Calcaneogenesis: the use of tibial bone transport for treatment of massively infected hindfoot defects.

Massive hindfoot defects which result after se- questrectomy of chronic osteomyelitis (COM) or Trauma or after tumors resection is a real challenge to the treating surgeons with either amputation or other reconstructive plastic procedures as the only available options, Calcaneal osteomyelitis is a major cause with classical surgical management to cure the infection has limited success in preservation of the hindfoot shape, function, and mechanical stability. The surgical procedure reported with the use of the Ilizarov apparatus for partial or total calcaneal OM is aimed to preserve the Hindfoot. Materials and Methods: We retrospectively reviewed 10 patients which were treated by radical debridement of the infected area, Ilizarov frame application and arthrodesis with bone reconstruction by the Ilizarov apparatus using tibial transport for Hindfoot salvage. The mean age at presentation was 33.5 years (range; 24-57) and the mean follow-up was 5.1 years (range; 2-12).Patients clinical and radiographic data were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle- Hindfoot score. Results: The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score was 48.3(range; 38-86) while the mean postoperative (AOFAS) was 58.5 (range; 45-73) , p value < 0.01 . Clinically all patients had anatomically stable feet with deformity correction and no signs of infection recurrence. Conclusion: The use of Ilizarov distal tibial bone transport to fill massive hindfoot defects proved to be a reliable method for elimination of infection and reconstruction of large defects without the need for bony or soft tissue plastic procedures. The technique also has the ability to produce a rigid limb fixation following debridement and to fill in massive hindfoot defects due to other etiologies as well.

A new technique of hindfoot reconstruction in chronic calcaneal osteomyelitis using the Ilizarov apparatus - a case series.

Calcaneal osteomyelitis (OM) is a challenging disease. Traditional surgical management has a limited success in preservation of the foot. The surgery proposed with the use of the Ilizarov apparatus for calcaneal OM aims to preserve the function, shape, and stability of the foot. Five patients between the age of 21 and 36 years, with isolated total and subtotal calcaneal OM, were treated with this technique in Royal Jordanian Medical Services (RJMS) institutions. Complex treatment included two stages: 1) radical sequestrectomy, and fixation of the foot in a favourable position with the Ilizarov fixator; 2) arthrodesis, reconstruction of the foot in order to fill in the bone defect. The patients were followed-up in the immediate (one month) and long-term (from one to six years) periods after treatment. The infection process was arrested and no recurrence was encountered. Weight-bearing ability was recovered. The shape of the hind foot was maximally close to natural. The patients reported high satisfaction.

Treatment of postoperative tibial chronic osteomyelitis using bone transport techniques; an observational study.

PURPOSE: Postoperative Tibial chronic osteomyelitis is one of the most challenging orthopaedic conditions especially when extensive, the anatomy of subcutaneous anteromedial part of the tibia with less soft tissue coverage complicates the situation. The extent of infected tibial part varies in size and duration from one patient to another. We report our experience using Bifocal and Monofocal bone transport techniques with regard to clinical outcome, recurrence of infection and re-fracture rate. METHODS: This is a retrospective observational review of 49 patients with postoperative Tibial chronic osteomyelitis which were treated using either Bifocal distraction compression BFDCO technique group I (31 patients) or Monofocal compression osteosynthesis MFCO technique Group II (18 patients). The average age of the patients was (41.6 ± 13.1 years), (range: 17-67 years). Leg length discrepancy was measured in 33 (58.9%) patients with an average of (1.4 ± 1.7 cm). Contracture of the ankle joint and equinus deformity were detected in 36 (64.3%) patients. Pre and Post-operative radiography together with Modified Irzhansky A.A et al. leg functional assessment system were used to assess the functional outcome. RESULTS: The time spent in the Ilizarov fixator (External Fixation Index) in the first group was (142 ± 72 days) and in the second group was (75 ± 54 days). The infection recurred in 2 patients (6%) in group I and in 5 patients (28%) in group II. Lack of consolidation or re-fracture within 6 months after the dismantling of the apparatus was detected in 6 patients (19.5%) in group I and in 5 patients (27.8%) in group II. Lack of consolidation or re-fracture within 6 months after dismantling of the apparatus in group I was detected in 6 patients (19.5%) in group I and in 5 patients (27.8%) in Group II. The average functional state score (AFSS) in the first group was (12.45 ± 2.41) on admission and increased to (16.16 ± 2.99) on the final follow-up which corresponded to a "good" result. In the second group II the AFSS was (12.11 ± 2.22) on admission and increased to (15.06 ± 2.88) at the final follow-up which corresponded to a "satisfactory" result. CONCLUSION: Treatment of Tibial chronic osteomyelitis using either Bifocal or Monofocal bone transport is an effective method. However our results have demonstrated better functional outcome and less infection recurrence and re-fracture rates when using the Bifocal distraction compression technique (BFDCO).

