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.     

Arthroscopic ankle arthrodesis

BACKGROUND: Arthroscopic arthrodesis has been used mainly for in situ fusion of arthritic ankles without deformity. This paper presents the application of arthroscopic arthrodesis of ankles with marked deformity. METHODS: The results of 78 consecutive cases of arthroscopic ankle arthrodeses, performed in 74 patients, were retrospectively evaluated. Forty-eight ankles had minor deformity (group A), whereas 30 ankles had a varus or valgus deformity of more than 15 degrees (maximum 45 degrees) (group B). The average hospital stay was 3.8 and 3.4 days in groups A and B, respectively (p = 0.74). Postoperative treatment included ankle immobilization for 3 months. Progressive weightbearing was initiated at 2 weeks. Mean followup was 21.1 months. RESULTS: Fusion occurred in 47 of 48 (97.9%) ankles in group A at an average time of 13.1 +/- 5.8 weeks and in 29 of 30 (96.7%) ankles at 11.6 +/- 2.4 weeks in group B (p = 0.19). Unplanned operative procedures were required in 11 ankles (14.1%). One superficial wound infection occurred. Symptomatic arthritis from the adjacent joints developed in six ankles (7.7%). Postoperative ankle alignment in the frontal plane averaged 0.7 and 0.4 degrees of valgus (p = 0.41), whereas the sagittal plane angle averaged 106 +/- 4 degrees and 104.5 +/- 7 degrees in groups A and B, respectively (p = 0.22). The outcome was graded as very good in 79.2% (38 feet) in group A and 80% (24 feet) in group B, fair in 18.8% (9 feet) in group A and 16.7% (5 feet) in group B and poor in one ankle in each group (p = 0.68). CONCLUSIONS: The arthroscopic technique offered high fusion rates and low morbidity. Deformity correction was achieved with good results.     

Fresh ankle osteochondral allograft transplantation for tibiotalar joint arthritis

BACKGROUND: Conventional treatment for tibiotalar joint arthritis relies on arthrodesis or prosthetic arthroplasty. Fresh osteochondral allografting is an alternative procedure to replace diseased articular cartilage. METHODS: Eleven patients (average age 43 years; range 18 to 65 years) had fresh osteochondral grafting of the tibiotalar joint. The diagnoses were posttraumatic arthritis in seven ankles, osteoarthritis in two, and an osteochondral defect in two. Precise cuts were made using the Agility (DePuy, Warsaw IN) ankle arthroplasty jigs. Bipolar replacements were used in nine ankles and unipolar in two. Results were evaluated using outcome scores, physical examinations, and standing ankle radiographs. RESULTS: At a minimum followup of 24 (average 33; range 26 to 45) months, six of the 11 ankles had successful grafting procedures. The average AOFAS score preoperatively improved from 55 to 73 postoperatively (p = 0.01). The patients' pain, gait, and walking surface scores were all significantly improved (p < 0.05). Of the five failures three underwent successful repeat allografting and one was revised to a total ankle arthroplasty, and one has had no further surgery. The ankle range of motion arc was 30 degrees or more in six ankles. Additional surgery included five talofibular joint debridements, three repeat graftings, two hardware removals, and one conversion to a prosthetic ankle replacement. There was one intraoperative fibular fracture and one superficial wound infection. The serum of 10 patients tested positive for cytotoxic HLA antibodies postoperatively. Radiographs revealed moderate and severe joint degeneration in six ankles; however, this did not necessarily correlate with a poor outcome. Poor results tended to occur in ankles with a graft-host size mismatch or graft thickness of less than 7 mm. CONCLUSION: Fresh osteochondral transplantation for tibiotalar joint arthritis is a promising alternative to arthrodesis and prosthetic replacement. Early results demonstrate successful outcomes and good pain relief in over half the patients in this series.     

Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing

Nineteen patients (20 feet) with severe hindfoot and ankle deformity underwent tibiotalocalcaneal fusion with a retrograde locked intramedullary nail as a limb-salvage procedure. The purpose of this study was to compare the complication rates of this procedure in diabetic versus nondiabetic patients. There were 8 men and 11 women with preoperative diagnoses including Charcot neuroarthropathy, primary osteoarthritis, rheumatoid arthritis, equinocavovarus, posttraumatic osteoarthritis, gouty arthritis, and ankle malunion. Ten of 20 procedures were performed in patients with diabetes. The average patient age was 56 years, and the average postoperative follow-up was 19.8 months. Nineteen of 20 ankles (95%) achieved successful fusion with an average time of 4.1 months. Four patients (21%) required either a fracture brace or an ankle foot orthosis at final follow-up. Five patients (25%) had major complications and 11 patients had minor complications. Major complications included osteomyelitis (n = 2), Charcot arthropathy (n = 2), failure of fixation (n =1), soft-tissue necrosis (n = 1), cardiac arrest (n = 1), cerebral vascular accident (n = 1), and fatal pulmonary embolus (n = 1). All patients with major complications were diabetic, and 14 of 20 combined major and minor complications occurred in patients with diabetes. The complication rate was found to be high in diabetic patients with end-stage deformity undergoing a limb salvage     

Effect of a semi-rigid ankle stabilizer on performance in persons with functional ankle instability

STUDY DESIGN: Within-group repeated measures. OBJECTIVES: To determine the effect of a semi-rigid prophylactic ankle stabilizer (PAS) on performance of subjects with post-acute, unilateral ankle sprains who have mechanically stable ankles, but are functionally impaired. BACKGROUND: Most studies on PAS performance to date are limited to subjects with noninjured, nonimpaired ankles. No research has been reported to determine the effect PASs have on performance in subjects who have a mechanically stable, nonacute ankle sprain with functional impairment. METHODS AND MEASURES: Twenty-five subjects (8 men and 17 women; average height = 168.91 +/- 33.02 cm, average weight = 61.10 +/- 29.5 kg, and average age = 16.2 +/- 6 years) met the qualification criteria of the study. Subjects had unilateral grade I or II lateral ankle sprains of 3 to 4 weeks duration and were cleared medically to return to activities of daily living. Each subject's injured ankle was mechanically stable as determined by physical exam but was functionally impaired as determined by instability during the modified Rhomberg test. Separate 2 x 2 ANOVAs with repeated measures on brace condition (Aircast SportStirrup and nonbraced control) and test session (test session 1 and test session 2) were completed to assess the effect of ankle stabilization on 2 dependent variables (36.58-m shuttle-run and vertical-jump). RESULTS: Shuttle-run time was significantly faster for the braced condition (mean = 9.43 +/- .72 seconds) than for the nonbraced control (mean = 9.57 +/- .75 seconds), regardless of test session. Shuttle-run time was significantly faster for test session 2 (mean = 9.43 +/- .79 seconds) than for test session 1 (mean = 9.57 +/- .68 seconds), regardless of brace condition. No significant main or interaction effects occurred for vertical-jump. CONCLUSIONS: Use of a semi-rigid PAS significantly increased shuttle-run but not vertical-jump performance. This effect was immediate and did not require PAS acclimation.     

Effect on balance and gait secondary to removal of the second toe for digital reconstruction: 5-year follow-up

Foot anatomy and lower limb function were analyzed in 11 children (aged 6.5-12.5 y) 5 years after removal of one or two second toes for digital reconstruction. In addition to physical examination and x-rays, postural balance and three-dimensional measurements of gait were analyzed. Among the 15 operated feet, five had bridle scars, three had claw deformities of the third toe, five had pain in the first intermetatarsal space, and seven had overt or early-stage hallux valgus (including five after unilateral toe removal). Hallux valgus deformation was also observed in three nonoperated feet. Maintenance of balance and rate of displacement of the center of pressure when standing on one foot with eyes closed were significantly altered for operated limbs compared with nonoperated limbs. Gait was rapid because of increased step cadence. Foot progression angle and ankle and knee joint sagittal kinematics during walking were normal. Although children appeared to not be affected in their daily life by the removal of the second toe(s), related foot anatomic and functional modifications require further follow-up.     

