Congenital clubfoot (CCF) is one of the most common congenital deformities of the foot, with an incidence of 0.1% to 0.2%, a male to female ratio of 2:1, and a bipedal incidence of about 50%. According to statistics, about 100,000 children with congenital clubfoot are born each year worldwide, and the medical security system and specialist training mechanism in western countries are more perfect, which can provide early and correct good orthopedic treatment for CCF [1-2], and it is rare to see adolescent CCF due to delayed treatment, while pediatric orthopedic surgery is rarely established in local and municipal hospitals in China, and orthopedic surgery or foot and ankle surgery specialties are rarely established in large hospitals in various provinces and municipalities. As a result, a large number of adolescent CCF with delayed treatment or failed previous surgical treatment remain in China, and their surgical orthopedic techniques, concepts, and expected outcomes are different from those of preschool children, which is one of the challenges of orthopedic surgery. The technical concepts introduced in Europe and the United States cannot meet the orthopaedic and reconstructive needs of Chinese patients. Based on the introduction and application of Russian Ilizarov technique, the authors integrated different technical concepts, summarized and explored, and formed a new concept of foot and ankle orthopaedics and reconstruction with their own technical characteristics. 39 cases (54 feet) of adolescent CCF patients were treated surgically from September 2003 to July 2010, of which 26 cases and 41 feet received an average follow-up of 37 months after surgery with satisfactory results Satisfactory.
1. Clinical data
1.1 General data
All 26 cases in this group met the diagnostic criteria for congenital clubfoot. There were 15 male cases and 11 female cases, including 6 right foot cases, 5 left foot cases and 15 bipedal cases, totaling 41 feet. The age ranged from 10 to 36 years old, with an average of 16 years old, and the deformity of clubfoot was graded according to the foot landing and force area [3]: 9 feet with Ⅰ° deformity, with the weight-bearing area on the anterolateral side of the foot; 17 feet with Ⅱ° deformity, with the weight-bearing area on the anterolateral edge of the foot, i.e., the fourth and fifth metatarsals; 15 feet with Ⅲ° deformity, with the weight-bearing area on the dorsal side of the foot or the dorsal side of the foot; in severe cases, the foot was extremely inwardly turned and internally rotated, with the toes pointing inward and backward. The foot center was upward. In 6 cases, 9 feet were combined with internal rotation deformity of the lower leg; 1 case was combined with hip subluxation; 10 patients had soft tissue release or bony surgery (mainly Carroll surgery) in childhood, and the deformity recurred after surgery.
1.2 Classification of clubfoot deformity and strategy of orthopedic surgery method (see Table 1)
(1) Preoperative examination to assess the deformity category, determine the orthopedic plan and the expected goal of efficacy, and recommend staged correction for severe bipedal deformity. (2) Individualized limited orthopedic surgery was performed, with external fixator fixation and postoperative adjustment to the desired outcome needed for orthopedic surgery. (3) Patients will attend the outpatient clinic at the scheduled time to remove the external fixator and walk with a calf brace or with pathological shoes for more than 3 months. (4) The whole medical treatment and rehabilitation of a patient is under the responsibility of one doctor, and the patient is instructed to review regularly in 3 years (before the adolescent patient turns 18).
1.3 Preoperative preparation of Ilizarov external fixation retractor
According to the patient’s age, the degree and nature of foot deformity, measurement of the deformity angle, the maximum diameter of the lower leg and the size of the foot, the retractor components are selected and the general framework of the Ilizarov retractor with individualized features is assembled so that only small adjustments can be made during intraoperative installation to save surgical time. The basic configuration of the foot and ankle retractor [4]: it consists mainly of a ring-type external tibial fixator and a horseshoe-shaped external foot fixator fixator, connected by two hinges in the middle, with one retractor bar posteriorly and one anteriorly (Figure 1).
Fig. 1. a basic framework of Ilizarov horseshoe foot deformity external fixation retractor orthosis
Fig.1 a basic framework of Ilizarov external fixation for drafting orthopaedic in equinus.
