Deformity correction and lengthening of lower legs with an external fixator

Deformities combined with shortening in 34 lower limb segments of 28 patients were treated with an Ilizarov external fixator or a Taylor spatial frame at the same level as the osteotomy. We compared an acute correction group (A) with a gradual correction group (G) in patients undergoing deformity correction followed by lengthening. We retrospectively examined the amount of deformity correction, length gained, distraction index, maturation index, and external fixation index in both groups. The mean age of subjects was 12.9 years for A, 17.9 years for G. The mean deformity correction was 17.8 degrees for A, 25.1 degrees for G. Mean lengthening was 5.5 cm for A, 5.0 cm for G. Mean distraction index was 16.4 days/cm for A, 10.6 days/cm for G (P<0.05). Mean maturation index was 40.5 days/cm for A, 29.5 days/cm for G (P=0.081). Mean external fixation index was 58.6 days/cm for A, 42.5 days/cm for G (P<0.05). The distraction index and external fixation index differences between the two groups were statistically significant. Gradual correction may represent a better approach than acute correction with the use of external fixators to treat deformity combined with shortening.

Lengthening of congenital forearm stumps

The Ilizarov device and distraction osteogenesis method became very useful in correction and elongation of forearm defects. Two cases of forearm elongation with congenital transverse defect are described. The construction of the device is provided. During follow-up examination, 2 and 7 years after the treatment, good clinical results were achieved in both patients with the use of upper limb prosthesis employing the patient's own elbow joint. Presented application of the Ilizarov method can significantly improve possibilities for the use of prosthesis in patients with congenital upper limb defects and result in better cosmetic and functional outcome.

Treatment of a congenital pseudarthrosis of the tibia by osteogenic protein-1 (bone morphogenetic protein-7): a case report

Congenital pseudarthrosis of the tibia remains one of the most difficult orthopaedic problems to treat. Before the use of a recombinant bone morphogenetic protein (bone morphogenetic protein-7; osteogenic protein-1) the patient with congenital pseudarthrosis of the tibia in this report had had 12 unsuccessful surgeries. Five months after radical resection of sclerotic tibial segments, Ilizarov fixation and administration of osteogenic protein-1 osteogenic device, the congenital pseudarthrosis of the tibia healed; at 45 months the tibia increased in size and the patient was fully weight bearing.

A new double elevating osteotomy in management of severe neglected infantile tibia vara using the Ilizarov technique

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.

Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.

[Mini-invasive distraction technique for treatment of severe ankle and foot deformities secondary to ischemic contracture of the leg]

OBJECTIVE

To explore the Ilizarov mini-invasive distraction technique for the treatment of severer ankle and foot deformities secondary to ischemic contracture of the leg.

METHODS

Based on the tension-stress low of Ilizarov, a serial of adjustable three dimensions external distractive instrument was developed in our department. From April 2002 to March 2004, 8 patients with ankle and foot deformities secondary to ischemic contracture of the leg induced by trauma and fracture were treated with the distractive instrument. Of them, 4 patient were male and 4 female, aged from 13 to 31 years with an average of 23 years. Five affected legs were in the left and 3 in the right. Preoperative abnormal style included talipes equines in 6 feet and equinovarus in 2 feet, with extensive scar contracture in the legs. Five patients suffered from failure of soft tissue release before, two patients with severe bony deformity of the feet were underwent limited foot triple osteotomy in this department before the distractive correction. The distraction was begun from 7 d after operation and distractive time from 29 to 60 d with an average 46 d.

RESULTS

All of the 8 patients were followed up from 10 months to 29 months, with an average of 13 months. All of deformities in the feet were corrected satisfactorily, full feet contacted with the ground in stand or walking and achieved with good function. No complication, such as pin tract infection, skin necrosis and neurovascular injury was occurred in this group.

CONCLUSIONS

Mini-invasive distraction technique for treatment of severe ankle and foot deformity secondary to ischemic contracture of the leg is safe and mini-injury, it is also an effective approach for the treatment of various kinds of rigid foot anomaly.

The Revised ???Reconstructive Ladder??? and Its Applications for High-Energy Injuries to the Extremities

In this report, we tried to evaluate the merits of the classic "reconstructive ladder" and other reconstructive tools, such as acute shortening followed by distraction osteogenesis and a vacuum-assisted closure device, for the treatment of high-energy injuries. Thirty-seven patients suffering from high-velocity injuries to the extremities caused by war weapons and blast terror attacks were treated at our institution. The fractures were initially stabilized by the Association for the Study of Internal Fixation (AO/ASIF) unilateral tubular external fixator, which was changed 2-3 days later to a circular Ilizarov frame for 19 patients. Temporary acute shortening was performed for 5 patients. Skin grafts were performed for 21 patients, local or regional flaps for 14 patients, and free flaps for 6. Vacuum-assisted closure was selected for 8 patients. The wounds were successfully closed in all the patients. Two patients with upper-limb injuries had nonunion. Motor nerve injuries recovered in 7/10 patients. Due to hypergranulating tissue, 2 patients treated with vacuum-assisted closure (VAC) had to stop treatment early. Their wounds were closed with skin graft or local flap. The classic reconstructive ladder, starting from direct closure and ending with a free flap, should be extended for limb traumas and include acute shortening with or without angulation, followed by distraction osteogenesis and the VAC system on the same step as the free flap.

