Ankle Deformity Research Articles

Vertical Wire Forefoot Fixation: An Advanced Technique for the Dynamic External Fixation Apparatus

External fixation is used for the correction of select foot and ankle deformities. We have found the traditional forefoot crossing wire technique to be insufficient in terms of both individual metatarsal control and forefoot manipulation when using a dynamic ring fixator to correct forefoot deformities. We developed a forefoot fixation technique at the University of Cincinnati Medical Center, using 5 vertical wires to gain greater forefoot control while performing more precise skeletal manipulation for multiplanar deformity correction. The associated risks of infection, neurovascular injury, and other soft-tissue injury should be further investigated. This proposed vertical wire construct is an advanced method with which the foot and ankle surgeon can correct complex lower limb deformities.

Effect of Intermittent Serial Casting on Equinus Ankle Deformity in Children with Hemiplegic Cerebral Palsy

AbstractBackground: Equinus is the most common problem in ambulatory children with spastic hemiplegic cerebral palsy, which results in an unstable and inefficient gait pattern. Without proper management at an early stage, it can lead to permanent foot deformities.Aim of Study: The aim of this study was to evaluate the effect of serial casting on ankle range of motion, tone of the calf muscle and ankle kinematics during gait in children with spastic hemiplegic cerebral palsy.Material and Methods: Twenty-five spastic hemiplegic cerebral palsy children of both sexes (15 boys and 10 girls) participated in this study. Patients were selected at level I according to Gross Motor Function Classification System and the degree of spasticity ranged from 2 to 3 according to Modified Ashworth Scale with true equinus, with their mean age were 4.8±0.8 years. They were randomly assigned to two groups. The first group, 12 children, Group (A) who received a selected physical therapy program once a day/3 times a week for three successive weeks; while the second group, 13 children, Group (B) who received three consecutive casts for five days each and removed in the last two days in each week to conduct the same selected physical therapy program which conducted for the Group (A). Ankle range of motion was assessed by electronic goniometer, calf muscle spasticity was assessed by modified ashworth scale and ankle kinematics during gait was assessed by observational gait scale.Results: The results of the present study revealed that Group (B) showed statistically significant improvement in ankle range of motion, tone of calf muscle and ankle kinematics during gait (p=0.0001 for all) than those of the Group (A).Conclusion: Serial casting of equinus ankle deformity could improve ankle range of motion, tone of calf muscle and ankle kinematics during gait in children with spastic hemiplegic cerebral palsy.

Prediction of Number of Casts and Need of Tenotomy Using Pirani Score in the Management of Clubfoot.

Clubfoot also called as congenital tailpipes equinovarus is a complex ankle and foot deformity characterized by forefoot adduction and supination, midfoot cavus and hindfoot varus and equinus. It is estimated that more than 100,000 babies are born each year worldwide with clubfoot, and 80% are seen in developing nations. Different scoring systems are used for grading the severity of deformity or monitoring the natural history of clubfoot. The Pirani scoring system is now routinely used in most clubfoot clinics, including Cure Ethiopia, Children's Hospital. A facility based retrospective study was conducted on 278 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani system between September 2013/14 to September 2017/2018. Age at presentation, number of casts required, need for percutaneous Achilles tenotomy, casting effects were recorded. A total of 287 clinical folders of children were retrieved (424 feet). The mean (±SD) number of casts required for correction of the deformity was 5.54 ± 1.63. The number of cast required for correction is significantly, and positively correlated with initial severity of Pirani score (r = 0.62 for right foot; r = 0.675 for left foot). There is a significant difference on the overall initial Pirani score between tenotomy and non- tenotomy group (P value < 0.001). The study revealed that severity of initial Pirani score can be used to estimate the number of Ponseti cast required for correction of clubfoot deformity and the need for tenotomy. Besides, the number of Ponseti cast required may not be affected by age of a child at the commencement of treatment.