1.4 Basic surgical procedure
The patient is placed in the supine position, with the affected limb padded and a tourniquet applied. According to the overall relationship between the patient’s age, the degree and type of deformity and the line of gravity of the lower extremity, surgery is performed to eliminate the factors that form or aggravate the clubfoot and to reasonably balance the muscle strength of the internal and external rotation muscles of the foot; to correct the rotational deformity of the lower leg or the inversion deformity of the lower tibia. The surgical strategy and procedures are: limited release of the soft tissue of the posterior medial ankle and partial correction of the bony deformity by multi-point osteotomy. In the presence of a significant imbalance of the internal and external rotation muscles, the anterior tibialis muscle is externally placed (or half of the tendon is externally placed), and the assistant extends the externally turned foot in the appropriate orthopedic position with the back of the hand and temporarily fixes the foot and ankle joint in the orthopedic position with two 2-mm kerf pins. The skin incision was sutured. 9 feet in this group were Ⅰ° horseshoe valgus deformity, and the intraoperative orthosis could achieve satisfactory orthopedic results, and the combined external fixator was installed, and the rest were fitted with Ilizarov external fixation retractor.
1.5 External fixation retractor threading pin installation procedure
In all cases of residual foot deformity after orthopaedic surgery, the author’s modified Ilizarov external fixation retractor orthosis (32 feet in this group) was routinely installed, which is the core technology and new concept of functional reconstruction for obtaining excellent results in juvenile CCF. The method of pin fitting follows the principles of the Ilizarov technique and the author’s modified procedure [3,5]: the circular ring of the retractor is placed in the lower part of the calf, with the calf positioned as far as possible in the center of the ring and perpendicular to the steel ring; the horseshoe ring is positioned against the foot so that the foot is in the center of the ring and the two planes coincide. The hinge is located medially and laterally to the ankle joint, centered on the axis of rotation of the ankle joint and located anterior to the talar body. A full pin of 2.0-2.5 mm is worn on the tibia with a 3.5-4.0 mm half pin or threaded pin attached to fix the steel ring; one 2.0 mm Kirschner pin is applied through the 1-5 metatarsals in the forefoot, and a half pin of 3.0-4.0 mm or a 1.5-2.0 mm Kirschner pin across the talus in the midfoot, and two 2.0 mm Kirschner pins across the heel, respectively, are attached to the horseshoe ring for fixation. One retractor rod was installed anteriorly and posteriorly to the ankle joint, and a spring was added between the retractor nut and the retractor frame. A certain tension of the draft bar is maintained at the end of the installation so that the externally fixed retractor becomes a force-bearing unit. This allows slow stretching of the forefoot in multiple planes, changing the relative position relationship between the forefoot and hindfoot, and correcting forefoot pronation and concave arch deformity. The hindfoot ring is connected to the distal tibial ring through the posterior medial and posterior lateral threaded rods to correct the plantarflexion and pronation deformity of the hindfoot, and the forefoot ring is connected to the proximal tibial ring through an anterior lateral retractor rod, which pulls the forefoot upward enough to correct the plantarflexion and pronation deformity of the forefoot (Figure 1).
1.6 Postoperative management
After the local swelling and pain of the affected foot are reduced 5-7 days after surgery, the threaded rod can be rotated to begin correction of the clubfoot deformity. The sequence of correction is to first retract the screw on the medial side of the foot to correct the forefoot pronation and rotation deformity; then retract the screw on the medial side of the ankle joint to correct the mid-hindfoot pronation deformity and simultaneously retract the ankle joint gap to avoid compression of the tibial talus joint [6]; and finally retract the screw on the anterior and posterior side of the ankle joint to correct the foot drop deformity. The frequency and speed of nut rotation depends on the local soft tissue condition and the patient’s tolerance, and should be 0.5-1 mm/d, and should be done in 4-6 times a day. The pulling speed can be slightly faster in the early stage, and slower in the middle and late stage, so that the sensation and blood circulation of the foot are normal and there is no obvious pain. In the process of correcting horseshoe deformity, regular positive and lateral ankle X-rays are performed to find out whether the ankle joint gap is propped up and whether the medial and lateral ankle joint hinges of the retractor correspond to the center of rotation of ankle dorsiflexion and plantarflexion to prevent anterior and posterior displacement of the talofibular joint. A foam pad can be placed on the bottom of the foot to allow the affected foot to walk with proper weight bearing (Figure 2f,2g). The deformity is gradually corrected by continuous slow stretching and appropriate overstretching, so that the ankle joint is overstretched by 5° to 10° and the foot is mildly valgus and then the stretching is stopped. The brace is then maintained in the corrected position and weight-bearing walking for 4-6 weeks so that the corrected bone and joint structure follows woff’s law [7] (mechanical stresses and weight-bearing stresses allow the bone to rebuild bone tissue adaptations in accordance with biomechanical requirements) and adapts to the new full foot weight-bearing stress changes. Patients with severe deformity should be given good psychological guidance because of the long time with external fixator.