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.

Current concepts and techniques in posttraumatic arthritis

Posttraumatic arthrosis is a commonly encountered clinical problem, but the pathoetiology of its development is not yet clarified. Many contributing mechanical biologic factors interplay with the traumatic event that necessarily precedes the posttraumatic syndrome. New biologic concepts involving the ability of the cartilage to repair and how such healing can be promoted are being realized in new modalities of treatment. The traumatic event as such and the resulting pathomechanical consequences require new ways of evaluation.

Operative reconstruction for septic arthritis of the hip

The long-term effects of initial treatment for infantile septic arthritis of the hip differ and depend on patient age, infecting organism, and timing and adequacy of surgical and pharmacologic treatment. Appropriate and timely reconstructive operations benefit hip growth and development by providing the best possible hip joint mechanics at skeletal maturity. Any surgical treatment for severe sequelae, however, must be regarded as a measure that temporarily improves clinical function and delays the more definitive procedures that are reserved for adult patients. This article summarizes the surgical modalities currently available to reduce and stabilize a damaged femoral head and neck and to reconstruct femoral-acetabular articulation.

Management of nonunion with distraction osteogenesis

Nonunions of long bone fractures represent a clinical entity that is commonly perpetuated by a high velocity injury. There are both bony and soft tissue factors responsible for the nonunion. This paper is focused on the reported clinical and radiographic outcomes whenever treatment protocols pertaining to distraction osteogenesis are implemented.

Pulsed low-intensity ultrasound: a new salvage procedure for delayed unions and nonunions after leg lengthening in children

From 1998 to 2001, 112 lengthening procedures with or without deformity correction were performed in 108 children by external fixation with the Ilizarov method. Of these cases, 16.9% did not lead to a solid bone consolidation. Two children were operated the second time, mainly because of the parent's decision. Seventeen delayed unions or nonunions in 13 children were treated with low-intensity pulsed ultrasound. All 17 cases healed within 3 to 12 months without any risk of surgical intervention.

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

BACKGROUND

Malunion and nonunion of an ankle fusion site are associated with pain, osteomyelitis, limblength 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.

Modification of the Ilizarov external fixator for aseptic hypertrophic nonunion of the clavicle: an option for treatment

OBJECTIVE

To assess the results of treatment of aseptic hypertrophic nonunion of the clavicle by external fixation using a modified Ilizarov apparatus.

DESIGN

Prospective study.

SETTING

A consecutive series of 12 patients from 2 specialized orthopaedic institutions, treated by the 3 senior authors.

PATIENTS

Twelve patients (5 females) with a mean age of 38.7 +/- 12.4 (range, 18-50) years with an aseptic hypertrophic nonunion of the clavicle were treated operatively during the period 1994 to 1998. Ten patients had previously been treated nonoperatively, whereas 2 had been treated surgically; the treatment in all had failed. All patients had pain with shoulder stiffness.

INTERVENTION

Patients were treated using the Ilizarov external fixation technique. The operation was performed under general anesthesia and an Ilizarov external fixator was applied percutaneously under fluoroscopic control, without a skin incision or bone grafting. The patients were then monitored clinically and radiologically for 24 to 96 (mean, 45.4) months.

MAIN OUTCOME MEASUREMENTS

Radiologic evaluation and clinical assessment by the Constant numerical score.

RESULTS

The mean Constant preoperative score was 30.4 +/- 9 (range, 18-44). Healing of the nonunion occurred in all patients treated by the Ilizarov technique. Nine patients had pain relief and gained unlimited range of motion, whereas 3 patients had mild pain during elevation of the arm. A mean period of 75.4 (range, 50-95) days was needed for gradual bone reduction and union. The mean Constant outcome score was 68.8 +/- 14.7 (range, 46-85).

COMPLICATIONS

2 patients had superficial pin infections that cleared with local therapy and antibiotics, and 1 patient had a reoperation for a nonunion after a fall onto the floor.

CONCLUSIONS

Ilizarov fixation seems to be an effective method in the treatment of aseptic hypertrophic clavicle nonunions, even in patients where previous surgery has failed.

Ilizarov treatment of complex tibial pilon fractures

We treated 21 consecutive patients between 1998 and 2002 with complex tibial pilon fractures, eight type B and 13 type C, using percutaneous reduction and fixation with the small diameter Ilizarov apparatus. The average patient age was 34+/-5.6 years (range 28-52 years). Nine of the patients had open fractures (two type I, four type II, and three type IIIA). The patients were followed up regularly at 6-month intervals for 2 years. All fractures united. The fixator was removed at an average of 26.6+/-4.2 weeks (range 20-34 weeks). The average American Orthopaedic Foot and Ankle Society ankle-hind foot score was excellent in 11 patients, good in five, fair in four, and poor in one. Thirteen patients were able to squat and climb stairs.

