Application of Ilizarov frame (see text). A, Frame is applied perpendicular to mechanical axis, not femoral shaft axis. Distally, reference wire is placed parallel to femoral condyles. Proximally, reference pin is drilled perpendicular to mechanical axis. B, Ilizarov femoral lengthening frame is constructed on proximal and distal reference pins. Middle ring is larger in diameter than distal two rings to accommodate conical shape of thigh. C, Completed femoral frame. Graduated telescopic distractors are placed in alternating up-down position for greater stability. Olive wires add greater stability to construct. “Empty” middle ring serves as even push-off point. D, Modified Ilizarov frame in place after femoral corticotomy for lengthening. SEE TECHNIQUE 29.49.