Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

BACKGROUND: In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods. PATIENTS AND METHODS: We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients. RESULTS: The mean external fixation time was 6 (3.6-10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with flail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening. INTERPRETATION: The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening     

组合式外固定器治疗合并患肢短缩的足踝部畸形

背景：传统的足踝部畸形的矫正需要通过手术来完成,术后需要“静态”的维持。Ilizarov技术遵循的“张力-应力法则”和“牵拉组织再生技术”,在一定程度上打破了传统的矫形模式。目的：探讨Ilizarov技术治疗合并患肢短缩的足踝部畸形的临床疗效。方法：回顾分析2006年8月至2012年10月采用Ilizarov技术治疗的17例下肢及足踝部畸形患者的临床资料。其中男10例,女7例,年龄20~37岁,平均27.5岁。脊髓灰质炎后遗症导致患肢短缩合并足踝负重位外翻畸形患者5例,先天性马蹄内翻足合并患肢短缩7例,高弓足合并患肢短缩3例,跟腱挛缩、仰趾畸形合并患肢短缩2例。所有患者在有限手术重建足踝部软组织平衡或者截骨矫正畸形后安装Ilizarov组合式外固定支架,同时做胫骨的延长。结果：17例患者佩戴Ilizarov支架的时间是16~44周,足踝部矫形支架在3~6个月矫形满意、骨融合确实后单独拆除,骨延长支架根据需要继续佩戴。所有患者都获得随访,随访时间6~48个月,患肢延长2~6 cm,延长段骨矿化满意,足踝部矫形满意。足踝功能参照AOFAS评分：术前（43±5.1）分,术后（76±7.2）分。结论：对于各种原因导致的合并下肢短缩的足踝部畸形的矫治,Ilizarov技术灵活的器械组合可同时完成多方向的畸形矫正,在矫正畸形的同时实施骨延长术。     

Posttraumatic Reconstruction of the Ankle Using the Ilizarov Method

Reconstruction of the ankle after trauma requires a variety of treatment strategies. Once the personality of the problem is appreciated, a tailored approach may be implemented. The Ilizarov method provides a versatile, powerful, and safe approach. It is particularly useful in the setting of infection, bone loss, poor soft tissue envelope, leg length discrepancy, bony deformity, and joint contracture. In this article, a variety of posttraumatic ankle pathologies are discussed. Treatment methods including osteotomy, arthrodesis, distraction, correction of contracture, nonunion repair, and tibia and fibula lengthening are reviewed. The use of the Ilizarov method for acute and/or gradual correction as well as the application of simultaneous treatments at multiple levels is discussed in this article.     

Correction of equinus deformity by means of a new unconstrained ilizarov frame system

PurposeThis study aimed to clarify the effectiveness of a novel technique utilizing the new unconstrained Ilizarov frame system by evaluating the clinical outcomes of equinus deformity correction.MethodsFrom January 1998 to December 2012, a total of 9 consecutive patients (median age: 33 years) with equinus deformity were treated by using a simple, unconstrained, hinge-less Ilizarov frame, which was developed to correct talar subluxation using an unconstrained frame system. All patients had equinus deformity >30°, although preoperative radiographs showed a congruous ankle joint with no fixed bony deformity. Preoperative equinus deformity was evaluated as well as dorsal flexion (DF) in Ilizarov at 3 months after removal and at final follow-up. Furthermore, the presence or absence of talar subluxation at the time removal of the Ilizarov apparatus, and whether or not ankle arthrodesis was finally indicated, was evaluated.ResultsMedian follow-up period was 76 months. Median preoperative equinus deformity was −40° None of the patients showed anterior or posterior subluxation of the talus at the time of removal. Three months after removal of the Ilizarov apparatus, the median DF angle was −5° However, 4 patients showed less than −15° of DF and underwent ankle arthrodesis with the ankle joint in the 5° DF position. At the final follow-up, median DF angle was 5°.ConclusionThis technique allows for safe, gradual correction of equinus deformity without talar subluxation, although additional procedures, such as ankle arthrodesis, may be needed in some cases.     

Correction of a Severe Poliomyelitic Equinocavovarus Foot Using an Adjustable External Fixation Frame

One-stage surgical correction of severe equinocavovarus deformity can result in complications ranging from skin necrosis to tibial nerve palsy. Fewer complications have been reported when severe deformities were treated by gradual correction using external frames such as the Ilizarov external fixator or the Taylor Spatial Frame™. We describe a case of a 64-year-old female patient with severe poliomyelitic equinocavovarus whose deformity required her to ambulate using the dorsum of her right foot as a weightbearing surface. We treated the deformity with gradual correction using a Taylor Spatial Frame™, followed by ankle arthrodesis. At the most recent postoperative evaluation, 20 months after the initial surgery, the patient was pain free and ambulating on the sole of her right foot.     

