V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet
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1 Journal of Orthopaedic Surgery 2008;16(2):215-9 V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet E Segev, E Ezra, M Yaniv, S Wientroub, Y Hemo Department of Pediatric Orthopaedics, Dana Children s Hospital, Tel-Aviv Sourasky Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel ABSTRACT Purpose. To report the treatment outcomes of V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet. Methods. 13 patients (14 feet) aged 8 to 18 years underwent V osteotomy via the calcaneus and talus, followed by gradual distraction of soft tissue and bone for foot reconstruction. Eight of the clubfeet were idiopathic and had undergone previous surgeries. The remaining 6 were neurogenic and their pathologies were: Charcot Marie Tooth disease (n=2), myelomeningocele (n=2), neurofibromatosis (n=1), and distal arthrogryposis (n=1). Three of them had undergone previous surgeries. The Ilizarov frames were retained for 3 to 6 months and the patients were followed up for 1.8 to 8.9 years. Range of movement of the ankle and foot, appearance and position, gait, pain, function, and patient satisfaction were assessed according to the modified grading system. The talo-1st metatarsal angle was measured on anteroposterior radiographs. Results. Scores associated with the appearance and position of the foot, and thus patient satisfaction were significantly improved, but not for range of movement, pain, and function. The mean preoperative and final talo-1st metatarsal angles were 39.7 and 8.7 degrees, respectively (p<0.01). Ten feet achieved the plantigrade position, one had residual equinus, and 3 had residual adduction and supination. Conclusion. satisfaction improved significantly despite no major improvement in pain, function, and range of movement of the ankle and foot. This reflects the importance of the appearance and position of the foot, and justifies the decision to undergo this long and demanding procedure. Key words: ; fixators, external; Ilizarov technique; osteotomy; recurrence INTRODUCTION It is a challenge to treat patients aged >8 years with residual after a series of failed surgeries. Such feet become stiff and un-amenable to soft-tissue Address correspondence and reprint requests to: Dr Eitan Segev, Department of Pediatric Orthopaedics, Dana Children s Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv, 64239, Israel. esegev@tasmc.health.gov.il
2 216 E Segev et al. Journal of Orthopaedic Surgery (a) (b) (c) Figure 2 12: clinical and radiographic results before and after V osteotomy and the use of Ilizarov technique. Figure 1 7: (a) correction of the right foot and deformation of the left foot, (b) application of the Ilizarov frame to the left foot, and (c) the clinical result at the final follow-up. correction. Neurogenic clubfeet tend to recur after soft-tissue release because of muscle imbalance and pose functional and cosmetic problems. Callosities or pressure sores may develop on the lateral and dorsal parts of the foot after prolonged walking. Soft-tissue distraction is effective for patients aged <8 years, but may recur in older children. 1 4 The conventional triple arthrodesis involves removal of bony wedges and straightening of the foot, but tends to stiffen the joints below the ankle, shorten the foot, and arrest future growth of the small bones. This procedure s ability to correct the deformity is limited and further adjustment is not feasible. The Ilizarov technique of distraction osteogenesis 5 has been used to correct residual clubfeet with encouraging results. 1 4 Double osteotomy (V shape) via the calcaneus and talus followed by gradual distraction of the soft tissues and bones enables reshaping of the foot. Reorientation of the foot may correct the deformities, increase length, and preserve residual movement in the joints. We report our 9-year experience in the treatment of residual idiopathic or neurogenic clubfeet. MATERIALS AND METHODS The study was approved by our institutional review board. Between January 1998 and January 2005, 13 patients (14 feet) aged 8 to 18 years underwent V osteotomy via the calcaneus and talus, followed by gradual distraction of soft tissue and bone for reconstruction. Eight of the clubfeet were idiopathic (Fig. 1) and had undergone previous surgeries (one foot had had one operation, 3 had had 2, and 4 had had 3). The remaining 6 were neurogenic and their pathologies were: Charcot Marie Tooth disease (n=2), myelomeningocele (n=2), neurofibromatosis (n=1), and distal arthrogryposis (n=1, Fig. 2). Three of the patients had each undergone 2 previous surgeries. The Ilizarov frames were retained for 3 to 6 months and the patients followed up for 1.8 to 8.9 years (Table 1). Under tourniquet control, the posterior tibial neurovascular bundle was exposed via a medial
