Correction of neglected clubfoot using the Ilizarov external fixator

BACKGROUND: This study was conducted to evaluate the corrective capability of the Ilizarov external fixator in the treatment of neglected clubfoot. METHODS: Thirty patients (38 feet) with a mean age of 19 (5 to 39) years with severe deformities and stiff feet associated with neglected clubfoot were studied. A limited soft-tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. Progressive correction of the deformities was achieved through a standard setting of the Ilizarov external fixator. The device was used for 16 weeks, on average, and after removal a short-leg walking cast was used for an additional 6 weeks, followed by an ankle-foot orthosis (AFO) for 6 months. RESULTS: The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). After a mean followup of 58 (range 12 to 107) months, the results were good in 30 feet (78.9%); fair in three feet (7.9%); and poor in five feet (13.2%). Early complications were a distal tibial fracture in one foot, dislocation of the first metatarsophalangeal joint in one foot, and arterial damage that resulted in amputation of the toes in one foot. Recurrence of the deformity was found in 19 feet (50%): 11 minor, three mild, and five severe. Spontaneous ankylosis developed in 28 feet (73.7%). Nine feet (23.7%) required arthrodesis for symptomatic arthritis of the ankle or midfoot and deformity that could not be treated with orthoses. CONCLUSION: The Ilizarov external fixator allows simultaneous correction of all the severe foot deformities associated with neglected clubfoot with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding excessive shortening of the foot. Even in those patients in whom final corrective arthrodesis is necessary, this may be carried out with minimal bone resection, since the severe deformities of the foot and ankle have been corrected.     

Correction of relapsed or neglected clubfoot using a simple Ilizarov frame

We present the results of using a simple Ilizarov fixator frame in treatment of 66 feet in 52 patients (mean age 8.5 years) of 58 relapsed and eight neglected clubfeet with grade III or IV severity with a mean follow-up of 40 (26–58) months. Our frame, in spite of being simple and easy for surgeons and patients to handle, achieved satisfactory correction comparable to the literature.

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Résumé Nous présentons les résultats de lutilisation dun cadre simple de fixateur Ilizarov dans le traitement de 66 pieds bots chez 52 malades (âge moyen 8,5 années) avec un suivi moyen de 40 mois (26–58). Il sagissait de pieds bots de niveau de sévérité III ou IV, 8 négligés et 58 récidives. Notre cadre, bien que simple et de maniement facile pour les chirurgiens et les malades, a conduit à une correction comparable aux résultats de la littérature.

     

Correction of severe residual clubfoot deformity in adolescents with the Ilizarov technique

Correction of severe residual clubfoot deformities in adolescents is a difficult undertaking and historically has had mediocre success without an accompanying arthrodesis procedure. Soft tissue release alone has yielded extremely high recurrence rates. Additional osteotomies have been used for correction of single deformities in one plane. The use of Ilizarov external fixation techniques has allowed for improvement of correction, stabilization, and decrease in recurrence rates. The technique, however, is difficult and should be performed by surgeons who are familiar with correction of pediatric foot and ankle deformities and are versed fully in Ilizarov fixation techniques.     

Functional outcome of salvage of residual and recurrent deformities of clubfoot with Ilizarov technique

Relapse may occur in severe clubfeet deformities whether treated surgically or nonsurgically. In this study, we evaluate the results of correction of residual and recurrent congenital clubfoot using soft tissue distraction or osteotomy using the Ilizarov external fixation system. This study included 35 feet in 28 patients who were treated between 1999 and 2007. Of these 16 feet in 13 patients with an average age of 13.7 years (range from 11 to 29 years) were treated by percutaneous calcaneal V-osteotomy and gradual correction by the Ilizarov method. Nineteen feet in 15 patients with an average age 10.5 years (range from 4 to 22 years) were treated by soft tissue distraction by the Ilizarov technique. The mean average follow up period was 5.6 years (range from 1 to 8 years). At the time of fixator removal, a plantigrade foot was achieved in 30 feet. Mild residual varus and equinus deformities were present in five feet.At the final follow foot pressure measurement showed recurrent or residual deformity in 10 feet (7 treated by osteotomy and 3 treated by soft tissue distraction). Recurrence may occur with both techniques, depending on many factors such as bone morphology, the number of the pervious operations and the degree of stiffness of the foot prior to the operation.     

