Charcot Arthropathy of Foot and Ankle: Radiographic and Clinical Patterns with Related Outcomes.

PURPOSE: Our aim is to retrospectively review and evaluate the patterns of affection of Charcot arthropathy of foot and ankle. METHODS: Two hundred twenty-eight patients (235 feet) with post-acute Charcot were reviewed and classified anatomically through plain radiographs into type I and type II based on single or multiple regions affected, respectively. Type I included ankle, Lisfranc (tarsometatarsal), naviculocuneiform, forefoot, and hindfoot which includes one of the following: talonavicular joint, calcaneocuboid joint, or calcaneus. Type II included peritalar, perinavicular, mid-tarsal Charcot, or any other combination. Both types were further classified into four stages (A, stable with no deformity; B, stable with deformity; C, unstable; and D, deformity/instability with associated mechanical ulcers). RESULTS: The most common type was type IIC (27.2%) followed by type IID (18.3%), while types IA and IIA represented the least common types (3.4% and 3.8%, respectively). Types IA and IIA were managed conservatively. All patients in types IC, ID, IIB, IIC, and IID and the majority of type IB received fusion surgery to achieve stability and correction of deformity. Type II D had the highest complication rate (30%). Five patients ended up with amputation, and all were stage IID. CONCLUSION: Affection of single region has better prognosis than affection of two or more regions. Stage A has the best prognosis and can be managed conservatively provided good diabetes control. Surgery is indicated in all cases of types IC, ID, IIB, IIC, and IID to achieve stability and correction of deformity and prevent complications. Mechanical ulcer (stage D) carries the worst prognosis and highest complication rate.

Screw versus suture button in treatment of syndesmosis instability: Comparison using weightbearing CT scan.

BACKGROUND: The superiority of screw or suture button fixation for syndesmotic instability remains debatable. Our aim is to compare radiographic outcomes of screw and suture button fixation of syndesmotic instability using weight bearing CT scan (WBCT). METHODS: Twenty patients with fixation of unilateral syndesmotic instability were recruited and divided among two groups (screw = 10, suture button = 10). All patients had WBCT of both ankles ≥12 months postoperatively. RESULTS: In suture button group, injured side measurements were significantly different from normal side for syndesmotic area (P = 0.003), fibular rotation (P = 0.004), anterior difference (P = 0.025) and direct anterior difference (P = 0.035). In screw group, syndesmotic area was the only significantly different measurement (P = 0.006). CONCLUSION: While both screw and suture button didn't completely restore the syndesmotic area as compared to the contralateral uninjured ankle, external malrotation of the fibula was uniquely associated with suture button fixation. LEVEL OF EVIDENCE: III Retrospective Cohort Study.

Functional pedal construct achieved by combined operative treatment in peritalar complex Charcot arthropathy: A prospective study of 38 feet.

BACKGROUND: Charcot arthropathy of the peritalar complex carries a high risk of amputation if not properly managed. Our aim is to assess the functional outcome of severe Charcot arthropathy of the peritalar complex following enblock resection of the ulcer, massive debridement and stabilizing all the elements of the peritalar complex. METHODS: We prospectively studied 38 feet in 35 patients with peritalar complex Charcot arthropathy. All Feet underwent intense debridement and fusion using a combination of (Ilizarov) external fixation, and (plate and locked nail) internal fixation. Thirty two feet were graded as Eichenholtz 2, and six feet were graded as Eichenholtz 3. The mean follow up was 35.9months. RESULTS: The mean AOFAS score was significantly elevated from 25.4±9.1 preoperatively to 67.6±5.7 at the most recent follow-up (p<0.001). Complete bony fusion was achieved in 28 feet. Unsound bony fusion occurred in 8 feet. Two feet required below knee amputation. CONCLUSION: Peritalar complex Charcot arthropathy is not uncommon variety. Such cases carry high risk of complications and amputation is not excluded. The proper timing of surgery is crucial. Massive debridement and rigid fixation with strict follow up is mandatory to achieve the ultimate goal of obtaining a plantigrade, stable, mechanically sound, painless and infection free pedal construct.

Intra- and periarticular osteoid osteoma: Percutaneous destruction and alcoholisation.