Transverse patellar fractures“0” fixation system Double-head cannulated compression screw

Purpose: This study evaluated the angular kinematic and moment of the ankle and foot during shod walking and barefoot walking in individuals with unilateral chronic ankle instability (CAI). Methods: Recreational soccer players with unilateral CAI were recruited for this cross sectional study conducted between January and August 2019. A total of 40 participants were screened for eligibility but only 31 met the inclusion criteria based on the methods of Delahunt et al and Gribble et al. Except for 3 participants not attending the evaluation session, 28 participants were finally included. A three dimensional motion analysis system made up of ProReflex motion capture unit and an AMTIb Kistler force plate, embedded in the middle of nine meter walkway, were used to assess the ankle and foot angles and moment during shod walking and barefoot walking conditions. A Statistical Package for Social Sciences (version 20.0) was used to analyze data. Results: During shod walking, the ankle joint plantar-flexion range of motion (ROM) at 10% of the gait cycle (GC) and dorsiflexion ROM at 30% of the GC were significantly higher than those during barefoot walking for both feet (p = 0.001, 0.001, 0.027, and 0.036 respectively). The inversion ROM during shod walking was significantly higher than that during barefoot walking for both feet at 10% and 30% of the GC (p = 0.001. 0.001, 0.001, and 0.042 respectively). At 10% of the GC, the eversion moment was significantly higher between barefoot and shod walking for both feet (both p = 0.001). At 30% of the GC, there was no significant difference between shod and barefoot walking plantar-flexion moment of both feet (p = 0.975 and 0.763 respectively), and the eversion moment of both feet (p = 0.116 and 0.101 respectively). Conclusion: At the early stance, shod walking increases the ankle plantar-flexion and foot inversion ROM, and decreases the eversion moment for both feet in subjects with unilateral CAI. Therefore, the foot wearing condition should be considered during evaluation of ankle and foot kinematics and kinetics.     

三关节融合术治疗儿麻后遗马蹄内翻足远期效果综合分析

目的：综合评价三关节融合术治疗儿麻后遗马蹄内翻足的远期疗效。方法：用临床标准和足底压力测定对术后１６年３个月的２４名病人２４足进行了综合评定。结果：临床效果优良１９足,可５足;Ｘ线片显示：三关节融合率、踝关节退行性变发生率１００％。畸形复发为肢短造成的马蹄足复发。患足疼痛发生在踝关节及足底胼胝区,胼胝区压力明显大于对侧足相应区域（Ｐ〈０．０１）。临床疗效优良者,其动、静态足底压力较均匀。临床疗效可     

微创牵拉技术治疗小腿缺血性肌挛缩后遗重度踝足畸形

目的探讨用llizarov微创牵拉技术,治疗小腿缺血性肌挛缩后遗重度踝足畸形的疗效。方法根据llizarov张力-应力法则,自行研制了可调式具有三维矫形功能的踝足关节牵拉外固定器。2002年4月至2004年3月,应用微创牵拉技术治疗因下肢创伤、骨折等原因并发的小腿缺血性肌挛缩后遗固定性踝足畸形患者8例。其中男4例,女4例;年龄13—31岁,平均23岁。左下肢5例,右下肢3例。术前畸形类型：马蹄内翻足6例,马蹄足2例,伴有小腿广泛性瘢痕挛缩,其中5例既往行软组织松解手术矫正足畸形失败。术后牵拉时间29—60d,平均46d。结果8例患者均获得随访,随访时间10-29个月,平均13个月。畸形足皆获得满意矫正,能全足持重行走,功能良好,未发生针道感染、皮瓣坏死、血管、神经损伤等并发症。结论微创牵拉技术矫正缺血性肌挛缩后遗踝足畸形,具有安全、微创、效果满意的优点,为缺血性肌挛缩后遗僵硬性踝足畸形的外科治疗开辟了一条有效途径。     

