Taylor spatial frame in severe foot deformities using double osteotomy: technical approach and primary results

The Gradual Correction of Adult Severe Rigid Equinus Deformity Using Minimal Invasive U-Osteotomy With Taylor Spatial Frame

BACKGROUND

U-osteotomy with Taylor Spatial Frame correction is a rarely reported treatment method particularly well-suited for severe rigid equinus deformity in adults. The purpose of this study was to evaluate the effectiveness and efficacy of deformity correction and clinical outcome using this technique.

METHODS

We present a retrospective review of 30 feet in 26 patients who received U-osteotomy with Taylor Spatial Frame. Radiologic outcomes were measured using the anterior tibiotalar angle (TTA) with conventional weightbearing radiographs. Functional assessments included American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores and patient satisfaction using Likert scale.

RESULTS

The etiology included trauma (9), neglected or relapsed clubfoot (6), spina bifida (5), poliomyelitis (4), Charcot-Marie-Tooth disease (4), and iatrogenic (2). All patients had equinus deformity with TTA more than 140 degrees (median 157.5, 141-177). There were varus deformity in 19 feet, limb length discrepancy in 6 legs, and genu procurvatum deformity in 2 legs. The duration of gradual correction was 53.6±13.5 days (33-73 days), and the external fixation time was 147.8±25.2 days (98-203 days). At last follow-up, TTA in all patients improved significantly (P < .001) to 113.5 degrees (111.8-116.0). All patients had plantigrade feet, except for 2 cases of residual mild equinovarus deformity, 2 cases of residual mild hindfoot varus deformity, 1 case of moderate hindfoot varus recurrence. The AOFAS scores significantly improved (P < .001) from 51.0 points (29.0-66.0) to 76.0 points (69.5-88.0). Eighteen patients were very satisfied, 6 patients were somewhat satisfied, and 2 patients were somewhat dissatisfied.

CONCLUSION

Using minimally invasive U-osteotomy with Taylor Spatial Frame to gradually correct the adult severe rigid equinus deformity proved to be an effective and relatively safe method associated with high patient satisfaction rates.

LEVEL OF EVIDENCE

Level IV, case series.

Updates in the Surgical Management of Recurrent Clubfoot Deformity: a Scoping Review

PURPOSE OF REVIEW

This article focuses on the current advances in surgical management for clubfoot deformity, supported by up-to-date longitudinal studies on each approach.

RECENT FINDINGS

Long-term analysis following primary and repeated soft tissue releases has demonstrated good results in young patients with low relapse rates. Tibialis anterior transfer following the Ponseti method shows no difference in long-term pedographic analysis in comparison to the Ponseti method alone. Furthermore, tibialis anterior transfer following surgical relapses provides good long-term results with improved correction in talus-first metatarsal angle. Bony osteotomies may also play a role in addressing surgical relapses in older children. However, talar neck osteotomy may result in avascular necrosis of the talar dome. Hexapod external fixation may be considered by experienced surgeons to correct rigid clubfoot deformities in older patients with good long-term results and drastic improvements in pain perception. Long-term analysis of anterior distal tibial epiphysiodesis (ADTE) for recurrent equinus deformity following surgical correction has demonstrated statistical improvements in the anterior distal tibial angle (ADTA) and ankle dorsiflexion. Talectomy and naviculectomy are rarely used in today's practice as long-term studies have demonstrated high relapse rates and residual pain impeding patient mobility. Surgical correction following failure of the conservative approaches can be implemented to achieve full correction in clubfoot deformity. It is difficult to achieve a plantigrade feet with pain-free gait with repeated surgical interventions. Therefore, proper choice of the initial surgical technique is essential for achieving satisfactory long-term outcomes.

Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7-14-year Follow-up

Charcot arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. Conventional surgical treatment includes extensive surgical exposure, excision of bone, acute correction and internal fixation, which is not always appropriate in presence of active ulceration, infection and poor bone quality. A minimally invasive approach to osteotomies and gradual correction of deformities using a circular frame are proving helpful in minimizing the complications. Taylor Spatial Frame (TSF) hexapod with its various modules is well suited for a range of foot and ankle deformities. We have advocated minimally invasive targeted hind and mid foot osteotomies and gradual correction with Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. There are 2 female and 8 male patients in this cohort. Appropriate TSF module was chosen for each patient– a long bone module for ankle and hindfoot deformities (4 patients) and a forefoot 6x6 butt frame (6 patients) for foot deformities. An osteotomy through the midfoot was performed in all chronic stable foot deformity cases. In the ankle and hindfoot deformities, a combination of soft tissue distraction correction of equinus and acute correction of hindfoot deformity through a calcaneal osteotomy, were used. Our outcome measures are complete healing of the ulcers and resolution of infection, clinically plantigrade foot and ability to wear regular or diabetic footwear. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. We achieved ulcer and infection free plantigrade feet that fit in to regular or diabetic footwear in 9 out of 10 patients. 9 patients remain ulcer and infection free at a minimum of 7 years and maximum of 14 years follow up. Taylor Spatial Frame treatment provides an alternative to conventional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities.