Correction of clubfoot through a peritalar release using the cincinnati approach

Surgical Principles The Cincinnati approach described by Crawford et al. [1] allows a complete medial, posterior and lateral exposure of hind- and midfoot as well as a correction of any deformity of the subtalar, talonavicular, and calcaneocuboid joints (subtalar joint complex): Correction of the rotational malposition between talus and os calcis with simultaneous reduction of the talonavicular and calcaneocuboid joints. After wound closure the corrected position is maintained by a long leg cast. In severe clubfeet an additional fixation with Kirschner wires of the talonavicular and the subtalar joints may be indicated.     

Correction of juxtaarticular deformities in children using the Ilizarov apparatus

Background Deformity correction using external fixation was performed for various disorders in children. We reviewed 18 children who underwent juxtaarticular deformity correction using the Ilizarov apparatus with either a transverse or focal dome osteotomy. The amount of deformity correction, external fixation time, external fixation index, length gained, and incidence of complications were examined.Methods A series of 27 operations were performed in lower limb segments on 10 femurs and 17 tibias in 10 boys and 8 girls. The mean age at operation was 12 years (5–18 years). Deformity corrections were performed using a transverse osteotomy in 16 segments and a focal dome osteotomy in 11.Results The average deformity corrected was 19° (6°–31°). Acute correction was done in 14 segments and gradual correction in 13 segments. The mean lengthening was 4.2 cm in 12 segments (2–8 cm). The mean external fixation time was 161 days (78–352 days). In acute corrections, the external fixation time with a focal dome osteotomy (101 days) tended to be shorter than with a transverse osteotomy (142 days).Conclusions Accurate limb alignment was obtained for all cases. A focal dome osteotomy by maximizing the area of bony contact was more effective than a transverse osteotomy for acute deformity correction.     

Ilizarov external fixator in treatment of severe recurrent congenital talipes equinovarus

Aim  

Severe recurrent congenital talipes equinovarus deformity remains a significant problem in orthopedic surgery particularly in the developing countries with limited facilities. Surgical treatment of patients with severe recurrent congenital talipes equinovarus is difficult and has many complications. This study discusses the results of using Ilizarov external fixator in treatment of severe recurrent congenital talipes equinovarus deformity.     

Correction of complex foot deformities using the Ilizarov external fixator.

There are many drawbacks to using conventional approaches to the treatment of complex foot deformities, like the increased risk of neurovascular injury, soft-tissue injury, and the shortening of the foot. An alternative approach that can eliminate these problems is the Ilizarov method. In the current study, a total of 23 deformed feet in 22 patients were treated using the Ilizarov method. The etiologic factors were burn contracture, poliomyelitis, neglected and relapsed clubfoot, trauma, gun shot injury, meningitis, and leg-length discrepancy (LLD). The average age of the patients was 18.2 (5-50) years. The mean duration of fixator application was 5.1 (2-14) months. We performed corrections without an osteotomy in nine feet and with an osteotomy in 14 feet. Additional bony corrective procedures included three tibial and one femoral osteotomies for lengthening and deformity correction, and one tibiotalar arthrodesis in five separate extremities. At the time of fixator removal, a plantigrade foot was achieved in 21 of the 23 feet by pressure mat analysis. Compared to preoperative status, gait was subjectively improved in all patients. Follow-up time from surgery averaged 25 months (13-38). Pin-tract problems were observed in all cases. Other complications were toe contractures in two feet, metatarsophalangeal subluxation from flexor tendon contractures in one foot, incomplete osteotomy in one foot, residual deformity in two feet, and recurrence of deformity in one foot. Our results indicate that the Ilizarov method is an effective alternative means of correcting complex foot deformities, especially in feet that previously have undergone surgery.     

