The Journal of Foot & Ankle 54 (2015) 821–825

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The Journal of Foot & Ankle Surgery

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

Bi O Jeong, MD, PhD, Tae Yong Kim, MD, Wook Jae Song, MD

Department of Orthopaedic Surgery, Kyung Hee University College of Medicine, Seoul, Korea article info abstract

Level of Clinical Evidence: 4 The purpose of the present retrospective study was to report the correction of severe, rigid equinus de- formities using an Ilizarov external fixator alone, without adjunctive open procedures. Ten feet in 10 patients Keywords: ankle deformity with rigid equinus deformities were enrolled and underwent gradual correction using an Ilizarov external fi gait xator alone, without additional open procedures. The range of ankle motion was measured preopera- gradual correction tively and at the last follow-up visit. The radiographic outcome was assessed using the lateral tibiotalar angle Ilizarov external fixator on ankle radiographs taken preoperatively, immediately after removal of the Ilizarov fixator, and at the last talus follow-up visit. The mean duration of external fixator treatment was 40.1 13.5 days. The preoperative mean ankle range of motion was 55.5 22.2 of dorsiflexion and 63.0 20.8 of plantarflexion. At the last follow-up visit, the mean dorsiflexion had increased to 2.5 6.8 and the mean plantarflexion had decreased to 30.5 12.6. The mean lateral tibiotalar angle was 152.9 19.7 preoperatively, 103.9 9.4 immediately after removal of the Ilizarov external fixator, and 113.9 11.6 at the last follow-up visit. Immediately after fixator removal, all the patients had clinical correction of their deformity to a plantigrade foot using the Ilizarov external fixator alone, with a mean correction of 49.0 17.4 . Some recurrence was noted at the last follow-up examination, with a final mean correction of 39.0 18.0. The present study has demonstrated successful correction of severe, rigid equinus deformity with the use of an Ilizarov external fixator without the need for adjunctive soft tissue procedures. This method can be effective for patients with a high risk of complications after open procedures owing to their poor soft tissue envelope. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

Equinus deformity is associated with congenital disorders, trauma, correct equinus deformities (19–23). Most of the existing studies have burns, neuromuscular disease, and limb lengthening (1–3). A rigid reported the use of an Ilizarov external fixator combined with open equinus deformity will result in a tip-toe gait, making ambulation procedures such as soft tissue release (11,24–27). Experience with difficult. Conservative treatment, such as stretching exercises, dy- correction of equinus deformities using an Ilizarov external fixator namic splinting, and serial casting, can be attempted for mild equinus alone without adjunctive soft tissue procedures is limited. deformities (4). If conservative treatment does not result in adequate Thus, we hypothesized that the ankle range of motion would heel weightbearing or a compensated toe gait, surgical options should significantly improve both clinically and radiographically using an be considered (5–7). The surgical options for correction of equinus Ilizarov external fixator alone in cases of severe rigid equinus defor- deformities include soft tissue release, tendon transfer, or mity. Our primary aim was to evaluate the extent of correction wedge resection, and hindfoot fusion (4,8–18). These procedures are possible using an Ilizarov external fixator alone, without adjunctive technically challenging and the risk of complications is high, in soft tissue procedures, in patients with a rigid equinus deformity and particular, in the setting of associated infection or poor soft tissue to investigate the extent to which equinus deformities recur after envelope (8,12). correction. In such cases, an Ilizarov external fixator with the concept of distraction histogenesis has been used as a less-invasive attempt to Patients and Methods

Our institutional review board approved the present study, and all patients pro- Financial Disclosure: None reported. vided informed consent. Ten feet in 10 patients with an equinus deformity were Conflict of Interest: None reported. enrolled from March 2000 to October 2012 and underwent placement of an Ilizarov Address correspondence to: Bi O Jeong, MD, PhD, Department of Orthopaedic external fixator alone for gradual correction. Of the 10 patients, 8 were male (80%) and 2 Surgery, Kyung Hee University College of Medicine, 1 Hoegi-dong, Dongdaemun-gu, were female (20%), and the mean age at correction was 28 (range 15 to 55) years. Seoul 130-702, Korea. All patients were ambulatory preoperatively, with varying severity of limp due to E-mail address: [email protected] (B.O. Jeong). the tip-toe gait. The etiology of equinus deformities was spastic type cerebral palsy in 2

1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.12.039 822 B.O. Jeong et al. / The Journal of Foot & Ankle Surgery 54 (2015) 821–825