Improved Ilizarov method for management of deformity and ulceration on foot and ankle of spina bifida.

OBJECTIVE: To analyze the characteristics of foot and ankle deformity with ulceration in patients with spina bifida, to conclude experiences on management with improved Ilizarov method in one stage. METHODS: 77 cases suffering foot and ankle deformity with ulceration of spina bifida were included from January 2008 to June 2019, in which 30 male and 47 female, aged 6-46 years with an average age of 22.86 years. There were 10 cases on left, 14 on right and 53 on both. The improved Ilizarov method combined soft tissue surgery, bone osteotomy and Ilizarov technique in one stage, by which the ulcer was dressed aseptically and avoid weight bearing preoperatively, no special treatment, no debridement, no flap coverage and no bacterial culture. Antibiotics were given for 3 days routinely, and the dressing was removed 5 days later. If there was exudation, gauze could be used to wrap continually, if there was no swelling and exudation, no need further more caring. General appearance and radiological image of ulcer and deformity were observed during the period of evaluation and treatment, surgical method and complications, foot & ankle function and overall function were evaluated using AOFAS scoring system and special table designed by authors. RESULTS: 77 cases were followed up for 6-132 months with an average of 50.5 months. Achilles tendon subcutaneous lengthening was performed in 2 cases, posterior tibial tendon and Achilles tendon simultaneous released for 31cases, subtalar joint arthrodesis 25 cases, calcaneus osteotomy 5 cases, triple osteotomy 28 cases, ankle arthrodesis 19 cases, internal rotation osteotomy of tibia was performed in 1 case and 1 case in external rotation osteotomy. There were 67 cases using Ilizarov fixators and 10 cases using Hybrid fixators for immobilization and correction. Stable feet were obtained and ulcers healed simultaneously when all deformities of foot and ankle had been corrected. The healing time of ulcer was average 26.5 days ranging 7-36 days, and there was no infection or delayed healing occurred in any case. Ankle ankylosis in 25 cases, 3 cases of pin tract infection, 2 wires were broken. The AOFAS score significantly increased from 70.5 ± 4.5 preoperative to 81.6 ± 3.9 postoperative; based special table evaluating, Excellent 28 cases, Good 42 cases, Fair7 cases. CONCLUSION: The patients with foot & ankle deformity and ulceration suffered from spinal bifida can be treated by improved Ilizarov method in one stage, and the results are satisfactory with short treatment period and decreased complications. TRANSLATIONAL POTENTIAL OF THIS ARTICLE: The characteristics of foot and ankle deformity with ulceration inpatients with spina bifida have been analyzed and the experiences on management with improved Ilizarovmethod in one stage have been summarized in this study, which updated treatment concept of neurogenic deformity with ulceration on foot and ankle joint.

Closed arthrodesis in infected neuropathic ankles using Ilizarov ring fixation.

AIMS: Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. METHODS: We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function. RESULTS: The union rate for Group A was 81% (17/21) while it was 84.6% (33/39) for Group B. All the nonunions in Group A underwent revision with an open technique and achieved 100% union. Mean duration of IRF was 71.5 days (59 to 82) in Group A and 69 days (64.8 to 77.7) in Group B. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was similar in both groups. The postoperative hospital stay was shorter in Group A (21 days (SD 8)) than Group B (28 days (SD 9)). In the latter Group there were more problems with wound healing and greater requirement for antibiotic treatment. The mean operating time was 40 minutes (SD 9) in Group A compared to 80 minutes (SD 13) in Group B. Recurrence of infection occurred in 19% (4/21) and 15.5% (6/39) for Group A and Group B respectively. CONCLUSION: We found CAA using an IRF to be an effective method for ankle arthrodesis in infected neuropathic foot and ankle cases and afforded comparable results to open methods. Due to its great advantages, Ilizarov method of CAA should always be considered for neuropathic ankles in suitable patients. Cite this article: Bone Joint J 2020;102-B(4):470-477.

