Lower Limb Deformities: Deformity Correction and Function Reconstruction 9811396035, 9789811396038

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Sihe Qin Jiancheng Zang Shaofeng Jiao Qi Pan  Editors

Lower Limb Deformities Deformity Correction and Function Reconstruction

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Lower Limb Deformities

Sihe Qin  •  Jiancheng Zang Shaofeng Jiao  •  Qi Pan Editors

Lower Limb Deformities Deformity Correction and Function Reconstruction

Editors Sihe Qin Rehabilitation Hospital of National Research Center for Rehabilitation Technical Aids Beijing China

Jiancheng Zang Rehabilitation Hospital of National Research Center for Rehabilitation Technical Aids Beijing China

Shaofeng Jiao Rehabilitation Hospital of National Research Center for Rehabilitation Technical Aids Beijing China

Qi Pan Rehabilitation Hospital of National Research Center for Rehabilitation Technical Aids Beijing China

ISBN 978-981-13-9603-8    ISBN 978-981-13-9604-5 (eBook) https://doi.org/10.1007/978-981-13-9604-5 © Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Dedicated to the patients who have been treated, your eyes for treatment and your smiles after treatment continually inspired me to work hard and move forward. Dedicated to the doctors and disabled people all over the world. Dedicated to my family and every member of my team.

Preface

This is an orthopedic surgery book that spans over 40 years and contains many notable reallife stories. It is unique in that this book originated from a Chinese primary level surgeon’s decade of solitary exploration which occurred over the same time as the country’s development. Like gathering sand into a tower, he has accumulated more than 35,000 clinical cases, in the process of which he created a unique medical model with Chinese characteristics that is different from Western treatment. He also created a dual-track treatment model focusing on simultaneous development of humanities and medical technology. His technological leap in orthopedics and academic sublimation was enhanced not only by Chinese cultural wisdom, but also from the innovative thinking of Dr. G.A. Ilizarov who was also a primary surgeon in the Russian border region. Nowadays, after years of hard work, Dr. Qin and his team has emerged from what was once a fairly lonely pursuit in the remote areas of China into a spotlight of worldwide recognition. Although their achievements have been highly regarded and affirmed by the academic community, they believe their exploration will continue, because they are born for orthopedic surgery.

First, the Origin of the Qin Sihe Orthopedic Surgery Forty years ago, in May 1978, the 27-year-old Qin Sihe performed two surgeries of equinovarus foot deformity correction for the first time in a small township hospital called Miaoshan Hospital in Shandong, China. Both surgeries achieved satisfactory results. This was the starting point for his journey into the surgical treatment path of polio sequela which he continued over the next 40 years. The first patient was a 17-year-old boy named Li Qiugang. He was suffering from severe equinovarus foot deformity caused by trauma during his childhood. After he was treated with surgery of Achilles tendon and posterior tibial tendon lengthening, and triple arthrodesis, his full foot could be placed in parallel. His foot’s morphological function was still very good in the ensuing 30 years after the surgery (Fig. 1). But unfortunately, Li Qiugang died of gastric cancer at the age of 51 (33 years after surgery). The second patient was a 7-year-old girl, Li Yonglan (Fig. 2), who developed poliomyelitis at the age of 1, resulting in a clubfoot with ankle valgus and muscle paralysis; she could only walk with her weight on the instep side before surgery. After Dr. Qin surgically treated her with Achilles tendon lengthening, posterior tibial muscle transposition, and the correction of Varus, she could finally walk with ordinary shoes. Forty years later, at age of 47, Li Yonglan’s walking function was still good (Fig. 3). Not only that, she married at the age of 20, gave birth to a son, and now has a grandson. From the perspective of traditional Chinese values, she has a happy family structure with children and grandchildren, all thanks to the surgery. During the 7 years at Miaoshan Rural Hospital (Figs.  4 and 5), Dr. Qin Sihe surgically treated more than 2000 polio patients with sequelae of lower limbs. However, it is clear that without the local government’s support, it would have been very difficult for him to make such achievements in such a small hospital (Figs. 6 and 7).

