he examined the patients and planned the treatment. It is during this time where a surgeon was able to learn a lot. Importantly, he would not only evaluate the physical condition of the patient but also the patient's psycho-emotional status. He would then take both into account while planning the treatment. He had that extraordinary intense, piercing look, which patients described as hypnotic. I don't remember a single patient who did not feel better after just being examined by Ilizarov. He was very observant and often could detect something you missed in patient's behavior or on x-rays.
On the date of a surgery, there may be up to six or seven patients in different operating rooms at the same time being operated by Ilizarov. Your responsibility was to start the application of an external fixator according to the plan and wait for Ilizarov to come and examine your efforts before preforming the bone cut. Only the familiar doctors, who spent hours in his office learning, were considered proper assistants. Ilizarov had to know and recognize who he worked with. If he had not often seen you during the consultations and previous surgeries, he would not acknowledge your presence and continue looking for a proper assistant. If you are the proper assistant, then you can get your share of education, often in the manner of a harsh critique of your frame application skills and suggestions on how to remedy the situation [Figure 5]. After the fixator position and stability are to his satisfaction, he would perform the “corticotomy.̶ ; This technique is often misrepresented in current presentations and publications. There was no elevation of the periosteum and periosteal elevators placement. There should be one tiny skin incision, no more than 5-7 mm wide, just enough to pass a very narrow (but very sharp!) osteotome. Then he would do multiple passes of the osteotome, trying not to go too much through the medullary canal but not avoiding it entirely. Then the cut was completed by rotational osteoclasis [Figure 6]. When I saw his “corticotomy” technique for the first time – it looked scary! Often the result was a multi-fragmented bone division, but as long as the osteotomy did not propagate into the pin sites, these multiple fragments increased the area of healing and promoted the growth of healthy distraction regenerate.
|Figure 5: Ilizarov in surgery: Dr. C. Alekberov presenting in-surgery films to the Shef and learning… (Photo by the author, Kurgan 1987)|
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After surgery is complete, you were responsible for managing the postoperative care of the patient and frame adjustments according to the plan developed by Ilizarov. All patients from the first postoperative day should be able to walk, and the ones with lower extremity surgery should bear weight on the operated limb. After the initial few days, the patient's crutches would be swapped for one cane. Physical therapy is started on the first postoperative day and continues throughout the entire treatment. There was an outstanding department for physical therapy, where patients were often performing group exercises to keep them motivated. You were also responsible for periodically presenting the patient for Ilizarov's consultation. The drill is the same as before the surgery: you need to get an appointment and present the patient to the Shef. He would carefully examine the patient and the series of radiographs. He would check that everything was done correctly and if the patient is compliant with the instructions and satisfied with the progress. If Ilizarov was not satisfied or if the patient was not happy, you may receive some instructions on how to correct the situation [Figure 2]. Often, you may be criticized as “stupid and not worthy to be called a surgeon” right in front of the patient. He may even say that you ruined his perfect operation. Then he may do some frame adjustments and recommend some changes. Surprisingly, after all this critique, none of the patients were unhappy with me continuing their care; instead they always felt relieved and motivated to continue the treatment…
It was not an easy learning experience, but I am happy to have had Ilizarov as my teacher and to have learned from Professor Ilizarov. He taught us not only his Method but how to practice medicine. The patient is always first. No matter how severe the pathology is and no matter how complicated the patient's personality is – you are there to help improve their life. Your burdens and personal problems do not matter; you must dedicate the time necessary to understand the patient's condition, prepare a thorough treatment plan, and achieve the treatment goal. Not only should the physical conditions be evaluated but the patient's psycho-emotional status as well. Both the patient and their family should be prepared and ready for treatment. There are no small details in the patient pre-op evaluation and complaints, as well as there are no small problems during the treatment. Each one must be evaluated and acted upon. What may seem like a little obstacle may develop into a devastating event without appropriate action. Complications can be managed. Physical therapy is a key to success in limb reconstruction – you are trying to restore the function, so you must work on the muscle and joint function while correcting a bone deformity. Finally, I've learned the importance of working as a team. Build your own team if you can. If you cannot – then you need to join the strongest team and be a team player. If you work on Ilizarov's team specifically – you must follow the rules and the requirements of the leader.
Nowadays, Ilizarov's students are working in different countries in many parts of the world. We all learned the value of education, knowledge-sharing, and the importance of spreading the knowledge of the Method. It is not a static technique and not a dogma. It continues to develop and improve patient lives according to the principles of our Teacher. From the little Siberian town, he opened the world for us, so we can share his vision and build upon it.
Books about Ilizarov. Hope they will be professionally translated some day:
| References|| |
Буньков С. Хирург Илизаров. [Ilizarov the Surgeon] Челябинск: Южно-Уральское книжное издательство, 1972.
Нувахов Б. Доктор Илизаров/Предисловие Ю. Сенкевича. [Doctor Ilizarov/Foreword by Y. Senkevich] М.: Прогресс, 1988. ISBN 5-0100-1938-8
Каплунов А. Г. Неизвестный Илизаров. Штрихи к портрету. [Unknown Ilizarov. Finishing touches to a portrait] Волгоград: Издатель, 2008. ISBN 5-9233-0654-9.
Шевцов В. И. Хирургия моей жизни. [Surgery of my life] Курган: Полиграфкомбинат «Зауралье», 2014. ISBN 9785990557017 5990557019
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]