[Correction of tibial multiplanar deformities using single Taylor external fixator combined with biplanar osteotomy].

Objective: To investigate the effectiveness of single Taylor external fixator combined with biplanar osteotomy on correction of tibial multiplanar deformities. Methods: Between October 2016 and December 2021, 11 patients with tibial multiplanar deformities (20 sides) were treated with single Taylor external fixator and biplanar osteotomy. Of them, 4 were male and 7 were female; the average age ranged from 13 to 33 years (mean, 21.9 years). Diagnosis included rickets severe genu varum deformity (7 cases, 14 sides), rickets severe genu valgum deformity (2 cases, 4 sides), multiple osteochondromatosis calf deformity (1 case, 1 side), neurofibromatosis medial lower leg anterior arch deformity with short of leg (1 case, 1 side). After fibular osteotomy and tibial multiplanar osteotomy, a Taylor external fixator was installed. After operation, the deformities were corrected successively and fixed completely. The osteotomy healed, then the external fixator was removed. Before operation and at 12 months after operation, the full-length X-ray films were taken. The leg-length discrepancy, medial proximal tibial angle (MPTA), lateral distal tibial angle (LDTA), posterior proximal tibial angle (PPTA), anterior distal tibial angle (ADTA), and tibial rotation angle were measured. The degree of lower limb deformity was scored with reference to a customized tibial mechanical axis scoring table. Results: Osteotomy was successfully completed without neurovascular injury and other complications. The external fixator was adjusted for 28-46 days, with an average of 37 days, and the external fixator was worn for 136-292 days, with an average of 169 days. Mild needle infection during the fixation period occurred in 3 sides, refracture at the distal tibial osteotomy in 1 side after removing the external fixator, and nonunion of the distal fibular osteotomy in 1 side. All patients were followed up 369-397 days (mean, 375 days). At 12 months after operation, the lower limb discrepancy decreased, but there was no significant difference ( P>0.05). MPTA, LDTA, PPTA, ADTA, and tibial rotation angle improved, and the differences in LDTA, ADTA, and tibial rotation angle were significant ( P<0.05). The score of lower limb deformity was significantly higher than that before operation ( P<0.05), and the results were excellent in 9 sides, good in 8 sides, fair in 3 sides, with the excellent and good rate of 85%. Conclusion: Single Taylor external fixator combined with biplanar osteotomy is effective in the correction of tibial multiplanar deformities.

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.

[Surgical treatment of limb deformity and disability: a statistical analysis of 35 075 cases from QIN Sihe orthopaedic team between May 25, 1978 and December 31, 2018].

OBJECTIVE: To investigate the characteristics and corrective strategies of various limb deformities treated by QIN Sihe orthopaedic team in the past 40 years, so as to provide a large sample for understanding the causes, types, and treatment methods of limb deformity and disability in China. METHODS: A clinical data of 35 075 cases who were treated by QIN Sihe orthopaedic team between May 1978 and December 2018 was summarized. The age, gender, deformity characteristics, etiological and pathological composition, regional distribution, and surgical methods of the patients were analyzed. RESULTS: There were 20 458 males (58.33%) and 14 617 females (41.67%). The age ranged from 1 to 82 years (mean, 20.5 years). The majority people (19 363 cases, 55.20%) were 11-25 years old. Of which, 33 259 cases (94.82%) were operated on lower extremity. The geographical distribution of patients covered 33 regions in China and 12 foreign countries. There were 202 etiologies involved neurological, heredity, metabolism, traumatic sequelae, congenital, vascular, lymphoid, skin, endocrine, iatrogenic, and so on. The disease covered all subsubjects of orthopaedics. The top six deformities secondary to poliomyelitis sequelae, cerebral palsy, traumatic sequelae, spondylolysis sequelae, genu varum and genu valgum, and congenital talipes equinovarus. There were 280 kinds of surgical methods, the majority of which were Achilles tendon lengthening, supracondylar osteotomy, subtalar joint arthrodesis, tibiofibular osteotomy, metatarsal aponeurosis, and Achilles tendon replacement of peroneal longus muscle, etc. Orthopaedic surgery combined with external fixation were applied in 8 702 cases, including Ilizarov fixator in 3 696 cases and Hybrid fixator in 5 006 cases. CONCLUSION: QIN Sihe orthopaedic database with 40 years is the largest one of limb deformity and disability in China. It reflects the etiology, type, population characteristics, surgical methods and strategy of limb disability and deformity which can be treated by orthopaedic surgery. The data needs to be further excavated and deeply studied in future because of its important academic value and historical significance.