伊利扎诺夫技术治疗儿童顽固性马蹄内翻足

目的 提高儿童顽固性马蹄内翻足畸形的治疗效果。方法 应用伊利扎诺夫技术治疗儿童顽固性马蹄内翻足畸形11例12足，先行跟腱延长和足后路松解，再在胫骨中下1/3处，跟骨及1-5跖骨骨干多平面贯穿张力细克氏针或橄榄针，分别固定于环形，半环形及马蹄形骨外固定器上，并通过多根螺纹杆相互连接成三维立体的骨外固定装置。通过对骨外固定装置各部件间距进行延长，压缩和旋转待调节，以及舟，骰骨的截骨延长，从而矫正畸形足的下垂，内翻，内收及短足畸形。结果 术后随访时间2-10年，平均4.5年，按Garceau分级标准评定；优5例6足，良4例4足，可2例2足，优良率达83.3%。有2例2足遗留轻度前足内收畸形，4例4足有较明显的跗骨间关节僵硬，但其步态和负重力线均与正常儿童无明显差别。结论 应用伊利扎诺夫技术治疗儿童顽固性马蹄内翻足疗效好，副作用小，但应严格掌握手术适应证。     

应用Ilizarov技术治疗青少年重度马蹄内翻足

目的 :探索青少年重度马蹄内翻足的治疗方法。方法 :应用足踝部有限软组织松解 ,结合术后外固定器缓慢牵伸松解关节挛缩 ,以及二期关节融合与肌力平衡手术治疗青少年重度马蹄内翻足 10例 (16足 )。结果 :16足均获得满意的畸形矫正及足底持重 ,3例遗有轻度前足内收。结论 :应用Ilizarov技术结合有限的手术治疗 ,可获得青少年重度马蹄内翻足的良好畸形矫正和功能恢复。     

Correction of Madelung's deformity by the Ilizarov technique

We present our experience with correction of Madelung's deformity by the Ilizarov technique. Seven patients (eight deformities) were treated by osteotomy of the radius with subsequent lengthening and angular correction. They were reviewed at a mean of 30 months (1.5 to 5.5 years). At the time of operation their mean age was 19 years (9 to 44). At follow-up all were free from pain and supination had improved by a mean of 34 degrees and pronation by 9 degrees. Flexion had increased in most cases with a median increase of 15 degrees, but only one patient gained further extension. Radial and ulnar deviation were increased by a mean of 6 degrees and 9 degrees, respectively. Radiographic measurements showed that the mean volar angulation had been reduced from 25 degrees to 11 degrees, ulnar inclination from 45 degrees to 30 degrees and carpal malalignment (volar translation) from 7 to 2 mm. The mean lengthening of the radius was 12 mm (6 to 25). All the patients were satisfied with the functional and cosmetic results.     

矩形瓣成形术治疗严重内眦赘皮

我院自1990年以来,引用、改进矩形瓣成形术,对严重内眦赘皮14例26个内眦进行整复,取得了良好的效果。文中阐谜了手术设计、方法及本术式的优点和注意事项,并与其它常规术式做了比较,认为矩形瓣成形术是一种较为理想的严重内眦赘皮整复法。     

矩形瓣成形术治疗严重内眦赘皮

我院自１９９０年以来，引用、改进矩形瓣成形术，对严重内眦赘皮１４例２６个内眦进行整复，取得了良好的效果。文中阐述了手术设计、方法及本术式的优点和注意事项，并与其它常规术式做了比较，认为矩形瓣成形术是一种较为理想的严重内眦赘皮整复法。     

Correction of knee and ankle valgus in hereditary multiple exostoses using the Ilizarov apparatus

Background Hereditary multiple exostoses (HME) is a genetic disorder that causes limb deformities due to disturbance at the growth plates. Materials and methods Six adolescents, whith symptomatic valgus deformity at the ankle and knee (seven affected legs) underwent correction procedures using the Ilizarov apparatus. In 5 legs, a bifocal Ilizarov apparatus was used, whereas in 2 legs the use of a monofocal apparatus was sufficient. Results Correction of the mechanical axis was achieved in all cases, and limb length discrepancy was equalized in the 3 cases that underwent limb elogation. The average knee and ankle corrections were 15° and 18°, respectively. The average time from application to removal of the Ilizarove apparatus was 4.6 months. No major complication occurred. Conclusions The use of the Ilizarov method in adolescents with HME enables successful simultaneous correction of multiplanar, multifocal complex limb deformities.     