How to cite this article: Lahoti O, Abhishetty N, Shetty S. Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7–14-year Follow-up. Strategies Trauma Limb Reconstr 2021;16(2):96–101.

Narrative review of ring fixator management of recurrent club foot deformity

Despite the widespread use of the Ponseti method for treatment of clubfeet, there continue to be a significant number of patients who present with a severe, stiff clubfoot as a result of extensive intra-articular soft tissue release or lack of access to care. In such patients, circular external fixators can be utilized for deformity correction with distraction across soft tissues, joints, and osteotomies. Ilizarov or hexapod circular fixators may be utilized according to surgeon preference. Indications for soft tissue release and osteotomies to aid in correction of clubfoot deformity with Ilizarov and hexapod fixators are not standardized and are guided by patient age, joint congruity, soft tissue suppleness, and osseous deformity. Correction time varies according to clubfoot deformity severity. Following deformity correction, external fixators are left in place for several weeks to stabilize the soft tissues and allow for osteotomy healing. Complications range from relatively minor pin tract infections that resolve with oral antibiotics to tarsal tunnel syndrome, osteomyelitis, or disabling arthritis requiring revision procedures. At Scottish Rite Hospital for Children, we prefer to correct severe residual clubfoot deformity with a hexapod external fixator. Acute correction and gradual correction via distraction are considered for each segmental deformity and utilized to efficiently correct deformity while minimizing soft tissue trauma. The purpose of this article is to summarize the relevant literature related to circular external fixator treatment of recurrent clubfoot deformity and outline our approach to the segmental deformities of the foot and ankle in this patient population.

Treatment of Relapsed and Neglected Pes Equinovarus with Binary Arthrodesis and Hexapodal Spider Frame

PURPOSE

The aim of this study was to assess the clinical and radiological outcomes of patients with recurrent or neglected pes equinovarus (PEV), who underwent talonavicular or calcaneocuboid arthrodesis with a hexapod spider frame.

METHODS

The study included 18 patients; a total of 25 feet were treated with dual arthrodesis and a hexapod spider frame. The International Club Foot Study Group (ICFSG) scoring system and visual analog scale (VAS) were used to assess preoperative status and postoperative outcomes. All functional, morphological and radiologic evaluations during the follow-up were done as described by Kling et al.

RESULTS

Patients were followed up for an average of 24.1 ± 11.8 months. The mean age of our cohort was 8.84 ± 2.83 years. The mean duration of correction was 3 weeks and the mean duration treatment length was 15.3 ± 1.9 weeks. Postoperative assessment revealed eight excellent, 13 good, and four poor outcomes, according to the ICFSG scoring system. There was a significant difference between preoperative and postoperative ICFSG scores, 12 feet showed an excellent outcome, 12 feet had good outcomes, and one foot was rated as a failure in the final assessment, based on the Kling criteria. There was also a significant difference between preoperative and postoperative VAS scores.

CONCLUSION

Dual arthrodesis plus a hexapod spider frame is a valuable option for patients with recurrent or neglected PEV. It can be offered safely to avoid secondary recurrences and potential complications in cases of rigid feet as well as challenging cases that are resistant to soft tissue manipulation.

Treatment of complex foot deformities with hexapod external fixator in growing children and young adult patients

BACKGROUND

Treatment of complex foot deformities in growing children and young adult patients is challenging. The traditional approach consists of extensive soft tissues releases, osteotomies and/or arthrodesis. More recently, distraction osteogenesis has been proposed as an alternative strategy. The aim of this study was to describe our treatment strategy and report clinical outcomes of the patients affected from complex foot deformities treated by distraction osteogenesis and hexapod external fixator.

MATERIALS AND METHODS

We retrospectively reviewed 10 consecutive patients with complex foot and ankle deformities treated from 2014 to 2016 at our unit. A TrueLok external fixator system was used in all patients. Final outcome was classified as good, fair and poor according to the criteria indicated by Paley and Ferreira. The results were also evaluated by the pre-operative and post operative American Orthopedic Foot and Ankle Score (AOFAS) and The Manchester-Oxford Foot Questionnaire (MOXFQ).