[Data analysis of 8 113 cases of limb deformities corrected by external fixation].

Objective: To analyze the data of external fixation instruments (including Ilizarov instruments) used by QIN Sihe orthopaedic surgical team in the treatment of limb deformities in the past 30 years, and to explore the indications for the application of modern external fixation techniques in the correction of limb deformities and individual device configuration selection strategy. Methods: According to QIN Sihe orthopaedic surgical team, the use of external fixator between January 1988 and December 2017 was analyzed retrospectively. The total use of external fixation and the proportion of different external fixators were analyzed in gender, different operation time, different age, different parts, and different diseases. Results: External fixators were used in 8 113 patients, 69 of them were used simultaneously in both lower extremity surgery, so 8 182 external fixators were used. Among them, there were 4 725 (57.74%) combined external fixators, 3 388 (41.41%) Ilizarov circle fixators, 64 (0.78%) single arm external fixators (including Orthofix), 5 (0.06%) Taylor space external fixators. There were 4 487 males (55.31%) and 3 626 females (44.69%). According to the analysis of different time periods, the number of external fixators increased year by year, and the number of applications increased after 2000. The main age of the patients was 11-30 years old, of which 1 819 sets (22.23%) were used at the age of 21-25 years. The use of the external fixator covered almost all parts of the limbs, with the ankle and toe areas being the most common, reaching 4 664 sets (57.00%), and the upper extremities the least, with 152 sets (1.86%). The 8 113 cases covered more than a dozen disciplines and more than 150 kinds of diseases. The top 5 diseases were poliomyelitis sequelae, cerebral palsy, deformity of lower extremity after spina bifida, traumatic sequelae, and congenital equinovarus foot. Conclusion: Ilizarov technique has been widely used in extremity deformity, disability, and complicated orthopedic diseases caused by vascular, lymphoid, nerve, skin, endocrine, and other diseases. The indication of operation is far beyond the scope of orthopedics. The domestic external fixator and its mounting tools can basically meet the requirements of various treatments. The technique of external fixation has entered a new era of tension tissue regeneration under stress control, natural repair of tissue trauma and deformity, and reconstruction of limb function.

[Limited orthopaedic surgery combined with external fixation for the treatment of lower extremity sequelae of middle and old aged post-poliomyelitis].

Objective: To summarize the effectiveness of limited orthopedic surgery combined with external fixation for the treatment of lower extremity sequelae of middle and old aged post-poliomyelitis, and then to explore the strategy of surgical correction and functional reconstruction method. Methods: From the database of 23 310 cases of poliomyelitis sequelae treated by QIN Sihe Orthopaedic Surgical team between September 1982 and December 2017, 629 patients over 41 years old were retrieved and the epidemiological characteristics of the patients were analyzed. Between March 2011 and June 2015, 57 patients with poliomyelitis sequelae treated with limited operation and external fixation were followed up 2-6 years, and the history of poliomyelitis sequelae was 41-67 years (mean, 47.1 years). Preoperative histopathological gait included 29 cases of quadriceps gait, 17 cases of walking with crutch, and 11 cases of claudication only. The operative methods included Achilles tendon lengthening in 52 cases, supracondylar osteotomy in 39 cases, knee flexion release in 36 cases, calcaneal arthrodesis in 27 cases, flexion and hip arthrodesis in 21 cases, tibia and fibula osteotomy in 19 cases, triple arthrodesis in 11 cases, and tendon transposition in 1 case. After operation, 18 cases were treated with combined external fixator and 39 cases with Ilizarov ring external fixator. Results: Of the 629 cases, 481 cases were less than 50 years old (76.47%), accounting for 144 cases between 51 and 65 years old (22.89%). Among them, 495 cases (78.70%) were diagnosed after 2003. Of the 57 patients obtained complete follow-up information, 7 had slight infection of needle path during traction orthopaedics, 2 had early postoperative venous thrombosis of lower extremities, and 2 had incomplete paralysis of the common peroneal nerve. There was no complications such as skin incision infection, vascular injury, and bone nonunion. According to the evaluation standard of postoperative efficacy standard in correction of lower extremity deformities, the results were excellent in 23 cases, good in 20 cases, fair in 12 cases, and poor in 2 cases, with an excellent and good rate of 75.44%. The 2 patients with poor effectiveness were reoperated to improve their function. Conclusion: Limited orthopedic surgery combined with external fixation for the treatment of lower extremity sequelae of middle and old aged post-poliomyelitis can effectively correct deformities of lower limbs, improve function, delay the disability aggravated by decay, and avoid serious complications.

