The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases.

PURPOSE: Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries. METHODS: Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities. RESULTS: The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results. CONCLUSION: Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.

A modified angled plate for fixation of proximal femoral varus osteotomy in neuromuscular hip dislocation: Mechanical and clinical study.

INTRODUCTION: Proximal femoral osteotomy is an important step in the management of paralytic hip dislocation. Fixation by the angled plate is demanding and carries the risk of many complications. In this study, we made certain modifications for the angled plate. Does this plate provide a stable fixation for proximal femoral varus osteotomy? The main objective of this study was to assess the results of the modified plate in fixation of proximal femoral varus osteotomy in patients with neuromuscular hip dislocation. HYPOTHESIS: This new system would offer significant advantages over the existing systems in terms of easy application and stable fixation. MATERIAL AND METHODS: Twenty patients with paralytic hip dislocation were included in this study. The ages ranged from 5 to 15 years with a mean of 8.88±2.92 years. There were 12 boys and 8 girls. Seventeen patients had cerebral palsy and 3 had meningocele disease. Preoperative radiographs were done, and the migration percentage (MP), acetabular index (AI), and neck-shaft angle (NSA) were measured. All patients were treated with open reduction, pelvic osteotomy, and proximal femoral varus osteotomy. The femoral osteotomy was fixed by the modified angled plate in all cases. RESULTS: The osteotomy sites united in all patients and the mean time of union was 2.9±0.65 months. The acetabular index, migration percentage, and neck-shaft angle were reduced postoperatively. This reduction was statistically significant. The hips remained stable throughout the period of follow-up in all patients. No cases were complicated by non-union or implant failure. CONCLUSION: The modified angled plate (canulated interlocking blade Plate 90°) is a good method for the fixation of proximal femoral varus osteotomy in the management of neuromuscular hip dislocation. It provides a stable fixation. LEVEL OF EVIDENCE: IV; case series.

Single stage reconstruction of segmental skeletal defects by bone graft in a synthetic membrane.

INTRODUCTION: Segmental skeletal defects are very difficult to treat. The current options are lengthy procedures, require more than one surgery and plagued with many complications. The aim of this study is to assess the results of bone graft in surgicel as a synthetic membrane for reconstruction of segmental skeletal defects in one stage surgery. METHODS: Fourteen patients with segmental skeletal defects were included in the study. The ages ranged from 20 to 54 years with an average of 32 years. The defects were due to high energy trauma in all cases. The size of the defects ranged from 5 to 12 cm with an average of 7 cm. They were located in the distal femur in 11 cases and middle third of the femur in three cases. All cases were treated by the synthetic membrane technique in one stage surgery. Surgicel was used as a synthetic membrane and both the fibular strut autograft and morselized allograft were used to fill the defects in all patients. RESULTS: All cases healed without additional procedures after the index surgery except in three cases. The time-to-bone union ranged from six to 13 months with an average of eight months. After physiotherapy all patients regained good range of knee movements except two cases. The complications included deep wound infection in two cases, nonunion of the graft in one case and joint stiffness in two cases. CONCLUSION: Primary bone graft in surgicel as a synthetic membrane is a good technique for management of post-traumatic bone defects. It reduces the time and number of surgeries required for reconstruction of this difficult problem.

Reconstruction of infected nonunion of the distal humerus by Ilizarov external fixator.

BACKGROUND: Infected nonunion of the distal humerus represents a true challenge as the fragment is usually small and difficult for fixation. The aim of the present study is to assess the results of Ilizarov external fixator in management of infected nonunion of the distal third humerus. MATERIAL AND METHODS: Twenty-three patients with infected nonunion of the distal humerus were included in this study. The ages ranged from 19 to 58 years with an average of 35 years. Seventeen cases were males and 6 were females. All patients were treated by radical debridement and application of Ilizarov external fixator in one stage surgery. RESULTS: Bony union was achieved in all cases. Bone graft was required in 12 patients with hypotrophic nonunion. The external fixation time ranged from 4 to 9 months with an average of 5.6 months. Infection was controlled in all cases without recurrence during the period of follow up. The complications included pin tract infection in 7 cases, radial nerve injury in one case, elbow stiffness in 4 cases and refracture after frame removal in one case. CONCLUSION: Ilizarov external fixator is effective in management of infected nonunion of the distal humerus. The thin tensioned wires produce good grip in the small or osteoporotic bone fragments.