The treatment of infected diaphyseal femoral defects by lengthening one of the bone fragments by Ilizarov

We analyzed 30 patients with infected diaphyseal defect of femur, which have been treated by lengthening one of the bone fragments with Ilizarov apparatus. The mean length of the bone defect was 6 cm. Substitution of the defect, bone healing and elimination of the infection was achieved in 27 patients. The mean time of apparatus fixation was 10 months. According to Palley scoring system, 10 patients had excellent functional results.

[Ultrastructural characteristics of endotheliocytes of skeletal muscle hemomicrocirculatory bed during tibial lengthening using G. A. Ilizarov technique]

The method of transmission electron microscopy was used to study the ultrastructure of endotheliocytes in the hemomicrocirculatory bed of the anterior tibial muscle of adult dogs during tibial lengthening with Ilizarov method. The capacity of endotheliocytes to reduction and renewal was established. The tension stress induced in the biological tissues of the lengthened limb stimulates and supports high activity of endotheliocyte nuclear apparatus, which is characterized by the prevalence of euchromatin. Presence of capillaries with closed lumen at all time points studied is indicative of a prolonged angiogenesis process in the terminal parts of the hemomicrocirculatory bed, which is accompanied by regeneration and growth of the muscle fibers. After the cessation of distraction, while the muscle tissue continued to grow and differentiate, the endotheliocyte growth and the activation of their synthetic apparatus was noted.

Novel Approach to Calvarial Bone Transport Using a Rabbit Model

Calvarial defects sometimes require cranioplasty to protect the brain. Alloplastic materials, such as acrylic resin, hydroxyapatite ceramics, and titanium, involve various problems, such as vulnerability, infection, deformity resulting from growth, and high cost. We devised a new bone transport model in the rabbit based on the distraction osteogenesis theory of Ilizarov. Twelve Japan white rabbits with a mean body weight of 2.5 kg aged 12 weeks were used. Craniectomy (7 x 14 mm) was performed in 12 rabbits. Trapezoid bone osteotomy was performed anterior to the calvarial defect in 10 rabbits. The distraction device (Extension-plates) was fixed between the trapezoid bone island and the skull. Distraction was initiated 5 days postoperatively. The device was activated once every other day, with approximately 0.75 mm or 0.5 mm per activation. Bone distraction was continued until the rod could not be moved. The lengths of distraction were 4 mm in two cases, 5 mm in one case, 6 mm in one case, and 7 mm in two cases, with a mean of 5.5 +/- 0.56 mm. Both radiographic and histological findings showed osteogenesis by intramembranous ossification and trans-chondroid bone formation. Distraction osteogenesis has potential clinical applications in cranioplasty, especially in children because usage of autogenous bone is difficult if not impossible in most cases.

[Reconstruction of the infected war defects of the tibia: a fragment elongation according to the Ilizarov technique]

INTRODUCTION/AIM

The treatment of tibia defects complicated with chronic osteomyelitis is difficult, often requiring one or more surgical interventions with prolonged periods of functional incapacity.

METHODS

We treated 20 patients with tibia defects, who had been wounded during the war operations in the former Yugoslavia, complicated with chronic osteomyelitis by applying the Ilizarov apparatus. In 10 patients with the average defect of 4.7 cm, interfragmentary diastasis of 1.5 cm, and 3.1 cm of shortening we applied the bilocal synchronous compressive - distractive method (BSCD). In the remaining 10 patients with average defect of 6.4 cm, interfragmentary diastasis of 5.5 cm, and 1.6 cm of shortening we applied bilocal alternating distractive - compressive osteosynthesis (BADC).

RESULTS

The average followup was 93 months. In the group A, the average distraction index was 10.6, maturation index 39.8, and external fixation index 52.5. In the group B, the average distraction index was 11.7, maturation index 47.1, and external fixation index 60.1. The average time from the application to the apparatus removing was in the group A 6.5 months, and in the group B 11.9 months. There were 27 complications: 11 problems, 8 disturbs, and 8 true complications. Pin-track inflammation of the soft tissue was noted most frequently (6 patients).

CONCLUSIONS

One stage of repairing inflamation and the restitution of defect in lower leg tissue was the advantage of this type of treatment. All of the patients recovered. There was not any bad result, either in osteal or in functional outcome.