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Fig. 1  The photo was taken for Prof. Qin and his first patient Li Qiugang (left), who underwent surgery of ankle and foot deformity correction 30 years ago

Fig. 2  Seven-year-old patient with clubfoot secondary to polio sequela, she could walk normally 2 years after surgery

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Fig. 3  Her family photo 40 years after surgery Li Yonglan (left 1)

Figs. 4 and 5  Dr. Qin Sihe worked in Miaoshan hospital in 1982

Fig. 6  This photo was taken 36 years ago; a crawling child could walk on a single crutch

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Fig. 7  This photo was taken also 36 years ago; this man could walk independently postoperatively

At the beginning of work in Miaoshan hospital, Dr. Qin developed a good work habit. First, he designed a detailed orthopedic examination table for limb examination. And then he personally filled in the medical record of each patient, complete with photographs of all the preoperative limb malformations and postoperative follow-ups. Finally, these photos were regularly organized and archived. This archival action is crucial to the subsequent development of Chinese orthopedics. Thirty years later, with China fully entering the information age and the big data concept introduced into orthopedic surgery, these precious files have become the basis of the Qin Sihe Orthopedic Surgery Database (Figs. 8 and 9).

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Fig. 8  (1) In northwestern China, Du Huizhi, a 21-year-old polio patient, could only walk with the right lower limb and a cane before surgery. (2–3) She sent a photo to Dr. Qin 3 years after surgery. In the photo, she not only resumed standing and walking independently, but also learned to ride a bicycle. (4) Photo of Du and Qin 20 years after surgery. (5) Photo of Du and Qin 32 years after surgery

 econd, Dr. Qin Carried Out Excessive Surgery in the Cold Hei Long S Jiang Province Hei Long Jiang Province is the coldest region in China, with a high incidence of limb malformations such as polio sequelae and a severe lack of orthopedic surgeons. At the end of 1985, Qin Sihe was introduced as a specialist doctor to Hei Long Jiang to create the “Polio

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Fig. 9  The patients from Tibet were paid by Ministry of Civil Affairs

Treatment Center.” There he led the medical team to the frontier and poor areas to treat patients with physical disabilities (Fig. 10). At that time, since most hospitals there only had simple medical equipment, in order to meet the massive treatment needs of patients, the local government and hospitals tried their best to create conditions for him to complete a large number of fast, high-­quality operations. According to his records, he had performed an average of ten surgeries a day at that time, and sometimes more than 260 operations a month. With such an intense surgical schedule, Dr. Qin gradually developed his clinical insight and perfected his surgical skills for rapid examination, diagnosis, and surgical planning. While handling this enormous number of patients, he developed effective orthopedic procedures which ensured curative surgical results while avoiding surgical and post-­surgical

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Fig. 10  A large number of polio sequelae patients from remote rural areas were waiting for Qin in line for the examination and operation

infections. In summary it became an effective, comprehensive, efficient, and economic surgical process. During the 6.5 years of work in the far north region, more than 10,000 cases of lower limb deformities such as poliomyelitis and cerebral palsy were surgically treated, which led to the birth of the “Qin Sihe New Technical System for Surgical Treatment of Polio Sequelae.” This project was awarded the National Science and Technology Progress Award in 1992.

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 hird, Qin Sihe Entered Beijing to Set Up a Physical Disability T Correction Center At that time Beijing had a large number of patients with sequelae of polio requiring surgical treatment but lacked the specialists to perform surgery. At the end of 1992, the national program “Three Rehabilitations” (cataract rehabilitation, polio sequelae correction, and hearing training for deaf children) was vigorously implemented by the government. And so, it happened that Dr. Qin Sihe, who had accumulated rich experience in this field, was transferred to Beijing. Upon arriving he established an orthopedic surgery department in the newly built Guan Zhuang Hospital and set up the Beijing Disabled Correction Center for Polio. In this center, in addition to continually operating on a large number of patients, he was also commissioned by the government to hold a number of Polio Sequelae Surgical Treatment Training Courses and thereby trained many doctors from all parts of mainland China.

 ourth, Qin Sihe Took the Lead in Studying and Introduced the Ilizarov F Method from Russia to China With the expanding impact of Dr. Qin’s techniques for the treatment of lower limb disabilities, many patients with complicated limb deformities sought medical treatment from him. However, it was difficult for him to treat them with his surgical concept at that time, even after researching the classic orthopedics books like Campbell’s Operative Orthopedics. So, in 1988, Dr. Qin began to study the Russian Ilizarov technology, and in 1989, he invited Russian Ilizarov technical experts to give a lecture and surgical practice demonstration in Harbin, China. In July 1992, Dr. Qin went to Russia to sign an orthopedic cooperation agreement. After 1995, he established a three-person cooperation alliance with Dr. Xia Hetao from Beijing and Dr. Li Gang, who was working in the UK, to implement, develop, and localize the Ilizarov technology in China (Fig.  11). By December

