The Ilizarov technique in treating denervated ankle-foot deformities

Dong Wang; Jun-Jun Shi; Le Zhang; Ying-Wei Jia; Hu-Yun Qiao; Hong Liu; Bao-Na Wang; Jian-Cheng Zang; Si-He Qin; Yong-Hong Zhang

doi:10.26599/JNR.2021.9040021

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Research Article | Open Access

The Ilizarov technique in treating denervated ankle-foot deformities

Dong Wang^{¹^,²}, Jun-Jun Shi^², Le Zhang^¹, Ying-Wei Jia^², Hu-Yun Qiao^², Hong Liu^², Bao-Na Wang^², Jian-Cheng Zang^³, Si-He Qin^⁴, Yong-Hong Zhang^²()

1 Shanxi Medical University, Taiyuan 030001, Shanxi, China

2 The Second Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi, China

3 School of Population Medicine and Public Health, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100730, China

4 Rehabilitation Hospital Affiliated to National Reserach Center for Rehabilitation Technical Aids, Beijing 100176, China

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Abstract

Background:

Neurological injuries or diseases may cause ankle-foot deformities that seriously affect patients’ quality of life.

Objective:

This study aimed to explore the feasibility of the Ilizarov technique for treating complex ankle-foot deformity with neurotrophic disorders.

Methods:

In this retrospective study, 10 patients, including 6 males and 4 females, with complex ankle-foot deformities with nerve injury were treated from January 2014 to May 2019. The age of the patients ranged from 13 to 57 years with an average of 27.9 years. The reasons of nerve injury were as follows: sequelae of spina bifida in five patients, post-traumatic injury of the common peroneal nerve and tibial nerve in four patients, and subacute degeneration of the spinal cord in one patient. Minimally invasive surgery was used for osteotomy, muscle strength balance, and external ring frame fixation, and various deformities were gradually corrected after the operation. The ankle- foot function was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score before surgery and at long-term follow-up after surgery.

Results

: All 10 patients were followed up for 12 months to 3 years, with an average of 1.9 years. The deformities of all 10 patients were corrected; and of the 10 patients, three partially recovered their nerve function. A significant difference (p < 0.001) between the AOFAS score (81.6 ± 10.45) evaluated in the long-term follow-up and that evaluated preoperatively (31.1 ± 14.69). The AOFAS comprehensive score was excellent in two patients, good in six patients, and fair in two patients.

Conclusion:

The Ilizarov technique combined with minimally invasive osteotomy and muscle strength balance could safely correct complex ankle-foot deformities with neurotrophic disorders.

Keywords

Ilizarov technique denervated ankle-foot deformities external ring fixator

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Journal of Neurorestoratology

Volume 9 Issue 4,
December 2021

Pages 255-268

DOI: 10.26599/JNR.2021.9040021

Cite this article:

Wang D, Shi J-J, Zhang L, et al. The Ilizarov technique in treating denervated ankle-foot deformities. Journal of Neurorestoratology, 2021, 9(4): 255-268. https://doi.org/10.26599/JNR.2021.9040021

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10.26599/JNR.2021.9040021.T001Table 1Basic data of patients.

Serial number	Sex	Age	Primary disease	Unilateral or bilateral	Disease course	Number of operations before coming to the hospital
1	Male	47	Comminuted fracture of left calcaneus, Charcot’s joint	Unilateral	Open reduction and internal fixation of left calcaneal fracture in May 2016. A deformity of the left foot was found in May 2017.	1
2	Male	26	Severe traumatic deformity of right calf and right foot	Unilateral	The right tibia and fibula were fixed with Kirschner wires at the age of 7, and the right calf was found to be shortened, the right ankle was stiff and fixed, and the right foot was deformed.	1
3	Male	19	Sequelae of spina bifida	Bilateral	A lumbar mass was discovered in 2000. In 2008, a tumor resection was performed. In 2011, a horseshoe varus deformity of the right foot and a valgus left foot deformity were discovered.	1
4	Male	23	Sequelae of spina bifida	Bilateral	The lumbosacral mass was raised at birth, and the feet were slightly deformed. At the age of 10, the bulge worsens and the deformity of the feet worsens.	0
5	Female	26	Sequelae of spina bifida	Bilateral	In 2000, the left foot clubfoot deformity was corrected. Postoperative deformity worsened with limited mobility.	1
6	Female	33	Sequelae of spina bifida	Unilateral	Meningocele was found at birth. Surgery was performed at 6 months. At the age of 12, the lateral side of his left foot was ruptured. Lumbar spine surgery was performed at the age of 17.	2
7	Female	20	Sequelae of spina bifida	Unilateral	A bulge on the waist was found at birth. Tethered cord was released at the age of 19.	1
8	Male	57	Spinal cord subacute com bined degeneration	Bilateral	There is no obvious cause of intermittent weakness of both lower limbs for 6 years. At the age of 19, the tethered spinal cord was released, and the bulge was excised and repaired.	0

9	Male	13	Crushed by car accident	Unilateral	Surgery was performed after a truck crushed his left foot in 2010. After the foot varus was found in 2016, left Achilles tendon lengthening was performed.	2
10	Female	15	Car crash injury	Unilateral	In 2014, a car accident caused extensive avulsion and bleeding of the skin on the right calf. In the emergency department, debridement + neuromuscular exploration and anastomosis + external fracture fixator + VSD placement + right lower extremity skin exfoliation reduction and skin grafting surgery was performed. After that, there were 2 skin grafts and VSD replacement surgeries.	3

VSD, vacuum sealing drainage.