Bone transport with frozen devitalized bone: an experimental study using rabbits and a clinical application

We evaluated the feasibility of bone transport with frozen devitalized bone in the tibia of 20 adult female rabbits. A 1.5-cm segmental defect was created, followed by proximal tibial transverse osteotomy to remove a 2.5-cm segment to be transported after devitalization with liquid nitrogen. The proximal and distal tibia and the devitalized autogenous bone each were fixed with two half-pins. After 2 weeks, transport of the devitalized segment was initiated at 1 mm/day. In a control group, callus formed at proximal and distal osteotomy sites, and distracted callus gradually maturated. The docking site fused and the medullary canal reappeared by 8 weeks after completing distraction. In the frozen-bone group, bone formation proceeded from the proximal tibial end, and the distraction callus slowly matured. The transported segment remained nonviable until revascularization proceeded from its periphery, evident 8 weeks after completion of distraction. Docking sites fused well without infection at pin sites. There was no sign of infection around the pin sites of the devitalized bone. We finally describe similar successful treatment of a 13-year-old girl with tibial deformity resulting from osteofibrous dysplasia who was treated successfully with this procedure. Therefore, bone transport using frozen devitalized bone can regenerate living bone. This experimental model represents the development of a new reconstruction technique of bone transport with devitalized bone.

Outcome after foot and ankle deformity correction using circular external fixation

BACKGROUND

External fixation is the method of choice for correction of chronic severe foot and ankle deformities. We report our experience and outcomes of circular external fixation.

METHODS

Fifty-five patients (60 feet) were treated with circular external fixation. The mean age at surgery was 36 (range 16 to 65) years. The mean followup was 4.4 (range 1 to 10) years. The mean time spent in external fixation was 2.1 (range 1 to 12) months.

RESULTS

There were six excellent, 35 good, eight fair, and six poor results, five of which had below knee amputations. All the patients who had an amputation were treated for infected nonunion of the ankle.

CONCLUSION

Circular external fixation was found to be an effective method for treating a variety of complex foot and ankle problems. The complications were more common in patients with infected nonunions.

Outcome of pelvic support osteotomy with the Ilizarov method in the treatment of the unstable hip joint

Instability of the hip joint in the young adult is a difficult problem. Patients with an unstable hip secondary to any aetiology usually have loss of bone from the proximal femur or shortening of the limb or both. In this study we report our results in the treatment of the unstable hip joint in young adults by pelvic support osteotomy using the Ilizarov method. From 1997 to 2004, 25 patients (17 females and 8 males) with an unstable hip joint were treated in the Orthopaedic department of Mansoura University Hospital, Egypt. Their mean age was 22.4 years (range: 19 to 35). The main complaints were pain, leg length discrepancy, limping, and limited abduction of the hip. All patients underwent valgus extension osteotomy in the proximal femur and distal femoral osteotomy for lengthening. The average follow-up ranged from 2 to 7 years. All hips were pain free at follow-up. The Trendelenburg sign became negative in 20 patients. There was no limb length discrepancy and alignments of the extremity were re-established. Five patients had a lurch gait. Valgus extension osteotomy has provided stability of the hip joint and maintained some motion of the hip joint. By using the Ilizarov technique, we could prevent the valgus effects created by the valgus extension osteotomy while achieving lengthening of the femur through the distal osteotomy in the femur.

Cortical plasticity following surgical extension of lower limbs

Human cortical plasticity has been studied after peripheral sensory alterations due to amputations or grafts, while sudden 'quasi-physiological' changes in the dimension of body parts have not been investigated yet. We examined the cortical reorganization in achondroplastic dwarfs submitted to progressive elongation (PE) of lower limbs through the Ilizarov technique. This paradigm is ideal for studying cortical plasticity because it avoids the perturbation connected with deafferentation and re-afferentation. Somatosensory evoked-potentials (SEP) and fMRI studies were performed before and after PE during foot and knee stimulation, above and below the surgical fracture. A body schema test was also performed. Following PE, cortical modifications were observed in the primary somatosensory cortex for foot stimulation and in higher order somatosensory cortices for foot and knee. The former modifications tended to decrease 6 months after the elongation ending, whereas the latter tended to persist. Results are interpreted in terms of cortical adaptation mediated by temporary disorganization.

The use of the Ilizarov technique in the treatment of upper limb deformity in patients with Ollier's disease

Between 1997 and 2001 three children with Ollier's disease underwent treatment of five upper limb segments using the Ilizarov technique. Average length discrepancy was 8.4 cm in the arm and 4.5 cm in the forearm, but coexisting large angular deformities were the major problem in all the children. Full correction of the axial deviations was achieved in all children. Restoration of length was achieved in all arms, but residual forearm length discrepancy persisted. In four segments conversion of the abnormal cartilage into normal regenerate was observed on radiograms. The problems, obstacles, and complications are similar to those met in more usual lengthening procedures. The Ilizarov technique should be the treatment of choice in restoring the correct axis and length of a limb in patients with Ollier's disease.

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.

Prophylactic surgical correction of Crawford's type II anterolateral bowing of the tibia using Ilizarov's method

The treatment of anterolateral bowing with an intact tibia is directed toward prevention of the fracture and subsequent pseudoarthrosis. Patients with anterolateral bowing of the tibia are usually treated with an ankle-foot orthosis until the deformity is improved. There is no documentation that an orthosis can prevent the fracture or correct the deformity, and if the deformity is not corrected, it will result in different mechanical problems. In this study, 6 legs in 6 patients with anterolateral bowing of the tibia with a narrow sclerotic medullary canal (Crawford type II) were treated using Ilizarov's method. The average age was 6.8 years. All patients underwent correction of the anterolateral bowing by excision of the affected part. If the gap was less than 4 cm, acute shortening followed by bone lengthening was done. If the gap was more than 4 cm, bone transport was preferred. The mean duration of follow-up was 3.2 years. The anterolateral bowing was corrected in all patients. Complications such as pin track infection, premature consolidation and delayed union at the docking site were encountered. We believe that Ilizarov's method offers a more efficient solution for this type of deformity than prophylactic orthotic treatment or prophylactic bypass bone graft.