Intra- or periarticular osteoid osteoma (00) is uncommon, and therefore a diagnostic challenge. Symptoms are: chronic synovitis, decreased range of motion, joint effusion, and joint contracture. Radiographically, the classical perifocal sclerotic margin is often absent, which leads to a significant delay in diagnosis. The authors retrospectively studied 50 cases of intra- and peri-articular OO, treated with percutaneous destruction and alcoholisation. The mean follow-up period was 8.7 years (range, 1 to 15 years). The diagnosis was only made after +/-14 months (range, 8 to 18 months), due to atypical symptoms (nightly pain absent in 38%) and uselessness of plain radiographs (in 100%). CT-scan, contrast enhanced MRI and bone scan brought the solution. The technique was successful in 48 out of 50 cases (96%): incomplete excision occurred in 2 patients. The diagnosis of intra- or periarticular OO should be considered in case of unexplained joint pain where conservative treatment is inefficient.

Lateral column lengthening (LCL) using a rectangular shape graft for managing symptomatic flexible flatfoot showed acceptable early functional and radiological outcomes.

PURPOSE: We aimed to report the results of performing lateral column lengthening (LCL) using a rectangular-shaped graft to correct the flat foot deformity. METHODS: A total of 28 feet of 19 patients (10 males, 9 females) having an average age of 10 ± 3.2 years who were unresponsive to conservative management underwent flat foot deformity correction through LCL procedure supplemented with rectangular-shaped graft harvested from the fibula. Functional assessment was performed according to the American Orthopedic Foot and Ankle Society (AOFAS) scale. The radiographic assessment consisted of four parameters, Meary's angle in both anteroposterior (AP) and lateral (Lat.) views, calcaneal inclination angle (CIA), and calcaneocuboid angle (CCA). RESULTS: After an average of 30.2 ± 8.1 months, the AOFAS improved significantly from 46.7 ± 10.2 preoperatively to 86.7 ± 9.5 at the last follow up (P < 0.05). All the osteotomies showed healing at an average of 10.3 ± 2.7 weeks. All the radiological parameters showed significant improvement at the last follow up compared to the preoperative measurements, CIA from 6.3 ± 2.8-19.3 ± 3.5, Lat. Meary's angle from 19.3 ± 4.9-5.8 ± 2.5, AP Meary's Angle from 19.3 ± 5.8-6.1 ± 3.1, and CCA from 23.9 ± 8.2-6.8 ± 4.5, (P < 0.05). No pain at the site of the fibular osteotomy was reported in any of the patients. CONCLUSION: Lateral column lengthening using a rectangular graft effectively restores bony alignment with good radiological and clinical results, high patient satisfaction, and acceptable complications.

Distraction osteogenesis in management of composite bone and soft tissue defects.

A soft tissue defect is one of the most difficult problems that may accompany bone defects. Plastic surgery is often required. During distraction osteogenesis, not only the bone but also the soft tissues are lengthened, which may help in spontaneous closure of the soft tissue defects. This study examines 11 cases of composite bone and soft tissue defects which were managed by distraction osteogenesis. After debridement of the necrotic tissues, the soft tissue defects ranged from three by four centimetres to five by 14 centimetres and the bone defects ranged from four to 12 centimetres. All the soft tissue defects healed during the process of bone transport without the need for plastic surgery, except in one case. The complications were successfully managed during the course of treatment. Distraction osteogenesis is a good method for simultaneous treatment of composite bone and soft tissue defects.

Bifocal and trifocal bone transport for failed limb reconstruction after tumour resection.

The aim of the present study is to assess the results of bifocal and trifocal bone transport for elimination of bone defects due to failed limb reconstruction after tumour resection. Thirteen patients, nine with giant-cell tumour and four with osteosarcoma, with bone defects resulting from wide tumour resection were managed by bone transport with an Ilizarov frame. The ages ranged from 12 to 46 years. Bone transport was used as a second line of management after failure of other modalities for reconstruction. According to the Enneking system for the functional evaluation after surgical treatment of musculoskeletal tumours, the percentage rating of function was 47% in one case, 70% in 2 cases and more than 85% in 10 cases. Most of the complications were treated successfully during the course of treatment. Bone transport with two or three osteotomies is a reliable method for eliminating bone defects as a limb salvage procedure after failure of other modalities for reconstruction.

Functional outcome of salvage of residual and recurrent deformities of clubfoot with Ilizarov technique.

