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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 372-377

Correction of neuromuscular foot deformity by a circular frame


Orthopedics and Traumatology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt

Date of Submission27-Jul-2019
Date of Decision18-Sep-2019
Date of Acceptance14-Oct-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Ibrahim Elsayed A-Abuomira
Assistant professor of Orthopedics and Traumatology, Faculty of Medicine, Al-azhar University. Assiut, 82511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_100_19

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  Abstract 


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.

Keywords: Charcot–Marie–Tooth syndrome, circular frame, neuromuscular foot deformity


How to cite this article:
A-Abuomira IE. Correction of neuromuscular foot deformity by a circular frame. Al-Azhar Assiut Med J 2019;17:372-7

How to cite this URL:
A-Abuomira IE. Correction of neuromuscular foot deformity by a circular frame. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 6];17:372-7. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/372/278421




  Introduction Top


Causes of neuromuscular deformities

Poliomyelitis, Charcot foot, cerebral palsy, Charcot–Marie–Tooth hereditary neuropathy, and spina bifida can cause neuromuscular deformities. Neurologic disorder of the foot leads to deformities and functional disabilities. They are often treated by either orthotic or soft-tissue procedures such as tendon release, lengthening, or transfer. However, soft-tissue procedures may be difficult, especially with the absence of functional tendons for transfer or coexisting irreducible deformities [1],[2],[3].

Neuropathic foot deformities present a formidable challenge to orthopedic, rehabilitation, and pediatric specialists since these deformities are insidious in onset, multiplanar, and most difficult to recognize and attribute an incipient cause. Neuropathic foot deformities are unremitting in their progression, and thus present an ever-increasing risk for foot amputation [4]. Conventional operative techniques include arthrodesis, corrective osteotomies, tendon transfers, and extensive release of contractures [5].

Acute correction in severe cases of neuropathic foot deformities may result in wound-healing problems and neurovascular complications. In addition, some cases of lower-limb problems require simultaneous corrections of foot deformity and leg lengthening together with tendon transfers to augment stabilization of foot [5].

It is typically preferred for static or dynamic gradual correction of hind foot and ankle deformities because of the versatility of the components and strength for weight bearing. It is also chosen over acute correction when the deformity is complex, often involving an oblique plane, a rotational component, and/or limb shortening [6],[7],[8].

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 [6],[7].

The Ilizarov ring fixator is considered to have several advantages over other surgical options in the treatment of axial deformity [8],[9],[10],[11],[12],[13],[14],[15],[16],[17].

For use in deformity correction, the surgeon uses hinges and translation mechanisms to build a custom-made frame system for each distinct deformity [6],[7],[8],[9].

The Ilizarov method is based on the principles of distraction osteogenesis (histogenesis) and it is a treatment option for corrections of neuropathic foot deformities. The Ilizarov method is considered safer than conventional techniques of the management and yields satisfactory results [5].


  Patients and methods Top


In this study, 18 feet and ankle deformities in 13 patients were operated ([Table 1],[Table 2],[Table 3]) upon using the Ilizarov technique and fixator during the period from January 2013 to April 2018 in the Al-Azhar University Hospital, Assiut, Egypt. The study is approved by Al-Azhar-Assiut-Faculty of Medicine Ethical committee. All patients were assessed preoperatively by assessment of history, examination, radiography, and planning. The aim of surgical treatment is to achieve painless foot and stable plantigrade. In this study, a total of 13 patients were reviewed in whom ankle and foot deformity was corrected using circular external fixation.
Table 1 Distribution of cases of neuromuscular foot deformity

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Table 2 Distribution of cases of neuromuscular foot deformity

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Table 3 Distribution of cases of neuromuscular foot deformity

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The inclusion criteria included a patient who agreed to the use of either a circular external fixator for any deformity correction in the ankle and foot. The exclusion criteria included patients with incomplete documentation including radiographs, medical record, and loss of follow-up. With written informed consent from the patients before the procedure, the following parameters were assessed: sex, age at surgery, affected side, cause of neuropathic foot deformity, surgical procedure, preoperative and postoperative deformity parameters (motion improvement or healing rate of fusion or fracture) in radiographs, and significant complications (soft tissue/bone-related, hardware-related).


  Results Top


Sex distribution

Thirteen patients with neuromuscular foot deformity were included in this study; six (46.2%) patients were males, whereas seven (53.8%) patients were females.

Age distribution

The patients’ age ranged between 6 and 62 years, and the mean age was 22.6 years.

Analysis of data

Our aim was surgical correction to produce a stable, painless, plantigrade (defined as a foot at 90–100° to the limb), and, when possible, a cosmetically acceptable foot. The aim of surgery in neuropathic foot is to achieve functional improvements and not just a cosmetically normal limb. The mean follow-up period was 7.17 years (range, 6 months to 15 years). [Table 1],[Table 2],[Table 3] show details about the type of surgical procedure performed, and the period in the external fixator and in a cast for each patient.