Segmental cement extraction system (SEG-CES) and the Ilizarov method in limb salvage procedure after total knee cemented prosthesis removal in a former osteosarcoma patient

Survival of osteosarcoma has greatly improved in the past few decades. Knee prosthesis is a well-recognized limb salvage procedure for osteosarcoma of the distal end of the femur. One drawback is that prostheses have a limited life and prosthetic failure with the inherent high rate of reoperations remains a serious long-term problem for former osteosarcoma patients. The segmental cement extraction system (SEG-CES) is a technique to remove cement in arthroplasty revision, based on a cement-bone interface with a lower strength compared to the old cement-new cement interface. We report the case of a 32-year-old former osteosarcoma patient in whom the SEG-CES was applied to remove a long-stemmed total knee cemented prosthesis. The prosthesis was placed 17 years before for a recurrent telangiectatic osteosarcoma of the left femur. Thirteen years after the prosthesis implantation, the patient complained of knee instability, pain, and complete failure of the extensor apparatus. The extraction of the prosthesis was performed using cylindrical batters of diameter corresponding to the diameter of the axle, two hammer extractors clamping the prosthesis components between two jaws. Extraction of the periprosthetic cement in the femoral and tibial components was done using the SEG-CES technique. The successful prosthesis removal performed in this patient allowed us to perform an external fixation with bone lengthening and reconstruction by the Ilizarov method.

Management of calcaneal fracture using the Ilizarov technique

Treating calcaneal fractures nonoperatively versus operatively is controversial. The aim of open reduction is to reduce the articular surface and to restore the calcaneal bone anatomy to recover its function. The disadvantages of open reduction include wound complications, risk of screw penetration of the articular surface and peroneal tendons, and irritation by the fixation plate. We treated 12 patients with Sanders Type 3 calcaneal fractures with poor skin condition persisting for more than 3 weeks, making them unsuitable candidates for typical open reduction and internal fixation. The 12 patients had open reduction of the articular surface of the subtalar and calcaneocuboid joints, then a bone graft using a direct approach to the subtalar joint. The fracture reduction was completed by fixing the calcaneal tuberosity with an Ilizarov external fixation frame and distraction. These outcomes of these 12 patients were compared with outcomes of a control group having the same type of fracture but treated with open reduction and internal fixation. We used the American Orthopaedic Foot and Ankle Society scoring system to assess the outcome. Both groups had similar functional and radiographic outcomes. The internal fixation group had a higher complication rate. The Ilizarov apparatus for reduction and fixation seems to be a safe and effective alternative to open reduction and internal fixation in patients with poor skin condition.

Role of Ilizarov external fixator in the management of proximal/distal metadiaphyseal pediatric femur fractures

Given the constraints of a short metaphyseal fragment and adjacent growth plates, there are limited options for operative fixation of metadiaphyseal fractures of the femur in children. This article outlines the surgical technique and reports early results of metadiaphyseal pediatric femur fractures treated with an Ilizarov external fixator by a single surgeon. Ten skeletally immature males with 5 proximal and 5 distal metadiaphyseal femur fractures underwent closed reduction and application of an Ilizarov external fixator. Time in the fixator averaged 138 (range, 104-180) days. At a mean follow-up of 26 months, there were no cases of loss of reduction, refracture, malalignment, leg length inequality, or loss of knee and hip mobility. Although superficial pin tract infections were common, no patient developed deep infection or required premature pin removal. One patient developed a transient foot drop after external fixation for a distal metadiaphyseal fracture, which recovered after revision of the pin construct. A low profile Ilizarov fixator can be effective in the management of certain metadiaphyseal pediatric femur fractures that may be difficult to manage by traditional methods.

[Knee arthrodesis with external ring fixator after infected knee arthroplasty]

INTRODUCTION

Infection following knee arthroplasty is a severe complication which may lead to arthrodesis or even amputation. We wanted to examine the results after arthrodesis of the knee using the Ilizarov ring fixator in eight patients.

MATERIALS AND METHODS

Eight patients (seven females, one male) who underwent knee arthrodesis with the Ilizarov external fixator were studied retrospectively. Their median age was 63 (51-84) years. The mean follow-up period after removal of the fixator was 10 months.

RESULTS

Six arthrodeses healed without further operation. One patient died before the end of follow-up. One patient had an above-knee amputation because of chronic infection. Associated complications were the complications/problems which are already well known.

DISCUSSION

The Ilizarov ring fixator is a reliable method for performing arthrodesis after removal of an infected total knee arthroplasty.

Ipsilateral fibular transfer for a large tibial defect caused by a gunshot injury: case report

Segmental bony defects in open fractures of the tibia are bridged with bone grafting, free vascularized fibular grafts, or an external ring fixator. A 33-year-old man sustained a gunshot injury to his left leg, resulting in Gustillo type IIIB open fractures of the tibia and fibula. The tibia had a segmental massive defect of 19 cm in the midshaft. Debridement and immediate application of an Ilizarov external fixator were performed. The midportion of the ipsilateral fractured fibula served as a bridging vascularized graft for the tibial defect. Good bony union and fibular hypertrophy were obtained. Use of a fractured fibula from a zone previously injured by a gunshot has not been reported. This case demonstrates the successful transfer of a fractured fibula for the bridging of an ipsilateral tibial defect caused by a gunshot injury.

Pre-centralization soft tissue distraction for Bayne type IV congenital radial deficiency in children

There are several surgical options for the treatment of severe congenital radial deficiency. The aim of the current study was to evaluate the results of a staged protocol consisting of gradual soft tissue distraction with an Ilizarov external fixator followed by centralization of the ulna. Three patients (four extremities) with Bayne type IV radial club hand were treated at an average age of 18 months. At a follow-up of 26 months, an average correction of 72 degrees in the hand-forearm angle and an improvement of 19 mm in the hand-forearm position were obtained. There were no cases of neurovascular compromise, wound infection, carpal resection, or ulnar shortening. All families were pleased with the results. These findings suggest that a staged surgical approach is a technically feasible alternative in the treatment of severe congenital radial club hand deformity in young children.

Treatment of tibial hemimelia without amputation: preliminary report

Treatment of tibial hemimelia, traditionally, is by amputation. This is not acceptable in our community. Hence we treated our cases without amputation. We treated two cases of type Ia and four cases of type II tibial hemimelia. The age at operation ranged from 3.5 to 13 years For type Ia cases, we applied the Ilizarov external fixator to the femur, fibula and foot to centralize the fibula between the femoral condyles and talus using gradual distraction. The second step was the Brown procedure. Then the fixator was reapplied to correct the deformities. For type II, synostosis of the tibia and fibula was performed followed by differential lengthening. Then we overlengthened the femur. After follow-up for 2-5.5 years, all patients showed improved function and were satisfied. The tibial lengthening ranged from 6 to 8.5 cm, and femoral lengthening ranged from 5 to 7 cm.

Surgical correction of bowlegs in achondroplasia

A retrospective review of 39 surgical procedures to correct bowlegs in achondroplasia was performed. Three operative procedures had been used sequentially over 27 years. Sixteen tibiae were treated by proximal closing wedge tibial osteotomy, proximal fibular epiphysiodesis and casts. Twelve tibiae were treated by opening wedge osteotomies using external fixation with no fibular shortening. Eleven tibiae were treated by the Ilizarov technique with 3-cm tibial lengthening, deformity correction, and distal translation of the proximal fibula. The Ilizarov technique is the most satisfactory method for correction of proximal bowlegs in early childhood. Distal tibial osteotomy and fibular shortening is recommended for correction of distal bow legs in older children.

Treatment of femoral nonunions by using cyclic compression and distraction

Eleven patients with femoral diaphyseal nonunions after intramedullary nailing were treated with cyclic compression and distraction with an external fixator over the nail. We evaluated the limitations of this technique and whether patients having this closed procedure could achieve union without additional operative procedures. Patients with hypertrophic nonunions (n = 4) were treated with gradual compression of the nonunion site. Cyclic compression and distraction was done in patients with oligotrophic (n = 2) or atrophic nonunions (n = 5) to stimulate consolidation. The average age of the patients was 32.9 years (range, 21-48 years), and the average followup was 40.5 months (range, 24-64 months). Union was achieved in an average of 5.8 months in all patients after one operation and without additional surgical intervention. However, pain necessitating strong analgesic agents and pin-related complications consisting of osteomyelitis, septic arthritis, and pin breakage in the atrophic nonunion group were a major limitation of this technique. Based on our study, the cyclic compression and distraction technique can be used in hypertrophic and oligotrophic nonunions that have failed one or more prior exchange nailings. However, it might not be an option for treatment of patients with atrophic nonunions unless pin-site problems are resolved.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Extreme bone lengthening using distraction osteogenesis after trauma: a case report

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.

Reconstruction with Distraction Osteogenesis for Juxta-articular Nonunions with Bone Loss

BACKGROUND

Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis.

METHODS

Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation.

RESULTS

Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two.

CONCLUSION

Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.