Fig. 11  Qin Sihe cooperated with Li Gang (left 1) and Xia Hetao (middle) to complete the application and development of Ilizarov technology in China

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2017, Dr. Qin’s orthopedic team had used the Ilizarov technology to treat 8113 cases of complex limb deformities and saved more than 100 patients with severe deformities from amputation.

 ifth, Qin Sihe Has Created a Convenient and Efficient “Individualized F Diagnosis and Technical Route” In the past 40 years, Dr. Qin completed operations mostly in primary and intermediate hospitals where there was usually no advanced medical equipment available. The level of hospitals in mainland China are divided into three levels: primary hospitals are basic level hospitals; county district hospitals are secondary hospitals; metropolitan hospitals and university affiliated hospitals are the most superior hospitals with the best equipment. Even though he is often invited to go to high-tier hospitals to carry out difficult and complicated operations, he rarely relies on high technology equipment to perform complex tests on patients. Instead he relies more on careful bedside observation, detailed inquiry, and deep communication so that he understands the patient’s complete medical history. Then he diagnoses the type of disease and determines the surgical and rehabilitation process based on the comprehensive and systematic physical examination and basic imaging technology. Through this closer connection with the patients, Dr. Qin is able to gain a better understanding of their physical and psychological condition and on the basis of this he creates a “happy orthopedic surgical ward” featuring individualized diagnosis technical route and humanistic care. Moreover, it is precisely because of the introduction of this adaptable diagnosis technical route and humanistic care, Dr. Qin’s team does not have to depend on the high-tech equipment diagnosis. They are able to treat many difficult orthopedic diseases with less medical costs while offering more individualized and efficient diagnosis and surgical options. This was even hard to achieve in upper-scale hospitals with expensive high-tech equipment. During his operation, he used less G-arm X-ray machine for detection, and rarely used electric knife, saw, and other tools, which greatly shortened the operation time. Another innovation was Dr. Qin’s method of treating the dressing for the postoperative wound. It applied the medical principle of Chinese traditional dog skin plasters that uniformly compress and promote blood circulation to accelerate wound repair. This application showed remarkable curative effect in orthopedic treatment. At the same time, the incidence of surgical complications and sequelae was also reduced to the lowest level. According to statistics, from 2000 to present, there have been more than 10,000 surgeries performed by the team without any bone infection, and the infection rate of surgical incision is less than 1/1000 (Fig. 12). The continuous improvement of Qin Sihe’s unique orthopedic surgery treatment methods and technical system attracted increasing attention from other doctors. Since 2008, some outstanding young doctors gathered around Dr. Qin and formed a team with senior-level and intermediate-level doctors complementing each other, including four young and middle-aged experts who are also the editors of this book.

Sixth, the Establishment of Case Database for Orthopedic Surgery Dr. Qin has been collecting case data since the beginning of his work in 1978. For each orthopedic surgery, he would fill out a corresponding self-designed case examination form by himself with specific information such as the age, causes, type of deformity, degree of paralysis disability, and operation method, and then take preoperative and postoperative photos. He would regularly organize and archive these patient records with the result being that today, 40 years later, he has an archive of 34,459 patient records. This data on limb deformity operations assembled by an individual doctor is considered to be unprecedented from a perspective of quantity, form and detailed description across all aspects of technology, psychology, quality of life, social support, etc.

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Fig. 12  Database in Qinsihe Orthopedic Institute

Over the past 40 years, spending time with patient’s day by day, Dr. Qin’s data collection started with black and white film photographs and simple case forms to digital photography and specialized examination forms. Qin Sihe has assembled a valuable database based on his own accumulation and good working habits. He intends to use the next 5 years to digitize and matrix all the medical records, and to form a three-dimensional database including both technical elements and humanistic information. Moreover, these actual case histories are the best narrative of the development of Qin Sihe orthopedic surgery methods. Over the past 40 years, China has experienced ever-changing social development and scientific progress. Similarly, Dr. Qin’s database truly and comprehensively presents the traditional Chinese orthopedic techniques at the beginning of Reform and Opening up, and also reflects the process of localization of Ilizarov technology since the 1990s, witnessing the birth of the “lower limb orthopedic surgery road with Chinese characteristics.”