The use of free nonvascularized fibular graft in the induced membrane technique to manage post-traumatic bone defects.

PURPOSE: The aim of the present study is to assess the results of free nonvascularized fibular graft in the induced membrane technique to manage bone defects. MATERIALS AND METHODS: Fifteen patients with segmental skeletal defects were treated by the induced membrane technique using free nonvascularized fibular graft. The ages ranged from 20 to 48 years with an average of 32 years. The cause of the defects was post-traumatic bone loss in all cases. The defects were located in the distal femur in nine cases, proximal tibia in two cases and middle third of the tibia in four cases. The defects ranged from 5 to 14 cm with an average of 8 cm. All cases were treated by the induced membrane technique in two stages. Autogenous cancellous bone graft and free nonvascularized fibular graft were used to fill the defect in the second stage of surgery. RESULTS: All cases healed without additional procedures after the second stage except in two cases. The time-to-bone union ranged from 4 to 13 months with an average of 7 months. After physiotherapy, all cases regained good range of ankle and knee movements except two cases. The complications included nonunion of the graft in two cases, deep wound infection in one case, and chronic pain along the iliac crest in one case. No cases were complicated by implant failure or refracture. CONCLUSION: The use of free nonvascularised fibular graft in the induced membrane technique reduces the time of healing and improves the final outcome.

Unhappy triad in limb reconstruction: Management by Ilizarov method.

AIM: To evaluate the results of the Ilizarov method in management of cases with bone loss, soft tissue loss and infection. METHODS: Twenty eight patients with severe leg trauma complicated by bone loss, soft tissue loss and infection were managed by distraction osteogenesis in our institution. After radical debridement of all the infected and dead tissues the Ilizarov frame was applied, corticotomy was done and bone transport started. The wounds were left open to drain. Partial limb shortening was done in seven cases to reduce the size of both the skeletal and soft tissue defects. The average follow up period was 39 mo (range 27-56 mo). RESULTS: The infection was eradicated in all cases. All the soft tissue defects healed during bone transport and plastic surgery was only required in 2 cases. Skeletal defects were treated in all cases. All patients required another surgery at the docking site to fashion the soft tissue and to cover the bone ends. The external fixation time ranged from 9 to 17 mo with an average of 13 mo. The complications included pin tract infection in 16 cases, wire breakage in 2 cases, unstable scar in 4 cases and chronic edema in 3 cases. According to the association for study and application of methods of Ilizarov score the bone results were excellent in 10, good in 16 and fair in 2 cases while the functional results were excellent in 8, good in 17 and fair in 3 cases. CONCLUSION: Distraction osteogenesis is a good method that can treat the three problems of this triad simultaneously.

Ilizarov bone transport versus fibular graft for reconstruction of tibial bone defects in children.

The aim of this study was to compare the results of treatment of segmental tibial defects in the pediatric age group using an Ilizarov external fixator versus a nonvascularized fibular bone graft. This study included 24 patients (age range from 5.5 to 15 years) with tibial bone defects: 13 patients were treated with bone transport (BT) and 11 patients were treated with a nonvascularized fibular graft (FG). The outcome parameters were bone results (union, deformity, infection, leg-length discrepancy) and functional results: external fixation index and external fixation time. In group A (BT), one patient developed refracture at the regenerate site, whereas, in group B (FG), after removal of the external fixator, one of the FGs developed a stress fracture. The external fixator time in group A was 10.7 months (range 8-14.5) versus 7.8 months (range 4-11.5 months) in group B (FG). In group A (BT), one patient had a limb-length discrepancy (LLD), whereas, in group B (FG), three patients had LLD. The functional and bone results of the Ilizarov BT technique were excellent in 23.1 and 30.8%, good in 38.5 and 46.2, fair in 30.8 and 15.4, and poor in 7.6 and 7.6%, respectively. The poor functional result was related to the poor bone result because of prolonged external fixator time resulting in significant pain, limited ankle motion, whereas the functional and bone results of fibular grafting were excellent in 9.1 and 18.2%, good in 63.6 and 45.5%, fair in 18.2 and 27.2%, and poor in 9.1 and 9.1%, respectively. Segmental tibial defects can be effectively treated with both methods. The FG method provides satisfactory results, with early removal of the external fixator. However, it had a limitation in patients with severe infection and those with LLD. Also, it requires a long duration of limb bracing until adequate hypertrophy of the graft. The Ilizarov method has the advantages of early weight bearing, treatment of postinfection bone defect in a one-stage surgery, and the possibility to treat the associated LLD. However, it has a long external fixation time.

