Preoperative Ilizarov frame construction for correction of ankle and foot deformities

The Ilizarov method is being used increasingly to correct many orthopedic deformities. The frames required for ankle and foot deformity correction are among the most difficult to construct owing to the complexity of the deformities which must be corrected. A technique using a rubberized material (Pedilen) to create an exact replica of a preoperative ankle and foot deformity is described. This exact model, both in size and shape, may then be used on a workbench to preconstruct an Ilizarov frame that resembles the patient's deformity exactly in three dimensions with respect to size and shape. This allows thoughtful frame construction before operation reducing operating time and minimizing frustrations that may arise with complex deformities.     

Use of external fixation in the reconstruction of the Charcot foot and ankle

External fixation allows the progressive foot and ankle surgeon to approach Charcot foot and ankle deformities in a new way. Surgeons can now correct Charcot pathology with percutaneous techniques using a new generation of external fixation frames. These fixators allow the surgeon to adjust or manipulate the Charcot foot after surgery and the patient early weightbearing. External fixation provides the foot and ankle surgeon the opportunity to reconstruct and stabilize this destructive disease.     

Review of the effect of early amniocentesis on foot deformity in the neonate

A recent publication by the Canadian Early and Mid-Trimester Amniocentesis Trial Group reported an increase in orthopaedic foot deformities in infants whose mothers underwent an amniocentesis from 11 to 12 + 6 gestational weeks versus a group sampled between 15 to 16 + 6 gestational weeks. Because the sampling of the former group was at the time of maximum foot growth and maximum acquisition of amniotic fluid, the authors hypothesize that the foot deformities are secondary to decreased fetal movement during a key phase in foot and ankle development.     

Reconstructive foot and ankle surgeries in diabetic patients

Diabetic foot and ankle deformities are secondary to long-standing diabetes and neglected foot care. The concept of surgical correction for these deformities is quite recent. The primary objective of reconstructive foot and ankle surgery is the reduction of increased plantar pressures, reduction of pain and the restoration of function, stability and proper appearance. Foot and ankle deformities can result in significant disability, loss of life style, employment and even the loss of the lower limb. Therefore, restoration of normal, problem free foot function and activities will have a significant impact on peoples’ lives. Reconstructive surgical procedures are complex and during reconstruction, internal and external fixation devices, including pins, compression screws, staples, and wires, may be used for repair and stabilization. The surgeries performed depend on the type and severity of the condition. Surgery can involve any part of the foot and ankle, and may involve tendon, bone, joint, tissue or skin repair. Corrective surgeries can at times be performed on an outpatient basis with minimally invasive techniques. Recovery time depends on the type of condition being treated.KEY WORDS: Diabetic foot, foot deformities, foot reconstruction, planter pressure points     

Advanced techniques in foot and ankle reconstruction

Complex deformities of the foot and ankle remain a difficult problem for even the most experienced surgeon. Many techniques are available to provide correction and no single one is appropriate for all cases. Identical deformities often can be treated with different techniques with equally successful outcomes. Each deformity is unique and the surgeon should be capable of using multiple techniques to provide the most appropriate treatment for the patient and the deformity. Simple deformities often can be handled with simple techniques but more complex problems often require more complex solutions. The techniques discussed here have worked well at the authors' institution but are undergoing constant reevaluation and occasional modification. It is important that the surgeon and the patient understand that with these techniques it is usually possible to provide a functional outcome but never possible to provide a normal foot or ankle. If appropriate goals are set, correction of these challenging deformities can be satisfying to surgeon and patient.     

脊椎裂后遗足踝畸形的临床分析

目的 分析脊椎裂后遗足踝畸形的发病情况、临床特点、畸形类别与矫形治疗状况.方法 对我科1990年1月至2009年7月接受手术治疗脊椎裂后遗足踝部畸形患者进行回顾性研究,对资料进行总结分析.结果 手术治疗脊椎裂后遗足踝部畸形共107例患者.其中男性44例,女性63例;手术年龄1.3～52.0岁,平均17.7岁,其中18岁以上者50.5%(54/107).隐性脊椎裂50.5%(54/107),显性(囊性)脊椎裂49.5%(53/107).1例为胸椎裂(T3～8),余106例为腰骶椎裂.单侧足受累49例(左侧22例,右侧27例),双侧足受累58例,共165足.畸形类型:内翻足76足,外翻足23足,夏科连枷足15足,其他类足畸形51足.合并其他受累部位:膝部屈曲或膝反屈畸形4例,髋部畸形17例(包括髋内收、屈曲或髋关节脱位,骨盆倾斜、双下肢不等长等),合并大小便功能障碍30例.本组54例隐性脊椎裂致足踝畸形患者中,29例既往在多个医院未能确诊发病原因,误诊或漏诊的比率高达53.7%(29/54).107例患者中,既往接受过足踝畸形矫形手术者仅26例.18岁以上既往未能实施合理矫形外科治疗遗留严重足踝畸形者50.5%(54/107).结论 脊椎裂继发畸形主要在足踝部.由于缺乏对此病的整体认识与矫形治疗经验,延误了对此类疾病的早期诊断、早期干预的治疗时机,遗留了很多未经矫形外科治疗的严重足踝畸形.     

