Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Brief Clinical History

KA is a 14 year old adolescent girl who was born in Kenya with a severe clubfoot . As a child she had multiple surgeries but records are not available. She presented with the main complaint of toe walking and some vague forefoot pain. Her desire was for a plantigrade foot that would allow for normal shoe wear.

2 Preoperative Clinical Photos and Radiographs

See Figs 1, 2, and 3.

Fig. 1
figure 1

Preoperative lateral foot X-ray showing talar dome depression, hindfoot and midfoot coalitions, and cavus

Full size image
Fig. 2
figure 2

Preoperative mortise X-ray showing adductus and coalitions

Full size image
Fig. 3
figure 3

Preoperative sagittal plane CT slice showing talar dome depression, cavus, and coalitions in the hindfoot and midfoot

Full size image

3 Preoperative Problem List

  • Midfoot cavus

  • Midfoot adductus

  • Dense scar tissue from previous unknown surgeries

  • Anticipated toe flexion contractures

  • Hindfoot and midfoot coalitions

  • Limited ankle joint motion

  • Supination deformity

4 Treatment Strategy

KA’s main complaint was her inability to wear a normal shoe due to fixed bony deformities and limited ankle motion. Her hindfoot was in neutral alignment and the adductus and cavus were in the midfoot. Due to her dense scar tissues and degree of calculated correction, a prophylactic tarsal tunnel release and toe slings to prevent toe contractures were planned. Because of her coalitions, a multi-planar deformity correction of cavus, adduction, lengthening, and rotation through a single, percutaneous Gigli saw osteotomy were to be performed. A miter frame to allow ankle joint distraction and to stabilize the hindfoot was planned.

5 Basic Principles

Circular external fixation allows for gradual, precise, simultaneous correction of multi-planar deformities. The use of a miter frame construct allows simultaneous correction of adjacent deformities such as ankle joint distraction, hindfoot stabilization, and correction of midfoot deformities. Dense scar tissue and the degree and amount of anticipated correction were the main considerations for prophylactic tarsal tunnel decompression and the use of toe slings. Temporary toe pinning could also be considered.

6 Images During Treatment

See Figs. 4, 5, 6, and 7.

Fig. 4
figure 4

Intraoperative images showing subperiosteal Gigli saw placement, subperiosteal freer elevator through lateral incisions, and olive wires proximal and distal to osteotomy site positioned to correct adductus

Full size image
Fig. 5
figure 5

Intraoperative fluoro image showing subperiosteal Gigli saw placement; extent of midfoot deformity is evident

Full size image
Fig. 6
figure 6

(a, b) Intraoperative clinical pictures of miter frame showing forefoot ring mounted orthogonal to rotational deformity

Full size image
Fig. 7
figure 7

Clinical picture showing adjustable toe slings to prevent flexion contracture during correction

Full size image

7 Technical Pearls

Miter frames are technically challenging to apply due to the bulk of the frame and close proximity of the rings. As such, passing the Gigli saw should be done prior to frame placement to allow unhindered access to the foot. Remember to make your incisions along the line of pull of the saw to avoid damaging soft tissue. The hindfoot ring should be mounted along the axis of the calcaneus, but you must consider the ultimate position of the forefoot and tibial rings and make adjustments as necessary to allow placement of the struts. Placing threaded rods or long bolts to mark the equator of the hindfoot ring is helpful for getting orthogonal mounting X-rays. Because of the hindfoot fusion, a talar neck wire was not needed but should be considered if control of the talus is required. Finally, a butt-type frame that statically spanned the ankle and allowed pure midfoot correction could be considered as well.

8 Outcome Clinical Photos and Radiographs

See Figs. 8, 9, 10, and 11.

Fig. 8
figure 8

Intraoperative lateral fluoro image taken in maximal dorsiflexion at time of frame removal

Full size image
Fig. 9
figure 9

Postoperative standing lateral X-ray showing plantigrade foot

Full size image
Fig. 10
figure 10

Postoperative standing AP X-ray showing improvement in adductus

Full size image
Fig. 11
figure 11

(a, b, and c) Postoperative clinical standing front view of the foot and ankle

Full size image

9 Avoiding and Managing Problems

As with any surgery, preoperative planning is essential. Anticipating problems before they occur makes treating them easier. Performing the tarsal tunnel release at the time of the index surgery prevents having to do it later as an unplanned surgery with the frame in place. Similarly, passing the Gigli saw prior to frame application allows unhindered access. It is also important to have adequate frame mounting and deformity parameters prior to leaving the OR because visualization of the osteotomy site can be difficult once the fixator is in place.