Hemi-wedge osteotomy in the management of large angular deformities around the knee joint.

BACKGROUND: Angular deformity around the knee joint is a common orthopedic problem. Many options are available for the management of such problem with varying degrees of success and failure. The aim of the present study was to assess the results of hemi-wedge osteotomy in the management of big angular deformities about the knee joint. MATERIALS AND METHODS: Twenty-eight limbs in 21 patients with large angular deformities around the knee joint were treated by the hemi-wedge osteotomy technique. The ages ranged from 12 to 43 years with an average of 19.8 years. The deformity ranged from 20° to 40° with a mean of 30.39° ± 5.99°. The deformities were genu varum in 12 cases and genu valgum in 9 cases. Seven cases had bilateral deformities. Small wedge was removed from the convex side of the bone and put in the gap created in the other side after correction of the deformity. RESULTS: At the final follow-up, the deformity was corrected in all cases except two. Full range of knee movement was regained in all cases. The complications included superficial wound infection in two cases, overcorrection in one case, pain along the lateral aspect of the knee in one case and recurrence of the deformity in one case. No cases were complicated by nerve injury or vascular injury. CONCLUSION: Hemi-wedge osteotomy is a good method for treatment of deformities around the knee joint. It can correct large angular deformities without major complications.

Comminuted long bone fractures in children. Could combined fixation improve the results?

Comminuted diaphyseal fractures in the pediatric age group represent a major orthopedic problem. It is associated with a high incidence of complications and poor outcomes because of the instability and difficulty in treatment. The aim of this study was to evaluate the efficacy of combined external skeletal fixation and flexible intramedullary nails in reconstruction of comminuted diaphyseal fracture in skeletally immature patients. Combined external fixator and elastic stable intramedullary nails were used in the management of 27 pediatric patients (15 males and 12 females) with unstable comminuted diaphyseal fractures of the tibia and femur. There were 19 fractures of the femur and eight fractures of the tibia. The average age of the patients was 8.7 years (range 7-14 years) for the femur and 10.8 years (range 6-15 years) for the tibia. Fractures were classified according to the system of Winquist and Hansen as grade II (five cases), grade III (nine cases), and grade IV (13 cases). All cases were operated within 6 days (range 0-6 days) after injury. The mean follow-up period was 2.8 years (range 2-3.5 years). The average duration of the external fixation was 1.6 months for fractures of the tibia, whereas it was 1.4 months for fractures of the femur. The average time for tibia fracture union was 2.8 months for fractures of the tibia, whereas it was 1.9 months for fractures of the femur. Malalignment in varus less than 5° was noted in one patient. One patient had a limb-length discrepancy of 1.5 cms. There were five cases (18.5%) with pin-tract infection. According to the Association for the Study and Application of the Methods of Ilizarov evaluation system, bone results were excellent in 23 cases (85.2%), good in three cases (11.1%), and poor in one case (3.7%). Functional results were excellent in 22 (81.5%) cases and good in five (18.5%) cases. Combined use of external fixators and elastic intramedullary nails is a good method for the treatment of comminuted long bone fractures in children.

Hybrid External Fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C Tibial Plafond Fractures.

Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence.

Management of segmental skeletal defects by the induced membrane technique.