Surgical treatment of the severe sequelae of infantile septic arthritis of the hip

We retrospectively reviewed 45 hips in 43 patients with severe sequelae of infantile septic arthritis of the hip to compare the efficacy of various hip reconstructive and salvage surgeries, and to propose an algorithmic treatment protocol for the different types. Ten hips were classified as Choi Type IIIA, three as Type IIIB, 14 as Type IVA, and 18 as Type IVB sequelae. A total of 78 hip surgeries and 18 limb-length equalizations (three contralateral femoral epiphysiodesis and 15 ipsilateral femoral and/or tibial lengthenings) were done. The first surgical reconstructions were done at an average age of 5.9 years (range, 1.1-14.8 years), with a 9.5-year average followup. Type IIIA hips had better functional results than the other types. In Type III hips, early realignment osteotomy of the proximal femur or bone-grafting of the pseudarthrosis was indicated. In Type IVB hips, satisfactory results were observed in only five of 10 hips treated by trochanteric arthroplasty compared with satisfactory results in all four hips treated by Ilizarov's hip reconstruction osteotomy. The latter operation seems to be better indicated in older patients with Type IVB hips, or with Type IVA hips in which previous reconstructive surgery was unsuccessful.

[Injectable carrier system for growth factor application in minimally invasive stimulation of bone healing]

The characterization and cloning of growth factors for bone healing provide an enormous potential for minimally invasive treatment procedures for bone defects or fractures. However, the clinical application of injection vehicles for these growth factors must be made user-friendlier. In this study, two different injection vehicles were tested for their practicability and efficacy to enhance callus maturation during distraction osteogenesis. Calcium phosphate carriers showed a rather low user-friendliness and were less efficient in the animal model of distraction osteogenesis in sheep. Collagen carriers provided both a higher practicability for injection procedures and a higher efficacy.

Above-knee Ilizarov external fixation for early periprosthetic supracondylar femoral fracture--a case report

Supracondylar femoral fractures above a total knee replacement are rare injuries that may be challenging to treat. We present a 60-year-old woman who sustained a supracondylar femoral fracture 10 days following a total knee replacement. This patient had multiple risk factors. The fracture was not deemed amenable to conventional treatment. This patient underwent fixation of her femoral fracture above a total knee replacement using a two-ring above-knee Ilizarov external fixator. This allowed full mobilization of the affected limb during fracture healing. The fixator was removed at 10 weeks, at which time the fracture was solidly healed. At the most recent follow-up, 14 months from injury, she was fully weight-bearing without walking aids and had a knee range of motion of 0-120 degrees .

Reconstruction of defects following bone tumor resections by distraction osteogenesis

INTRODUCTION

The authors present the results of nine patients (two females, seven males) who had bone tumors that were treated with en bloc resection and distraction osteogenesis between 1991-2000.

MATERIALS AND METHODS

The average age of the patients was 19.3 years (14-42 years). The histological diagnosis was osteosarcoma in four cases, Ewing's sarcoma in two, giant cell tumor in one, osteofibrous dysplasia in one and osteoblastoma in one. A uniplanar external fixator was applied to one case and circular external fixator to the other eight cases.

RESULTS

The average follow-up period was 59.1 months (27-129 months). The external fixator was removed at an average of 18.1 months (range, 4-19 months). The average bone defect after resection was 14 cm (8-24 cm) and the average external fixation index, distraction index, and maturation index were 31.5 (18.7-40.0), 11.2 (10.9-11.2) and 17.8 (7.5-32.7), respectively. The function of the affected leg was excellent in four patients, good in three, fair in one and poor in one according to the Enneking scoring system. We did not observe any early consolidation or osseous binding in the defect area in any patient. Frequent complications were pin tract infection and non-union at the docking site.

CONCLUSION

Our results indicate that the Ilizarov method allows effective restoration of bone defects in the treatment of bone tumors despite various disadvantages.

[Elastic stable intramedullary nailing in Ilizarov bone lengthening]

PURPOSE OF THE STUDY

Bone lengthening with the Ilizarov technique gives good results but certain disadvantages are common: possible axial deviation during lengthening, long time to bone union, risk of fracture after removal of the external fixator. Associating the Ilizarov technique with elastic stable intramedullary nailing (ESIN) commonly used in traumatology has to be evaluated. We conducted an experimental study and report results of the first clinical application.

MATERIAL AND METHODS

Eleven lengthenings of the tibia were conducted in dogs aged 1 to 4 years using an Ilizarov external fixator associated with ESIN. Lengthening started on day 1 and continued for 28 days. X-rays were obtained every week during lengthening, then at 15 and 30 days during the fixation period and 30 days after removal of the fixator. In two cases, arteriography was performed. In a pilot clinical trial, fourteen patients (8 males, 6 females) were treated with this method (1 humerus, 1 forearm, 7 femurs, 5 tibias). Mean patient age was 14 years.

RESULTS

In the experimental study, the x-rays showed rapid ossification of the regenerate which led to increased tibia length in 7 cases from 1.25 to 2 mm/day. Total bone union was observed in four dogs during the lengthening period. At day 15 of the fixation period, all tibia had fused with a good quality cortical bone and healing of the growth part of the regenerate. In three dogs, the external fixator was removed at day 15 of fixation and weight-bearing was total with the ESIN in place. No axial deviation and no skin problems were observed. The medullary artery was seen on the two arteriograms. In the clinical trial, bone union of the regenerate appeared earlier than in the Ilizarov series. The regenerate always displayed good density on the x-rays, proving intense bone activity. In three patients, the lengthening rate was increased to avoid premature bone fusion. The endosteal bone regenerate was obvious. Mean healing index was 18.6 days/cm (SD=6.2). Weight-bearing was allowed at six weeks. The desired correction was achieved in all patients and no complications were related to ESIN.

