Use of Ilizarov External Fixation Without Soft Tissue Release to Correct Severe, Rigid Equinus Deformity

Evaluation and Management of Cavus Foot in Adults: A Narrative Review

Objective: Cavus foot is a deformity defined by the abnormal elevation of the medial arch of the foot and is a common but challenging occurrence for foot and ankle surgeons. In this review, we mainly aim to provide a comprehensive evaluation of the treatment options available for cavus foot correction based on the current research and our experience and to highlight new technologies and future research directions. Methods: Searches on the PubMed and Scopus databases were conducted using the search terms cavus foot, CMT (Charcot–Marie–Tooth), tendon-transfer, osteotomy, and adult. The studies were screened according to the inclusion and exclusion criteria, and the correction of cavus foot was analyzed based on the current research and our own experience. At the same time, 3D models were used to simulate different surgical methods for cavus foot correction. Results: A total of 575 papers were identified and subsequently evaluated based on the title, abstract, and full text. A total of 84 articles were finally included in the review. The deformities involved in cavus foot are complex. Neuromuscular disorders are the main etiologies of cavus foot. Clinical evaluations including biomechanics, etiology, classification, pathophysiology and physical and radiological examinations should be conducted carefully in order to acquire a full understanding of cavus deformities. Soft-tissue release, tendon-transfer, and bony reconstruction are commonly used to correct cavus foot. Surgical plans need to be customized for different patients and usually involve a combination of multiple surgical procedures. A 3D simulation is helpful in that it allows us to gain a more intuitive understanding of various osteotomy methods. Conclusion: The treatment of cavus foot requires us to make personalized operation plans according to different patients based on the comprehensive evaluation of their deformities. A combination of soft-tissue and bony procedures is required. Bony procedures are indispensable for cavus correction. With the promotion of digital orthopedics around the world, we can use computer technology to design and implement cavus foot operations in the future.

Soft Tissue Management and Tibialis Posterior Tendon Transfer in Acute Correction for Neglected Drop Foot Deformity

Acute correction of rigid drop foot deformity can be problematic due to the skin defect that may occur in the medial part of the ankle. The purpose of this study is to present an innovative solution for this problem. We hypothesized that acute correction for rigid ankle contractures without arthrosis might be possible if the medial skin defect could be closed. Therefore, we described a surgical technique for acute functional correction of rigid drop foot deformities. The closure of the medial defect was performed by applying a flap and partial-thickness skin graft. We have retrospectively evaluated the results of 18 patients who were treated between 2010 and 2016 with this technique. The mean age of the patients was 37 ± 9.5 (22-56) years. Foot drop etiology was firearm-related nerve injury. Corrections were performed after 14.6 ± 7.9 (8-38) months following the injury. At the end of an average follow-up period of 44.4 ± 6.2 (37-60) months, 14 of 18 patients (78%) recovered without complications, 3 patients experienced partial loss in the medial skin graft region, and 1 patient developed a superficial infection. None of the patients have developed pes planus. We observed that the ankle flexion contracture, which was 34° ± 9.2° (20°-50°) preoperatively, could reach an average of 2.2° ± 2.5° (0°-6°) dorsiflexion after surgery. We suggest that acute correction and tibialis posterior tendon transfer in the treatment of rigid foot drop deformity can be performed with an effective skin closure with low soft tissue complications.

Treatment of Severe Rigid Posttraumatic Equinus Deformity With Gradual Deformity Correction and Arthroscopic Ankle Arthrodesis

BACKGROUND

Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications.

METHODS

We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period.

RESULTS

Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2.

CONCLUSION

Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Operative management of equinus associated with lower limb venous malformations

OBJECTIVES

Functional impairment is a common complaint in patients with venous malformations. Equinus can occur when the venous malformation involves the lower limb, a challenging condition with only a few studies to guide treatment choices. This study was aimed to investigate the operative management of equinus associated with lower limb venous malformations.

METHOD

Between August 2015 and September 2017, a total of 12 patients presented with equinus associated with lower limb venous malformations and underwent surgical correction. Preoperative and postoperative clinical symptoms, physical examination and orthopaedic evaluation were retrospectively reviewed. 8 patients who experienced pain underwent percutaneous sclerotherapy prior to the operation. Surgical management included gastrocnemius intramuscular aponeurotic recession, Z-lengthening of the Achilles tendon, Hoke technique and Taylor Spatial Frame external fixation.