BACKGROUND: Surgical reconstruction of segmental skeletal defects represents a true challenge for the orthopedic surgeons. Recently, Masquelet et al. described a two-stage technique for reconstruction of bone defects, known as the induced membrane technique. The aim of this study is to assess the results of the induced membrane technique in the management of segmental skeletal defects resulting from debridement of bone infection. MATERIALS AND METHODS: Seventeen patients with segmental skeletal defects were treated in our institution by the induced membrane technique. The average age of the patients was 43 years (range 26- 58 years). The causes of the defects were infected gap nonunion in 12 cases and debridement of osteomyelitis in 5 cases. The defects were located in the tibia (n = 13) and the femur (n = 4). The mean defect was 7 cm (range 4 cm - 11 cm). All cases were treated by the induced membrane technique in two-stages. RESULTS: Bone union happened in 14 patients. The limb length discrepancy did not exceed 2.5 cm in the healed cases. The mean time of healing was 10 months (range 6-19 months). The complications included nonunion of the graft in five cases, failure of graft maturation in two cases, reactivation of infection in two cases and refracture after removal of the frame in one case. These complications were managed during the course of treatment and they did not affect the final outcome in all patients except three. CONCLUSION: The induced membrane technique is a valid option for the management of segmental skeletal defects. It is a simple and straight forward procedure, but the time required for growth and maturation of the graft is relatively long.

Can platelet-rich plasma shorten the consolidation phase of distraction osteogenesis? An experimental study.

PURPOSE: The purpose of this study was to evaluate the effects of platelet-rich plasma (PRP) on distraction osteogenesis. MATERIALS AND METHODS: Tibias of 36 New Zealand white rabbits were distracted at a rate of 0.25 mm/8 h for 20 days with a circular external fixator. The animals were randomly divided into a control group that did not receive PRP therapy and an experimental group, with PRP injection into the distracted area. Radiographic examinations were performed at the 10th, 20th, 30th, 40th and 50th days after end of distraction. By the 50th day after distraction, all animals were sacrificed, the external fixator was removed and the tibia was dissected. After that, each group was subdivided into two subgroups: one for pathological study and another one for mechanical study. RESULTS: Radiologic scores were statistically similar at the 10th, 20th and 30th days. However, the experimental group demonstrated higher radiologic scores at the 40th and 50th days. Histopathologic examination revealed a statistically significant higher score in the experimental group. The PRP injected group showed an improvement of their mechanical properties. CONCLUSION: The results of this study show that PRP has beneficial effects on new bone formation during distraction osteogenesis.

Musculoskeletal congenital malformations: do paternal occupational exposures play a role?

BACKGROUND: Paternal occupational exposures to potential health hazards are likely to affect congenital malformations through the spermatogenesis cycle. PURPOSE: The aim of this case-control study was to assess the relationship between the risk of musculoskeletal congenital malformations in offspring and paternal workplace exposure to potential health hazards during the preconception period. METHOD: The study comprised 105 patients (cases) with a musculoskeletal congenital malformation(s) and 135 controls matched for age and demographic characteristics. Both parents of each case and control were interviewed in the hospital by a trained physician. They also completed a questionnaire focusing on the preconception period and on the 3-month period immediately before and after the pregnancy conception date, respectively, of the child under study. RESULTS: The odds of having a child with a congenital malformation was higher (P < 0.05) if the father was occupationally exposed to pesticides, solvents, or welding fumes during the preconception period. CONCLUSION: Control of workplace exposures and adherence to threshold limit values of these potential health hazards should be adopted to minimize the risk of fathers having offspring with a congenital malformation.

Is there a safe zone to avoid superficial radial nerve injury with Kirschner wire fixation in the treatment of distal radius? A cadaveric study.

AIM OF THE STUDY: To determine the relation of the superficial radial nerve to bony land-marks and to identify a safe zone for K-wire pinning in the distal radius. METHOD: The superficial radial nerve was dissected in sixteen upper extremities of preserved cadavers. RESULTS: We found that the superficial radial nerve emerged from under brachioradialis at a mean distance of 8.45 (±1.22) cm proximal to the radial styloid. The mean distance from the first major branching point of the superficial radial nerve to the radial styloid were 4.8 ± 0.4 cm. All branches of the superficial radial nerve were found to lie in the radial half of an isosceles triangle formed by the radial styloid, Lister's tubercle and the exit point of the superficial radial nerve. There is an elliptical area just proximal to the Lister's tubercle. This area is not crossed by any tendons or nerve. It is bounded by the extensor carpiradialis brevis, extensor pollicis longus. CONCLUSION: Pinning through the radial styloid is unsafe as the branches of the superficial radial nerve passé close to it. The ulnar half of the isosceles triangle is safe regarding the nerve. The elliptical zone just proximal to the Lister's tubercle is safe regarding the tendons and nerve.

Indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures.

The aim of the present study is to assess the results of indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures. The study included 28 patients with high-energy tibial plateau fractures (Schatzker type V and VI). The ages ranged from 22 to 58 years with an average of 35 years. The trauma was a road traffic accident in 16 cases and a fall from a height in 12 cases. Concomitant soft tissue injuries were present in 18 cases such as skin wounds in 6 cases, excessive swelling with skin blisters in 9 cases, and compartment syndrome in 3 cases. After clinical and radiological evaluation all the patients were treated by indirect reduction using a traction table and a hybrid external fixator. The average time to healing was 3.2 months. At the final follow-up the range of knee movement ranged from 0 degrees-140 degrees with an average of 110 degrees. The results were satisfactory in 23 cases and unsatisfactory in 5 cases according to the Rasmussen knee functional score. Complications included pin tract infection in 12 cases, an extension lag in 2 cases, varus deformity of about 15 degrees in one case, deep infection in one case and early osteoarthritic changes in 2 cases. Hybrid external fixation is a good method for treatment of comminuted tibial plateau fractures. It allows for early joint movement and reduces the risk of serious complications.

Results of the percutaneous pinning of proximal humerus fractures with a modified palm tree technique.

PURPOSE: Many techniques are available for closed reduction and percutaneous fixation of proximal humeral fractures. The palm tree technique was described by Kapandji in 1989. In that technique three curved wires are inserted through one hole at the V-shaped insertion of the deltoid muscle. It is a good technique but it has some disadvantages. In this study we introduced some modifications for the technique, and we evaluated the clinical results of the modified technique in treatment of 18 cases. METHODS: Eighteen patients with displaced proximal humeral fractures were treated by closed reduction and percutaneous fixation with the palm tree technique after minor modifications. The age of the patients ranged from 38 to 75 years with an average of 56 years. Eleven were females and seven were males. The fractures were two-part in 13 cases and three-part fractures in five cases. RESULTS: The average time of healing was seven weeks. The follow-up period ranged from 14 months to 39 months with an average of 22 months. The Constant score ranged from 45 to 88 with a mean of 73. The results were satisfactory in 77% and unsatisfactory in 23% of the cases. The complications included pin tract infection in two cases, intraarticular wire migration in one case, skin necrosis around the wires in three cases and malunion with varus deformity in one case. No cases were complicated by neurovascular injury, loss of fixation or avascular necrosis of the humeral head. CONCLUSIONS: The palm tree technique is a good method for fixation of proximal humeral fractures. It produces good grip in both of the proximal and distal fragments and allows for early joint movements. Our modifications allow for easy insertion of the wires, increase the stability of fixation and minimize the risk of complications.

Arthrodesis of the ankle joint by Ilizarov external fixator in patients with infection or poor bone stock.

BACKGROUND: Ankle arthrodesis is the most common surgical treatment for end stage ankle arthritis. Many surgical techniques have been described to achieve this purpose. The aim of the present study is to assess the results of the Ilizarov external fixator in performing ankle fusion in patients who have infection or poor bone stock at the region of the ankle joint. PATIENTS AND METHODS: Twelve patients with secondary ankle arthritis were treated by ankle arthrodesis using the Ilizarov external fixator. Eight were males and four were females. The age ranged from 23 to 56 with an average of 42.8 years. Active infection was present in 7 cases and the bone stock was deficient in 5 cases. Bone lengthening was done in 4 cases to equalize the limb length. RESULTS: Sound fusion was achieved in all the cases except one. Infection was controlled in all the infected cases. Ten cases could walk without support, one could walk with a cane and one case required an ankle foot orthosis. All patients were satisfied with their results except one. The complications had included pin tract infection in 9 cases, varus deformity of about 15 degrees in 1 case and fibrous ankylosis in 1 case. CONCLUSION: The Ilizarov technique is a good method for ankle fusion especially in presence of infection, bone defects or shortening.

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.