 eventh, Qin Sihe Became Acquainted with Western S Orthopedics Circles In the first 20 years of his career, Dr. Qin devoted himself to learning and clinical practice, so that he could develop a surgical model that could correct the limb deformities, improve limb function, terminate disability, and improve the patient’s quality of life so as to cure them both physically and mentally. Therefore, he did not study for a master’s degree at that time. Except for Western academic materials he came across while researching and reading, he did not have the opportunity to interface with Western orthopedics. However, that changed in the next 20 years. In the fall of 2000, Dr. David P. Roye, Chief of Pediatric department Children's Hospital of New  York, Columbia University, United States, went to Harbin in northeast China to

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Fig. 13  Prof. David Roye right 2 and Dr. Qin Sihe were performing surgery

perform surgery on children with physical disabilities. During the 1 week they spent together in China, Dr. Qin and Dr. Roye appreciated and learned from each other (Fig. 13). Professor Roye gave high comments on Dr. Qin’s surgery technique and suggested that he publish his new methods of polio sequelae surgery in English. So in 2006, Qin Sihe published a book on the surgical treatment of polio sequelae, for which Professor Roye wrote the preface. In April 2012, Dr. Qin hosted the first international conference on External Fixation and Bone Reconstruction in Beijing and served as the President of ASAMI China (Association of Study and Application of the Method of Ilizarov, ASAMI). Professor Nuno Craveiro Lopes from Portugal attended the meeting (Fig.  14), visited the orthopedic department, and performed a surgery with Dr. Qin. Dr. Lopes was surprised to find that there were many hidden mysteries of surgical treatment for limb deformity unknown to the Western world. So he ­suggested that Dr. Qin translate his Chinese works into English as soon as possible to let the Western world know about Qin Sihe orthopedic surgery. In 2012, on the recommendation of Professor Lopes, Dr. Qin led his team to Brazil to attend the newly established international limb extension and reconstruction (ILLRS) conference and signed to join ILLRS officially on behalf of China. Since then, the orthopedic surgery of Qin Sihe has received the attention of many countries. Since 2015, the ASAMI society of India and the Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics of the Kurgan province in Russia have sent eight senior physicians to Beijing for further study. They also expressed the hope that there would be an English textbook which could embody Dr. Qin’s thoughts on orthopedic surgery. Subsequently, many internationally renowned orthopedic specialists, such as Dror Paley (US), Maurizio A.  Catagni (Italy), Durai Nayagam (UK), A.  Gubin (Russia), Hae-Ryong Song (Korea), M.M. Bari (Bangladesh), Gamal Hosny (Egypt) and Hariram Jhunjhunwala (India), sincerely recommended that Dr. Qin publish the English version of the work. Based on the encouragement and expectations of so many international experts and peers, the renowned Springer-Verlag Publishing Group reached out to Dr. Qin and signed up to publish the book.

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Fig. 14  (1) Prof. Nuno Lopes (left) was appointing Dr. Qin as the president of ILLRS China. (2) Prof. Nuno Lopes (left 4) with Dr. Qin and his team in operation theater. (3) In the preface of Chinese monograph, Prof. Nuno Lopes hope that Qin would publish an English monograph as soon as possible

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Fig. 14 (continued)

Eighth, the Important Time Nodes In 1978, Qin Sihe surgically cured the first patient with ankle deformity. In 1998, Dr. Qin edited and published a Chinese edition of the book Lower Limb Deformity Surgery, which is a classic work in Chinese orthopedic surgery. Since then, Dr. Qin and his orthopedic team have published nine books such as Surgical Treatment of Polio Sequelae, Pediatric Orthopedic Surgery, Surgical Treatment of Cerebral Palsy, External Fixation and Ankle Reconstruction, Fracture & External Fixation. In 2018, on the occasion of the 40th anniversary of Dr. Qin’s orthopedic surgery, the 10th book, the English edition of Lower Limb Deformity, Deformity Correction and Functional Reconstruction was completed. This book is coming out as a result of globalization because the development of China and its improvement in medical practices. In this book, Dr. Qin summarizes his experiences of over 35,000 surgeries over 40 years and in effect gives his readers a seat in a time machine to see and understand the evolution of this branch of medicine from its early stage prototypes to the comprehensive and sophisticated practice it has become today.