Management of foot pain associated with accessory bones of the foot: two clinical case reports

STUDY DESIGN: Case study. OBJECTIVES: To discuss the differential diagnosis, the nonsurgical and postoperative management of common accessory bones of the foot. BACKGROUND: Accessory bones of the foot that are formed during abnormal ossification are commonly found in asymptomatic feet. Two of the most common accessory bones are the accessory navicular and the os peroneum. Their painful presence must be considered in the differential diagnosis of any acute or chronic foot pain. The optimal treatment for the conservative and postoperative management of painful os peroneum and accessory navicular bones remains undefined. METHODS AND MEASURES: Therapeutic management of the fractured os peroneum included bracing, taping, and foot orthotics to allow healing of involved tissues, and stretching. The focus of the postoperative management of the accessory navicular was joint mobilization and progressive strengthening. Dependent variables included level of pain with provocation and alleviation tests of joint and soft tissue; girth and sensory tests of the foot and ankle; goniometric measures of foot and ankle; strength of ankle and hip muscles; functional tests; and patient's self-reported pain status. RESULTS: The patient with the fractured os peroneum was treated in 13 visits for 10 weeks. At discharge from physical therapy, the patient had the following outcomes relative to the noninvolved side: 100% return of normal sensation tested by light touch and vibration; pain decreased from 6/10 to 1/10; 100% reduction of swelling with ankle girth to normal; 100% range of motion of ankle and subtalar joints. Strength in plantar flexion and eversion remained 20% impaired (80% return to normal) secondary to pain. Upon discharge, he still reported mild pain when walking but was able to return to previous leisure activities. The second patient with the accessory navicular was treated in 18 visits over 9 weeks. Relative to the uninvolved side, she was discharged with the following: 70% return of range of motion in the foot and ankle, 100% of strength in hip and ankle, and 100% return of balance. She could squat and jump without pain and she returned to full premorbid activity level. CONCLUSIONS: Rehabilitative management of both cases addressed specific impairments and was successful in improving the patients' activity limitation. Clinicians should be aware that these accessory bones are possible sources of disability, secondary to foot pain.     

下胫腓联合螺钉治疗下胫腓韧带联合损伤的临床观察

目的：探讨踝关节周围骨折合并下胫腓韧带联合损伤的手术方法。方法：对2005年9月至2007年12月用下胫腓联合螺钉固定治疗的20例（21踝）下胫腓韧带联合损伤患者进行回顾性研究,其中男11例（12踝）,女9例（9踝）;年龄27～52岁,平均36岁。所有患者结合病史、查体及影像学检查进行诊断,按照Lauge-Hansen分型进行手术治疗。X线测量：①胫骨前结节与腓骨的重叠阴影;②下胫腓联合间隙;③内踝关节面与距骨关节面的间隙。临床疗效采用改良Baird-Jackson评分标准进行评价。结果：20例（21踝）均获得随访,时间1～2.2年,平均1.3年。术前正侧位下胫腓联合重叠影为（0.46±3.56）mm,下胫腓联合间隙为（5.69±0.88）mm,胫距关节内间隙为（5.67±1.23）mm,踝穴位下胫腓联合重叠影为（-0.87±0.96）mm;术后下胫腓联合重叠影为（7.14±0.62）mm,下胫腓联合间隙为（3.28±0.39）mm,胫距关节内间隙为（3.12±0.33）mm,踝穴位下胫腓联合重叠影为（2.91±0.30）mm,与术前比较差异均有统计学意义（P〈0.01）。术后CT复查显示：下胫腓联合仍存在一定程度分离的有4例,均为轻度。术后Baird-Jackson评分为（86.24±13.26）分（62～98分）,在各项评定内容中,13踝（61.90%）获得无痛踝关节,16踝（76.19%）无踝关节不稳征象,11踝（52.38%）恢复正常行走能力,8踝（38.10%）恢复正常奔跑能力,11踝（52.38%）恢复正常的工作能力。踝关节背伸活动度（21.05±5.00）°,跖屈活动度（33.57±5.76）°,内翻活动度（19.48±4.57）°,外翻活动度（24.05±4.86）°。踝关节发生创伤性骨性关节炎表现的患者3例,无一例发生断钉;临床疗效优12踝,良2踝,可4踝,差3踝。结论：下胫腓联合3层皮质螺钉固定是治疗下胫腓韧带联合损伤的有效方法之一,精细的手术操作技术和下胫腓联合解剖关系的恢复是患者获得良好踝关节功能的重要因素,术后常规?     

