Distraction osteogenesis for complex foot deformities: Gigli saw midfoot osteotomy with external fixation.

Open midfoot wedge osteotomy correction can cause neurovascular compromise, requires extensive exposure, sacrifices normal joints, and shortens the foot. We used a minimally invasive technique to treat complex foot deformities by combining percutaneous Gigli saw midfoot osteotomy, circular external fixation, and acute, gradual, or gradual with acute manipulation correction. The medical records of 23 patients (26 feet) with complex foot deformities (congenital, 18 feet; neuromuscular, 4 feet; post-traumatic, 3 feet; malunion, 1 foot) who had undergone treatment within an 18-year period (1990 through 2007) were retrospectively reviewed. We also performed the procedure on 10 cadaveric limbs to determine whether anatomic structures were at risk. Correction was achieved in all feet. The mean duration of external fixation treatment was 4.2 (range 3 to 7) months. The mean follow-up duration was 4.7 (range 2 to 18) years. A significant difference was observed in the pre- and postoperative, lateral view, talar-first metatarsal angle (p = .001). Minor complications (4 feet) consisted of bony exostoses. Major complications included recurrent deformity in 3 feet and sural nerve entrapment in 1 foot. Two patients had mild and one moderate foot pain. Three patients had impaired gait function; the remaining patients had functional gait. The mean interval until wearing regular shoes after external fixation removal was 2.3 (range 1 to 4) months. All but 1 of the patients were satisfied with the final results. We observed no cadaveric neurovascular injury. Our results have shown that percutaneous Gigli saw midfoot osteotomy can be performed without neurovascular injury and is capable of successfully correcting complex foot deformities.

Distraction osteogenesis for complex foot deformities: U-osteotomy with external fixation.

BACKGROUND: Certain complex foot deformities can be corrected surgically with a U-osteotomy. This osteotomy is indicated for patients with a uniform deformity of the entire foot relative to the tibia, preexisting stiffness and/or fusion of the subtalar joint, and a pain-free ankle joint. The goal is to create a plantigrade foot through gradual osseous repositioning of the entire foot relative to the tibia by means of external fixation. If needed, foot height can be increased simultaneously. METHODS: Fifteen complex multiplanar foot deformities in fifteen patients were treated with a U-osteotomy and gradual correction by means of external fixation. Deformities resulted from congenital causes (seven), trauma (three), and developmental causes (five). The mean patient age at the time of surgery was twenty years (range, four to sixty-three years). The mean duration of external fixation was five months (range, three to eleven months). The mean duration of follow-up was five years (range, three to nineteen years). Clinical and radiographic results were assessed. RESULTS: Osseous union and a plantigrade foot were achieved in all fifteen patients. Seven complications related to the U-osteotomy occurred in four patients, including deep pin-track infection in two, premature osseous consolidation in two, postoperative tarsal tunnel syndrome in two, and peroneal nerve entrapment in one. When comparing the preoperative and final postoperative radiographs, three significant differences were observed: the calcaneotibial angle changed by a mean of 18° valgus (range, 6° to 40° valgus) (p = 0.003), the calcaneus was translated posteriorly by a mean of -8 mm (range, -2 to -20 mm) (p = 0.001), and foot height increased by a mean of 20 mm (range, 3 to 40 mm) (p < 0.001). Fourteen patients were able to walk without supports or assistance; one used only one cane or crutch to walk. CONCLUSIONS: U-osteotomy with gradual correction by means of external fixation can be used to obtain a plantigrade foot in patients with complex multiplanar deformities of the foot relative to the tibia.

Nerve structures at risk in the plantar side of the foot during anterior tibial tendon transfer: a cadaver study.

BACKGROUND: Anterior tibial tendon transfer is a common procedure for treatment of clubfoot recurrence. Fixation of the tendon usually includes passing the tendon through the lateral cuneiform. Drilling the bone and passing sutures through the plantar aspect of the foot may cause neurovascular damage. METHODS: Anterior tibial tendon transfer was performed through the lateral cuneiform in twelve cadaveric limbs. Drill holes were made perpendicular to the lateral cuneiform surface (group A), made perpendicular to the weight-bearing surface (group B), inclined 15° in the frontal and sagittal planes (group C), or aimed at the middle of the plantar aspect of the foot (group D). Two unmodified Keith needles and two blunted Keith needles were each passed ten times per foot. A dissection was performed. The average distance from the drill hole to the nerve structures and the number of punctures of nerve structures were reported. RESULTS: In group A, the drill hole was 1.7 mm from a medial plantar nerve branch and 5 mm from the nerve bifurcation. In group B, the hole was 0.3 mm from a branch of the lateral plantar nerve and 25.3 mm from the lateral plantar nerve bifurcation. The drill hole in group C was 1.7 mm from the lateral plantar nerve bifurcation. In group D, the drill direction resulted in an inclination of 22° in the frontal plane and 4° in the sagittal plane. The drill exited 7.7 mm from a medial plantar nerve branch and 4.3 mm from a lateral plantar nerve branch. The medial and lateral plantar nerve bifurcations were at a distance of 13 mm and 14.7 mm, respectively, from the drill hole in group D. Unmodified Keith needles punctured nerve structures twelve times in group A, twenty times in group B, six times in group C, and once in group D. Use of blunted Keith needles resulted in no nerve punctures. CONCLUSIONS: When anchoring the transferred anterior tibial tendon in the lateral cuneiform for the treatment of clubfoot recurrence, the drill should be aimed at the middle of the plantar surface of the foot to minimize the risk of nerve damage. Passing the sutures with a blunt needle might prevent damage to nerves or vessels when anterior tibial tendon transfer to the lateral cuneiform is performed for the treatment of clubfoot recurrence.

Problems, obstacles, and complications of metatarsal lengthening for the treatment of brachymetatarsia.

Metatarsal lengthening by distraction osteogenesis is a challenging procedure that is associated with various adverse results. This article presents and classifies adverse results arising from metatarsal lengthening. Our premise of classification is that not all adverse results that occur secondary to distraction osteogenesis of the metatarsal are true complications that affect the final outcome, but rather are problems and obstacles that present hurdles to completion of treatment. Our classification differentiates among problems, obstacles, and complications during metatarsal lengthening with external fixation. The cause of each adverse result is also discussed and clinical and surgical pearls to avoid these problems, obstacles, and complications are presented.

Equinus deformity in the pediatric patient: causes, evaluation, and management.

Many types of equinus exist in the pediatric population. This article reviews the causes, clinical and radiographic evaluation, and treatment of pediatric equinus deformity. It discusses the conservative and surgical management of the different types of equinus and when these treatments are best employed. The underlying pathophysiology for each equinus case must be understood to ensure that the treatment is appropriate.