RESULTS

There were eight female and four male patients with a mean age of 14.3 ± 5.9 years. The mean follow-up period was 34.8 ± 9 months. The range of motion of ankle dorsiflexion (with knee extended) improved for each patient (mean, 25.4 degrees; standard deviation, 8.5 degrees). No neurovascular complications were observed.

CONCLUSION

Operative correction of equinus associated with lower limb venous malformations is safe and effective. Selective preoperative sclerotherapy is necessary for optimal outcomes.

Talectomy for the Management of Resistant Talipes Equinovarus Deformity; Does Adding Ilizarov External Fixator Provide Extra Advantages?

BACKGROUND

The management of resistant talipes equinovarus (TEV) is challenging. Residual deformity and recurrence are among the most feared complications. This study was conducted to evaluate the effectiveness of talectomy in the management of arthrogrypotic TEV and to investigate the value of adding a simplified Ilizarov fixator (SIF).

PATIENTS AND METHODS

A total of 42 resistant TEV feet among 23 arthrogrypotic children were operated between January 2012 and 2016. The average age was 6.7 ± 1.67 years. The feet were divided into 2 groups; group A (Casting group) included 20 feet (11 children) that were managed by talectomy and casting, while group B (Fixator group) included 22 feet (12 children) that were treated using a SIF concomitant with talectomy. The results were evaluated morphologically by Dimeglio grading system and functionally by Legaspi system.

RESULTS

The average follow-up was 36.62 ± 3.88 months. With the numbers available in this study, there was significant improvement (p ≤ .05) in the Dimeglio scores in both groups, which was significantly more evident (p ≤ .05) among the fixator group. The majority of the good functional results were reported among the fixator group, while the poor feet were observed mainly in the casting group (p ≤ .05). The functional end results were significantly affected (p≤ .05) by the final Dimeglio scores. The age had also statistically significant effect (p≤ .05) on the functional end results in group A only.

CONCLUSION

Talectomy is an effective procedure for salvaging arthrogrypotic TEV. Supplementation of the procedure by SIF was associated with more satisfactory morphological and functional results particularly in older children.

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.

Taylor Spatial Frame in Treatment of Equinus Deformity

BACKGROUND

An equinus deformity interferes with activities of daily living. Correction of the deformity ranges from conservative (heel cord stretching, orthotics) to surgical treatment (Baumann, Strayer, Achilles lengthening, soft tissue releases). Severe contractures increase surgical intervention with extensive dissections to release soft tissues. This study investigated the clinical outcomes of gradual overcorrection using a Taylor spatial frame (TSF) with tendo-Achilles lengthening (TAL) added as necessary.

MATERIALS AND METHODS

This retrospective chart review evaluated patients with significant equinus treated with a TSF at a single large tertiary referral centre. Data collected included: diagnosis; patient demographics; laterality; time in frame; additional procedures; complications; degree of equinus deformity preoperatively and at every follow-up visit. Patients were followed at 1 week, 3 weeks, 6 weeks, 3 months, and 6 months intervals, and yearly thereafter.

RESULTS

Twenty-four patients (26 procedures) were treated with a TSF for equinus and had complete preoperative and follow-up measurements over 2 years. The angle of deformity increased from a preoperative -21.5 (range, -69.0 to -1.0) degrees to a postoperative 4.9 (range, -17.0 to 17.0) degrees (z = -4.4573, p = 0.0001, N = 26, Wilcoxon signed-rank test). A secondary outcome was a weak association (not statistically significant) between time in the TSF and the postoperative deformity angle. Four complications occurred during the follow-up (two pin site infections, one broken pin, and one plantar abscess). Three patients had recurrence of equinus deformity at time of last follow-up.

CONCLUSION

Using a TSF for correcting severe, fixed equinus contractures of the ankle joint is successful with minimal soft tissue-related complications. Overcorrection should be achieved in order to compensate for the loss of some dorsiflexion after frame removal. No added benefit was observed from having the frame on for a long time after correcting the deformity. Adding TAL is not necessary in all cases and required only in severe deformities of more than 25°.