Tibiocalcameal arthrodesis as a surgical option for Charcot ankle deformity

Object. To assess the effectivity and safety of different tibiocalcaneal arthrodesis types in treatment of patients with Charcot ankle deformity depending on disease severity. Materials and methods. We have analyzed the outcomes after treatment of 16 patients with diabetic neuropathic ankle arthropathy (Charcot ankle) at the stage of septic complications in bones of ankle and subtalar joints. The observation period was more than 1 [1–3] year. Ilizarov fixator for TCA was used in 8 cases; internal fixation with cannulated screws was applied in 8 cases.Results. In the early periods (up to 1 month from the operation) no complications were revealed. Complications in later terms developed in 4 patients: three with internal fixation and one with external.Conclusion. In our opinion, when choosing foot fixation tactics for heel-tibial arthrodesis, risk groups should be considered stage D according to Rogers classification and stage 3 according to Wagner classification, and after resection of bones in these patients external fixation is preferable. In the remaining stages, internal fixation is advisable because of the patient's higher quality of life and shortening of the rehabilitation period.

Amputation Versus Staged Reconstruction for Severe Fibular Hemimelia: Assessment of Psychosocial and Quality-of-Life Status and Physical Functioning in Childhood.

Background:Fibular hemimelia, a congenital disorder characterized by the partial or complete absence of the fibula, tibial growth inhibition, and foot and ankle deformity and deficiency, is the most common deficiency of long bones. The purpose of the present study of children with congenital fibular hemimelia was to examine the functional and psychosocial outcomes at a minimum of 2 years after treatment either with amputation and a prosthesis or with reconstruction and lengthening.Methods:Twenty children who were managed with primary amputation were compared with 22 children who were managed with staged limb reconstruction. The average age of the patients at the time of evaluation was 9 years (range, 5 to 15 years). Patients and parents completed psychosocial, quality-of-life, and satisfaction surveys. Patients underwent instrumented gait analysis and a timed 25 or 50-yard dash. The number and nature of surgical procedures were recorded from a retrospective chart review.Results:Families of children managed with amputation had lower economic and educational levels and were more ethnically diverse compared with the families of children managed with limb reconstruction. Scores on psychosocial and quality-of-life surveys were comparable with those from healthy patient populations. Parents of males treated with amputation perceived a lower school-related quality of life for their child; socioeconomic and ethnic differences between groups might account for this finding. Statistically but not clinically significant differences were measured during instrumented gait analysis at a self-selected walking speed and during a timed 25 or 50-yard dash. The majority of patients and parents reported satisfaction with the treatment method selected and would select the same treatment method again.Conclusions:At this interim stage of growth, there were no significant functional or psychological differences between groups. Both groups were satisfied with the outcome in mid-childhood, irrespective of the selection of amputation or limb reconstruction.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A comparative study between standard and accelerated ponseti method in management of idiopathic congenital talipes equinovarus

Introduction: Congenital Talipes Equinovarus is one of the most common congenital deformities of foot and ankle. Ponseti method of serial manipulation and once weekly casting has claimed a success rate of 95 %. However, modification of the Ponseti method in terms of duration with twice weekly casting can shorten the time immobilized in plaster with increased parents compliance. Materials and Methods: A randomized comparative study was carried out for total 64 patients (100 clubfoot) attending the Outpatient department of Orthopaedics, Silchar Medical College and Hospital from 1st June, 2017 to 31st May, 2018. 32 patients each in Standard Ponseti group and Accelerated Ponseti group were allotted according to computer generated randomisation plan. The method of manipulation was similar in both the groups with once weekly casting in Standard Ponseti group and twice weekly casting in Accelerated Ponseti group. The initial and final Pirani scores, number of casts required for correction, treatment time in plaster, rate of tenotomy and relapse of deformity in the Standard and Accelerated Ponseti groups were recorded and compared using paired and unpaired t-test methods as required. Results: The two groups did not differ with respect to their initial and final Pirani scores. The mean number of casts required was 5.92 + 1.09 in Standard Ponseti group, and 6.09 + 1.11 in Accelerated Ponseti group (p-value = 0.4203). However, there was significant difference in the treatment time in plaster with mean treatment time of 41.42+7.62 days(range -28 to56 days) in Standard Ponseti group and 21.13 +3.94days(range-14 to 31 days) in Accelerated Ponseti group with p-value < 0.05. 41 out of 48 feet in Standard Ponseti group and 46 out of 52 feet in Accelerated Ponseti group required percutaneous tenotomy. Relapse of equinus and adduction deformity was seen in 3 feet each in Standard and Accelerated Ponseti groups on follow up.Conclusion: Accelerated Ponseti method of twice weekly casting has similar results as Standard Ponseti method with the advantage of earlier correction of the deformity and better parents compliance.

The Use of Three-Dimensional (3D) Biometric Measurements to Predict Additional Alignment Procedures in Total Ankle Replacement

Category:Ankle ArthritisIntroduction/Purpose:Preoperative evaluation of ankle and hindfoot deformities in patients undergoing total ankle replacement (TAR) is challenging. Characterizing deformity based on conventional radiographs is limited by its two-dimensional (2D) nature and is influenced by anatomical and operator-related bias. The final decision to perform associated corrective alignment procedures, that include calcaneal osteotomies, midfoot and forefoot osteotomies/fusions, and soft tissue balancing, is made intraoperatively following insertion of the TAR components. The use of weightbearing cone beam CT (WB CBCT) images and three-dimensional (3D) biometric tools, encompassing the hindfoot alignment, foot tripod, and center of the ankle joint, may be an effective surgical planning instrument. In this retrospective study, we assessed the ability of these tools to predict additional procedures performed at the time of TAR.Methods:In this retrospective study, we enrolled 22 patients that underwent TAR and had preoperative WB CBCT studies. We excluded seven patients with isolated ankle CBCT images and three with metallic hindfoot implants. Patients demographics, type and number of additional alignment procedures were noted. The WB CBCT data sets were screened using built-in semi-automatic measurement software. 3D coordinates (x/y/z) were identified for the specific anatomical landmarks required to calculate Foot and Ankle Offset (FAO), which included the WB points of the first, fifth metatarsal heads and calcaneus, as well as the highest point of the talar dome. FAO is a representation of the torque (offset) between the hindfoot/forefoot midline and the center of the talus, and is given as a percentage of foot-length. Patients were then divided into varus and valgus hindfoot alignment groups accordingly to their measured FAO, using available literature FAO values for normally aligned feet (2.3%, ±2.9%).Results:We included 12 patients (6F/6 M), mean age 65 (range, 47-80). The mean preoperative FAO was 5.73 (CI -0.99 - 12.55). Seven patients had valgus and 5 patients had varus alignment of the hindfoot. The mean number of additional procedures was 2 (range, 0 to 5), and included: calcaneal osteotomy (58%), Achilles lengthening/Gastroc recession (58%), Cotton osteotomy (25%), First TMT fusion (17%), talonavicular fusion, naviculo-cuneiform fusion, and Brostrom procedure (8%). The FAO positively correlated with occurrence of additional alignment procedures (p=0.003). Patients with valgus hindfoot alignment had significantly increased number of additional procedures (2.7; CI 1.6 – 3.8) when compared to varus alignment patients (1.2; CI -0.1 – 2.5) (p=0.03), and were found to have a 1.8 fold greater chance to have a calcaneal osteotomy.Conclusion:This is the first study to evaluate the role of 3D biometric tools and semi-automatic WB CBCT measurements in the preoperative assessment of foot alignment in patients undergoing TAR. We found that increased Foot and Ankle Offset (FAO) significantly predicts the occurrence and number of additional alignment procedures, including calcaneal osteotomies. We believe that the use of biometrics and semi-automatic measurements, which account for the relationship between the center of the ankle and the tripod of the foot, can enhance the preoperative assessment, surgical planning and outcomes of TAR patients. Prospective and postoperative studies demonstrating correction are needed.

Compensatory Function of the Subtalar Joint for Lower Extremity Malalignment.

It is important to evaluate the subtalar joint and hip-knee-ankle alignment to understand lower extremity alignment. In this review, we focused on the compensatory changes in the subtalar joint alignment for the deformity of the knee and ankle joint, reviewing previous research. The subtalar joint alignment was compensatory valgus in patients with varus knee and ankle deformity, whereas it was uncertain whether the subtalar joint alignment was compensatory varus in patients with valgus knee and ankle deformity. The subtalar joint valgus alignment improved after total knee arthroplasty or high tibial osteotomy for varus knee deformity, even if the deformity was severe. In contrast, whether the subtalar joint alignment changed after the surgery for ankle or valgus knee deformity has not been considered. Further research on the compensatory function of the subtalar joint is needed.

Intra- and Extra-Articular Deformity of Lower Limb: Tibial Condylar Valgus Osteotomy (TCVO) and Distal Tibial Oblique Osteotomy (DTOO) for Reconstruction of Joint Congruency.

Osteotomies are the established surgical procedure for the deformity of the lower limb induced by osteoarthritis (OA) of the knee and ankle. Closed-wedge (CW) and open-wedge (OW) high tibial osteotomy (HTO) are extra-articular surgery, which aim to shift the mechanical axis from medial to slightly lateral and reduce the overload in the medial compartment of the varus deformed knee by extra-articular correction. However, varus deformity of the knee with the teeter effect, which could be accompanied with subluxation and thrust due to the medial-lateral soft tissue imbalance, is not resolved only by the shift of mechanical axis. The depression of the medial tibia plateau, so-called pagoda deformity, is the intra-articular deformity, which could potentially cause the teeter effect and involves intra-articular incongruency. In such case, the osteotomy with novel concept should be developed to overcome the issues, both the imbalance of soft tissue and intra-articular deformity. Tibial condylar valgus osteotomy (TCVO) is an intra-articular osteotomy, which improves the joint congruency of the medial-compartment knee OA with subluxation and/or intra-articular deformity and also provides better joint stability. A similar argument is raised in the treatment of the ankle OA. Low tibial osteotomy (LTO) is an extra-articular surgery to correct malalignment of lower leg. Distal tibial oblique osteotomy (DTOO) is a novel surgery to improve the bony congruency of the ankle OA. In DTOO, the distal tibia is cut obliquely from the proximal medial to the distal lateral in the coronal plane and towards the center of the tibiofibular joint to improve the bony congruency of the ankle joint. Tibial condylar valgus osteotomy (TCVO) and distal tibial oblique osteotomy (DTOO) can correct intra-articular deformity of knee and ankle, respectively. The rationale and indication of TCVO and DTOO for the treatment of the lower limb by reconstructing the joint congruency are discussed.

Case of incomplete fibular hemimelia with tarsal coalition, pes planus, ball and socket ankle

Fibular hemimelia (FH) is a congenital disease with a clinical spectrum ranging from mild fibular hypoplasia to fibular aplasia. There is no proven genetic factor. Some anomalies can accompany FH such as tarsal coalition, ulnar hemimelia, amelia, syndactyly, several extremity anomalies, renal anomalies and cardiac anomalies. Our case is about unilateral and incomplete type of right-side FH in a 14 years old female patient. Tibia was curved (bowing) and short. Disparity of measure with left lower extremity was monitored. Tarsal coalition in osseous form, tibial curve anomaly and small bone part placed in fibula distal region compatible with FH, were visualized. There was curved joint form in the same ankle with hemimelia compatible with ball and socket ankle deformity. Calcaneal inclination angle was 120. The findings were compatible with pes planus.

Correction of neuromuscular foot deformity by a circular frame

Background Neuropathic deformities impair foot and ankle joint mobility, often leading to abnormal stresses and impact forces. Neuropathic foot deformities present a formidable challenge to orthopedic, pediatric, and rehabilitation specialists since these deformities are multiplanar, insidious in onset, and most difficult to attribute to and recognize an incipient cause. Aim The aim of our study was to determine the use of a circular frame in the correction of neuromuscular foot deformity. The aim of surgical treatment is to achieve painless foot and stable plantigrade. The use of a circular frame, with or without gradual correction, may allow the patient to be more functional during the period of healing because a circular frame will typically allow partial to full weight bearing during the period of recovery. Patients and methods In this study, 18 feet and ankle deformities in 13 patients were operated upon using the Ilizarov technique and fixator during the period from January 2013 to April 2018. Results The aim of surgery in neuropathic foot is to achieve functional improvements and not just a cosmetically normal limb. Compared with the preoperative status, all patients were satisfied with their gait. The correction period ranged from 2 to 3.5 months. Conclusion We have treated 13 patients affected by neuropathic foot deformities caused by poliomyelitis, meningocele, Charcot–Marie–Tooth syndrome, and post compartmental. Correction of foot deformities and leg-length discrepancy was performed by the Ilizarov method to obtain stable plantigrade and enable wearing of a normal shoe. Multiple surgical techniques were used (closed method, arthrodesis, open method with osteotomy, leg or tendoachilles’ lengthening) in most of the patients, with few complications.

Calcaneotalotibial arthrodesis by retrograde intramedullary nailing using expert tibia nail for charcot osteoneuropathy of the foot: A case series

IntroductionCharcot osteoneuroarthopathy (CN) is a progressive degenerative arthropathy determined by the interaction of neuropathy, osteopaenia and proinflammatory cytokines. The aim of treatment is to maintain the foot on plantigrade position, recover foot deformity, osseous stability, and prevent ulceration. Intramedullary fixation in calcaneotalotibial arthrodesis has been described in promotion of rigid internal fixation with minimal soft tissue violation producing deformity correction, minimal periosteal aggression, vascular damaged and good functional outcome, with less postoperative fusion time and able to achieve fusion of the ankle and the subtalar joint after failed fusion. Presentation of caseTwo patients with charcot foot underwent tibiocalcaneal arthrodesis with retrograde intramedullary technique by Expert Tibial Nail (ETN). The patients are both male 59 years with right ankle deformity 9 months prior to admission and history of trauma and 40 years old with history of Type 2 Diabetes Mellitus. Visual analog scale (VAS), AOFAS and SF score were assessed pre and post operative. DiscussionA good stability, plantigrade ankle and painless foot on both patients were achieved with a mean score 9 for satisfaction. Pre and 3 months post operative VAS were 4 and 1, AOFAS Scale were 58 and 83, mean of SF-36 were 28.4 and 48.6 for physical condition, 37.3 and 67.2. for mental condition consecutively. No severe postoperative complication were recorded ConclusionTibiotalocalcaneal arthrodesis with retrograde intramedullary technique using ETN system was proven to have a good option for ankle joint salvage with improvement of clinical and functional score. Hence, its application in the charcot joint is promising.

Lower Limb Deformity and Total Knee Replacement

Abstract As the population becomes more active and life expectancy increases, gonarthrosis has proportions of epidemics. Total knee arthroplasty (TKA) is an intervention that decreases pain and gives the patients the possibility of quickly returning to the desired level of activity. It is an intervention with a patient satisfaction rate of about 90-95% with a survival of the implant over 15 years of 90%. When dealing with TKA the following elements should be taken into account: clinical examination (walking analysis), leg deformities and knee alignment (foot deformation management), posterior tibial tendon dysfunction, cavovarus foot, posttraumatic deformity, neuropathic arthropathies, ankle arthrosis, foot deformities and knee arthroplasty. Ankle or foot deformity may be causes of progression of gonarthrosis or a TKA failure. Post-operative alignment of TKA is an extremely important element in the long-term survival of the prosthesis. By improving biomechanical alignment of the complete pelvic limb, TKA survival and patient satisfaction will increase.

Post Traumatic Multi-Injured patients. To wait, to operate or to use Damage Control Orthopedic template? A case report

Abstract Purpose. Damage Control Orthopedics (DCO) is a surgical concept used in the recovery of seriously injured patients. Given that the leading cause of death among trauma patients remains uncontrolled hemorrhage, DCO emphasizes on preventing the "lethal triad” of acidosis, coagulopathy and hypothermia, rather than correcting the anatomy immediately. Thereby, we are presenting the crucial importance of using this technique in severe trauma cases. Methods. A 23-year-old female was admitted in the Emergency Room as a multi-trauma patient. Following the Advanced Trauma Life Support protocol, fully exposure examination showed bilateral forearm and femur deformities, with bilateral open femur fracture, left ankle deformity and pelvic ecchymosis. X-rays confirmed fractures of the ribs, bilateral pulmonary contusion, fracture of the left ankle fracture, bilateral superior and inferior pubic ramus, and bilateral femur fractures with both bone midshaft fracture on the right leg. DCO was proceeded immediately, during which external fixators were placed on the fractures, while splinting both forearms. After 11 days in the Intensive Care Unit (ICU), the patient underwent the definitive surgeries. Results. Managing the patient with the DCO protocol first and not rushing with the definitive surgical procedures resulted in a proper stabilization. After two years follow up, the patient fully recovered and returned to a normal life style. Conclusion. Performing a definitive operation on severely injured patients results in deleterious effects that could lower life expectancy. Short-term physiological recovery should be prioritized over definitive management and DCO should be proceeded in order for the best outcomes to be achieved.

Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation

BackgroundA number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads.MethodsRetrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform.ResultsIn group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant.ConclusionsBalance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients’ balance.

Treatment strategy for flail foot with sensory disorder of spina bifida sequela in adult

To summarize the main methods and comprehensive effects of limited surgery combined with external fixation for the treatment of flail foot with sensory disorder of spina bifida sequela in adult. The clinical data of 22 cases (30 feet) of the adult spina bifida sequela who suffered from flail foot with sensory disorder and treated by limited surgery combined with external fixation were retrospectively analysed between January 2005 and December 2015. There were 14 males and 8 females with an age of 8-38 years (mean, 21.5 years). All 30 feet were distal ankle sensory loss, including 2 cases (2 feet) on the left side, 2 cases (2 feet) on the right side, and 18 cases (26 feet) on both sides. There was 1 foot accompanied by ulcerative plantar ulcers, and 3 feet lost their toes due to foot osteomyelitis in the weight-bearing area. Combined with 3 cases of hip dislocation, 3 cases of scoliosis, 4 cases of knee deformity, and 3 cases of ptosis. There were 5 cases of normal control of urine and stool, 10 cases of partial control of urine and stool, 6 cases of overflow urinary incontinence, and 1 case of cystostomy. According to X-ray film, the lesion of spina bifida was evaluated, the laminar insufficiency was located at L 3-L 5 in 8 cases, L 5, S 1 in 9 cases, and L 3-S 3 in 5 cases. In the patients, 12 feet were performed ankle joint arthrodesis, 10 feet subtalar arthrodesis, and 8 feet tibia-talus-calcaneus arthrodesis. Ilizarov external fixator was used in 18 feet, Hybrid fixator in 8 feet, Hybrid fixator and cannulate screws in 3 feet, and Ilizarov fixator and cannulate screws in 1 foot. All 22 patients were followed up 10-80 months (mean, 48.5 months). All ankle deformities were corrected effectively after operation, the middle and hind feet were stable, the plantar foot was restored, the whole foot was loaded, and the ulcer healed without recurrence. There were 2 cannulate screws ruptured in the subtalar arthrodesis, bone healed after screws break; no complication such as surgical infection, neurovascular injury, and so on happened. At last follow-up, based on the evaluation criteria of QIN Sihe lower limb deformity correction, the results were excellent in 15 feet, good in 9 feet, and fair in 6 feet, with an excellent and good rate of 80.0%. The treatment of flail foot with sensory disorder of spina bifida sequela is more demanding. The limited surgeries combined with external fixation play an important role for recovering the stability of foot and ankle, better clinical results, and less complications.

Development of intraoperative plantar pressure measuring system considering weight bearing axis.

Surgical reconstructions in three dimensions are needed for treatment of foot and ankle deformities. However, surgical results might be influenced by the skill and experience of doctors which complement the limited information for reconstructions in three dimensions. To solve these, studies were carried out to measure plantar pressure distribution during surgery. Though, it was impossible to accurately measure plantar pressure distribution accurately during operation. Therefore, we proposed an intraoperative plantar pressure measurement (IPPM) device that enables proper navigation in the push direction. For this purpose, first, we investigated how the physiological load axis passes through the human body to identify the pushing direction of the pressure sensor of the device toward the patient's foot. In particular, we hypothesized that the physiological load axis passes through the femoral head center and we evaluated this in a measurement experiment with nine healthy subjects. Second, based on these results, we developed the IPPM device that has two force sensors to identify the pushing direction toward the femoral head center and a conductive ink sensor to measure plantar pressure distribution. Finally, we conducted the experiments with nine healthy subjects and two users. From the first experimental results, the physiological load axis was found to pass through the femoral head center in normal standing posture. From the evaluation experiment, there are no significant differences statistically in plantar pressure distributions between the conditions of using IPPM device and without using it for both a medical student and a surgeon. However, in some cases the plantar pressure distribution can be reproduced similarly to that of the standing posture, and also from the evaluation experiment concerning the relation between CoP position and NCC, the NCC tends to increase when the position of the CoP is closer to that at the standing posture. The IPPM device has possibility to reproduce the plantar pressure distribution during surgery and prevent the recurrence of surgical complications.

Supramalleolar Osteotomy Combined With an Intra-articular Osteotomy for the Reconstruction of Malunited Medial Impacted Ankle Fractures.

Malunion of a medial impacted ankle fracture may cause varus ankle deformity. This retrospective study examined the use of supramalleolar osteotomy combined with an intra-articular osteotomy in patients with malunited medial impacted ankle fractures. Twenty-four patients with malunited medial impacted ankle fracture were treated between January 2011 and December 2014. Using Weber's classification, 10 had type A fractures and 14 had type B, and with the AO classification, 20 had 44A2 and 4 had 44B3. All of these patients had varus ankle deformity. Supramalleolar osteotomy combined with an intra-articular osteotomy was performed. The visual analog scale (VAS) for pain during daily activities, the Olerud and Molander Scale and the modified Takakura classification stage were used to determine the clinical outcomes and a radiographic analysis was performed. The radiographic parameters, including the tibial ankle surface (TAS) angle and talar tilt angle (TTA), showed significant differences between the preoperative and follow-up assessments. The mean tibial lateral surface (TLS) did not show a significant change. The average Olerud and Molander Scale score improved significantly from 56.4 ± 6.21 preoperatively to 77.0 ± 6.11 at the latest follow-up ( P < .01). The mean VAS decreased significantly from 6.7 ± 0.8 preoperatively to 3.1 ± 0.6 at the latest follow-up ( P < .01). No significant difference in the modified Takakura classification stage was observed between the preoperative assessment and the last follow-up. The use of a supramalleolar osteotomy combined with an intra-articular osteotomy was an effective option for the treatment of malunited medial impacted ankle fractures associated with varus ankle deformity. Level IV, retrospective case series.

Treatment of complex foot deformities with hexapod external fixator in growing children and young adult patients

BackgroundTreatment 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 methodsWe 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). ResultsA 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±21.2 pre-operatively to 67.25±15.1 post-operatively (p=0.005). A statistically significant improvement was observed for the MOXFQ score as well (from 60.6±23.3 to 33.0±25.2, p=0.020). ConclusionsOur 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.

ANKLE ARTHRODESIS WITH THREE CANCELLOUS SCREWS

Purpose — to evaluate the efficiency of the proposed method of arthrodesis by three cancellous screws in patients with posttraumatic arthrosis of the ankle joint.Materials and Methods. After removal of talus and tibia cartilage and autografting the proposed method features placement of foot into the optimal position and fixation of the ankle joint with three cancellous screws. 23 patients with posttraumatic ankle deformity arthrosis of grades III–IV underwent surgery according to the described procedure. Condition of all patients prior to and after the surgery was evaluated using the international ankle and rear foot assessment scale of the American Orthopedic Society of the Foot and Ankle (AOFAS).Results. In 20 patients (88%) the ankle ankylosis was reported within 2.5 months, which was confirmed by X-ray examination. In 2 patients (8%) the ankylosis took place in the period up to 4 months. Loss of the correct position of the foot with screws migration was reported in one patient (4%). The authors observed that patients with postoperative deviation of the tibiotalar angle not exceeding 5 degrees as compared to a healthy limb demonstrated the best functional outcomes.Conclusion. The suggested technique ensures a secure fixation of talus in a predetermined position, a single-step compression between the closed joint surfaces and allows an early effective rehabilitation.