Correction of complex foot deformities using the Ilizarov external fixator.

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 foot. An alternative approach that can eliminate these problems is the Ilizarov method. In the current study, a total of 23 deformed feet in 22 patients were treated using the Ilizarov method. The etiologic factors were burn contracture, poliomyelitis, 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 Ilizarov method is an effective alternative means of correcting complex foot deformities, especially in feet that previously have undergone surgery.     

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.     

Wedge-shaped distal tibial epiphysis in the pathogenesis of equinovalgus deformity of the foot and ankle in tibial lengthening for fibular hemimelia

Fibular hemimelia is associated with an equinovalgus deformity of the foot and ankle and different degrees of wedging of the distal tibial epiphysis. This deformity is often a major problem during lengthening of the shortened tibia. To determine the significance of the wedge-shaped distal tibial epiphysis in the pathogenesis of the equinovalgus deformity of the foot and ankle during and after lengthening, we reviewed 20 patients who had undergone tibial lengthening by either the Wagner or the Ilizarov technique. The mean duration of follow-up after removal of the fixator was 5.2 years (range, 2.3-9.7 years). Three types of wedge-shaped distal tibial epiphyses were identified. A mildly wedged (type I) epiphysis was found in seven patients, a moderately wedged (type II) epiphysis was found in seven patients, and a severely wedged (type III) epiphysis, in six patients. Premature fusion of the lateral part of the distal tibial physis and growth retardation of the tibia were common after lengthening in patients with the type II or type III epiphysis. After lengthening, all patients with a type II or type III epiphysis had a recurrence or aggravation of foot deformities that existed before lengthening. This usually necessitated various secondary operative procedures to obtain a plantigrade foot. We believe that after lengthening, one should anticipate varying degrees of mild growth retardation and minimal foot deformity in patients with type I epiphysis, worsened asymmetric growth retardation and progressive foot deformity in patients with type II epiphysis, and severe growth retardation and severe foot deformity in patients with type III epiphysis.     

Foot lengthening using the Ilizarov device: the transverse tarsal joint resection versus osteotomy

The aim of the study was the evaluation of both the foot correction and foot lengthening obtained using the distraction method with osteotomies versus distraction after the transverse tarsal joint resection. Ten patients (10 feet) aged from 5 years to 24 years (average, 10.5 years) were analyzed. Seven of them were treated for severe equinovarus deformity: six of congenital and one of post-traumatic etiology. In three patients, the indication for treatment was foot shortening due to hypoplasia with tibial shortening, combined with foot deformity. Preoperative shortening of the foot ranged from 1.5 cm to 10 cm (average, 4.5 cm). In four patients, osteotomy between the tarsometatarsal and transverse tarsal joints was carried out. In two cases, 'V-shaped' osteotomy through the hindfoot and midfoot was performed. In the remaining four patients, wedge resection of the transverse tarsal joint was performed. The follow-up was a mean of 32 months (range, 12-55 months). It was observed that foot lengthening after transverse osteotomy of the midfoot is difficult and unpredictable, because of distraction at the adjacent joints level instead of osteotomy site. The greatest lengthening of the foot (mean, 4 cm) was observed in the patients with the transverse tarsal joint resection. It was concluded that the transverse tarsal joint resection following callus distraction in the place of the resected joint is the effective method for foot lengthening, which can be combined with deformity correction.     