RESULTS

A plantigrade foot was obtained in eight patients at the end of treatment, while in two patients a recurrence of the deformity was noted. Result was classified as good in 6 patients, fair in 2 patients, and poor in 2 patients. The AOFAS score improved from 33.9±21.2 pre-operatively to 67.25±15.1 post-operatively (p=0.005). A statistically significant improvement was observed for the MOXFQ score as well (from 60.6±23.3 to 33.0±25.2, p=0.020).

CONCLUSIONS

Our study shows that the TrueLok hexapod external fixator is a safe and effective tool in treatment of complex rigid foot deformities. Nevertheless, deformity recurrence can be observed in some cases and treatment remains challenging. Distraction osteogenesis should be reserved as a salvage solution for particularly complex cases and should be performed at dedicated specialized centers.

Treatment Strategies and Frame Configurations in the Management of Foot and Ankle Deformities

To provide standardized nomenclature for various hexapod frame configurations for foot and ankle deformity correction, a unique classification of the hexapod external fixators was proposed. This classification is based on number of correction levels, secured anatomic blocks, and direction of the strut attachment. It allows the combination of all different foot and ankle frame assemblies into a few standard hexapod configurations, irrespective of which external fixator is used.

The Evolution of Limb Deformity: What Has Changed over the Past Ten Years?

Limb deformity correction has been widely discussed in orthopedic literature with an increasing interest in technologically based surgical strategies. However, principles described by Ilizarov and Paley still form the basis of these newly developing surgical systems. The recent advances and increased use of computers and mobile devices in the medical arena, along with the application of dynamic hexapod external fixation, have allowed for easier and more convenient strategies, leading to a greater outreach and more confidence in the newer surgeon when faced with addressing a patient with a limb deformity.

Patient-Specific 3-Dimensional Printed Titanium Truss Cage With Tibiotalocalcaneal Arthrodesis for Salvage of Persistent Distal Tibia Nonunion

Management of large structural defects of the ankle and hindfoot is challenging with modest outcomes in the literature. Tibiotalocalcaneal (TTC) arthrodesis using a retrograde intramedullary nail has been used for the treatment of talar avascular necrosis, severe tibial plafond fractures, ankle and hindfoot nonunions, Charcot arthropathy, and failed total ankle arthroplasty. External fixators and spatial frames provide robust multiplanar correction of deformity, but little is known in the literature regarding the salvage treatment of persistent nonunion refractory to frame treatment. In this report, we present the case of an open tibial plafond fracture with nonunion despite 1 year of fixator and frame management that was successfully treated using a patient-specific 3-dimensional printed titanium truss cage in combination with a retrograde TTC nail. At most recent 1-year follow-up, the patient had minimal pain, no wound complications, and was able to ambulate and work independently without an assistive device for the first time in 2 years since his original injury. The case presented here serves as a proof of principle that requires future research to determine its long-term clinical benefits, cost-effectiveness, and complications.

LEVEL OF EVIDENCE

Level V: Expert Opinion.

Tibiotalocalcaneal Arthrodesis Using a Nitinol Intramedullary Hindfoot Nail

Tibiotalocalcaneal (TTC) arthrodesis using an intramedullary hindfoot nail is a common procedure for deformity correction and the treatment of combined tibiotalar and subtalar end-stage arthritis. Nonunion at one or both fusion sites is a difficult complication that can result in reoperation, significant morbidity, and below-knee amputation. There is currently a need for sustained compression across fusion sites using a TTC hindfoot nail with good mechanical stability. The DynaNail TTC Fusion System (MedShape, Inc, Atlanta, GA) uses an internal nitinol compression element to apply sustained compression across the tibiotalar and subtalar joints after surgery. In preliminary clinical cases, we have found that the nail is safe, reliable, and has promising clinical and radiographic results in settings of hindfoot arthritis, complex deformity, Charcot arthropathy, and talar avascular necrosis.

LEVELS OF EVIDENCE

Expert opinion, Level V.

A comparative study of the correction of femoral deformity between the Ilizarov apparatus and Ortho-SUV Frame

PURPOSES

This study compared the six-axis external fixator Ortho-SUV Frame (OSF) and the Ilizarov apparatus (IA) in femoral deformity correction. Our specific questions were: (1) which of the fixators (OSF or IA) provides shorter period of femoral deformity correction, and (2) which of the fixators (OSF or IA) provides better accuracy of correction.