The HINTEGRA ankle: rationale and short-term results of 122 consecutive ankles

The HINTEGRA ankle was developed as an attempt to specifically address the needs of minimal bone resection, extended bone support, proper ligament balancing, and minimal contact stresses within and around the prosthesis. The purpose of this study was to determine the short-term results in a consecutive series of 116 patients (122 ankles). Preoperative diagnoses were posttraumatic osteoarthrosis in 91 ankles (75%), primary osteoarthrosis in 16 ankles (13%), and systemic arthritis in 15 ankles (12%). Eight ankles had to be revised. Four were revised because of loosening of at least one component; one because of dislocation of the meniscus; and three for other reasons. All revisions were successful. After an average of 18.9 months (range, 1-3 years), 84% of patients were satisfied, and the clinical result was rated as good or excellent in 82% of the cases. The American Orthopaedic Foot and Ankle Society hindfoot score improved from 40 points preoperatively to 85 points at followup. Eighty-three ankles (68%) were completely pain-free. The average range of motion clinically was 39 degrees (range, 15 degrees-55 degrees) and under fluoroscopy (true ankle motion) it was 37 degrees (range, 7 degrees-62 degrees). Radiographically, the tibial component was stable in all ankles, and no tilting of the component occurred since surgery. However, migration of the talar component was observed in two ankles. The concept of minimal bone resection and wide bony support was shown to be successful on the tibial and talar sides. Obtained function, pain relief, and patient satisfaction were promising and, compared with other devices, the results mostly were superior. This may support the idea that anatomic-shaped surfaces, as is the case in the HINTEGRA ankle, may be successful in total ankle replacement.     

Pirogoff ankle disarticulation as an option for ankle disarticulation

Eleven patients (12 ankles) who had Pirogoff ankle disarticulation were followed up for an average of 5.6 years (range, 2.1-8.9 years). After disarticulation of the Chopart joint, the talus was removed and the calcaneus was cut off in the coronal plane. The heel then was rotated 90 degrees to the tibial plafond. The postoperative result was evaluated using a scoring sheet. Excellent results were seen in four feet: two in patients with trauma, one in a patient with a metastatic tumor, and one in a patient with osteomyelitis. Good results were seen in two feet: one in a patient with trauma and one in a patient with diabetes mellitus. A fair result was seen in one foot in a patient with diabetes mellitus. Poor results were seen in four feet in three patients with arteriosclerosis and one foot in a patient with diabetes mellitus. In Pirogoff ankle disarticulation, the leg-length discrepancy is compensated for by using the calcaneus. The patients only had a leg-length discrepancy of 2.8 cm on average, which enabled them to walk outdoors wearing only a shoe orthosis. The postoperative results were unfavorable in patients with vascular diseases and were satisfying in patients without vascular diseases.     

