Distraction Osteogenesis for Complex Foot Deformities: U-Osteotomy with External Fixation (original) (raw)
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Jbjs Essential Surgical Techniques, 2012
Background: Certain complex foot deformities can be corrected surgically with a U-osteotomy. This osteotomy is indicated for patients with a uniform deformity of the entire foot relative to the tibia, preexisting stiffness and/or fusion of the subtalar joint, and a pain-free ankle joint. The goal is to create a plantigrade foot through gradual osseous repositioning of the entire foot relative to the tibia by means of external fixation. If needed, foot height can be increased simultaneously. Methods: Fifteen complex multiplanar foot deformities in fifteen patients were treated with a U-osteotomy and gradual correction by means of external fixation. Deformities resulted from congenital causes (seven), trauma (three), and developmental causes (five). The mean patient age at the time of surgery was twenty years (range, four to sixty-three years). The mean duration of external fixation was five months (range, three to eleven months). The mean duration of follow-up was five years (range, three to nineteen years). Clinical and radiographic results were assessed. Results: Osseous union and a plantigrade foot were achieved in all fifteen patients. Seven complications related to the U-osteotomy occurred in four patients, including deep pin-track infection in two, premature osseous consolidation in two, postoperative tarsal tunnel syndrome in two, and peroneal nerve entrapment in one. When comparing the preoperative and final postoperative radiographs, three significant differences were observed: the calcaneotibial angle changed by a mean of 18°valgus (range, 6°to 40°valgus) (p = 0.003), the calcaneus was translated posteriorly by a mean of-8 mm (range,-2 to-20 mm) (p = 0.001), and foot height increased by a mean of 20 mm (range, 3 to 40 mm) (p < 0.001). Fourteen patients were able to walk without supports or assistance; one used only one cane or crutch to walk. Conclusions: U-osteotomy with gradual correction by means of external fixation can be used to obtain a plantigrade foot in patients with complex multiplanar deformities of the foot relative to the tibia. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. D istraction osteogenesis has been used to treat various complex foot and ankle deformities, including those associated with relapsed or neglected clubfoot, fibular hemimelia, arthrogryposis, brachymetatarsia, poliomyelitis, posttraumatic cavoequinovarus, and other congenital deformities 1-11. Ilizarov described many uses and techniques of distraction osteogenesis, and he first described the U-osteotomy to correct complex hindfoot, midfoot, foot height, and equinus deformities in 1987 1. The U-osteotomy is indicated in patients with preexisting stiffness and/or fusion of the subtalar joint, a pain-free ankle joint, and a ''uniform'' deformity of the foot relative to the tibia (i.e., the forefoot deformity is the same as the hindfoot deformity) 1-9,12. In such cases, the foot itself does not have any deformities because the forefoot is not deformed relative to the hindfoot. Although the U-osteotomy corrects the position of the entire foot relative to the tibia, it cannot change Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
The Correction of Complex Foot Deformities Using Ilizarov??s Distraction Osteotomies
Clinical Orthopaedics and Related Research, 1993
Twenty-five very complex foot deformities were treated by Ilizarov distraction osteotomies. The osteotomy types included supramalleolar, U, V, posterior calcaneal, talocalcaneal neck, midfoot, and metatarsal osteotomies. In addition, the leg was lengthened and widened in most cases. The mean treatment time was 6.4 months. There were 20 minor or major complications related to the foot osteotomies in 18 feet, including deep pin-tract infection in three, failure of osteotomy separation in nine, acute postoperative tarsal tunnel syndrome in two, toe contractures in three, wire breakage or cutout in two, and buckle fracture in one. Nineteen secondary procedures were required in 13 patients to treat these complications. The final result was a plantigrade foot in 22 in late follow-up evaluation. The three nonplantigrade feet were attributable to unrecognized heel varus in one, ball and socket ankle joint in one, and partial growth arrest progressive deformity in one. Gait was improved in all cases. Pain was eliminated in all but two patients. Based on these criteria, the results were judged to be satisfactory in 22 and unsatisfactory in three. The Ilizarov method can successfully correct complex foot deformities despite complications.
Correction of complex foot deformities using the Ilizarov external fixator
Journal of Foot & Ankle Surgery, 2002
There are many drawbacks to using conventional approaches to the treatment of complex foot deformities, like the increased risk of neurovascular injury, soft-tissue injury, and the shortening of the foo t. An alternative approach that can eliminate these problems is the IIizarov method. In the current study, a total of 23 deformed feet in 22 patients were treated using the IIi zarov method. The etiologic facto rs were burn contracture , po liomyelitis, neglected and relapsed clubfoot, trauma, gun shot injury, meningitis, and leg-length discrepancy (LLD). The average age of the patients was 18.2 (5-50) years. The mean duration of fixator application was 5.1 (2-14) months. We performed corrections without an osteotomy in nine feet and with an osteotomy in 14 feet. Additional bony corrective procedures included three tibial and one femoral osteotomies for lengthening and deformity correction, and one tibiotalar arthrodesis in five separate extremities. At the time of fixator removal, a plantigrade foot was achieved in 21 of the 23 feet by pressure mat analysis. Compared to preoperative status, gait was subjectively improved in all patients . Follow-up time from surgery averaged 25 months (13 -38). Pin-tract problems were observed in all cases. Other complications were toe contractures in two feet, metatarsophalangeal subluxation from flexor tendon contractures in one foot, incomplete osteotomy in one foot, residual deformity in two feet, and recurrence of deformity in one foot. Our results indicate that the IIizarov method is an effective alternative means of correcting complex foot deformities, especially in feet that pre viously have undergone surgery.
Foot and Ankle Surgery, 2019
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 AE 21.2 pre-operatively to 67.25 AE 15.1 postoperatively (p = 0.005). A statistically significant improvement was observed for the MOXFQ score as well (from 60.6 AE 23.3 to 33.0 AE 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.