Ilizarov 技术矫治马蹄足畸形中胫距关节前脱位的治疗及预防

 目的 总结 Ilizarov 技术矫治马蹄足畸形中发生胫距关节前脱位的概率、治疗及预防方法。方法 回顾性分析 2011 年 10 月至 2012 年 4 月,应用 Ilizarov 技术矫治 38 例马蹄足畸形患者资料,其中 5 例于术后 14～28 d 发生胫距关节前脱位,男 4 例,女 1 例;年龄 19～30 岁,平均 23.8 岁;均为马蹄内翻足畸形患者。5 例患者初次手术采用 Ilizarov 技术矫治马蹄足畸形,同时行经皮跟腱延长术、经皮跖腱膜切断术、胫后肌松解、胫前肌移位,其中 4 例同期行距骨周围截骨术,1 例同期行第一跖骨基底截骨术,1 例同期行胫骨近端去旋转截骨术;发生胫距关节前脱位后,1 例经手法复位,4 例使用 Ilizarov 复位装置后继续按原计划牵伸调整外固定架矫形,直至满意。结果 5 例马蹄内翻足畸形患者在行 Ilizarov 技术矫形过程中发生胫距关节前脱位的概率为 13.2%（5/38）。5 例患者均获得随访,随访时间 6～12 个月,平均 10 个月,马蹄足畸形均完全矫正。末次随访时应用国际马蹄足畸形研究学组评分为 3～10 分,平均 4.8 分;其中优 2 例,良 3 例,优良率为 100%。无一例发生钉道感染、神经血管损伤、血栓等并发症。结论 胫距关节脱位是 Ilizarov 技术矫治马蹄足畸形中较常见的并发症,发生率约为 13%。发生胫距关节前脱位后,及时安装距骨复位装置可获得良好效果。围手术期管理应注意外固定铰链关节与踝关节瞬时旋转中心的匹配。     

Operative treatment of the difficult stage 2 adult acquired flatfoot deformity

In the flexible pes planovalgus deformity of stage 2 posterior tibial tendon dysfunction, osteotomies appear to have a significant role in operative management by restoring more normal biomechanics, allowing tendon transfers to function successfully. The options when considering osteotomies for stage 2 disease include lateral column lengthening, medial displacement calcaneal osteotomy, and combined double osteotomy technique. The tight Achilles tendon should be lengthened as well. Lateral column lengthening has been used extensively for treatment of flexible flatfeet. It has been shown clinically and radiographically to address all 3 components of the pes planovalgus deformity present in stage 2 posterior tibial tendon dysfunction. Lateral column lengthening is used in combination with a medial soft tissue rebalancing procedure. The mechanism of action is still speculative but clearly is not owing to tensioning of the plantar fascia as previously thought. Despite the excellent correction of foot posture obtained by use of lateral column lengthening for adult acquired flatfoot, many clinicians have reservations about its use because of reported secondary increases in the calcaneocuboid joint pressures. This increase in pressure has been shown to occur experimentally, increasing the potential risk of calcaneocuboid joint arthrosis. This experimental evidence is supported by Phillips' study of the original Evans procedure, which resulted in a 65% incidence of calcaneocuboid joint arthrosis at 13-year follow-up. Mosier-LaClair et al reported a 14% incidence of calcaneocuboid joint arthritis at 5-year follow-up after double osteotomy for stage 2 posterior tibial tendon dysfunction. This incidence has not been proved true in the remainder of the literature surrounding this procedure and its use for flexible flatfoot. To address the concern regarding potential calcaneocuboid arthrosis secondary to lateral column lengthening, calcaneocuboid joint distraction arthrodesis has been explored as an alternative technique. The results show good initial correction, but the follow-up is extremely limited, and one study reported loss of correction over time. Longer follow-up is needed to determine whether or not this technique would provide the lasting correction seen with the Evans procedure. Calcaneocuboid joint lengthening arthrodesis does result in some limitation of adjacent hindfoot motion. Although this limitation is significantly less compared with talonavicular and subtalar joint fusion, this procedure may result in increased local pressures and arthrosis of the midfoot or hindfoot. For the above-mentioned reasons, longer follow-up studies are needed to determine whether calcaneocuboid joint distraction arthrodesis would prove to be a reliable and safe alternative for lateral column lengthening in the treatment of adult acquired flatfoot. Medial displacement calcaneal osteotomy has been used for correction of the pes planovalgus foot in posterior tibial tendon dysfunction. It has been used extensively for the surgical treatment of flexible flatfoot throughout the literature. Medial displacement osteotomy, in combination with flexor digitorum longus tendon transfer, can address all 3 components of adult acquired flatfoot. It does not recreate the medial longitudinal arch in all patients, however. Although the mechanism of action of medial displacement calcaneal osteotomy is unknown, it has been proved that it is not through the tightening of the plantar fascia in a windlass effect as previously thought. In contrast to lateral column lengthening, however, medial displacement calcaneal osteotomy does address the deforming valgus force of the Achilles tendon. Functionally transferring the insertion of the Achilles tendon medially removes a constant valgus-deforming force. The osteotomy can then act as a double tendon transfer with the flexor digitorum longus tendon to aid in foot inversion. For stage 2 posterior tibial tendon insufficiency, the authors favor the combination double osteotomy technique with a flexor digitorum longus tendon-to-medial cuneiform tendon transfer, débridement or removal of the posterior tibial tendon, and percutaneous heel cord lengthening. Early results were positive at 1.5 years after surgery with respect to maintenance of correction and functional improvement with no evidence of calcaneocuboid arthrosis. More recently, the intermediate 5-year follow-up has been assessed for this combination of procedures, and similar results were found. There was a high rate of patient satisfaction and functional improvement, and surgical correction of the flatfoot deformity was maintained and compared favorably with the contralateral normal foot. Although the intermediate follow-up found a 14% incidence of calcaneocuboid arthrosis, 50% of these patients had preoperative evidence of calcaneocuboid joint arthritis. (ABSTRACT TRUNCATED)     