Charcot-Fuß

Neuro-osteoarthropathy is accompanied by the destruction of single or multiple joints involving little or no pain. Diabetic patients suffering from symmetric distal polyneuropathy are the main risk group. The main location is the foot (Charcot foot). Inadvertent or repetitive trauma appears to be the main trigger mechanism for Charcot foot. Undiagnosed and untreated fractures and dislocations, foot and ankle deformities and instabilities with consecutive ulcerations may be the consequence, which again may increase the risk for later extremity loss due to the need for amputation or at least functional deterioration. Early diagnosis in the acute phase is of the utmost importance for the patient's prognosis. The primary strategy consists of unloading and immobilizing the foot and the corresponding extremity followed by stage-related protected remobilization until definite healing occurs. Surgical intervention is a key-stone in the treatment of complications at any stage. Surgery is an essential part of treatment and should be integrated into the overall treatment plan. The main indications for orthopedic reconstruction are non-plantigrade foot and ankle deformities or instabilities with concomitant ulcers that cannot be adequately addressed by non-operative measures, mainly in the chronic stage of Charcot foot. As such, surgical reconstruction can contribute to the long-term preservation of the affected foot and help to maintain or improve the patient's mobility and quality of life.     

Digital surgery: current trends and techniques

Digital deformities continue to be a common ailment among many patients who present to foot and ankle specialists. When conservative treatment fails to eliminate patient complaints, surgical correction remains a viable treatment option. Proximal interphalangeal joint arthrodesis remains the standard procedure among most foot and ankle surgeons. With continued advances in fixation technology and techniques, surgeons continue to have better options for the achievement of excellent digital surgery outcomes. This article reviews current trends in fixation of digital deformities while highlighting pertinent aspects of the physical examination, radiographic examination, and surgical technique.     

Recurrence rates of burn contracture ankle equinus and other foot deformities in children treated with Ilizarov fixation

The purpose of this study was to determine recurrence rates of pediatric foot and ankle burn deformities treated with the Ilizarov method. A total of 19 patients with 29 foot and ankle deformities were studied. The most common deformity treated was equinus (23). Rocker-bottom and cavus foot deformities were each treated three times. The average age of the patient at the time of the burn injury was 3.2 years, and the average age at the time of fixation was 9.4 years. Equinus contractures averaged -34 degrees (34 degrees of plantarflexion) before surgery and +7 degrees (7 degrees of dorsiflexion) after treatment with the Ilizarov fixator. The recurrence rate for all 29 ankles and feet was 69% (20/29). The recurrence rate for equinus contractures was 74% (17/23). The average time to recurrence was 17.3 months. Only short-term follow-up was available on four of the six feet and ankles that did not recur. Deformity correction in burned feet and ankles is difficult to obtain by any means. The authors recommend using the Ilizarov method to obtain correction of moderate to severe foot and ankle deformities in pediatric burn patients, but the correction obtained is not stable and deformity will likely recur. Parents and patients should anticipate adjunctive nonoperative and operative procedures to keep their feet plantigrade as they grow. In young children, the possibility of having additional surgeries, including repeat Ilizarov procedures, should be discussed. Even older children should expect additional surgeries to prevent recurrent deformities.     

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.     

Linear scleroderma and foot deformity in children

Linear scleroderma is a subtype of localized scleroderma generally observed in children, and may produce secondary bone and joint deformities. Its localization at the foot or ankle is rarely reported. A complete review of the literature reveals 21 cases of foot or ankle deformity due to linear scleroderma to which we add one case. The clinical and radiological aspects of the deformity, its pathogenesis, histological findings as well as orthopaedic management are presented and discussed.     

Tenotomy and tendon transfer about the forefoot, midfoot and hindfoot

Tendon lengthening and transfer are essential surgical procedures for every foot and ankle surgeon to master, because they are useful in restoring balance and correcting flexible foot deformities. These techniques are even more useful in treating the high-risk patient, because they involve minimal soft-tissue injury and maximum preservation of vascularity. The primary goal of this article is to supplement the foot and ankle surgeon's options for treating static and dynamic foot deformities in the high-risk patient by discussing useful tendon lengthening and transfer procedures about the forefoot, midfoot, and hindfoot.     