3 Vol. 16 2, August 2008 V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet 217 Diagnosis Previous surgery Age at surgery (years) 1 Idiopathic 2 Charcot-Marie- Tooth disease 3 Idiopathic 4 Neurofibromatosis 5 Myelomeningocele 6 Idiopathic 7 Idiopathic 7 Idiopathic 8 Myelomeningocele 9 Idiopathic 10 Idiopathic 11 Charcot-Marie- Tooth disease 12 Distal arthrogryposis 13 Idiopathic Time in frame (months) Followup (years) Complications Pin tract infection Pin tract infection, toe flexion Pin tract infection release Pin tract infection Great toe necrosis, toe flexion Pin tract infection, Evans procedure Residual equinus,, Evans procedure pin tract infection Pin tract infection, toe flexion, Evans procedure Residual supination, pin tract, tibialis anterior infection tendon transfer Table 1 Demographic and clinical data of the patients Lateral wound dehiscence, toe flexion, residual supination, Evans procedure Lateral wound dehiscence, toe flexion Pin tract infection. Toe flexion Pin tract infection release, Grice procedure Pin tract infection, toe flexion, residual supination approach and protected. The tarsal tunnel was then released. The peronei tendons were elevated from the calcaneus via a lateral approach, and the cuboid and talus were exposed. The hind foot and forefoot were separated from the middle stationary fragment using a V osteotomy. A wedge shaped piece of bone was removed from the lateral aspect of the osteotomy to prevent impingement of the bone fragments. The modular 2 ring Ilizarov frame was then attached to the tibia. The hindfoot and forefoot deformities were corrected gradually in relation to the stationary middle fragment by proper orientation of the distractors and hinges 5 (Fig. 3). The frame was kept until bony consolidation. A cast was applied for 4 to 6 weeks after frame removal, followed by rehabilitation. Preoperatively and at final follow-up, range of movement of the ankle and foot, appearance and position, gait, pain, function, and patient satisfaction were assessed using the modified outcome grading system, 6 with a best possible score of 150. The talo-1st metatarsal angle was measured on anteroposterior radiographs. Preoperative and final follow-up results were compared using the Wilcoxon signed rank test, with adjustment for ties. A p value of <0.05 was considered statistically significant. RESULTS There was no significant difference in the functional and radiographic results between patients with idiopathic or neurogenic defects. Scores associated with appearance and position of the foot, and thus patient satisfaction were significantly improved, but not for range of movement, pain, and function (Table 2). In the respective preoperative and final follow-up, mean scores of ankle dorsiflexion were 4.3 and 4.6 (p=0.317), subtalar motion were 2.1 and 0.7 (p=0.102), heel position were 0.0 and 6.4 (p=0.002), forefoot adduction were 0.0 and 6.8 (p=0.002), supination
4 218 E Segev et al. Journal of Orthopaedic Surgery Figure 3 Medial and lateral views of a foot model showing the V osteotomy and Ilizarov technique. Table 2 Functional results, appearance, and patient satisfaction according to the modified outcome grading system 6 Ankle dorsiflexion Subtalar motion Heel position Forefoot adduction Supination Cavus Gait Pain Function satisfaction Total Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final right left Mean p Value Table 3 Radiographic results Anteroposterior talo-1st metatarsal angle Preop Final 1 34º 15º 2 50º 20º 3 53º 5º 4 30º 5º 5 38º 8º 6 75º 16º 7 right 24º 0º 7 left 40º 6º 8 35º 5º 9 50º 17º 10 30º 10º 11 32º 10º 12 30º 6º 13 35º 0º Mean* 39.7º 8.8º * p<0.01 were 0.0 and 5.7 (p=0.005), cavus were 0.0 and 7.9 (p=0.001), gait were 12.5 and 16.1 (p=0.004), pain were 17.1 and 18.6 (p=0.317), function were 12.9 and 14.3 (p=0.414), and patient satisfaction were 3.2 and 17.9 (p=0.001). The mean preoperative and final talo- 1st metatarsal angles were 39.7º and 8.8º, respectively (p<0.01, Table 3). 7 had residual equinus of the left foot after removal of the cast (Fig. 1). After intensive physiotherapy had failed, the was corrected to the plantigrade position with reapplication of the Taylor spatial frame. Three patients had residual adduction and supination of the forefoot after frame removal, because the talonavicular joint (not the talar neck) was separated and bony stabilisation was not achieved. It is important that the V osteotomy is through the talar neck for bony consolidation. Seven patients developed toe s and underwent flexor tenotomies. In one, the toes were stabilised with Kirschner wires and