"Beak" triple arthrodesis for severe cavus deformity

Attention is called to the principles of a technique described more than 20 years ago that has proved clinically useful in the correction of severe cavus and cavovarus deformities when foot stabilization by triple arthrodesis is indicated. The method obtains correction of the cavus deformity by depressing the anterior aspect of the foot beneath a beak or ledge created in the talus, thereby preserving the vascularity to the talus and the integrity of the anterior ankle joint without shortening the foot.     

Foot and Ankle Function after Tibial Overlengthening

Lengthening the tibia more than 25% of its original length can be indicated for proximal femoral deficiency, poliomyelitis, or femoral infected nonunion. Such lengthening of the tibia can adversely affect the ankle or foot shape and function. The present study aimed to assess the effect of tibial lengthening of more than 25% of its original length on the foot and ankle shape and function compared with the preoperative condition. This was a retrospective study of 13 children with severe proximal focal femoral deficiency, Aitken classification type D, who had undergone limb lengthening from June 2000 to June 2008 using Ilizarov external fixators. The techniques used in tibial lengthening included lengthening without intramedullary rodding and lengthening over a nail. The foot assessment was done preoperatively, at fixator removal, and then annually for 3 years, documenting the range of motion and deformity of the ankle and subtalar joints and big toe and the navicular height, calcaneal pitch angle, and talo-first metatarsal angle. At fixator removal, all cases showed equinocavovarus deformity, with decreased ankle, subtalar, and big toe motion. The mean American Orthopedic Foot and Ankle Society score was significantly reduced. During follow-up, the range of motion, foot deformity, and American Orthopedic Foot and Ankle Society score improved, reaching nearly to the preoperative condition by 2 years of follow-up. The results of our study have shown that tibial overlengthening has an adverse effect on foot and ankle function. This effect was reversible in the patients included in the present study. Lengthening of more than 25% can be safely done after careful discussion with the patients and their families about the probable effects of lengthening on foot and ankle function.     

Ilizarov External Fixation for Correcting Complex Postpolio Foot and Ankle Deformity: A Case Study

Given their severity and resultant loss of function, postpoliomyelitic foot and ankle deformities require a unique correction method. Correction with dynamic Ilizarov external fixation is one such modality, although it is technically demanding and requires precise preoperative planning. In our case study, a 40-year-old male with a severe postpoliomyelitic equinocavovarus right foot and ankle deformity was treated with gradual correction using dynamic, hinged Ilizarov external fixation. The external fixation was in place for a total of 103 days, with gradual correction performed in 2 successive steps, achieving a functional, plantigrade foot. We maintained this position in a short leg cast for 30 days, followed by bracing and physiotherapy for 6 months. More than 2 years after the index surgery, the patient had achieved a painless and plantigrade foot, allowing for functional ambulation. This method does not require osteotomies, ankle arthrodesis, or tendon transfer.     

Primäre Arthrodese des oberen Sprunggelenks nach nicht rekonstruierbarer Trümmerfraktur der distalen Tibia (Pilonfraktur)

OBJECTIVE: Ankle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy. INDICATIONS: Posttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC. CONTRAINDICATIONS: Ipsilateral foot injuries impairing ambulation after fusion. Severe injury to the posterior tibial nerve with absent plantar sensation. Soft-tissue injury not manageable surgically. Inadequate patient compliance. Advanced age. Severe osteoporosis. Acute infection. SURGICAL TECHNIQUE: Standard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional. Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5-1 mm per day depending on patient's age. After docking: Ilizarov ankle arthrodesis. RESULTS: Between January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19-68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external fixation 54.4 days/cm for the three bone distraction patients. Mean transport 6 cm (4.5-8.5 cm). One patient required repeat ankle arthrodesis.     