组合性手术治疗脊柱裂后遗踝足畸形

目的:探讨脊柱裂后遗踝足畸形的外科治疗策略以及不同踝足的畸形手术组合方法及其疗效。方法:回顾性分析1990年1月至2009年7月收治的107例脊柱裂后遗踝足部畸形患者的病例资料。其中男44例,女63例;年龄1.3～52岁,平均17.7岁;双踝足畸形58例,单侧49例(左侧22例,右侧27例)。马蹄足畸形类99足,行跟腱延长及肌腱移位术;跟行足畸形类25足,行踝前肌腱松解及肌腱移位术;内外翻足畸形类17足,行肌腱移位及跟骨截骨术;连枷足畸形15足,行跟距关节融合及跟腱短缩术;爪形趾畸形9足,行趾间关节融合或Ilizarov技术牵拉矫正。采用AOFAS综合评分系统从主观疼痛感觉、客观功能检查等方面评定疗效。结果:107例中79例127足获得随访,时间48～180个月,平均64个月。根据AOFAS综合评分系统,结果优89足,良26足,中9足,差3足。结论:脊柱裂踝足畸形外科治疗策略包括矫正畸形、平衡肌力、稳定关节和保留足的弹性4个基本原则。针对不同类型足畸形,采用相应的组合性手术方案进行治疗,不但可以有效的矫正畸形,而且能改善患者的行走功能,获得满意的疗效。     

Congenital longitudinal deficiency of the fibula: follow-up of treatment by Syme amputation.

Congenital longitudinal deficiency of the fibula presented two major problems in management: severe shortening of the limb and equinovalgus deformity of the ankle and foot. When the deformity was severe, our attempts at reducing the deformities of the foot and ankle with soft-tissue procedures and our attempts at achieving limb-length equality with various lengthening procedures were unsuccessful. Our best results in these patients were achieved with an early Syme amputation. The pattern of the deformity and the determination of the growth inhibition factor in the involved limb now enable us to make an early estimate of the deformity and plan appropriately. Syme amputation is definitive and allows the patient to have nearly normal function of the limb and a prosthesis of excellent appearance.     

Internal fixation techniques for midfoot charcot neuroarthropathy in patients with diabetes

Charcot neuropathic osteoarthropathy (CN) of the foot and ankle is a poorly understood destructive process that poses a great clinical challenge to foot and ankle specialists. Neuropathic fractures or dislocations in the foot and ankle predispose patients to increased morbidity, premature mortality, and can greatly decrease quality of life. Early recognition and treatment of CN is imperative to prevent the development of permanent deformities. The purpose of this article is to review the history, cause, and classification of CN and to discuss commonly used internal fixation techniques and their indications.     

Hindfoot issues in the treatment of the cavovarus foot

Cavovarus foot deformity is a result of a dysbalance of the extrinsic musculature about the foot. Because of the multi-articular bony structure of the foot and ankle, the slightest imbalance of muscular forces causes osteo-articular malalignment and consequent gross deformities. This article discusses hindfoot issues involved in the treatment of cavovarus foot.     

Adult-acquired flatfoot deformity

Originally known as posterior tibial tendon dysfunction or insufficiency, adult-acquired flatfoot deformity encompasses a wide range of deformities. These deformities vary in location, severity, and rate of progression. Establishing a diagnosis as early as possible is one of the most important factors in treatment. Prompt early, aggressive nonsurgical management is important. A patient in whom such treatment fails should strongly consider surgical correction to avoid worsening of the deformity. In all four stages of deformity, the goal of surgery is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex. However, controversy remains as to how to manage flexible deformities, especially those that are severe.     

Treatment of the cavus foot. Deformity in the pediatric patient with Charcot-Marie-Tooth

The orthopedic management of foot and ankle problems associated with Charcot-Marie-Tooth disease is becoming better understood but is still evolving. It is now known that Charcot-Marie-Tooth disease should be considered a spectrum of neurologic disorders with variable inheritance patterns, clinical course, and severity of deformities. Over half of the patients with Charcot-Marie-Tooth disease develop foot and ankle problems of which the cavovarus deformity is by far the commonest. Other clinical problems include weakness, parathesias, pain, and an unsteady gait. The cavovarus deformity seems to develop from a relative imbalance between the peroneus longus and tibialis anterior muscles and from an imbalance between the tibialis posterior and peroneus brevis muscles. Treatment of the cavovarus foot deformities should be individualized for each patient after careful preoperative evaluation. Surgery using a variety of soft tissue procedures and osteotomies seems to be the treatment of choice for the progressive cavovarus deformity in younger patients. For a patient who has severely rigid deformities a triple arthrodesis may be the only option but is considered by most to be a salvage procedure. It always should be kept in mind that Charcot-Marie-Tooth disease is a progressive neurologic disorder and the deformities can progress despite surgical intervention. Even though the results of treatment in this disease are difficult to evaluate because of the wide [figure: see text] spectrum of disease, it seems reasonable to believe that early surgical intervention in the flexible cavus foot can restore normal foot posture and help prevent or delay the need for more extensive bony procedures.