Applicability of histopathological osteomyelitis evaluation score (HOES) in chronic osteomyelitis of the foot - A feasibility study.

BACKGROUND: Diagnosis and classification of chronic osteomyelitis is not based on any objective criteria. None of the available methods for this is completely reliable. Tienmann et al. (2014) has described the so called histopathological osteomyelitis evaluation score (HOES) to overcome this limitation. But this has not been externally validated or tested in cases with foot osteomyelitis. METHODS: We prospectively reviewed the histopathological samples of 30 consecutive patients (30 feet) with foot osteomyelitis managed operatively. There were 19 males and 11 females with an average age of 41.6 (range, 27-63) years. The underlying pathology was spina bifida in 12, Charcot's arthropathy in eleven and post-traumatic in seven patients. The bones involved were calcaneum, talus and fifth metatarsal. Pathological diagnosis was made based on HOES by a single pathologist blinded to the clinical diagnosis and both were compared. Intra- and inter-observer reliability of HOES was assessed by analysing the scores of each patient assigned independently by four different pathologists (blinded to the clinical diagnoses and to each other) at two different occasions one week apart. RESULTS: All samples showed features of long-standing osteomyelitis. When attempting to classify to "acute on chronic", "chronic" and "quiescent" forms, the pathological diagnosis correlatead with the clinical diagnosis only in 16 cases (53.3 percent). Histological classification to Tienmann's types as per the scoring system yielded three distinct pathological entities that had common histological features with regard to bone, soft tissue and inflammatory infiltration. HOES exhibited excellent intra- and inter-observer reliability. CONCLUSIONS: HOES is well applicable in foot osteomyelitis both for diagnosis and classification by unambiguous and precise scoring system. This makes diagnostic labelling more accurate and repeatable. The clinical relevance of these histopathological types in guiding management and determining prognosis needs to be investigated further.

Management of Neurologic Deformity of the Ankle and Foot With Concurrent Osteomyelitis With the Ilizarov Method.

BACKGROUND: The combination of neurologic deformity of the ankle and foot with osteomyelitis is a therapeutic challenge. We investigated the role of Ilizarov with regard to eradication of infection, correction of deformities and improvement of patient function. METHODS: We retrospectively reviewed 77 patients (77 feet) with neurologic deformity of the ankle and foot with osteomyelitis treated sequentially in 3 stages by Ilizarov method. The 3 stages were (1) active debridement and Ilizarov stabilization, (2) further strengthening of Ilizarov fixator and active osteosynthesis consisting of strategies like arthrodesis, osteotomy distraction, bone transport, or combination thereof, (3) consolidation of fusion/regeneration achieved in second stage. Patients with Charcot arthropathy were not included in the study. There were 43 males and 34 females with mean age of 34.4 (range, 18 to 70) years. All patients had a minimum of 1 year follow-up and 49 patients had 5 years follow-up. RESULTS: Mean duration of external fixation was 179.9 (range, 128 to 413) days. The success of infection eradication was 90.9% and 91.9% at the end of 1 and 5 years, respectively. We achieved plantigrade feet in all cases with no recurrence of deformity. The American Orthopaedic Foot & Ankle Score (AOFAS) improved from a median preoperative value of 74 (interquartile range, 65 to 75.25) to 81 (interquartile range, 77 to 88) ( P < .0001). The improvement of the score was by 7 points only considering the painless nature of the pathology, and the fact that pain contributed to 40% of total score. A total of 39 complications occurred in 30 patients which were managed successfully by alteration of rehabilitation and carefully chosen interventions. CONCLUSION: Ilizarov external fixation was an effective technique to address problems associated with neurologic foot and ankle deformity with infection. It allowed eradication of infection and achievement of a stable plantigrade foot. It had some disadvantages like lengthy duration of treatment, pin-tract infections, need for operative expertise, and supervised rehabilitation, but we feel these were definitely outweighed by its benefits. LEVEL OF EVIDENCE: Level IV, retrospective case series.