There were five cases who underwent correction by an open method with V-shaped osteotomy and calcaneal osteotomy. A closed method (bloodless technique) with the Ilizarov fixator and without any additional procedures was used in six patients, triple and ankle arthrodesis were used in three cases, supramalleolar osteotomy was used in two cases, and Chopart joint arthrodesis was used in one case. The additional procedures performed included knee arthrodesis, Achilles tendon lengthening in eight cases, proximal tibial lengthening in one case, and limb lengthening in 13 cases. A plantigrade foot was achieved in nearly all patients at the time of fixator removal and the leg-length discrepancy was eliminated in all cases. Postoperatively, all patients were satisfied with their gait in comparison with preoperative status. The correction period ranged from 2 to 3.5 months. The mean duration of fixator usage was 4.2 months (range, 3–7 months) for the foot portion of the fixator and about 6.1 months (range, 5–10 months) for the tibial portion. In most cases, time of treatment depended on tibial segment consolidation rather than osteotomy of the foot. There were residual varus and equinus deformities of the foot in two cases that were corrected by repeated circular fixator applications. There were recurrent deformities in two patients, who were then corrected by a V-shaped osteotomy of the foot ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7]).
Figure 1 Preoperative photographs male child 13 years old; he had meningocele showing severe foot deformity and dorsal ulcer.

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Figure 2 Preoperative plain radiography of right foot anteroposterior and lateral views.

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Figure 3 Photograph showing an Ilizarov frame of the right foot.

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Figure 4 Postcorrection photographs showing plantigrade fully corrected right foot.

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Figure 5 Photograph showing an Ilizarov frame of the left foot.

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Figure 6 Postcorrection photographs showing plantigrade fully corrected in both feet.

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Figure 7 Postoperative plain radiography of both feet, anteroposterior view.

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Statistical analysis

Thirteen patients with neuromuscular foot deformity were included in this study; six (46.2%) patients were males, whereas seven (53.8%) patients were females. Five cases were bilateral, six cases were right side, and two cases were left side. The correction period ranged from 2 to 3.5 months. The patient’s age ranged between 6 and 62 years, and the mean age was 22.6 years. The mean duration of fixator usage was 4.2 months (range, 3–7 months) for the foot portion of the fixator and about 6.1 months (range, 5–10 months) for the tibial portion. The mean follow-up period was 7.17 years (range, 6 months–15 years). Postoperatively, all patients were satisfied with their gait in comparison with preoperative status, with a highly significant difference (P≤0.05). There were residual varus and equinus deformities of the foot in two cases that were corrected by repeated circular fixator applications. There were recurrent deformities in two patients, who were then corrected by a V-shaped osteotomy of the foot.


  Discussion Top


All patients achieved the preoperative correction goal, whereas one patient had recurrent equinus and another had partial recurrence of forefoot supination. The main aim of surgery for patients with neuropathic foot deformity is not cosmesis, but improvement of the function of the foot [18],[19].

This must be made clear to the patients as some have unrealistically high expectations of what surgery can achieve.

There are many options for the management of foot deformities due to neuropathic causes. Traditionally, management of neurological foot deformities requires a combination of bony procedures and soft tissue for correction of the many components of the deformity [20]. Multiplanar foot deformities due to neurological disorders are associated with soft tissue contractures and severe joint stiffness. It addresses all the components of the deformity, leading to a stable foot, but with lower complication rates. In the Ilizarov method, the progressive correction and osteotomy maintains or even increases the length of the foot and the problems of shoe-fitting are avoided [18],[21].Huang [22] reports 11 cases of ankle, a significant challenge to the use of conventional corrective methods, such as triple arthrodesis, osteotomies, or talectomy. Acute corrections from large wedge resections of bone lead to a greater risk of damaging the neurovascular bundle, which is usually surrounded by adherent scar tissue. In addition, these conventional arthrodesis and closing wedge corrections produce additional shortening of the foot and lead to the requirement of shoes of different sizes [21],[22]. The Ilizarov method has some advantages over conventional methods in that it is able to correct the foot deformities, joint contractures, and limb-length discrepancy.


  Conclusion Top


We have treated 13 patients affected by neuropathic foot deformities caused by poliomyelitis, meningocele, Charcot–Marie–Tooth syndrome, and compartment. Correction of foot deformities and leg-length discrepancy is performed by the Ilizarov method to achieve painless foot and stable plantigrade. Multiple surgical techniques were used (closed method, arthrodesis, open method with osteotomy, leg or tendoachilles’ lengthening) and the aim of surgical intervention (painless foot and stable plantigrade) was achieved in the most of the patients, with few complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alvarez RG, Barbour TM, Perkins TD. Tibiocalcaneal arthrodesis for non braceable neuropathic ankle deformity. Foot Ankle Int 1994; 15:354–359.  Back to cited text no. 1
    
2.
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Segev E, Ezra E, Yaniv M, Wientroub S, Hemo Y. V-osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet. J Orthop Surg (Hong Kong) 2008; 16:215–219.  Back to cited text no. 19
    
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21.
Bradish CF, Noor S. The Ilizarov method in the management of relapsed club feet. J Bone Joint Surg Br 2000; 82:387–391.  Back to cited text no. 21
    
22.
Huang SC. Leg lengthening by the Ilizarov technique for patients with sequelae of poliomyelitis. J Formos Med Assoc 1997; 96:258–265.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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