Treatment of malunion and nonunion at the site of an ankle fusion with the Ilizarov apparatus

BACKGROUND: Malunion and nonunion of an ankle fusion site are associated with pain, osteomyelitis, limb-length discrepancy, and deformity. The Ilizarov reconstruction has been used to treat these challenging problems. METHODS: We reviewed the results in twenty-one ankles that had undergone a revision of a failed fusion, with simultaneous treatment of coexisting pathologic conditions, with use of the Ilizarov technique. Eight patients had undergone ankle fusion only, eleven had undergone ankle and subtalar fusion, and two had undergone pantalar fusion. Eighteen patients with an average limb-length discrepancy of 4 cm underwent limb lengthening simultaneously with the revision surgery. The average patient age was forty years. Indications for treatment were malunion (eleven patients), aseptic nonunion (eight patients), and infected nonunion (two patients). Clinical, subjective, objective, gait, and radiographic analyses were performed after an average duration of follow-up of 83.4 months. RESULTS: Solid union was achieved in all ankles. The functional result was excellent for fifteen patients, good for three, fair for two, and poor for one. The bone result was excellent for ten ankles, good for nine, fair for one, and poor for one. All eighteen patients who underwent gait analysis had a heel-to-toe progression gait, and twelve achieved normal walking velocity with their shoes on. A plantigrade foot was achieved in each case, and only two patients had >5 degrees of residual deformity. During the Ilizarov treatment, forty-one minor complications (treated conservatively) and twenty major complications (treated surgically) occurred. After removal of the circular frame, seven other complications, which required four additional operations, occurred. CONCLUSIONS: In patients with a failed ankle fusion, infection, limb-length discrepancy, and foot deformity can be addressed simultaneously with use of the Ilizarov apparatus to achieve a solid union and a plantigrade foot, usually with a clinically satisfactory result.     

The results of a primary and staged pantalar arthrodesis and tibiotalocalcaneal arthrodesis in adult patients

Twenty-three patients (twenty-seven feet) with either a primary or staged pantalar arthrodesis or a tibiotalocalcaneal arthrodesis were evaluated to determine their clinical status. The main indication for the operation was the presence of severe pain unresponsive to non-operative treatment. Fourteen feet (twelve patients) had a pantalar arthrodesis; a fusion of the ankle, subtalar, talonavicular and calcaneocuboid joints. Half the feet in this group had either a triple arthrodesis or an ankle fusion performed at an earlier time. The remaining seven feet had all joints fused during the same operation. Thirteen feet (eleven patients) had a tibiotalocalcaneal arthrodesis. Two of these feet had an ankle arthrodesis performed four and six years previously. The other eleven had the ankle and subtalar joints fused during the same operation. All patients were followed for a mean of fifty-five months (14 to 159 months) from the time of their final arthrodesis procedure. Overall, twenty-three of the twenty-seven feet achieved a solid arthrodesis of all joints operated upon. Four feet had a failure of fusion of only a single joint and all were in the pantalar group. The mean time to radiographic fusion was twenty-three weeks and resulted in a plantigrade foot with an average tibia-floor angle of 87 degrees. Complications occurred in ten feet (37%); of which there were three deep infections; two ankles and one subtalar joint. These arthrodeses procedures resulted in marked relief of the patients' preoperative pain, the main indication for performing the surgery. Postoperatively there was no pain in eleven feet, mild occasional pain in thirteen feet, and moderate pain in only three feet. However, when all parameters of our clinical rating scale were evaluated, only five patients had an excellent clinical result, nine were rated good, three were rated fair and six patients had a poor result. These operations must be considered to be salvage procedures. They are technically difficult to perform and major complications may occur. Pain relief appears to be the main indication for performing these operations, and may account for whatever improvement occurs in the patient's function.     

Correction of persistent clubfoot deformities with the llizarov external fixator Experience in 10 previously operated feet followed for 2-5 years

We reviewed the outcome in 10 idiopathic clubfeet in 7 patients treated with the llizarov external fixator (IEF) for persistent foot deformities after previous surgery. After follow-up of a median of 40 (25-56) months, 6 patients/parents were satisfied with the results and most of them reported better walking capacity and fewer problems finding shoes that fit. Severe equinus deformity was seen in 9/10 feet prior to treatment in the IEF and in no foot at follow-up. However, persistent reduction of ankle joint motion., limited walking capacity and intermittent pain were commonly found.