HOW TO CITE THIS ARTICLE

Dabash S, Potter E, Catlett G, et al. Taylor Spatial Frame in Treatment of Equinus Deformity. Strategies Trauma Limb Reconstr 2020;15(1):28-33.

Management of knee flexion contracture in haemophilia with the Ilizarov technique

BACKGROUND

There are limited reports about management of Knee flexion contracture (KFC) in haemophiliacs with Ilizarov technique. The aim of this study was to retrospectively analyzed the results of Ilizarov technique to treat KFC.

METHODS

Six patients with haemophilia A and one with haemophilia B were included in this study, with an average age of 17 years old. The mean preoperative KFC and flexion angle of the knee were 58 ± 21° (mean ± standard deviation) and 127 ± 12°, respectively. Preoperative HSS score (hospital for special surgery knee score) was 51 ± 4. The average time of follow-up was 39.3 ± 23.3 months.

RESULTS

All the patients achieved full correction of flexion contracture at the end of distraction and maintained at the last follow-up. The mean flexion angle at the end of distraction and at the last follow-up were 41 ± 35° and 38 ± 19° respectively, which were significantly lower than preoperative flexion angle. The mean HSS score at the end of distraction and at the last follow-up were 65 ± 4 and 64 ± 2 respectively, which were significantly higher than the preoperative HSS score. One patient suffered from transient numbness of left leg, and all the patients had loss of range of knee flexion at last follow-up.

CONCLUSIONS

Ilizarov is an effective and safe procedure to treat KFC in haemophiliacs. However, loss of knee flexion was the most common complication.

Surgical Treatment of Neglected Bilateral Hemophilic Equinus Contracture With External Fixation: A Case Report

Hemophilia is a disorder of blood coagulation with X-linked recessive inheritance. It is characterized by uncontrollable hemorrhage, and 80% of these occur intraarticularly. With recurrent hemarthrosis, recurrent synovitis occurs, which eventually leads to the formation of articular contractures. The key to the prevention of hemophilic joint complications is successful prevention of bleeding and management of the initial hemarthrosis. However, after the development of a rigid contracture, surgical correction remains the only method to correct the deformity. Achilles tendon lengthening, synovectomy, anterior osteophyte resection, corrective osteotomies, external fixators, or arthrodesis should be considered as surgical options. In the present report, we describe our experience using hybrid-type external fixators to manage bilateral neglected rigid equinus contractures in a hemophilic patient, with 78 months of follow-up data.

The Gradual and Acute Correction of Equinus Using External Fixation

Equinus is one of the most common deformities noted in foot and ankle biomechanics that, at times, if not identified and managed properly may lead to significant lower extremity pathology. With that being said, this deformity is also one that may be both underdiagnosed and undertreated. Treatment for equinus can range from conservative therapy to more aggressive surgical therapy. The purpose of this article is to review the clinical workup to properly identify the deformity and to explore the various treatment options for its timely management, which include gradual or acute correction of equinus using external fixation.

Stem cell therapy for enhancement of bone consolidation in distraction osteogenesis: A contemporary review of experimental studies

Objectives

Distraction osteogenesis (DO) mobilises bone regenerative potential and avoids the complications of other treatments such as bone graft. The major disadvantage of DO is the length of time required for bone consolidation. Mesenchymal stem cells (MSCs) have been used to promote bone formation with some good results.

Methods

We hereby review the published literature on the use of MSCs in promoting bone consolidation during DO.

Results

Studies differed in animal type (mice, rabbit, dog, sheep), bone type (femur, tibia, skull), DO protocols and cell transplantation methods.

Conclusion

The majority of studies reported that the transplantation of MSCs enhanced bone consolidation or formation in DO. Many questions relating to animal model, DO protocol and cell transplantation regime remain to be further investigated. Clinical trials are needed to test and confirm these findings from animal studies.

Cite this article: Y. Yang, S. Lin, B. Wang, W. Gu, G. Li. Stem cell therapy for enhancement of bone consolidation in distraction osteogenesis: A contemporary review of experimental studies. Bone Joint Res 2017;6:385–390. DOI: 10.1302/2046-3758.66.BJR-2017-0023.