Case 67: Clubfoot Sequela Treated with a Multilevel, Hexapod, External Fixator

Abstract

Clubfoot deformity is best addressed in young children with serial casting and Achilles tenotomy. When the window of opportunity for nonoperative treatment has passed, children will benefit from surgical correction. However, even with surgery the talipes equinovarus position is undertreated and persists into adulthood. In this case we present an 18 year old male with a history of surgically corrected clubfoot as newborn. He presented with ankle, knee, and back pain and a varus-procurvatum distal tibial deformity and a 3.5 cm tibial shortening. A double-level hexapod external fixator was used to correct the supramalleolar varus and tibial shortening. An aligned limb with no length discrepancy was achieved at the end of the correction.

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1 Brief Clinical History

An 18 year old male presented to the office with a history of a partially surgically corrected clubfoot as newborn. The deformity evolved as the patient grew, resulting in a right supramalleolar varus deformity and a short tibia. The patient started with right lower extremity pain at the age of 12. At 18 years of age, the patient came to the office with a chief complaint of ankle, knee, and back pain that partially improved with a shoe lift. A surgical correction was indicated to correct the distal tibial deformity.

2 Preoperative Clinical Photos and Radiographs

See Figs. 1, 2, 3, 4, and 5.

Fig. 1

Note the equinus and varus deformity. The smaller calf of the affected side is evident

Fig. 2

Distal tibial varus deformity showing a plantigrade foot through subtalar compensation

Fig. 3

Saltzman view showing the distal tibial varus

Fig. 4

AP tibias showing the right distal varus

Fig. 5

Distal tibial procurvatum

3 Preoperative Problem List

Distal tibial varus-procurvatum deformity

Tibial and peroneal nerve at risk

3.5 cm tibial shortening

4 Treatment Strategy

Supramalleolar osteotomy (SMO) to correct deformity

Peroneal nerve release to prevent injury

Anterior compartment fasciotomy to prevent compartment syndrome

Tarsal tunnel release

Gastrocnemius recession (Vulpius)

Proximal tibial osteotomy: for lengthening

External fixation to allow for gradual correction of deformity and shortening

5 Basic Principles

A single-level distal tibial TSF to correct the varus-procurvatum and shortening could have been an option. However, in order to decrease the stress on the soft tissues and the ankle joint, a double-level deformity correction was performed. The lengthening through the proximal osteotomy stretches only the gastrocnemius. On the other hand, lengthening through a distal tibial osteotomy stretches all tendons around the ankle joint, the joint itself, and the neurovascular bundle. In cases of equinus and varus correction, an Achilles lengthening procedure and tarsal tunnel release have to be performed prior to the external fixator placement. For a double-level tibial osteotomy, it is recommended to perform a prophylactic anterior compartment fasciotomy.

6 Images During Treatment

See Figs. 6, 7, 8, and 9.

Fig. 6

Incomplete SMO

Fig. 7

Proximal tibial TSF

Fig. 8

Lateral tibial X-ray: double-level TSF for proximal lengthening and distal varus correction

Fig. 9

AP tibial X-ray: double-level TSF for proximal lengthening and distal varus correction

7 Technical Pearls

Start with the soft tissue procedures (anterior compartment fasciotomy, tarsal tunnel release, and Achilles lengthening). Before placing the external fixator, perform an incomplete (2/3) Gigli saw SMO. The fixation of the distal tibial segment is with one full ring with at least one wire and a pin. For better stability, add a foot ring with calcaneal fixation wires.

8 Outcome Clinical Photos and Radiographs

See Figs. 10 and 11.

Fig. 10

Post ex fix removal: AP tibia

Fig. 11

Post ex fix removal: lateral tibia

9 Avoiding and Managing Problems

Start your surgery with a tourniquet, and do a tarsal tunnel release and passage of the Gigli saw around both the tibia and fibula, no more than 2 cm above the joint. Activate the Gigli saw and cut through the fibula and half way through the tibia, but do not complete it until the end of the procedure after the frame is fully applied, as it would be unstable. If you inadvertently complete the Gigli saw cut prior to frame mounting, stabilize the osteotomy temporarily with crossing wires.

Include both pins and wires in the distal tibial segment, to prevent wire cutout through the osteopenic bone.

Slight overcorrection into the valgus may be desirable in case decreased ankle joint space is present, in order to prevent overload of the medial cartilage.

10 Cross-References

• Case 52: Ankle Distraction and Supramalleolar Osteotomy for Arthrosis and Deformity

11 See Also in Vol. 1

Case 94: Correction of Tibia Recurvatum and Shortening in Skeletal Dysplasia