Relapse may occur in severe clubfeet deformities whether treated surgically or nonsurgically. In this study, we evaluate the results of correction of residual and recurrent congenital clubfoot using soft tissue distraction or osteotomy using the Ilizarov external fixation system. This study included 35 feet in 28 patients who were treated between 1999 and 2007. Of these 16 feet in 13 patients with an average age of 13.7 years (range from 11 to 29 years) were treated by percutaneous calcaneal V-osteotomy and gradual correction by the Ilizarov method. Nineteen feet in 15 patients with an average age 10.5 years (range from 4 to 22 years) were treated by soft tissue distraction by the Ilizarov technique. The mean average follow up period was 5.6 years (range from 1 to 8 years). At the time of fixator removal, a plantigrade foot was achieved in 30 feet. Mild residual varus and equinus deformities were present in five feet. At the final follow foot pressure measurement showed recurrent or residual deformity in 10 feet (7 treated by osteotomy and 3 treated by soft tissue distraction). Recurrence may occur with both techniques, depending on many factors such as bone morphology, the number of the pervious operations and the degree of stiffness of the foot prior to the operation.

Evaluation of Syndesmosis Reduction on CT Scan.

BACKGROUND: Computed tomography (CT) imaging has traditionally been considered the gold standard for evaluation of syndesmostic reduction, but there is no uniformly accepted method to assess reduction. The aim of this study was to evaluate the intra- and interobserver reliability of published measurement techniques for evaluation of syndesmotic reduction on weightbearing CT scan (WBCT) in hopes of determining which method is best. METHODS: Medical records were reviewed to identify patients who underwent operative stabilization of unilateral syndesmotic injuries. Exclusion criteria included patients younger than 18 years, ipsilateral fractures extending to the tibial plafond, any contralateral ankle fracture or syndesmotic injury, and body mass index greater than 40 kg/m2. Twenty eligible patients underwent WBCT evaluation of both ankles at an average of 3 years after syndesmotic fixation. The anatomic accuracy of syndesmotic reduction was evaluated by 2 observers using axial CT images at a level 1 cm proximal to the tibial plafond using 9 previously published radiological measurement techniques. Inter- and intraobserver reliability were assessed for each evaluation method. RESULTS: The syndesmotic area calculation showed the highest interobserver reliability (0.96), the highest intraobserver reliability for observer 2 (0.97), and the second highest intraobserver reliability for observer 1 (0.92). Fibular rotation had the second highest interobserver reliability in our results (0.84), with intraobserver reliability of 0.91 and 0.8 for first and second observers, respectively. The intraobserver reliability of the side-by-side method was 0.49 and 0.24 for the first and second observers, respectively, and the interobserver reliability was 0.26. CONCLUSION: Qualitatively assessing syndesmotic reduction via side-by-side comparison with the uninjured ankle had the least intra- and interobserver reliability and should not be relied on to determine syndesmotic reduction quality. In contradistinction, syndesmotic area calculation demonstrated the highest reliability when evaluating syndesmotic reduction, followed by fibular rotation. Given that syndesmotic area measurement techniques are not readily available on standard image viewers, technologically updating image viewers to allow such calculation would make this approach more accessible in clinical practice. LEVEL OF EVIDENCE: Level IV, case series.

Hybrid Fixation for Ankle Fusion in Diabetic Charcot Arthropathy.

BACKGROUND: Ankle fusion is difficult to achieve in the diabetic Charcot ankle Brodsky type 3a because of the poor quality of the bone and the inability to achieve a stable biomechanical construct. The aim of this study was to report the outcome of ankle fusion using a combination of an intramedullary nail and a circular external fixator in patients with diabetic Charcot arthropathy. METHODS: We prospectively studied 24 patients with diabetic Charcot arthropathy of the ankle who were treated by fusion of the tibiotalar joint using a combined retrograde intramedullary nail and Ilizarov external fixator. Their mean age was 50.7 ± 6.9 (range, 43-62) years. The mean follow-up after surgery was 36.4 ± 5.8 (range, 24-98) months. RESULTS: Twenty-two patients (92%) achieved clinical and radiographic solid bony fusion. No patients in this series needed amputation. All the patients were pain free, and the mean American Orthopaedic Foot & Ankle Society Score (AOFAS) improved significantly from 34.6 ± 6.8 to 66.4 ± 4.5 at the last follow-up. Two patients developed an ulcer over the heel due to a prominent nail. The ulcer healed after nail removal. Eight patients developed pin tract infection. CONCLUSION: We report a successful outcomes of ankle fusions using combined intramedullary nail locked only proximally and ring external fixator (hybrid fixation) in patients with diabetic Charcot arthropathy. LEVEL OF EVIDENCE: Level IV, case series.