2, postoperative external fixator pulling orthopedic and functional reconstruction process – case presentation
Patient Female, 12 years old, admitted to the hospital with the diagnosis of bilateral congenital clubfoot III°. The deformity was discovered after birth, and bilateral foot plaster fixation was performed in Nanning when she was 2 months old, which was ineffective. Pre-operative examination: foot dorsal weight-bearing limp gait, bilateral clubfoot deformity degree III, walking with anterolateral foot weight-bearing, no redness and swelling of ankle foot, no pressure pain, good blood flow, sensation and movement. x-ray: bilateral feet with severe inversion, heel spacing angle -30°. Treatment plan: right Achilles tendon lengthening, flexor [and flexor toe tendon lengthening, posterior tibial tendon lengthening, metatarsal tendon cutting + “U” shaped osteotomy around the talus + installation of Ilizarov external fixation retraction orthosis. The deformity was corrected and the osteotomy was healed 3 months after surgery, and the orthopedic shoes were worn for 8 weeks after removal of the external fixation. The deformity of the right foot was completely corrected half a year after surgery, and the patient was able to walk well with weight. The surgical method and external fixation of the left foot were performed in the same way as the right foot (Figure 2a to n).
Figure 2 Case presentation a preoperative whole body frontal view, with the affected foot touching the bottom dorsally when holding weight b, c preoperative frontal and lateral views of the affected foot d, e preoperative frontal and lateral X-rays of the affected foot f 3 months postoperative frontal view of the right foot g 3 months postoperative back view of the right foot h 3 months postoperative frontal and lateral X-rays of the right foot i, j 6 months postoperative frontal and lateral views of the right foot with complete correction of the clubfoot deformity to be operated on the left foot k 6 months postoperative frontal and lateral X-rays of the right foot . l 40 days after left foot surgery m, n 40 days after left foot surgery, the basic correction of clubfoot deformity was observed on the frontal and lateral x-ray.
Fig.2 Typical case introduction a In the preoperative systemic positive view, while standing the dorsum of foot bear full weight. b, c The preoperative systemic view of the feet d, e The preoperative X-ray of the deformed feet f The front view of the right foot 3 months post operation g The back view of the right foot 3 months post operation h The X-ray view of the right foot 3 months post operation i, j The systemic view of the right foot 6 months post operation while intending to do the left foot surgery k The X-ray view of the right foot 6 months post operation l The front view of the left foot 40 days post operation m, n The X-ray view of the left foot 40 days post operation m, n The X-ray view of the right foot 40 days post operation -ray view of the left foot 40 days post operation
3. Results
All patients had to achieve satisfactory orthopaedic goals before they could stop stretching and then walk with the external fixator for 2-6 weeks before removing it (the time of removing the external fixator should be assessed individually). After removal of the external fixator, the foot and ankle brace was routinely fitted or walked in appropriate orthopaedic shoes. In this group, 26 cases (41 feet) were followed up from 10 months to 6 years with a mean of 37 months. There were no skin incision infection, vascular nerve injury and bone non-healing in all the affected feet during the treatment period, and 6 cases had mild infection of the needle tract, which disappeared after symptomatic treatment. All the deformed feet were satisfactorily corrected and had full plantar weight holding and good walking function. In one case, the deformity partially recurred 2 years after surgery, and the Ilizarov retractor was installed for the second time to correct the deformity to the patient’s satisfaction. According to the scoring system of the International Clubfoot Foot Deformity Study Group (ICFSG) [8], with the scoring of morphological characteristics, functional status and X-ray examination results, the final follow-up results of 41 feet in this group: excellent 29 feet (70.7%), good 10 feet (24.4%), acceptable 2 feet (4.9%), poor 0 feet, with an excellent rate of 95.1% (Figure 2-5).