Ninth, Dr. Qin Sihe’s Gift to the World Orthopedics Academia This book provides a unique perspective to the world about how to consider the insights of doctors raised in a Chinese traditional culture and reality; how to accomplish the transformation of Ilizarov technology in China; and finally how to sublimate orthopedic surgery with

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natural philosophy. This book introduces the natural philosophy concepts of space and time, evolution, growth, environment, and regulation into the clinical treatment process in orthopedics. New terms such as “orthopedics natural reconstruction concept,” “28 words policy,” “evolution orthopedics,” “regeneration reconstruction,” and “body information interpretation” were proposed, and the principles of lower limb orthopedics treatment were summarized as “1 walk, 2 lines, and 3 balance.” In general, in this book Dr. Qin shows how he established the Chinese way of orthopedic surgery industry in terms of culture, language expression, academic guidance, and clinical path with Chinese characteristics, and then successfully put them into practice. For the global readers, the content and technical system shown in this book have a distinct meaning. This is a Chinese medical team which works different from a Western model. The team’s work is based on a wide variety of disability diseases prevalent in China which have no order and are massive in scale. The team views the patients as their teachers and learns the wisdom accumulated from Chinese history, art, and culture. The team does not follow hard rules, but rather innovates new ideas. In doing this they have created a brand new world for physical disability correction and rehabilitation. Those who want to experience the inner workings of Qin Sihe’s orthopedic surgery are welcome to come to China to observe the operation. This book clarifies the origin, formation, and development of lower limb orthopedic surgery in China over the past 40 years, the causes of limb deformities, the classification of diseases, and the characteristics of disease spectrum. At the same time, the book also explains the differences between the mental and technical system of Qin shine’s lower limb orthopedic practice and why it is different from the Western system. Dr. Qin has performed the most polio sequelae surgeries in the world. He is also one of the doctors who has performed the most operations for rare bone disease and severe limb disability using Ilizarov technology. During his medical journey, the destiny of tens of thousands of patients with physical disabilities was changed, as was the thinking of Dr. Qin and the many doctors who worked with him. Just as patients create doctors, in this case China’s own situation 40 years ago and its development since then have worked to create Dr. Qin’s orthopedic practice—the surgical rehabilitation mode of neurogenic limbs deformity, and the technical system of dynamic balance and functional reconstruction of lower limbs. As 2018 marks the 40th anniversary of China’s reform and opening-up, we have to admit that if without the trend of reform and opening-up, there would be no Qin Sihe orthopedic surgery, nor the birth of this book. Therefore, with the publication of this book, Dr. Qin would like to pay tribute to our great motherland, to the countless friends who once supported Qin Sihe orthopedic surgery, to the patients and their families who have promoted this discipline, and to the doctors who dedicated to this subject with their hope, passion, and gratitude over the past 40 years. As is known to all, the sixth World Ortho Reconstruction Congress (ILLRS-­ ASAMI-­BR) will be held in Beijing in September 2023. As the executive chairman of this congress, Dr. Qin Sihe will dedicate his first English book to all the friends in the world orthopedics academia.

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Beijing, China Oct. 2018

Best Regards Sihe Qin

Informative Abstract

Comprehensive and generously illustrated, the highlights of this book are all of the cases described using 182,088 words and 2656 living and nice pictures, not only classic and mild cases but severe cases treated by Prof. Qin Sihe, Head of Orthopedics Department, which is the biggest center for deformity correction and function reconstruction in China. Based on the lower limb deformities which is a common condition in China, this book is divided into 18 chapters, though any chapter can stand on it is own to guide the surgeon in specific situations. From congenital deformities to acquired deformities, the sequela of poliomyelitis, cerebral palsy, spina bifida sequela, Charcot-Marie-Tooth disease, osteogenesis imperfecta, congenital pseudarthrosis tibia, etc., more than 100 kinds of diseases are covered in this book. The diagnosis and treatment described in this book are based on Ilizarov technique, Paley’s principle, and Qin Sihe Natural Reconstruction theory. There are many clinical tips and tricks such as how to reduce X-ray during orthopedic operation, how to correct multiple deformities in one stage, how to balance the dynamic muscle in complex foot and ankle deformities, how to accomplish complex lower limb reconstruction surgery under no allogeneic blood transfusion, and so on. Ingenious application of Ilizarov external fixator, hybrid fixator or orthoses, and internal fixation with plate or intramedullary nail in the processes of treatment has been discussed. The decision-making of clinical practice according to Chinese culture and traditional wisdom is highlighted. It will be an invaluable resource for deformity correction and limb reconstruction surgeons and advanced trainees worldwide.