Randomized, double-blind, placebo-controlled, interventional phase IV investigation to assess the efficacy and safety of r-hirudin gel (1120I.U) in patients with hematomas.

BACKGROUND: Hirudin is the most potent direct thrombin inhibitor, and recombinant forms are routinely used in anticoagulation therapy. Recombinant hirudin gels are commercially available for the treatment of hematomas and associated symptoms. OBJECTIVES: To assess the efficacy and safety of a topically administered recombinant hirudin gel in patients with hematomas. PATIENTS/METHODS: This double-blind, placebo-controlled, phase IV investigation recruited patients presenting with at least one hematoma. Subjects were randomly assigned (1:1) recombinant hirudin gel (1120 IU/100 g) or a placebo, administered 2-3 times daily for 16 days. Changes in hematoma size, flare, and the proportion of patients achieving complete resolution of hematomas and associated edemas were investigated. RESULTS: By study end, a greater proportion of subjects in the treatment group achieved a complete resolution of hematomas versus placebo (98.0% vs 71.9%; P  < .001) and edemas (99% vs 50%; P  < .001). Patients in the recombinant hirudin group exhibited a marginally larger, yet significant, reduction in mean hematoma size versus placebo (99.9% vs 96.6%; P  < .001) and flare (93.6% vs 78.6%; P  < .001). Median time to hematoma resolution for the recombinant hirudin and placebo administered cohorts was 8 and 16 days, respectively (P  < .001). No adverse events were reported for the recombinant hirudin cohort. CONCLUSIONS: Topical recombinant hirudin is an effective, safe, and well tolerated intervention for the symptomatic treatment of hematomas. This trial was registered at http://www.clinicaltrials.gov as NCT01960569.

Functional outcome of four-corner arthrodesis for treatment of grade IV scaphoid non-union.

Functional limitations and pain are end results of scaphoid nonunion with progressive carpal collapse and radiocarpal arthritis. The aim of this study was to assess the functional outcome of four-corner arthrodesis with scaphoidectomy for the treatment of grade IV scaphoid nonunion with Scaphoid Nonunion Advanced Collapse (SNAC) stages II and III. Ten patients with symptomatic grade IV non union of the scaphoid and a mean duration of non unions of 12.1 +/- 2.81 months were treated using the four-corner arthrodesis technique. A dorsal midline longitudinal approach centered over the third metacarpal-capitate-lunate-radius axis, excision of the scaphoid, neutral alignment of the remaining carpal bones, and arthrodesis of the capitate, hamate, lunate, and triquetrum, were performed. Kirschner wires were used to secure the arthrodesis in all cases. A below-elbow thumb spica cast was applied for 3 months. Follow up period ranged from 8 to 24 months, with a mean of 16 +/- 4.7 months. All patients were assessed both functionally for pain, range of motion and grip strength, and radiographically for evidence of fusion and carpal alignment. Good results were achieved in 7 patients (70%) according to the modified Mayo Wrist Scoring Chart. There were no intraoperative complications. Postoperatively, one patient suffered superficial wound infection One patient showed dorsal impingement of the capitate and radius. Also, two patients suffered reflex sympathetic dystrophy. No patients showed deep infection or nonunion. The Four-corner Arthrodesis technique is a motion-sparing, limited arthrodesis that reliably results in pain relief, improved grip strength, and overall patient satisfaction with low associated non union and complication rates.

Proximal row carpectomy: a motion-preserving procedure in the treatment of advanced Kienbock's disease.