有限矫形手术与Ilizarov技术治疗青少年先天性马蹄内翻足

目的观察应用有限矫形手术与Ilizarov技术治疗青少年先天性马蹄内翻足(congenital clubfoot,CCF)的临床疗效,探讨CCF外科矫正与功能重建新技术、新理念。方法 2003年9月-2010年7月,收治25例40足青少年CCF。男14例20足,女11例20足;年龄12～25岁,平均15.7岁。左足4例,右足6例,双足15例。根据秦氏马蹄内翻足畸形分度:Ⅰ度9足,Ⅱ度17足,Ⅲ度14足。合并小腿内旋畸形9足,右侧髋关节半脱位1例。采用有限软组织松解与骨性截骨手术后,9足Ⅰ度畸形者安装组合式外固定器,31足残留畸形安装Ilizarov外固定牵伸器。术后5～7 d开始矫正,以0.5～1.0 mm/d为宜;待踝关节矫正至过伸5～10°,足呈轻度外翻后停止牵伸,矫正位携带外固定架并负重行走4～6周。双足畸形患者分两期进行手术,手术间隔3～6个月,平均4个月。结果 9足术后佩戴组合式外固定器6～12周,平均8周;31足佩戴Ilizarov外固定牵伸器6～17周,平均13周。患者均获随访,随访时间8个月～6年,平均37个月。牵拉矫形期间6例6足发生针道轻度感染,均经对症处理后感染消失。术后2年1例1足畸形部分复发,经再次安装Ilizarov外固定牵伸器负重行走4周,矫正满意;其余畸形足在随访期内均获得满意矫正和全足底持重。末次随访时根据国际马蹄足畸形研究会(ICFSG)的评分系统,获优28足,良10足,可2足,优良率95%。结论有限矫形手术结合Ilizarov技术矫治青少年CCF,符合生物学原理和微创外科原则,安全、微创、疗效确切。该马蹄内翻足手术矫形策略遵循骨科自然重建理念,尤其适用于传统矫形骨科手术难以治疗的Ⅲ度CCF。     

Relapsed clubfoot correction with soft-tissue release and selective application of Ilizarov technique

The Ilizarov technique is an alternative for the treatment of complex foot deformities in children. The authors retrospectively reviewed children with relapsed clubfoot deformity, treated with soft tissue procedures and additional correction with an Ilizarov frame. Twelve consecutive patients (13 feet) with relapsed clubfoot deformity after previous surgical correction were reviewed. Treatment included open releases. An Ilizarov frame was applied as an adjunct in seven patients (mean age of 7.8 years) with severe deformity where complete intraoperative correction was not achieved. Clinical and radiographic assessment was undertaken. The mean Laaveg–Ponseti score, for the 7 feet treated with the Ilizarov frame, was 85.1 after minimum 4 years follow-up. One recurrence of forefoot deformity required metatarsal osteotomies. Postoperative radiographic measurements revealed values that can be considered as normal. Complications included pin tract infections (12% of inserted wires). Flat-topped talus was observed in 3 feet. Deformity correction was possible when soft tissue procedures were combined with the use of Ilizarov technique, in order to support and gradually improve surgical correction.     

Foot lengthening using the Ilizarov device: the transverse tarsal joint resection versus osteotomy

The aim of the study was the evaluation of both the foot correction and foot lengthening obtained using the distraction method with osteotomies versus distraction after the transverse tarsal joint resection. Ten patients (10 feet) aged from 5 years to 24 years (average, 10.5 years) were analyzed. Seven of them were treated for severe equinovarus deformity: six of congenital and one of post-traumatic etiology. In three patients, the indication for treatment was foot shortening due to hypoplasia with tibial shortening, combined with foot deformity. Preoperative shortening of the foot ranged from 1.5 cm to 10 cm (average, 4.5 cm). In four patients, osteotomy between the tarsometatarsal and transverse tarsal joints was carried out. In two cases, 'V-shaped' osteotomy through the hindfoot and midfoot was performed. In the remaining four patients, wedge resection of the transverse tarsal joint was performed. The follow-up was a mean of 32 months (range, 12-55 months). It was observed that foot lengthening after transverse osteotomy of the midfoot is difficult and unpredictable, because of distraction at the adjacent joints level instead of osteotomy site. The greatest lengthening of the foot (mean, 4 cm) was observed in the patients with the transverse tarsal joint resection. It was concluded that the transverse tarsal joint resection following callus distraction in the place of the resected joint is the effective method for foot lengthening, which can be combined with deformity correction.