[Treatment of equinovarus accompanied with ulcer using Ilizarov technology and limited operation].

OBJECTIVE: To explore the surgical method and clinical curative effect of Ilizarov technique combined with limited surgical treatment for neurotrophic malnutrition equinovarus accompanied with weight-bearing area ulcer. METHODS: From July 2004 to December 2011, 21 cases of neurological disorders equinovarus with skin ulcer in weight-bearing area were treated including 14 males and 7 females with an average age of 21.3 years old ranging from 8 to 32 years. Among them,19 cases with talipes equinovarus were on account of spina bifid and 2 cases on account of spinal cord injury of lumbar sacral segment. Nine cases were on the left foot and 12 cases were right foot. The ulcer area in out-below side of the fifth metatarsal bone was in 6 cases, in basement of the fifth metatarsal bone in 5 cases,in lateral of calcaneocuboid joint 2 cases, and in lateral of subtalar joint in 8 cases. Surgical procedure included plantar medial release technique, tendo-chilles lengthenning, and three-joint partial osteotomy. During operation,the skin and soft tissue of ulcer were resected and the incision was sutured when the ulcer was in the lateral of subtalar joint, and ankle Ilizarov external fixation for extension was installed after correcting talipes equinovarus partially. For the legacy skin ulcer in weight-bearing area,the Shenrg-ji cream (Chinese characters) was used after operation for one time per day until the wound healed. Adjusting Ilizarov external fixation for correcting residual deformity until it is satisfaction. During this process weight-bearing walking was keeping. RESULTS: All cases were followed up from 6 to 52 months with an average of 28 months. All ulcers were healing and no recurrence. The ulcer healing time was 14 to 36 days postoperative (26 days in average). Eighteen deformity feet were corrected satisfactorily, and recovered fully plantar foot, 3 feet appeared mild deformity after 1 year. Ankle joint activity appeared limited in 15 cases and got completely rigidity in 6 cases. The AOFAS increased from preoperative 34.0±7.2 to 86.0±8.5 postoperatively; 8 feet got excellent, 10 good,3 fair. CONCLUSION: The clinical effect of Ilizarov technique combined with limited operation and the Sheng-ji cream in correction of the talipes equinovarus with skin ulcer in weigh-bearing area on account of neurotrophic malnutrition is satisfactory, the surgical method is simple and the treating course in security, and serious complications can be avoided.

[Combined procedure for the treatment of ankle and foot deformities secondary to spina bifida].

OBJECTIVE: To study surgical strategies for ankle and foot deformities secondary to spina bifida and treatment methods for different types of deformities. METHODS: From January 1990 and July 2009, 107 patients with ankle and foot deformities secondary to spina bifida were retrospectively analyzed. There were 44 males and 63 females, with an average age of 17.7 years (rangd from 1.3 to 52 years). Among the patients, 58 patients had double ankle deformities, 49 patients had unilateral deformities (22 cases on the left side, 27 cases on the right). Ninety-nine patients with equinus deformities were treated by achilles tendon lengthening and tendon transfering; 25 patients with talipes were treated by release of anterior tendon of ankle and tendon transfer; 17 patients with valgus and varus deformities were treated by tendon transfer and calcaneal osteotomy; 15 patients with flail deformities were managed treated by bone fusion between calcaneus and talus and shortening of achilles tendon; 9 patients with claw toe deformities were treated by bone fusion of interphalangeal joint or Ilizarovs distraction. AOFAS (American Orthopaedic Foot & Ankle Society) comprehensive scoring system was used to evaluate subjective pain and objective functional. RESULTS: Seventy-nine (127 feet) of 107 patients were followed up, and the duration ranged from 48 to 180 months (averaged, 64 months). According to AOFAS scoring system, the results were rated as excellent in 89 feet, good in 26 feet, moderate in 9 feet and poor in 3 feet. CONCLUSION: Treatment strategies for ankle-foot deformities mainly included four principles, deformity correction, muscular balance, joint stability and reservation of foot elasticity. Different combined procedure was applied for different foot deformities and received good therapeutic effects.