(20%), congenital neuromuscular disease (hereditary spastic paraplegia) in 1 (10%), advanced at a rate of 3 to 4 mm daily, or 1. If the pain intensified, correction was briefly chronic osteomyelitis after an open tibia fracture in 3 (30%), pyogenic Achilles tendinitis suspended until the pain had subsided. After receiving training on pin site dressing, the in 1 (10%), peroneal nerve palsy in 1 (10%), limb lengthening in 1 (10%), and tumor patients performed the dressing changes themselves on a daily basis. A radiographic excision on the calf in 1 patient (10%). None of the patients showed improved ankle examination was performed every 2 weeks to check for anterior translation of the talus. dorsiflexion, even after flexion of the knee . No patient had previously undergone Clinically, correction with the Ilizarov fixator continued until 5 of ankle dorsiflexion surgical treatment of the equinus deformity. The mean duration of the equinus had been achieved. After correction of the deformity, the Ilizarov external fixator was deformity was 7.4 (range 1 to 21) years. A mean of 3.5 (range 0 to 11) operations had maintained for a period equal to that required to achieve correction. When pin site been performed for the treatment of the causes of the equinus deformities but none for infection was observed, the Ilizarov external fixator was removed earlier and replaced correction of the equinus deformity itself. The skin condition was poor in almost all with a short leg cast or a brace for the remaining treatment period. At completion of the patients because most of the previous had been performed on the ankle or fixation period, full weightbearing ambulation was gradually attempted for several around the foot. weeks with the brace in place. The patients used an ankle foot orthosis after completion The mean follow-up period from the removal of the Ilizarov external fixator was of the correction. 1 year, 3 months (range 12 months to 2 years, 2 months). The clinical results were evaluated using the range of ankle joint motion. The heel weightbearing ambulation Results was measured preoperatively and at the last follow-up examination. The radiographic outcomes were measured using the lateral tibiotalar angle (lateral angle between the long axis of the tibia and the long axis of the talus) on weightbearing lateral ankle The mean duration required for correction of equinus deformity radiographs taken preoperatively, immediately after removal of the Ilizarov external using the Ilizarov external fixator was 40.1 (range 28 to 58) days. The fixator, and at the last follow-up visit. In addition, the Wilcoxon signed rank test was mean duration of maintaining the corrected ankle with the Ilizarov fi fl fl used to identify whether signi cant ankle dorsi exion and plantar exion improve- external fixator or cast after completion of the correction was 37.5 ments had occurred postoperatively. A p value of .05 was considered statistically significant. All statistical analyses were performed by a statistician using the SPSS (range 28 to 59) days. The preoperative mean ankle range of motion statistical software, version 13.0 (SPSS Inc, IBM Corp, Armonk, NY). demonstrated rigid equinus deformity, with 55.5 (range 80 to 15) in dorsiflexion and 63 (range 15 to 90) in plantarflexion. fi Surgical Technique These had signi cantly changed at the last follow-up visit to 2.5 (range 20 to 5) in dorsiflexion (p ¼ .003) and 30.5 (range 0 to The procedure was performed with the patient under general or spinal anesthesia. 40) in plantarflexion (p ¼ .003; Fig. 2). The overall mean ankle range With the patient in the supine position and the leg under tourniquet control, a pillow of motion showed statistically significant improvement from 7.5 was placed under the hip to rotate the ankle internally. Two rings were mounted to the (range 0 to 30) preoperatively to 28 (range 5 to 40) post- tibia using 2 tensioned wires. The tibial rings were considered as the base for distraction. The calcaneus was fixed with a wire and a half ring. A wire was passed operatively (p ¼ .011). At the last follow-up visit, ankle dorsiflexion through the midshaft of the first and fifth metatarsals. An additional wire was added was 5 in 1 patient (10%), 0 in 6 patients (60%), 5 in 2 patients just proximal to the metatarsal wires. The 2 wires used on the metatarsal were (20%), and 20 in 1 patient (10%). All the patients, except for the fi xed to the straight plates connected to the half ring of the calcaneus, and another patient with 20 of dorsiflexion, were able to achieve adequate forefoot half ring was connected to the distal part of the straight plate to which the metatarsal wires were fixed. The calcaneal half ring was connected to the tibial correction to allow heel walking during gait (Fig. 3). All patients were ring using 3 rods: 1 posterior and 2 on each side (medial and lateral). From the anterior ambulatory without assistance at the final follow-up visit. aspect, the forefoot half ring was connected to the tibial ring, again using 1 rod placed in The mean lateral tibiotalar angle on the weightbearing radio- the central hole of the half ring. One plane hinge was placed on the medial and lateral graphs of the ankle was 152.9 (range 114 to 170) preoperatively and rods to pivot on the talus center. We used uniplane hinges in most patients (Fig. 1). had improved to 103.9 (range 89 to 120) after removal of the Ili- Gradual correction was started 1 week after application of the Ilizarov external fi fixator. Initially, correction was performed 4 times daily to the maximal extent that was zarov xator. The mean radiographic correction was 49 (range 14 to not painful to the patient. When the patients began to feel pain, correction was 72 ). Some recurrence was seen at the final follow-up visit, with a