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Disclosure

The new surgical methods and treatment protocols involved in this book were approved by Ethics Committee of NRRA. As the clinical appearance and intraoperative pictures of patients are listed in this book, we have obtained the informed consent of the patients themselves and their families or their guardians.

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Acknowledgment

I acknowledge the contribution of many colleagues. I would like to express my sincere thanks to all those who have lent me hands in the process of writing this book. I recognize my good friends, Maurizio A. Catagni, Nuno Craveiro Lopes, JC Bongiovanni, Dror Paley, M.M. Bari, etc., who continually encouraged me to prepare a book on deformity in English. I am indebted to my secretaries, Yufang Liu, Yuxin Liu, and Dan Li, who have prepared many useful materials for data collection. Also, I am grateful for the enormous contribution from the professors and doctors who are in other hospitals and overseas (names attached in alphabetical order) in translation of language and revision of words. Without their help, it would be impossible for me to finish these chapters. Alexander Gubin Russian Ilizarov Scientific Center, Kurgan, Russia Ashiwani Ummat M.M Institute, Mullana Ambala, India Caicai Wang Chinese People’s University, Beijing, China Donghoon Lee  Donghoon Advanced Lengthening Reconstruction Institute, Seoul, Korea Gang Li Chinese University of Hong Kong, Sha Tin, Hong Kong Jianchao Gui Nanjing Medical University, Nanjing, Jiangsu, China Kai Zhang Binzhou Medical College, Binzhou, Shandong, China Kevin Tetsworth Royal Brisbane Hospital, Brisbane, Australia Lei Sun Orthopedic Journal of China, Taian, Shandong, China Ming Liu Shanghai Ninth People’s Hospital, Shanghai, China Mofakhkharul Bari Bari-Ilizarov Orthopaedic Centre, Dhaka, Bangladesh Qianyu Zhuang Peking Union Medical College Hospital, Beijing, China Ritesh Arvind Pandey CMC Hospital, Ludhiana, India Satish Shankar Nesari Shri Rajanna Hosamani Orthopaedic & Ilizarov Center, Belgaum, India Suheal A Khan MiST Foundation, Manchester, UK Wei Qin Qinsihe Orthopedics Institute, Beijing, China Xu Wang Huashan Hospital, Fudan University, Shanghai, China Yonghong Zhang Second hospital Shanxi Medical University, Taiyuan, Shanxi, China Yueju Liu Third Hospital of Hebei Medical University, Hebei, China Zhiyu Wang Department of Orthopaedics, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China

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Contents

1 Introduction�����������������������������������������������������������������������������������������������������������������   1 Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Xulei Qin, and Qi Pan 2 The Database of 34,459 Cases �����������������������������������������������������������������������������������  45 Sihe Qin, Yilan Wang, Jiancheng Zang, Quan Wang, Baofeng Guo, Qi Pan, Li Zhang, and Shaofeng Jiao 3 Application of the Ilizarov Technique�����������������������������������������������������������������������  67 Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Qi Pan, Lei Shi, and Yueliang Zhu 4 Application of Chinese Hybrid External Fixator����������������������������������������������������� 111 Jiancheng Zang, Sihe Qin, and Qi Pan 5 Lower Limb Deformities in Poliomyelitis Sequelae������������������������������������������������� 145 Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Qi Pan, Baofeng Guo, Xulei Qin, Yilan Wang, Lei Shi, Quan Wang, Li Zhang, and Xuejian Zheng 6 Lower Limb Deformities in Cerebral Palsy������������������������������������������������������������� 223 Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Qi Pan, Lei Shi, Baofeng Guo, and Li Zhang 7 Complex Deformity Correction and Functional Reconstruction of Lower Limbs����������������������������������������������������������������������������������������������������������� 263 Jiancheng Zang, Sihe Qin, Gang Li, Shaofeng Jiao, and Qi Pan 8 Clinical Data of Congenital Fibular Hemimelia and Tibia Hemimelia����������������� 299 Sihe Qin, Jiancheng Zang, Xulei Qin, Shaofeng Jiao, Lei Shi, and Qi Pan 9 Lower Limb Deformity Caused by Hereditary and Metabolic Diseases��������������� 383 Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Quan Wang, Xulei Qin, Qi Pan, and Lei Shi 10 Traumatic Sequelae of Lower Limb������������������������������������������������������������������������� 433 Sihe Qin, Jiancheng Zang, Yilan Wang, Shaofeng Jiao, Xulei Qin, and Qi Pan 11 Lower Limb Deformity Caused by Spina Bifida Sequelae and Tethered Cord Syndrome����������������������������������������������������������������������������������������������������������� 471 Jiancheng Zang, Sihe Qin, and Lei Shi 12 Lower Limb Deformities Caused by Immunological Diseases and Viral Infectious Diseases������������������������������������������������������������������������������������� 495 Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Lei Shi, and Xulei Qin 13 Nonunion, Bone Defects and Osteomyelitis ������������������������������������������������������������� 515 Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Yilan Wang, Yilian Han, Qi Pan, Xuejian Zheng, Wei Wang, Yueju Liu, and Quan Wang