Titrating the Amount of Bony Correction in Progressive Collapsing Foot Deformity
Foot & Ankle International, 2020
We recommend performing a medializing calcaneal displacement osteotomy (MDCO) as isolated bony procedure when there is an isolated hindfoot valgus, with adequate talonavicular joint coverage (less than 35%-40% uncoverage), and lack of significant forefoot supination, varus, or abduction. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT TWO: The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT THREE: Lateral column lengthening (LCL) procedure is recommended when the amount of talonavicular joint uncoverage is above 40%. The amount of coverage needed should be judged intraoperatively by the amount of correction of the uncoverage and by adequate residual passive eversion range of motion of the subtalar joint. Delegate vote: agree, 78% (7/9); disagree, 11% (1/9); abstain, 11% (1/9). (Strong consensus) CONSENSUS STATEMENT FOUR: The typical range when performing a lateral column lengthening is 5 to 10 mm of correction. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATETMENT FIVE: Indications for performing a cotton osteotomy should be determined clinically, not radiographically, related to residual forefoot supination after hindfoot deformity correction. Feel the balance of first ray in relation to the lateral ones, palpating the plantar aspect of the metatarsal heads.
Osteotomy, Arthrodesis, and Arthroplasty for Complex Multiapical Deformity of the Leg
HSS Journal ®, 2012
Background : Assessment of diaphyseal deformity in the tibia consists of delineating anatomic axes or cortical lines with resultant apices of deformity. Single-apex deformities have been well described both in terms of assessment and treatment, whereas double-level deformities with metaphyseal and/or juxtacortical involvement are less straightforward. Multiapical deformities of the lower extremity, though uncommon, are the next level of complexity and provide the surgeon with a difficult correctional mission. Case Description : We report two cases of multiapical deformity of the tibia, both of which were secondary to a distant history of tibial fracture with resultant knee and ankle joint degeneration and deformity. Both cases had three levels of deformity that were addressed with tibial osteotomy, ankle fusion, and total knee replacement. Initial presentation, problem lists, surgical treatment, and subsequent results are reviewed. Literature Review : Treatment of a post-traumatic three-level deformity has never specifically been addressed in the literature, although the principles of treatment are the same as for less complex deformities. Purposes and Clinical Relevance : These two cases present a treatment approach for complex, multiapical deformity of the tibia. The same principles of deformity correction used to treat less complex deformities are applied to these patients with an overarching synthesis that takes all aspects of the three deformities into account. Although these cases are complex and difficult, good results in terms of deformity correction and pain relief can be obtained.
Versatility of Ilizarov external fixator in management of foot and ankle deformity
Journal of Orthopaedics and Traumatology, 2005
Traditional methods of correcting foot deformities may be difficult to apply in some conditions, especially in presence of other lower limb problems. This study discusses the versatility of Ilizarov external fixator (IEF) in such cases. It was performed in 34 foot deformities in 33 patients, treated with IEF between 1997 and 1999. The average age of the patients was 15 years. The aetiology of foot deformity was recurrent congenital talipes equinovarus (n=10), neglected congenital talipes equinovarus (n=3), poliomyelitis (n=9), post-traumatic deformity (n=6), post-burn deformity (n=1), arthrogryposis multiplex congenita (n=2), and cerebral palsy, fibular hemimelia and tibial hemimelia (1 case each). Unconstrained IEF was applied for the foot in all cases. The leg construct was applied according to the target: foot deformity alone or associated with other leg problems. IEF construct was extended to the femur in cases with flexion knee deformity and hinges were added. Follow-up continued until overcorrection was maintained for the same period of correction followed by an appropriate cast for 8 weeks. The mean time for deformity correction and Ilizarov stabilisation was 16 weeks, and follow-up period was 23.1 months. The results were good in 31, fair in 2 and bad in 1. Additional procedures were performed, most often in the same operating time. Primary arthrodesis was done for 5 feet and for one revision of failed previous arthrodesis. Open corrective osteotomy for arthrodesis was performed in 2 cases. Two females were treated for flexion knee with bloodless technique. Wire-site infections, wire cut-through a calcaneum and metatarsals and fracture post-IEF removal were observed. Although it is technically difficult, IEF can be considered an effective and versatile way of treating foot and other associated lower limb problems through one-reconstruction attack.
Management of Severe Deformity Using a Combination of Internal and External Fixation
Foot and Ankle Clinics, 2011
Various pathologic conditions affect the foot and ankle joint and lead to functional failure. Trauma, long-standing inflammatory and crystal arthropathy, infection, neuropathy, osteochondritis, primary arthritis, and congenital foot deformities are a few common conditions seen in day-today practice. These conditions eventually change the biomechanics of the joints by altering foot and ankle alignment. Attenuation of the local soft tissue structures, including skin, ligaments, and tendons, causes further deterioration of the function. Painful foot and ankle pathology often leads to limited weight bearing and disuse osteopenia. The resultant deformity with bone and soft tissue abnormalities presents a challenging problem for orthopedic surgeons. Many of these conditions cause severe deformities of the foot and ankle with extreme varus of the distal tibia or hindfoot combined with leg length discrepancies. Also, severe deformities are often accompanied by infection and skin breakdown. These conditions are the most challenging cases for the foot and ankle surgeon, especially when the goal of surgical intervention is to restore the anatomy and achieve a plantigrade, painless, functional foot. 1 This article reviews the surgical techniques used to manage complex foot and ankle deformities, especially the combined techniques of internal and external fixation, and summarizes the results of clinical-based evidence. Smith & Nephew and Orthofix provided financial support for our institute to host an educational course. Dr Conway has received grants from Medtronic and Synthes.