4. Discussion
4.1 Characteristics of CCF in adolescents and previous confusion among orthopaedic surgeons
Soft tissue changes in CCF in early childhood are soft, skeletal changes are slight, and normal or near-normal functional recovery is often obtained with soft tissue release and muscle balance [1-2]. By the peak of adolescent development, different degrees of bone and joint deformity changes occur with age and long-term weight holding in abnormal conditions [9]. The deformities are characterized by the coexistence of soft tissue contractures and bony deformities of several joints, varying degrees of stiffness of the ankle-foot joint, tibial talar joint tilt, and in some patients, a combined torsional deformity of the lower leg. Previously performed medial plantar release (Carroll procedure) had many surgical complications, left skin incision scars, and was mainly adapted to pediatric patients. Therefore, before the concept of Ilizarov technique was popularized, the orthopedic reconstruction of juvenile CCF is a difficult problem in orthopedic surgery.
4.2 Indications for surgery
All patients with delayed treatment or recurrence of deformity after previous surgical treatment have the requirement and surgical condition to correct deformity and improve function, and the surgeon’s grasp of Ilizarov technique can achieve individualized expected efficacy goals; therefore, the indication for surgery depends on the degree of deformity of the patient and the orthopaedic technical ability of the presiding surgeon.
4.3 Advantages of combining the principles of limited orthopedic surgery and Ilizarov technology
At present, there are many domestic and foreign literature reports on the application of Ilizarov technique in the treatment of CCF with satisfactory results [4,10,11], but there is little literature on how to optimize the combination of orthopedic surgery with the principles of Ilizarov technique. The degree and type of deformity of juvenile CCF varies, especially the soft tissue contracture becomes extensive and rigid, and the extensive soft tissue release applied in the past can cause both blood circulation disorders of bones and soft tissues and easily produce postoperative skin necrosis and extensive scar contracture. In our group, 21 of the 32 cases had horseshoe clubfoot deformity above II°, and the simple application of traditional extensive soft tissue release, muscle balancing and joint fusion is risky and difficult to obtain satisfactory shape and function. The authors satisfactorily solved this problem by combining limited soft tissue release and bony osteotomy with Ilizarov distraction technique.
The Ilizarov technique can slowly retract the tense and contracted soft tissues of the foot and ankle, and can be supplemented with bone cutting and bone retraction [12,13], and the retracted tissues will undergo regeneration and biological remodeling [12,14]. and biological remodeling [4,14], avoiding tarsal resection and preserving the length of the foot. Therefore, it can be said that the Ilizarov technique is able to accomplish to some extent the practical purpose achieved by tissue engineering – structural and functional reconstruction of bone and soft tissues (including blood vessels, nerves, and skin). The addition of the adjustable variable of time in the process of retraction is a four-dimensional phase of the clinical technique concept (three-dimensional space plus one-dimensional time). The surgeon can precisely control the trajectory of bone movement with the retractor, the magnitude of deformity correction can be manipulated in real time by the surgeon or even by the patient and his family, and its risks can be effectively controlled [15,16], securely achieving the goal of treatment of clubfoot deformity and allowing the patient to obtain a normal-sized, pain-free, plantar-walking foot. Satisfactory results can be achieved even in extremely severe foot deformities, and recurrence of the deformity can be prevented to the maximum extent possible after correction of the deformity, and patient satisfaction is often greater than the physician’s expectations. In the case of Ⅰ° pronated foot deformity, good correction of foot deformity can be obtained during surgery, and fixation and orthopedic purposes can be satisfactorily achieved by only inserting pins to install the combined external fixator (Figure 6), and the assembly and pin fixation of the device is easier to learn than Ilizarov device.