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14 Genu Varum, Genu Valgum, and Osteoarthritis of Knee��������������������������������������� 571 Sihe Qin, Xuejian Zheng, Shaofeng Jiao, Yilan Wang, Jiancheng Zang, Qi Pan, Xulei Qin, and Li Zhang 15 Lower Limb Deformities Caused by Hemangiomas and Vascular Disorders����������������������������������������������������������������������������������������������� 625 Sihe Qin, Dingwei Zhang, Jiancheng Zang, Shaofeng Jiao, Qi Pan, Baofeng Guo, and Yilan Wang 16 Lower Limb Deformity Caused by Tumor and Tumor-Like Disease��������������������� 645 Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Xuejian Zheng, Qi Pan, and Baofeng Guo 17 Lower Limb Deformities Caused by Iatrogenic Factors and Social Reasons������� 665 Lei Shi, Sihe Qin, Yilan Wang, Jiancheng Zang, Shaofeng Jiao, Li Zhang, Xulei Qin, Qi Pan, Quan Wang, and Baofeng Guo 18 Limb Length Discrepancy ����������������������������������������������������������������������������������������� 691 Sihe Qin, Jiancheng Zang, Yilan Wang, Shaofeng Jiao, Xulei Qin, Xuejian Zheng, Hetao Xia, Aimin Peng, Qi Pan, and Baofeng Guo

Contents

1

Introduction Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Xulei Qin, and Qi Pan

1.1

Limb Deformity and Dysfunction

1.1.2 C  urrent Situation of Orthopedic Surgery in China

Sihe Qin and Jiancheng Zang

1.1.1 G  eneral Situation of People with Limb Dysfunction in China In 2010, it was reported, in China’s sixth population census and the third sample survey of disabled people, there were 85.02 million people with disabilities in China, including 24.72 million with limb disabilities and 13.86 million with multi-disabilities, most of with combined limb dysfunction, which means the limb deformity and dysfunction patients constituted more than 1/3 of the population. With the aging of population, physical disability, especially in the lower limbs, has risen markedly. For example, the most sequelae left by cerebrovascular accidents (strokes) are varying degrees of hemiplegia. Spinal stenosis, osteoporosis, and knee osteoarthritis affect lower limb dysfunction. Lumbar spine fissure (congenital meningococcal bulging), residual limb sensation, dyskinesia, with varying degrees of dysfunction. Cerebral palsy limb dysfunction is accompanied with language or intellectual disability. After the treatment of traumatic fractures and sports injuries, the most sequelae left are still lower limb deformities and dyskinesias, suggesting the development of lower limb orthopedics and functional reconstruction surgery in mainland China. System engineering including social medicine, rehabilitation, assistive devices (orthotics), etc. The prospects are broad and there is a long way to go.