5 Vol. 16 2, August 2008 V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet 219 an Ilizarov half ring with the frame on the foot. In the other 6 the foot was stabilised with a cast after frame removal. Four patients had dehiscence of the lateral surgical wound secondary to severe scarring and compromised blood supply. The wound dehiscence resolved after topical treatment with eusol and granuflex. 11 patients developed pin tract infection, which resolved with oral or intravenous antibiotics. 5 had necrosis of the great toe which resolved with eusol and granuflex. DISCUSSION The Ilizarov technique enables correction through soft-tissue distraction 1,7 9 or combination of softtissue distraction and bony manipulation. 2,3,10 Softtissue distraction is appropriate for feet with mild secondary bony changes and for younger patients. 5,11 Our patients were older and had scar and muscle imbalance around the foot secondary to previous surgeries. These feet had severe bony and joint changes, and soft-tissue distraction alone could have resulted in incongruent joints and recurrence. It is important to establish the vascular anatomy prior to distraction. This can be achieved using ultrasound Doppler scanning or angiography. Tarsal tunnel was routinely released to minimise the risk of vascular injury and the V osteotomy was performed via a lateral incision under direct vision. s report being satisfied with the appearance and plantigrade position of the foot, the ability to walk and to wear normal shoes. 1,4,7 They also attain a more balanced load on pedobarography. 12 The results from patient based responses are more favourable than clinical assessments by the surgeon. 13,14 Encouraging results are reported mainly from the cosmetic perspective and satisfaction, not function. 13,14 In our study, patient satisfaction improved significantly, despite no major improvement in range of movement of the ankle and foot, pain, and function. This reflects the importance of the appearance and position of the foot, and justifies the decision to undergo this long and demanding procedure. REFERENCES 1. Grill F, Franke J. The Ilizarov distractor for the correction of relapsed or neglected. J Bone Joint Surg Br 1987;69: Grant AD, Atar D, Lehman WB. The Ilizarov technique in correction of complex foot deformities. Clin Orthop Relat Res 1992;280: Paley D. The correction of complex foot deformities using Ilizarov s distraction osteotomies, Clin Orthop Relat Res 1993;293: de la Huerta F. Correction of the neglected by the Ilizarov method. Clin Orthop Relat Res 1994;301: Ilizarov GA. Transosseous osteosynthesis. Berlin/Heidelberg: Springer-Verlag; 1992: Ezra E, Hayek S, Gilai AN, Khermosh O, Wientroub S. Tibialis anterior tendon transfer for residual dynamic supination deformity in treated club feet. J Pediatr Orthop B 2000;9: Wallander H, Hansson G, Tjernstrom B. Correction of persistent deformities with the Ilizarov external fixator. Experience in 10 previously operated feet followed for 2-5 years. Acta Orthop Scand 1996;67: Brunner R, Hefti F, Tgetgel JD. Arthrogrypotic joint at the knee and the foot: correction with a circular frame. J Pediatr Orthop B 1997;6: Bradish CF, Noor S. The Ilizarov method in the management of relapsed club feet. J Bone Joint Surg Br 2000;82: Kocaoglu M, Eralp L, Atalar AC, Bilen FE. Correction of complex foot deformities using the Ilizarov external fixator. J Foot Ankle Surg 2002;41: Choi IH, Yang MS, Chung CY, Cho TJ, Sohn YJ. The treatment of recurrent arthrogrypotic club foot in children by the Ilizarov method. A preliminary report. J Bone Joint Surg Br 2001;83: Hutchinson RJ, Betts RP, Donnan LT, Saleh M. Assessment of Ilizarov correction of club-foot deformity using pedobarography. A preliminary report. J Bone Joint Surg Br 2001;83: Freedman JA, Watts H, Otsuka NY. The Ilizarov method for the treatment of resistant : is it an effective solution? J Pediatr Orthop 2006;26: Utukuri MM, Ramachandran M, Hartley J, Hill RA. -based outcomes after Ilizarov surgery in resistant clubfeet. J Pediatr Orthop B 2006;15:
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