Fig. 1. (A and B) Clinical photographs of an applied Ilizarov external fixator. B.O. Jeong et al. / The Journal of Foot & Ankle Surgery 54 (2015) 821–825 823

Fig. 2. (A) Clinical photograph of a 23-year-old male with a rigid equinus deformity from congenital neuromuscular disease (hereditary spastic paraplegia). (B) Clinical photograph of gradual correction with an Ilizarov external fixator. (C) Clinical photograph at the last follow-up visit showing that the angle of dorsiflexion had improved from 65to 0. Radiographs (D) of the same patient preoperatively, (E) during gradual correction, (F) after correction, and (G) at the last follow-up visit. The mean lateral tibiotalar angle had improved from 170 to 110. mean lateral tibiotalar angle of 113.9 (range 100 to 135) and mean reduction was performed with the patient under local anesthesia. radiographic correction of 39 (range 6 to 66; Table). Mild superficial pin site infection was observed in 3 patients (30%), No neurovascular complications were observed. Also, no hammer and these were successfully treated with oral antibiotics. No radio- toe deformities were present. One patient (10%) demonstrated ante- graphic finding of the progression of postoperative arthritis was noted rior translation of the ankle joint 3 days after correction, for which for any of the patients.

Fig. 3. (A) Clinical photograph of a 41-year-old male with a rigid equinus deformity from chronic osteomyelitis after an open tibial fracture. Six operations had been performed for the treatment of the causes of the equinus deformity. The skin condition of the ankle, foot, and surrounding area was poor. (B) Clinical photograph and (C) radiograph during gradual correction using an Ilizarov external fixator. (D) Clinical photograph at the last follow-up visit showing that the angle of dorsiflexion had improved from 65 to 20. The patient was unable to walk on his heels but was ambulatory without brace assistance. 824 B.O. Jeong et al. / The Journal of Foot & Ankle Surgery 54 (2015) 821–825

Table Clinical data for all patients

Patient No. Age (y) Preoperative Ankle Preoperative Ankle Radiographic Correction () Correction Last Follow-Up Visit Dorsiflexion () Plantarflexion () Loss () Immediately After Ilizarov At Last Ankle Ankle Removal Follow-Up Visit Dorsiflexion () Plantarflexion () 14930 60 33 22 11 0 30 21860 60 59 41 18 0 40 35565 70 64 49 15 0 40 42480 80 72 66 6 0 40 51875 75 53 49 4 540 62030 45 34 22 12 530 72365 70 60 52 8 0 35 81515 15 14 6 8 5 0 94165 65 48 33 15 20 30 10 19 70 90 53 50 3 0 20 Mean SD 28.2 14.5 55.5 22.2 63.0 20.8 49.0 17.4 39.0 18.0 10.0 5.0 2.5 6.8 30.5 12.6

Abbreviation: SD, standard deviation.