DISCUSSION

Bone lengthening may be obtained with an intramedullary locking nail which avoids the use of an external fixator but also destroys the endomedullary circulation. Our experimental and clinical study shows that use of an ESIN does not inhibit the endosteal regenerate and seems to improve new bone formation. In many patients, the lengthening rate had to be increased to avoid premature bone fusion. When used in optimal conditions, ESIN can stimulate new endosteal and periosteal bone formation. In addition, ESIN increases shaft stability avoiding the risk of axial deviation. ESIN plays an additional role of stabilization after early removal of the external fixation.

Evaluation of effectiveness of 10% polyvinylpyrrolidone-iodine solution against infections in wire and pin holes for Ilizarov external fixators

CONTEXT AND OBJECTIVE

Superficial infection at wire and pin insertions in the skin is a frequent disorder among patients utilizing the Ilizarov method. The objective of this study was to evaluate the effectiveness of daily topical application of 10% polyvinylpyrrolidone-iodine solution against infections of the holes for Kirschner wires and Schanz pins among patients using Ilizarov external fixators, in comparison with cleaning these holes only with 0.9% sterile physiological saline solution.

DESIGN AND SETTING

Controlled randomized clinical trial, in the Orthopedics and Traumatology Outpatient Clinic, Hospital São Paulo, and Orthopedics and Traumatology Center of Jundiaí.

METHODS

30 patients were treated using the Ilizarov technique: 15 were instructed to apply 0.9% physiological saline dressing on the wire and pin insertions and 15 to apply 0.9% physiological saline plus 10% polyvinylpyrrolidone-iodine. Patients were evaluated at outpatient return visits for identification of signs and symptoms of superficial infection at wire and pin insertion sites. Samples were collected from cases of purulent exudate secretion, for culturing and clinical tests.

RESULTS

The chi-squared and Fischer exact tests were applied, but no statistically significant association between the intervention of topical polyvinylpyrrolidone-iodine solution and the prevention of infections at wire and pin insertions could be found.

CONCLUSIONS

Topical 10% polyvinylpyrrolidone-iodine solution applied daily to Kirschner wire and Schanz pin insertions did not reduce the incidence of superficial infection at these holes, in comparison with mechanical removal of dirt using 0.9% physiological saline solution.

[Constituted adult equine from the ankle: surgical treatment by Ilizarov external fixator]

INTRODUCTION

Ilizarov's external fixator indications are classically used in children to lengthen the lower limbs. This technique is used for adults to gradually correct articular limitations, especially in the knee, ankle and foot.

METHOD AND RESULTS

We report a case of a 53-year-old patient with distal microangiopathy of the lower limbs leading to amputation of the toes and a bilateral, direct, irreducible, isolated equine feature? from the back foot to 0/50/60 degrees? on retraction of the Achilles tendon. The aim of patient management was to regain walking ability. Because of vascular and cutaneous fragility, the classical surgical treatment was contra-indicated. Progressive reduction by Ilizarov's external fixator was tried. Dorsal inflection was obtained by twice-daily screwing until a radiological angle of 90 degrees was obtained between the tibia and talus. At ten weeks post-surgery, the dorsal voluntary inflection ankle amplitude was symmetrical to 0/10/60 degrees. The patient walked with orthopaedic shoes compensating for the few degrees of residual equine.

DISCUSSION

Correction of adult equine without osseous deformation by Ilizarov's external fixator should be considered when conventional surgery is contra-indicated.

Nonunion of the diaphysis of long bones

The treatment of diaphyseal nonunion of long bones is difficult and controversial. We retrospectively reviewed 113 patients with diaphyseal nonunion treated by various modalities, during 15 years at one institution. There were 36 cases of nonunion of the tibia, 23 nonunions of the femur, 21 nonunions of the humerus, 13 nonunions of the radius, 18 nonunions of the ulna and two nonunions of the clavicle. The minimum followup was 24 months (average, 40 months, range 2-15 years). The nonunions were classified as aseptic (84) and septic (29) and additionally classified as hypertrophic (61) and atrophic (52) in order to determine the treatment. The treatment was individualized based on the stability at the nonunion site, need for bone grafting, and control of infection. All fractures healed and every patient in the study regained functional use of the limb without pain or instability and functional range of movements that they had at the time of presentation with nonunion. Residual problems seen in some patients were joint stiffness, limb length discrepancy, and angular deformity. Twenty-six patients required repeat surgery using bone grafting because no satisfactory progress of fracture healing was seen in 4 months. Complications were related to the iliac crest donor site and persistent infection at the nonunion site.

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.