[Limited operations and Ilizarov technique for correction of congenital clubfoot in adolescents].

OBJECTIVE: To observe the effectiveness of limited operations and Ilizarov techniques for correction of congenital clubfoot (CCF) in adolescents, and to explore the new methods and new ideas for functional reconstruction of CCF. METHODS: Between September 2003 and July 2010, 25 adolescent patients (40 feet) with CCF were treated. Of the 25 patients, 14 were male (20 feet) and 11 were female (20 feet) with an age range from 12 to 25 years (mean, 15.7 years). The left feet were involved in 4 cases, the right feet in 6 cases, and both feet in 15 cases. According to Qin's clubfoot deformity scale, 9 feet were rated as degree I, 17 feet as degree II, and 14 feet as degree III. In these cases, 9 feet were accompanied by internal rotation deformities of crus and 1 case by subluxation of right hip joint. After soft tissue release and osteotomy, 9 feet (degree I) were fixed by composite external fixation instruments, 31 feet by Ilizarov external fixation instruments. The deformity was corrected from 5 to 7 days after operation with distraction of 0.5-1.0 mm/d, then distraction stopped when the ankle was corrected at a hyperextension of 5 to 100 and light valgus. The affected limb might undergo weight bearing walking with external fixation at corrected position for 4 to 6 weeks. If one had both feet deformity, staged operation should be performed with a surgery interval of 3 to 6 months (mean, 4 months). RESULTS: The fixation time was 6-12 weeks (mean, 8 weeks) in 9 feet fixed by composite external fixation instruments, and it was 6-17 weeks (mean, 13 weeks) in 31 feet fixed by Ilizarov external fixation. Ml 25 patients were followed up 8 months to 6 years with an average of 37 months. During distraction process, slight pin track infection occurred in 6 cases (6 feet), which were cured after expectant management. One patient had recurrence of the deformity at 2 years postoperatively, who obtained satisfactory correction after Ilizarov external fixation for 4 weeks. The satisfactory correction and foot function were achieved in the other feet with walking on full weight-bearing. According to International Clubfoot Study Group (ICFSG) score, the results were excellent in 28 feet, good in 10 feet, and fair in 2 feet, with an excellent and good rate of 95% at last follow-up. CONCLUSION: Combined limited operation with Ilizarov technique for correcting adolescent CCF is accord with biology principle and minimally invasive surgical principle, so it is a safe, minimally invasive, and effective method. It also can broaden the operative indications and correct degree III talipes equinovarus which is unattainable by traditional orthopedic surgery.

[Limited internal fixation combined with external fixation for the treatment of deformity of the distal end of femur].

OBJECTIVE: To study therapeutic effects of limited internal fixation combined with external fixation in the treatment of deformity of distal end of femur, as well as to explore its effect on the function of knee joint. METHODS: From June 2004 to June 2009, 38 patients with deformity of distal end of femur were treated with osteotomy at femoral supracondylar and internalfixation combined with hybrid external fixator. Among the patients, 19 patients were male and 19 patients were female, ranging in age from 14 to 58 years, with an average of 26 years. Six patients had genu valgum, 4 patients had varus of the distal end of femur, 2 patients had varus combined with rotation deformity,3 patients had genu recurvation and 23 patients had deformity of genuflex. The function of knee joint was evaluated according to Dimeglio clinical assessment after the treatment. RESULTS: All the patients were followed up and the during ranged from 6 to 48 months, with a mean period of 23 months. All the deformity obtained satisfactory correction, without complications such as limitation of motion of the knee joint, under correction or over correction,displacement of the section of the osteotomy,internal fixation loosening and fracture. Nineteen patients got an excellent result, 12 good, 5 poor and 2 bad. CONCLUSION: Supracondylar femoral osteotomy and internal fixation combined with hybrid external fixator is a safe and effective surgery for the treatment of deformity of distal end of femur. This method combines the advantages of internal fixation and external fixation.