Kienbock's disease is an isolated disorder of the lunate bone resulting from vascular compromise to the bone. In stage IV, degenerative changes are present at the midcarpal joint, the radiocarpal joint, or both. The goal of proximal row carpectomy (PRC) is the creation of a new joint between the capitate and the radius. The aim of this prospective study was to evaluate the functional outcome after PRC in late stage Kienbock's disease. The evaluation included assessment of range of motion, grip strength, and pain reduction. Twelve wrists in 12 patients underwent proximal row carpectomy for the treatment of stage IV Kienbock's disease between 2002 and 2005. Objective and subjective function was assessed. The average length of follow-up was 2 years (range, 9 months to 4 years). There was one failure (8.3%) requiring fusion at three years. The eleven wrists that did not fail (91.7%) had an average flexion-extension are of 70 degrees, associated with an average grip strength of 80% of the contralateral side; all patients were very satisfied. The patients rated nine wrists as not painful, two as mildly painful, and one as moderately painful. Radiographs revealed reduced radiocapitate space in five and complete loss of the space in one. With the numbers available, there was no significant association between loss of joint space seen on radiographs and subjective and objective function. Overall, proximal row carpectomy had maintained a satisfactory range of motion, grip strength, and pain relief, and all twelve patients with Kienbock's disease, except one, were satisfied with the results and returned to their previous occupations. Caution should be exercised in performing the procedure in a young, heavy manual working patient.

Outcome of pelvic support osteotomy with the Ilizarov method in the treatment of the unstable hip joint.

Instability of the hip joint in the young adult is a difficult problem. Patients with an unstable hip secondary to any aetiology usually have loss of bone from the proximal femur or shortening of the limb or both. In this study we report our results in the treatment of the unstable hip joint in young adults by pelvic support osteotomy using the Ilizarov method. From 1997 to 2004, 25 patients (17 females and 8 males) with an unstable hip joint were treated in the Orthopaedic department of Mansoura University Hospital, Egypt. Their mean age was 22.4 years (range: 19 to 35). The main complaints were pain, leg length discrepancy, limping, and limited abduction of the hip. All patients underwent valgus extension osteotomy in the proximal femur and distal femoral osteotomy for lengthening. The average follow-up ranged from 2 to 7 years. All hips were pain free at follow-up. The Trendelenburg sign became negative in 20 patients. There was no limb length discrepancy and alignments of the extremity were re-established. Five patients had a lurch gait. Valgus extension osteotomy has provided stability of the hip joint and maintained some motion of the hip joint. By using the Ilizarov technique, we could prevent the valgus effects created by the valgus extension osteotomy while achieving lengthening of the femur through the distal osteotomy in the femur.

Prophylactic surgical correction of Crawford's type II anterolateral bowing of the tibia using Ilizarov's method.

The treatment of anterolateral bowing with an intact tibia is directed toward prevention of the fracture and subsequent pseudoarthrosis. Patients with anterolateral bowing of the tibia are usually treated with an ankle-foot orthosis until the deformity is improved. There is no documentation that an orthosis can prevent the fracture or correct the deformity, and if the deformity is not corrected, it will result in different mechanical problems. In this study, 6 legs in 6 patients with anterolateral bowing of the tibia with a narrow sclerotic medullary canal (Crawford type II) were treated using Ilizarov's method. The average age was 6.8 years. All patients underwent correction of the anterolateral bowing by excision of the affected part. If the gap was less than 4 cm, acute shortening followed by bone lengthening was done. If the gap was more than 4 cm, bone transport was preferred. The mean duration of follow-up was 3.2 years. The anterolateral bowing was corrected in all patients. Complications such as pin track infection, premature consolidation and delayed union at the docking site were encountered. We believe that Ilizarov's method offers a more efficient solution for this type of deformity than prophylactic orthotic treatment or prophylactic bypass bone graft.

Functional outcome following treatment of segmental skeletal defects of the forearm bones by Ilizarov application.

Managing a segmental skeletal defect is a challenge, even more so if the combination of local infection with bone defect exacerbates the problem and provides an even more negative prognosis. Several techniques have been tried, among which skeletal allografts, autologous cortical or cancellous bone graft and vascularised bone graft, each with its limitation and success. In this study, we report our results with the Ilizarov method of bone transport to overcome bone defects of forearm bones due to infection. This series included 16 patients with bone defects of forearm bones, following either debridement of osteomylitis or infected nonunion. The mean time from injury to the Ilizarov procedure was 11.7 months. The mean number of operative procedures before application of the Ilizarov device was 3.4. The mean length of the defects after debridement was 6.4 cm. Monofocal osteotomy was performed. The mean external fixation index, distraction index and maturation index were 41.5 days/cm, 19.8 days/ cm, and 21.7 days/cm respectively. The mean time in the frame was 8.9 months. The mean total duration of treatment was 11.4 months. There were 14 complications in 11 patients including pin-track infection, premature consolidation, delayed union at the docking site and refracture. Ilizarov's technique of bone transport is an ideal solution for a large skeletal defect in spite of the high incidence of associated complications.