10.26599/JNR.2021.9040021.T002Table 2The diagnosis and treatment for patients.

Serial number	Diagnosis	Preoperative ulcer	Treatment status	Treatment duration	Complications	Postoperative AOFAS evaluation
1	Postoperative deformity of left calcaneus fracture, left claw toe deformity, left common peroneal nerve injury	No	Postoperative deformity correction of left cal caneal fracture + first metatarsophalangeal joint and second interphalangeal joint fusion + external ring frame fixation	Remove the externa frame in 16 months	Second and third toe pressure ulcer, pin tract reaction	Fair
2	Post-traumatic shortening deformity of the right calf, anterior arch deformity of the distal 1/3 of the right tibia, clubfoot deformity of the right foot, claw toe deformity, malformation of the calcaneus of the right foot, deformity of the right talus, right Freiberg disease, common fibula nerve and tibial nerve injury	No	2017.01.13: line of right tibia and fibula fracture malunion and right distal tibia valgus anterior arch deformity, supra-ankle osteotomy correction + external ring frame fixation;2017.07.05: line of right foot trauma after club foot and high arch foot deformity ligament releasing + joint fusion + external ring frame fixation	Remove the externa frame in 13 months	Necrosis of the skin on the posterior side, pin tract reaction	Good
3	Bilateral clubfoot defor mity, lumbar and sacral intraspinal lipoma, spina bifida surgery	3 cm × 2 cm ulcer on the anterolateral side of the right foot, 3 cm × 3 cm ulcer on the an terior medial side of the left foot	Right clubfoot deformity, plantar fascia release + Achilles tendon release + posterior tibial tendon and fascia release + triple arthrodesis + external ring frame fixation	The external fixa tor was removed after 150 days on the right foot, but the left foot was not done	Pin tract reaction	Good
4	Bilateral severe clubfoot deformity with ulcer for mation on the back of the foot, sequelae of spina bifida	There is a 2.5 cm × 3.5 cm ulcer on the left foot and a 3 cm × 3 cm ulcer on the right foot	Right foot muscle strength balance + triple arthrodesis + external ring frame fixation	The external fixator was removed on the 103rd day after the right foot operation; the left foot was removed on the 86th day after the operation	Pin tract reaction	Good
5	Bilateral clubfoot defor mity; recurrence after correction of left foot deformity	No	Left calcaneal osteotomy + posterior tibial tendon and plantar fascia release + external ring frame fixation	The external fixa tor was removed on the 100th day after the opera tion, and the assis tive device was protected for half a year	Pin tract reaction	Excellent
6	Left foot varus deformity, right flat foot deformity, congenital spina bifida	There is a 5 cm wound rupture and a 1 cm × 1 cm skin break on the outside of the left foot	Left foot varus deformity correction + triple arthrodesis + anterior tibial tendon transposition + external ring frame fixation	Remove the exter nal fixator on the 100th day after the operation, and remove the brace after 5 months	Pin tract reaction	Good
7	Right clubfoot deformity, tethered cord syndrome, L5-S1 myelomeningocele	No	Triple arthrodesis of right horseshoe varus deformity + tendon transposition + external ring frame fixation	The external fixator was removed in the 6th month after the operation, and the plaster was removed in the 7th month	Pin tract reaction	Good
8	Spinal cord subacute combined degeneration, bilateral clubfoot defor mity	No	Bilateral clubfoot defor mity, external ring frame fixation	The external fixa tor was removed at the 5th month after the opera tion, and the brace was protected for 1 year	Pin tract reaction	Fair
9	Stiff clubfoot deformity of left foot	No	2018.08.22: Left foot deformity correction + anterior tibial tendon transposition + subtalar joint fusion + external ring frame fixation;2018.12.20: Correction of toe deformities	Remove the externa frame in 16 months	Pin tract reaction	Good
10	Placement of external fixator for open fracture of right tibia and fibula; soft tissue defect of right calf; bone exposure with wound infection; wound expansion; skin grafting; clubfoot deformity	3 cm × 3 cm skin defect can be seen on the inner side of the right calf, and bone exposure can be seen; 3 cm × 3 cm and 4 cm × 2 cm skin lesions can be seen on the right heel and the middle and lower part of the right calf	Removal of the right tibia external fixator + excision of exposed dead bone + external ring frame fixation + bone transport	The external fixa tor was removed on the 487th day after surgery	Pin tract reaction	Excellent

10.26599/JNR.2021.9040021.T003Table 3Comparative analysis of AOFAS score.

Serial number	Preoperative	Postoperative	Improvement
1	15	65	50
2	41	87	46
3	12	78	66
4	30	81	51
5	61	98	37
6	30	80	50
7	36	84	48
8	35	65	30
9	36	88	52
10	15	90	75
Mean ± SD	31.1 ± 14.7	81.6 ± 10.4	50.5 ± 12.8

Pairing t = -12.485, p < 0.001.