Table 1 Deformity types and surgical orthopaedic strategies (developed by Qin Sihe)
Chart.1 Deformity types and orthopedic surgery strategy of talipes varus
Deformity types
Pathology and clinical manifestations
Surgical orthopedic strategy
Hindfoot entropion without Achilles tendon contracture
Weight bearing on the lateral part of the heel
Heel valgus osteotomy or heel-talar joint fusion
Forefoot pronation
Mostly combined with horseshoe and forefoot weight-bearing on the outer edge
Soft tissue release with tarsal osteotomy
Total foot pronation (anterior and posterior foot)
Weight-bearing on the outer edge of the foot or dorsal foot touching the ground
Periprosthetic osteotomy or triple osteotomy with ten Ilizarov distraction
Ptosis of the first top bone
Mostly combined with contracture of metatarsal tendons
Release of the metatarsal tendon membrane and osteotomy of the base of the first metatarsal
Combination of knee and lower leg internal and external
Inversion or torsion deformity
Calf deformity and clubfoot deformity are causal factors that contribute to the development of the deformity
Simultaneous surgical correction of clubfoot and calf deformity
Inversion of the forefoot and ectropion of the hindfoot
Serpentine foot deformity
Limited osteotomy followed by ten Ilizarov techniques for distraction correction
Combined supra-ankle valgus or torsional deformity
X-ray examination, tibiotalar joint coronal line inclination
Simultaneous correction of foot deformity with supra-ankle osteotomy
Figure 3 Patient, female, 26 years old, with bilateral congenital clubfoot, had a release surgery at the age of 8 years, and the deformity recurred a-c III° deformity of both feet, preoperatively with dorsal and lateral weight-bearing of the forefoot d-e first distraction correction of the right foot, 48 days after surgery f 4 months after surgery of the right foot, the calf cast was replaced, 23 days after surgery of the left foot g 6 months after surgery of the right foot, 73 days after surgery of the left foot h-k removal of the external fixator with orthopedic brace for walking The patient was very satisfied with the complete correction of the inversion deformity of both feet at the 7-month postoperative follow-up.
Figure 4 Patient, male, 25 years old, bilateral congenital clubfoot, one release surgery at the age of 4 and 8 years old, recurrence of deformity
a-c Bilateral III° deformity with preoperative dorsolateral forefoot weight-bearing d-f 3 months postoperative on the right foot g-h 200 days postoperative on the right foot and 100 days postoperative on the left foot, with correction of bilateral clubfoot deformity. Should continue to walk with orthopedic brace for 3 to 5 months to prevent rebound of deformity
Figure 5 Patient, male, 36 years old, bilateral congenital clubfoot, walking on the back of the foot for 34 years
a-c Bilateral III° deformity, preoperative dorsal forefoot weight-bearing d-g Bilateral simultaneous soft tissue release, triple joint osteotomy, and installation of Ilizarov device, postoperative 97 days of slow distraction treatment, bilateral clubfoot deformity corrected h-j 3 years postoperative follow-up, bilateral foot deformity satisfactorily corrected, walking with full plantar weight-bearing, can walk in normal shoes
Figure 6 Patient, male, 15 years old, with bilateral congenital clubfoot and bilateral hindfoot pronation with high arch deformity
a-b I° deformity of both feet with anterolateral weight-bearing of the metatarsal c-e Preoperative X-ray examination showed that it was a concave arch deformity with inversion of the first metatarsal head of the heel f-i The patient underwent bilateral metatarsal tendon release, osteotomy at the base of the first metatarsal to correct the first metatarsal head prolapse, and bilateral osteotomy of the heel exostosis to correct the inversion of the heel, followed by fixation with a combined external fixator. The postoperative X-rays showed that the hindfoot pronation and high arched foot deformity were corrected, and the affected foot could walk with the external fixator with proper weight bearing.
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