Acetabular coverage in bladder exstrophy: role of 3-dimensional computed tomography.

We studied the acetabular coverage in bladder exstrophy patients and normal control children. The study included 13 patients with bladder exstrophy, who were divided according to their ages into group I below 5 years, group II between 5 and 10 years, and group III above 10 years of age. Four normal children served as controls, 2 were below 5 years, one was 7 and one was 12 years old. We measured the acetabular coverage (AC) and the center-edge-angle (CEA) by utilising the reconstructed 3-dimensional CT images. The mean right and left AC angles were 82 +/- 12 and 82 +/- 20 degrees in group-I, 107 +/- 15 and 103 +/- 17 in group-II and 119 +/- 24 and 116 +/- 22 in group-lII, respectively (p < 0.05). The mean right and left CEA angles were 33 +/- 4 and 32 +/- 4 degrees in group-I, 30 +/- 4 and 29 +/- 5 in group-II and 25 +/- 2 and 24 +/- 1 in group-III, respectively (p < 0.05). In controls, the mean right and left AC angles were 151 +/- 2 and 153 +/- 2 degrees for children below 5 years, 166 and 165 degrees in the 7 year-old child and 180 and 180 degrees in the 12 year-old child. The CEA angle ranged from 15 to 25 degrees. Acetabular coverage in bladder exstrophy patients is deficient during the first 5 years of life. Although it gradually improves over time, it does not reach to normal value.

The management of tibial pilon fractures with the Ilizarov fixator: The role of ankle arthroscopy.

BACKGROUND: Pilon fractures usually result from high energy trauma, and are commonly associated with extensive soft tissue damage which prevents the use of open reduction and internal fixation. PURPOSE: This study was designed to evaluate the use of the Ilizarov external fixator in the treatment of pilon fractures of the ankle, and to determine whether arthroscopy of the ankle could improve the outcome. METHODS: From February 2011 to May 2013 a total of 23 patients with unilateral closed pilon fractures were divided into two groups treated with and without arthroscopy during fixation with the Ilizarov external fixator. The fractures were classified according to the AO Rüdi and Allgower classification. Follow up ranged from 10 to 37 months with a mean of 18 months. RESULTS: All cases were evaluated at follow up by the AOFAS and the Bone et al. grading system. According to Bone et al. there were 3 cases excellent, 4 cases good, 2 cases fair, and 2 cases poor in Group A (without arthroscopy), whereas there were 4 cases excellent, 6 cases good, 2 cases fair in Group B (with arthroscopy). The AOFAS score for Group A was 77.8±5.8, and for Group B was 78.4±6.9. CONCLUSION: We concluded that the Ilizarov external fixator is an excellent method in treating pilon fractures as it minimizes the need for extensive surgery. We also conclude that the use of arthroscopy during pilon fracture fixation did not add statistically significant improvement to our results and it needs longer term investigation to assess its advantage - if any - to the final outcome. LEVEL OF EVIDENCE: level 2.

Assessment of percutaneous V osteotomy of the calcaneus with Ilizarov application for correction of complex foot deformities.

Complex foot deformity can be described as a foot with multiplanar abnormalities with or without shortening of the foot. Conventional surgical treatment may not be able to correct these deformities. In this study we evaluate the results of percutaneous V osteotomy of the calcaneus with an Ilizarov external fixator for treatment of complex foot deformity. Twenty feet with a complex deformity were treated by the Ilizarov method in 15 patients. The aetiologic factors were neglected or relapsed clubfoot (13 patients) and poliomyelitis (2 patients). All patients underwent percutaneous V osteotomy of the calcaneus and gradual correction of the deformity using Ilizarov's method. The mean duration of fixator application was 9.5 months (range, 6-13 months). The mean follow-up period was 1.8 years (range, 1 to 3 years). At the time of fixator removal, a plantigrade foot was achieved in 18 cases; gait was improved in all patients. There was residual varus deformity in two patients. A pin-tract infection was observed in all patients. No recurrence of the deformity occurred. The V osteotomy offers the most options for correction of complex foot deformities. Percutaneous technique is particularly useful for the complex foot deformity that has poor skin coverage, with poor blood supply. Gradual correction with the Ilizarov method yields good results for complex foot deformities.