[Vertebral pedicle screw-rods system for correcting paralytic scoliosis].

OBJECTIVE: To explore some operative problems of correcting paralytic scoliosis (PS) by using vertebral pedicle screws-rods system. METHODS: From May 2000 to May 2005, 18 patients with PS were corrected by screws-rods system which were made of titanium alloy. There were 10 males and 8 females, aging from 11 to 26 years. The primary disease included poliomyelitis in 13 patients and myelodysplasia (MS) in 5 patients (2 cases for second correction) with scoliosis of an average 85 degrees Cobb angle (55-125 degrees). The pelvic obliquity was found in all patients with an average 24 degrees angle (3-55 degrees). Of the 18 patients,3 cases were given perioperative halo-pelvic traction, 2 cases were given vertebral wedge osteotomy and correction and fixation, the other patients were purely underwent the treatment of pedicle screw-rods system implants. Fusion segment at operation ranged from 6 to 15 sections, applied screws the most was 16, the fewest was 6. RESULTS: There were no wound infections and neurologic complications, all wounds healed by the first intention. All scoliosis obtained obvious correction (P<0.001), the correction rate averaged 52.95% (44%-81%); the majority of lumbar kyphosis and pelvic obliquity were apparently corrected. The average clinical follow-up (16 cases) was 21 months (6-36 months), there was no implants failure. One patient with MS had a worse Cobb magnitude, the other patients had no curve progression (P>0.05). CONCLUSION: The use of vertebral pedicle screwsrods fixation to multiple vertebral bodys and short segment fusion for PS, the treatment method is reliable and the outcome is satisfactory. While performing the correcting operative procedures, the spinal, pelvic and lower extremity deformities and functions should be all considered as a whole.

[Ilizarov technique for correcting flexion deformity of the knee of arthrogryposis multiplex congenita].

OBJECTIVE: To study the methods and effects of Ilizarov distraction technique in treating the flexion deformity of the knee of arthrogryposis multiplex congenita. METHODS: Between August 1998 and February 2003, 6 patients (10 knees) with the arthrogryposis multiplex congenita were treated, 4 patients in double knees, 5 males, 1 female, mean age 8 years and 2 months, ranged from 3 years and 7 months to 13 years. The preoperative flexion degree was averagely 51 degrees. The patients accompanied 13 other parts malformation of limbs. The modified Ilizarov distraction apparatus of the knee was used. While installing the apparatus in the operation, the knees should be kept in the of location of maximum extension, the center of joint hinges on the apparatus should be placed towards the rotatory center of the knee, two groups of 2 mm K-wires were passed through the femur and tibia around the knee, who were fixed on the proximal and distal rings. Distraction was started after the surgical procedure 5 days via rotating the threaded rods at the posterior of the knee, at an average of 2 to 3 mm per day, at the first week, after 2 weeks with the rate modified to 2 mm per day, up to the knee extended to 0 degrees. The accompanied deformities of the hip and/or the foot might be corrected at the same time or next time. The average duration of the distraction was 37 days (23-48 days). During the correction all limbs might undergo weight. After 2 weeks at the end of distraction the fixator was removed and the patients could walk by a long-leg brace. RESULTS: Ten knees with the flexion contracture were sufficiently corrected without severe complications. Nine knees of all were followed up at an average time of 1 years and 3 mouths, no recurrence of the deformity was seen in all patients, their function of walk was significantly improved. CONCLUSIONS: Ilizarov technique is a simply, safe and effective method for managing the flexion deformity of the knee of the arthrogryposis multiplex congentia. The procedure is conformable to the biological theories and microsurgical principles.