METHODS

We retrospectively analysed 123 cases of femoral deformities (127 femora): 45 (47) treated with OSF (20 male and 27 female) and 78 (80) with IA (53 male and 27 female). The average age in the OSF group was 34.6 (range, 18-66) and in the IA group 35.8 (range, 18-76). All the deformities were categorized according to the number of planes and deformity components as simple, middle and complex deformities.

RESULTS

Elimination of simple deformities in the IA group took 58.3 ± 21.4 days, EFI 58.8 ± 39.8 days/cm, and lengthening was 4.6 ± 1.98 cm. Middle deformities were 71.3 ± 26.2, 61.9 ± 30.3 and 4 ± 2, respectively. In complex deformities we had 105.2 ± 21.8, 79.3 ± 35.4 and 3.2 ± 1.45, respectively. Normal alignment was achieved in 55.0% of cases in IA. In 45.0% of cases we had residual deformity. Elimination of simple deformations in the OSF group took 55.3 ± 12.8 days, EFI 47.5 ± 23 days/cm, and lengthening 4.5 ± 1.1 сm. Middle deformities were 43.6 ± 18.9, 59 ± 14.6 and 3.6 ± 2, respectively. In complex deformities we had 44.9 ± 11.5, 57.5 ± 9.4 and 3.6 ± 1.7, respectively. In the OSF group normal alignment was achieved in 85.1%. In 14.9% there was residual deformity.

CONCLUSION

Using OSF simplifies deformity correction and reduces its period by 2.3 times in complex deformities and by 1.6 times in middle deformities. Accuracy of correction with OSF was significantly higher than correction with IA.

Comparative clinical study on deformity correction accuracy of different external fixators

PURPOSE

In this study, the correction accuracy of Smart Correction spatial fixators and of Ilizarov-type external fixators are compared in terms of deformity complexity.

METHODS

Seventy-seven (40 male, 37 female) bone segments of 57 patients treated with a Smart Correction device were compared with 94 (51 male, 43 female) segments of 68 patients treated with an Ilizarov fixator. Mean age of the Smart Correction group was 20.69 ± 12.94 years, and or the Ilizarov group 22.45 ± 12.18 years. Patients were categorised according to limb lengthening and the number of deformity planes.

RESULTS

A longer correction period was found with Ilizarov (66.53 ± 47.7 days) compared with Smart Correction (49.05 ± 35.6 days) devices. The bone healing index of the Ilizarov group was significantly better compared with the spatial group. Residual deformity after treatment was significantly lower with the Smart Correction device; however, this relationship could not be shown between subgroups. Although there was no significant difference between subgroups, mean residual deformity was higher with the increasing number of planes of the deformity.

CONCLUSIONS

The Smart Correction fixator is an accurate device that allows ease of application and planning. It demonstrates higher accuracy for correcting deformities compared with an Ilizarov external fixator. With an increasing number of planes, the difference between the two devices becomes even more pronounced. The relationship between the complexity of the deformity and residual deformity may possibly be significantly greater in favour of the Smart Correction fixator in a study with a larger sample size.

Foot deformity correction with hexapod external fixator, the Ortho-SUV Frame™

External fixators enable distraction osteogenesis and gradual foot deformity corrections. Hexapod fixators have become more popular than the Ilizarov apparatus. The Ortho-SUV Frame™ (OSF; Ortho-SUV Ltd, St. Petersburg, Russia), a hexapod that was developed in 2006, allows flexible joint attachment such that multiple assemblies are available. We assessed the reduction capability of several assemblies. An artificial bone model with a 270-mm-long longitudinal foot was used. A 130-mm tibial full ring was attached 60 mm proximal to the ankle joint. A 140-mm, two-third ring forefoot was attached perpendicular to the metatarsal bone axis. A 130-mm, two-third ring hindfoot was attached parallel to the tibial ring. A V-osteotomy, which was combined with 2 oblique osteotomies at the navicular-cuboid bone and the calcaneus, was performed. The middle part of the foot, including the talus, was connected to the tibial ring. We assessed 5 types of forefoot applications and 4 types of hindfoot applications. The range of correction included flexion/extension in the sagittal plane, adduction/abduction in the horizontal plane, and pronation/supination in the coronal plane. Additionally, we reported the short-term results in 9 clinical cases. The forefoot applications in which the axis of the hexapod was parallel to the axis of the metatarsal bones had good results, with 52°/76° for flexion/extension, 48°/53° for adduction/abduction, and 43°/51° for pronation/supination. The hindfoot applications in which the hexapod encircled the ankle joint also had good results, with corresponding values of 47°/58°, 20°/35°, and 28°/31°. Clinically, all deformities were corrected as planned. Thus, multiple assemblies and a wide range of corrections are available with the OSF.