Correction of severe foot and ankle contracture due to CRPS using external fixation and pain management: report of a pediatric case

Republication of "Minimally Invasive Surgery Using the Circular External Fixator to Correct Neglected Severe Stiff Equinocavus Foot Deformities"

Background

Stiff equinocavus deformities of the foot are challenging to treat, often requiring extensive soft tissue dissection and bone removal. These procedures frequently yield suboptimal results and not infrequently amputation. Minimally invasive surgery using a circular external fixator potentially avoids the trauma to the soft tissue and may lead to improvement in outcomes and a lower amputation rate. The objective of this study was to evaluate the efficacy of minimally invasive surgery using a circular external fixator and limited soft tissue release to correct stiff equinocavus deformities.

Methods

The treatment outcome of 29 patients (31 feet) with stiff equinocavus deformities of the foot and ankle treated with minimally invasive surgery and circular external fixation were reviewed after a mean follow-up period of 63 months. Patients' demographics and cause of the deformities were recorded. Weight bearing radiographs of the foot were compared pre and postoperatively.

Results

Outcome was satisfactory (plantigrade foot with improvement/resolution of pain) in 21 of 31 extremities, fair in 6 of 31 extremities, and poor in 4 of 31 extremities. In the majority of patients, a significant improvement in the equinocavus deformities was achieved with a statistically significant improvement in calcaneus and navicular height. Two patients with Charcot-Marie-Tooth and severely insensate feet had a poor outcome, resulting in transtibial amputation.

Conclusion

Minimally invasive surgery with gradual correction of neglected stiff equinocavus deformities using a modular circular external fixator is a reliable initial limb salvage strategy. Minimally invasive surgery and gradual correction of neglected severe stiff equinocavus deformities using the modular circular external fixator to gradually correct neglected severe stiff equinocavus deformities, is a safe initial limb salvage strategy which may simplify secondary procedures such as arthrodesis.

Level of evidence

IV.

Comparison of three different correction trajectories for foot and ankle deformity treated by supramalleolar osteotomy using a novel external fixator

Based on the principle of distraction osteogenesis, external fixators are widely used in deformity correction of the foot and ankle. In this study, a novel ankle external fixator is proposed to correct complex multiplane deformities, especially for supramalleolar osteotomy to correct distal tibia deformities. The relatively simple structure and fewer struts in the proposed fixator reduce the complexity of adjusting the external fixator. Based on two existing adjustment strategies, a new strategy taking into account the orientation and shortest path of the ankle joint center is proposed, which is named joint adjustment for equal bone distraction. By proposing the inverse kinematic solutions of the novel external fixator, mathematical derivations of the bone trajectory and modelling of the bone shape for the three distraction strategies are performed. The results obtained by comparative analysis indicate that a uniformly spaced path of the ankle joint center can be acquired, and a smooth and uniform correction trajectory of the distal tibia end can be obtained using the new adjustment strategy. It can avoid bone end interference and only generates a maximum deviation 0.66% greater than the currently optimal 1 mm/day. The new strategy can perform multiplane corrections simultaneously, which shortens the correction time and reduces the patient's pain.

Minimally Invasive Surgery Using the Circular External Fixator to Correct Neglected Severe Stiff Equinocavus Foot Deformities

Background:

Stiff equinocavus deformities of the foot are challenging to treat, often requiring extensive soft tissue dissection and bone removal. These procedures frequently yield suboptimal results and not infrequently amputation. Minimally invasive surgery using a circular external fixator potentially avoids the trauma to the soft tissue and may lead to improvement in outcomes and a lower amputation rate. The objective of this study was to evaluate the efficacy of minimally invasive surgery using a circular external fixator and limited soft tissue release to correct stiff equinocavus deformities.

Methods:

The treatment outcome of 29 patients (31 feet) with stiff equinocavus deformities of the foot and ankle treated with minimally invasive surgery and circular external fixation were reviewed after a mean follow-up period of 63 months. Patients’ demographics and cause of the deformities were recorded. Weight bearing radiographs of the foot were compared pre and postoperatively.

Results:

Outcome was satisfactory (plantigrade foot with improvement/resolution of pain) in 21 of 31 extremities, fair in 6 of 31 extremities, and poor in 4 of 31 extremities. In the majority of patients, a significant improvement in the equinocavus deformities was achieved with a statistically significant improvement in calcaneus and navicular height. Two patients with Charcot-Marie-Tooth and severely insensate feet had a poor outcome, resulting in transtibial amputation.

Conclusion:

Minimally invasive surgery with gradual correction of neglected stiff equinocavus deformities using a modular circular external fixator is a reliable initial limb salvage strategy. Minimally invasive surgery and gradual correction of neglected severe stiff equinocavus deformities using the modular circular external fixator to gradually correct neglected severe stiff equinocavus deformities, is a safe initial limb salvage strategy which may simplify secondary procedures such as arthrodesis.

Level of evidence:

IV.

Lower extremity complex regional pain syndrome: long-term outcome after surgical treatment of peripheral pain generators

We undertook a retrospective study to evaluate the hypothesis that complex regional pain syndrome (CRPS) I, known as the "new" reflex sympathetic dystrophy, persists because of undiagnosed injured joint afferents, cutaneous neuromas, or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II, which is known as the "new" causalgia. We used a research protocol, with institutional review board approval, to review medical records for the purpose of identifying 30 patients with lower extremity reflex sympathetic dystrophy, based on their history, physical examination, neurosensory testing, and response to peripheral nerve blocks, who were treated surgically at the level of the peripheral nerve. In this report, we describe long-term outcomes in 13 of these patients who were followed up for a minimum of 24 months (mean, 47.8 months; range, 25-90 months). Based primarily on the results of physical examination and the response to peripheral nerve blocks, surgery included a combination of joint denervation, neuroma resection plus muscle implantation, and neurolysis. Outcomes were measured in terms of decreased pain medication usage and recovery of function, and the results were excellent in 7 (55%), good in 4 (30%), and poor (failure) in 2 (15%) of the patients. Based on these results, we concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and chronic nerve compression, which is indistinguishable from CRPS II, and amenable to successful treatment by means of an appropriate peripheral nerve surgical strategy.