膝关节牵伸技术治疗先天性多发性关节挛缩症屈膝畸形

目的　探讨用膝关节牵伸技术 (Ilizarov)治疗先天性多发性关节挛缩症屈膝畸形的方法及疗效。方法　 1998年 8月至 2 0 0 3年 2月收治先天性多发性关节挛缩症 6例 ,其中双膝 4例 ,共 10个膝关节。男 5例 ,女 1例 ,年龄 3岁 7个月至 13岁 ,平均年龄 8岁 2个月。术前屈膝畸形程度平均5 1° ,合并肢体其它部位畸形 13个。应用改良Ilizarov膝关节牵伸器 ,手术安装牵伸器时 ,应维持膝关节于最大伸展位 ,牵伸器的关节铰链对准膝关节的旋转中心 ,于膝上下股骨和胫骨各穿 2组 2mm克氏针与牵伸器上下的钢环固定。术后 5d旋转延长膝后的螺纹牵伸杆 ,第 1周 2～ 3mm/d ,第 2周后改成 1～ 2mm/d ,直至达到膝关节伸直到 0°位。合并髋、足关节畸形者 ,同期或第二期实施手术矫正。本组术后膝关节牵伸时间 2 3～ 4 8d ,平均 37d ,治疗期间患肢可负重锻炼 ,停止牵伸 2周后拆牵伸器再装支具行走。结果　 10个膝关节屈曲畸形完全矫正 ,无严重并发症 ,其中 9个膝术后随访平均 1年 3个月 ,畸形无复发 ,患者行走功能显著改善。结论　Ilizarov技术治疗先天性多发性关节挛缩症屈膝畸形 ,方法简单、安全 ,效果确实 ,符合生物学原理和微创外科的原则     

Complex foot deformities associated with soft-tissue scarring in children.

Two cases of deformities in scarred feet are presented. One case had an old, well healed forefoot amputation with severe equinovarus deformity, and the other had an equinus deformity following a burn injury 10 months prior. Both the cases were managed by primary release of the contracted joint capsules. The correction of the soft-tissue contractures was achieved by gradual distraction using the Ilizarov apparatus. The clinical presentation and surgical treatment of complex foot deformities, complicated by the presence of scar tissue, are presented. These cases illustrate the benefits of combining soft-tissue release with the Ilizarov technique of distraction histogenesis in the treatment of complicated foot deformities associated with scarring in pediatric patients.     

Ilizarov treatment for equinoplanovalgus foot deformity caused by melorheostosis

Melorheostosis often is disabling because of progressive contracture of the joint and soft tissue involved. Operative intervention often is hazardous and patients also have recurrences. A 14-year, 2-month-old boy, who presented with a recurrent equinoplanovalgus deformity of the right foot caused by melorheostosis, was treated successfully using the Ilizarov technique, including distraction osteotomy in the calcaneus. The patient had a painless, plantigrade, and functional foot at age 18 years.     

Tibial lengthening over an intramedullary nail

Background Long-term application of an external fixator to treat leg-length discrepancy and short stature often causes complications, such as pin-tract infection or loss of range of motion at the knee or ankle (or both). Prolonged fixator use also interferes with the activities of daily living. To minimize such problems, we have combined intramedullary nailing with external fixation. Using this technique, the external fixator can be removed more quickly after completing the lengthening. Methods We combined intramedullary nailing with lengthening in 13 tibias (8 patients) and then compared these cases with 17 standard tibial lengthenings (16 patients) using an external fixator alone. In both groups we excluded patients who had a history of previous bone infection, open fracture, immature bone, soft tissue compromise, antineoplastic chemotherapy, or bone deformity of a severity that required gradual deformity correction. We also excluded cases with lengthening of less than 3 cm. Results The mean external fixation index differed significantly between the two groups, but the consolidation index did not. Mean operating time for lengthening combined with intramedullary nail placement was approximately 60 min longer than for standard lengthening without nail placement; intraoperative blood loss was not greater in the nailing group. Complications related to the external fixator were far fewer in the combined intramedullary nailing and lengthening group compared with the control group, and callus formation was satisfactory for both groups. Conclusions A combination of intramedullary nailing and external fixation produces callus formation as good as that obtained by the standard Ilizarov method of lengthening. Furthermore, this combined procedure decreases the external fixation time and is associated with fewer complications.     

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

IntroductionThere are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy.Presentation of caseThe patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws.DiscussionThe patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain.ConclusionWe reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach.