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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 135-137

Management of neglected clubfoot by ilizarov device, without osteotomy: Yemen experience


Department of Orthopedic Surgery and Traumatology, Taj Medical Centre, Jeddah 23323, Saudi Arabia

Date of Web Publication10-Sep-2018

Correspondence Address:
Sharker Barker
Department of Orthopedic Surgery and Traumatology, Taj Medical Centre, Jeddah 23323
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_60_18

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  Abstract 


The medium-term clinical and functional results of treating neglected clubfoot deformities with Ilizarov device are good. In a limited health-care resource country (such as Yemen) and poor financial situation and education of the patients, the results of Ilizarov surgical correction of the neglected and severe deformities of the foot and ankle are promising, and it seems an excellent surgical option for this challenging condition.

Keywords: Clubfoot, deformity correction, foot and ankle, Ilizarov surgery, pediatric


How to cite this article:
Barker S. Management of neglected clubfoot by ilizarov device, without osteotomy: Yemen experience. Apollo Med 2018;15:135-7

How to cite this URL:
Barker S. Management of neglected clubfoot by ilizarov device, without osteotomy: Yemen experience. Apollo Med [serial online] 2018 [cited 2018 Nov 14];15:135-7. Available from: http://www.apollomedicine.org/text.asp?2018/15/3/135/240944




  Introduction Top


The resistant neglected clubfoot deformity presents a significant challenge for orthopedic surgeons in developing countries,[1] and it is a serious problem in Yemen, being a poor developing country. It is the most common congenital problem leading to locomotor disability. Approximately two-third children born with clubfoot deformity are born in the rural areas of Yemen, and the vast majority of these do not have access to appropriate medical care. The obstacles of poverty, lack of awareness, and lack of medical resources inaccessible location mean the treatment is not initiated.

Several corrective procedures for treatment neglected clubfoot have been described, with the goal to provide a pain-free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Encouraging results are reported with this method.[2]


  Materials and Methods Top


Eleven feet in nine children were treated by the author in the Department of Trauma and Orthopedic Surgery, Al-Gamhouria Modern General Hospital, Aden, between November 2011 and March 2014. There were seven boys and two girls between 4 and 8 years old. All the patients had a severe deformity of the foot and ankle and were treated for the first time. Resistant clubfoot with nonhealing ulcers over the callosities on the dorsum of the lateral column due to weight-bearing was excluded. The outcomes of these patients were graded on Reinker and Carpenter scale,[3] as shown in Table.



Operative technique

The limb was prepared and draped from foot to hip. When necessary, Z-plasty of the Achilles tendon was done for elongation. Preassembled Ilizarov device was made [Figure 1] according to the deformity of the foot as well as radiographs, to correct without any stress over the related soft tissue. Two wires are passed horizontally through the middle third of the tibia and fixed under tension to a ring. Similar wires are placed transversally through the posterior part of the calcaneus and fixed to the half ring. Another half ring for fixation the foot in the dorsal aspect with two plain wires, first was applied through from the first to second metatarsal bones and second from third to fifth or third metatarsal and connected with the half ring.
Figure 1: Preassembled Ilizarov fixator

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The apparatus was applied over the tibia through the hinges, plats, and conical washers were also used wherever required. The calcaneal half ring had three connections to the tibial ring (posteriorly, medially, and laterally), while the forefoot half ring had two connections situated medially and laterally. These hinges allow the rods to move without bending and also prevent the subluxation of joints during distraction. Correction of the deformity was started after 3 days after the application of the device. Distraction between the tibial and calcaneal rings lowered the heel by 1 mm/day, and at the same time, the distraction of the forefoot between the calcaneal and metatarsal half rings mobilized the metatarsals and metatarsal joints. Forefoot adduction was corrected by greater distraction, also by 1 mm/day of the medial side than of the lateral side. Finally, equinus deformity was corrected by shortening the anterior bar between the tibial and metatarsal rings until the foot in 10 degrees of ankle dorsiflexion. When correction was complete, the device was retained in a fixed position for 4–6 weeks, and then, to avoid relapse, the limb was immobilized in a full-leg plaster for 6–8 weeks. Daily active and passive exercises of the toes were recommended during the distraction period to avoid flexion contraction of the toes.


  Results Top


The mean age of our patients was 5.4 years (range: 4–8 years)[Figure 3]; there were two females and seven males. The mean distraction time for deformity correction was 7.9 weeks (range: 6–11 weeks). The mean duration of fixator was 15 weeks (range: 10–23 weeks), and the mean of splinting of the foot after removal Ilizarov device was 15 weeks (range: 12–20 weeks). The mean follow-up period was 18.7 months (range: 20–36 months). Achilles tendon elongation was performed in eight feet (72.7%). At the time of removal of the fixator, a plantigrade foot was achieved, and gait was improved in all the patients [Figure 2]. There was residual varus hindfoot deformity in four feet in two patients with bilateral deformity. Five feet (45.5%) were rated as excellent, two feet (18.2%) as good, and four feet (36.4%) as fair results. The fair result was noted in patients at age 7 and 8 years with bilateral deformity. Pin-tract infection was observed in all the patients and managed with regular dressing and oral antibiotics.
Figure 3: Pre-, intra-, and post-operative correction of the deformities in a 5-year-old child

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Figure 2: Pre-, intra-, and post-operative pictures of a patient before and after correction of the foot deformity

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  Discussion Top


Neglected clubfoot deformity is a more multiplanar deformity.[4] The Ilizarov technique allowed for a three-dimensional approach to correct the deformities of the foot and ankle, without the need for additional wide surgical exposure.[5] Professor Ilizarov had recognized it way back that this technique could be used to treat foot pathologies such as clubfoot.[6] Minor complications, such as pin-tract infection, related to this procedure were significant in our cases, due to poor hygienic conditions of these patients and lack of proper understanding of the instructions. However, these were manageable and, for the most part, did not compromise overall patient satisfaction in this very difficult to treat clinical condition.[5] Our study includes 11 feet in 9 patients with neglected clubfoot, who underwent limited soft-tissue dissection with Ilizarov distraction. All these patients were from rural areas nearby Aden city, where there is a lack of primary health care, scarcity of specialists to treat these patients at an early age, and easy access to a specialized hospital in Aden. Achilles tendon lengthening was performed in 8 feet (72.7%). Of the patients, 63.6% considered it as satisfactory, 5 (45.5%) as excellent, and 2 (18.1%) as good, while 4 (36.4%) considered it an unsatisfactory and fair result. Gradual soft-tissue compression and distraction with the setting of Ilizarov device was used for correction of the deformities in all patients. The same evaluation criteria were used in all patients as the same principle was used in them.

Our result compared fairly with the previously published studies on this subject. Ahmed[6] which included 18 feet in 13 patients with ages ranging from 3 to 12 years (mean: 5.5 years). Soft-tissue distraction by Ilizarov was done in 12 feet, elongation of Achilles tendon in 3 patients, and metatarsal osteotomy in 3 patients, and the average follow-up period was 15.8 months. Of these patients, 72.2% considered satisfactory (2 excellent and 11 good) while 27.8% considered unsatisfactory (4 fair and 1 poor). Prem et al.[7] followed 19 feet managed by Ilizarov soft-tissue distraction for 5–10 years postoperatively. They graded 14/19 feet good or excellent and 13/14 patients were satisfied with the result of the treatment. Utukuri et al.[8] treated 26 neglected clubfeet in 23 patients using the Ilizarov technique. They reported unsatisfactory results of soft-tissue and bony distraction with a recurrence rate of 70% for soft-tissue distraction and 55% for bony distraction after a more extended period of follow-up (47 months) but found that functional results (patient-based outcome) were better despite a poor surgical outcome. Reinker and Carpenter[3] achieved excellent and good results in 21 of 23 feet treated by Ilizarov's external fixation. Nineteen feet had received one or more osteotomies at the time of Ilizarov's external fixation application; the additional procedure was required during treatment, including four percutaneous Achilles tendon lengthening, two first metatarsophalangeal joint fusion, and talectomy, ankle arthrodesis, Achilles tenodesis, and plantar arthrodesis in one case. Hosny[9] used the bloodless technique in treating 23 feet in 22 patients without any real surgical incision. There was no necessity for soft-tissue release or osteotomy.

All of our patients had plantigrade foot, and the results were rated as good in 20 and fair in 3 cases. The follow-up in our study was up to 2 years, and in a situation like these, where the original foot and ankle deformities are so severe that the treatment option involves the use of an external fixator, minor or major recurrence of the deformities can be expected over time. (severe recurrence of the deformities and painful arthritis).


  Conclusion Top


We conclude that the medium-term clinical and functional results of treating neglected clubfoot deformities with Ilizarov device are good. In a limited health-care resource country (such as Yemen) and poor financial situation and education of the patients, the results of Ilizarov surgical correction of the neglected and severe deformities of the foot and ankle are promising, and it seems an excellent surgical option for this challenging condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lourenço AF, Morcuende JA. Correction of neglected idiopathic club foot by the Ponseti method. J Bone Joint Surg Br 2007;89:378-81.  Back to cited text no. 1
    
2.
Greisberg J. Recent innovations and future directions in external fixation of the foot and ankle. Foot Ankle Clin 2004;9:637-47, ix.  Back to cited text no. 2
    
3.
Reinker KA, Carpenter CT. Ilizarov applications in the pediatric foot. J Pediatr Orthop 1997;17:796-802.  Back to cited text no. 3
    
4.
Catagni MA, Malzev V, Kirienko A. Congenital and acquired foot deformities. In: Bianchi Maiocchi D, editor. Advances in Ilizarov Apparatus Assembly. Milan: Medical Plastic; 1994. p. 113-18.  Back to cited text no. 4
    
5.
Friedman HE, Levitz S. A literature review of the Ilizarov technique and some applications for treating foot pathology. J Foot Ankle Surg 1994;33:30-6.  Back to cited text no. 5
    
6.
Ahmed AA. The use of the Ilizarov method in management of relapsed club foot. Orthopedics 2010;33:881.  Back to cited text no. 6
    
7.
Prem H, Zenios M, Farrell R, Day JB. Soft tissue Ilizarov correction of congenital talipes equinovarus–5 to 10 years postsurgery. J Pediatr Orthop 2007;27:220-4.  Back to cited text no. 7
    
8.
Utukuri MM, Ramachandran M, Hartley J, Hill RA. Patient-based outcomes after Ilizarov surgery in resistant clubfeet. J Pediatr Orthop B 2006;15:278-84.  Back to cited text no. 8
    
9.
Hosny GA. Correction of foot deformities by the Ilizarov method without corrective osteotomies or soft tissue release. J Pediatr Orthop B 2002;11:121-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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