Discussion follow-up visit, with a mean loss of 10.0 5.0, for a final mean correction of 39.0 18.0. Carmichael et al (1) also reported that a Equinus deformity interferes with a normal gait owing to excessive relapse after correction with an Ilizarov external fixator was common plantarflexion of the ankle, which limits the ability to achieve a in pediatric patients with burn contracture. Biedermann et al (32) also neutral position. Surgical correction is performed to allow a planti- described a relatively high recurrence rate and found correction with grade foot for improved gait (11). Although open soft tissue release an Ilizarov external fixator meaningful as an alternative technique but has been the standard treatment of equinus deformities, skin and not as a final treatment technique. In our series, clinical correction with wound complications can easily develop in the course of the correc- the Ilizarov fixator continued 5 of ankle dorsiflexion; however, a tion (8,12). The present study reports the successful use of Ilizarov slight recurrence was found at the last follow-up visit in most patients. external fixation without an adjunctive soft tissue procedure to cor- Ankle dorsiflexion was 5 in 1 patient (10%), 0 in 6 patients (60%), 5 rect severe, rigid equinus deformity in a group of 10 patients with soft in 2 patients (20%), and 20 in 1 patient (10%). All the patients, except tissue compromise. for the patient with 20 of dorsiflexion, were able to achieve adequate One of the main risks of open surgical procedures to correct correction to allow heel walking during gait (Fig. 3). The 1 patient with equinus deformities is soft tissue complications. David et al (8) re- severe recurrence had undergone 6 surgical procedures, including skin ported infection and wound complication rates as high as 27% with grafting and sural flaps around the foot and ankle for the treatment of acute surgical correction. Moreover, neurovascular complications can an open tibial fracture and subsequent osteomyelitis. Gradual correc- occur, specifically in the posterior tibial artery and tibial nerve. To tion using an Ilizarov external fixator was performed for 50 days until prevent such complications, Lamm et al (28) recommended tarsal 5 of ankle dorsiflexion had been achieved. The Ilizarov external fixator tunnel release for a correction angle >10. was maintained for another 14 days, and a short leg cast was applied for Ilizarov external fixator is an appealing alternative to open the next 28 days for additional fixation. However, the equinus defor- correction, because it can reduce the risk of skin problems or neuro- mity recurred gradually during the follow-up period, demonstrating vascular complications by allowing for gradual correction rather than 20 of ankle dorsiflexion at the last follow-up visit. To avoid such acute correction. In most previous studies on the treatment of equinus postcorrection recurrences, we have continued to recommend the use deformities, an Ilizarov external fixator was applied in combination of an ankle foot orthosis even after completion of the correction. The with various open procedures. Therefore, it has been difficult to assess ankle foot orthosis helped prevent recurrence of the equinus deformity how much correction can be achieved with an Ilizarov external fixator in most patients, but it was not very effective for the 1 patient, in whom alone (11,24–27). To our knowledge, only 4 studies have been pub- heel walking was impossible because of the severe recurrence. The lished on this subject. Hosny (29) reported good results with their relatively severe recurrence in 1 patient was attributable to the very bloodless technique using only an Ilizarov fixator. Hosny (29) did not severe equinus deformity and poor soft tissue envelope observed report the ankle range of motion or the radiographic correction angle, preoperatively. Additional surgical treatment was also considered making it difficult to precisely analyze the extent of correction. Melvin when necessary; however, no additional surgery was performed for and Dahners (30) reported correction of equinus contracture 35 recurrence in the present study, because the patient with 20 of with a dynamic technique using an Ilizarov fixator in pediatric dorsiflexion was satisfied with the correction angle. patients. Carmichael et al (1) also reported a correction of about 41 Although recurrence of equinus deformities, determined by the with an Ilizarov fixator; however, these results also applied only to radiographic measure using the lateral tibial angle, had developed pediatric patients. A study by Tsuchiya et al (31) was the only study at the last follow-up visit, we obtained satisfactory clinical results. that used a method similar to that in our study, using an Ilizarov Specifically, the range of motion examination showed a mean external fixator alone in adult patients. They reported an equinus correction of ankle dorsiflexion of 53.0 21.4 at the last follow-up deformity correction of 36.1 (31). visit. This was 14 greater than the mean radiologic correction angle of Our results support the use of Ilizarov external fixation alone, 39.0 18.0. This suggests a possible measurement error between without adjunctive soft tissue procedures, in adult patients with severe the clinical measure of the ankle range of motion and the radiologic equinus deformities. We were able to obtain a mean correction of measurement. However, our clinical observation was that some of the 49.0 17.4, with a maximum observed correction of 72,12.9 larger difference resulted from additional correction in the midfoot joint than the mean correction of 36.1 reported in the only previous series that was not reflected on the ankle radiographs. Clinically, we of adult patients (31). The high level of correction might have resulted observed significant improvement in ankle dorsiflexion and heel because our patients had very severe deformities. We did observe contact on ambulation. The results of our study support the use of the some recurrence after removal of the Ilizarov external fixator at the last Ilizarov external fixator alone, without adjunctive soft tissue B.O. Jeong et al. / The Journal of Foot & Ankle Surgery 54 (2015) 821–825 825 procedures, in particular, to reduce the complication risks in patients 2. Hahn SB, Park HJ, Park HW, Kang HJ, Cho JH. 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