1. Millions of people with sequelae of poliomyelitis In the past 20 years, orthopedic surgeons in China studied mainly from western countries. They don’t have enough experience in the examination and treatment of poliomyelitis. This group of patients has been rushed to Qinsihe orthopedic department, that is why 23,310 cases of poliomyelitis patients included in Qinsihe Orthopedics Institute. 2. Uneven economical and medical development between different areas In the past 30 years, along with the rapid development of economic in China, large amount of resources was shifted to big cities, including medical resources. But most of the disabled people lived in the remote and poor area. They rarely have opportunities to get early diagnosis and effective treatment. 3. Problem of the branches in Chinese orthopedic surgery Due to the significant individualization of orthopedic and limb reconstruction surgery, we don’t have a special branch in Chinese medical system or Chinese medical association for it. So, we are lacking of surgeons who are good at limb reconstruction surgery. 4. Improper application of internal fixator Because of the different life and dietary habit, body of the Chinese people is different from people from western country. Most of the external fixators from big company are designed for people from western country, some of which are not that good for Chinese people. Abusing of them leads to many problems, nonunion, infection, etc.

S. Qin (*) · J. Zang · S. Jiao · X. Qin · Q. Pan Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China © Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_1

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5. Chinese people with severe lower limbs deformities are reluctant to take amputation Sometimes, for some severe limb deformities, amputation and prosthesis can help patient get function rapidly and may be the best choice for them. 6. Why Western orthopedic principles are not proper for the treatment of complicated limb deformity in China Chinese culture determines that patients with severe limb deformities and their families are unwilling to undergo amputation, and keep on seeking method which can save their limb and improve function. Improvement of clinical technique and thinking method in Qinsihe orthopedic department is in great need for this group of patients. Patients form doctors. For some very complex deformities, even in “Campbell orthopedic surgery,” it is difficult to find reliable treatment strategies and surgical methods. That is why Qin Sihe believes that the differences between western and Chinese patients including the body, culture, economic, demand, etc. are the reason why Chinese doctors should be more experienced in treatment of complex limb defect and deformity. Ilizarov technology has advantages in treating severe and complex bone and joint deformities, but its weakness is in treating dynamic dysfunction and soft tissue caused deformities, which requires the monolithic clinical thinking mode and skillful surgical techniques. This is the advantage of the Qinsihe orthopedic surgery. For the deformities secondary to soft tissue contracture and dynamic imbalance, combination of Qinsihe’s orthopedic strategy and surgical method and Ilizarov technology should be a very good choice.

Fig. 1.1  The evolution process of Qinsihe lower limb orthopedic technical system

Surgical experiences of 30000 cases

1.1.3 T  he Origin, Formation, and Development of Qinsihe Orthopedic Dr. Qin Sihe’s experience is similar with prof. G.A. Ilizarov. When he was a teenager, he suffered from serious illnesses twice and had undergone four surgeries. This experience made him the decision of being a good doctor. After graduating from medical school, he worked in a small hospital for more than 20 years. In 1993, when he came to Beijing first time, he worked in one of the smallest hospitals again in the eastern suburbs. He did not have the experience of study abroad in western countries. His teacher is his patients. Forty years unremitting effort on clinical practice, thinking, exploring make him a good habit of summarizing. Over 30,000 orthopedic surgeries gave him the clinical wisdom, surgical skills, and leadership ability. The pressure from the demand of patients with complex limb deformities forced Qin Sihe going to Russia to study Ilizarov technology and bring it back China. Then, he cooperated with Prof. Xia Hetao, who has a background of engineering, and Professor Li Gang, the professor of Chinese University of Hong Kong who is engaged in basic research on orthopedics, forming the Ilizarov method with Chinese characteristic. Inspired by Darwin’s evolution theory and the philosophy of Lao-Tzu, Qin Sihe proposed the concept of natural reconstruction of the limb and formed a surgical system for correction of lower limb deformity with Qin Sihe’s characteristics. It has good surgical indication, less injury, nice outcome, and lower risk. Chinese culture, philosophy, patients, and the special timing prosper the special orthopedic surgery of Qin Sihe (Fig. 1.1).

Ilizarov technology

Paley’s principle of Deformity Correction

Darwin’s evolution theory

Knowledge and technology integration in different disciplines

Characteristics of Chinese culture and physically handicap Qin’s guide line of clinical practice Natural Reconstruction Theory Expectation of limb deformity Happy orthopedics, Ecological & Medical ward

The technical system of lower limb deformity correction and functional reconstruction with Chinese characteristics

1 Introduction

1.2

3

Basic Surgical Technique

Finding out the contracture of fascia, tendon and muscle and releasing them to correct the joint flexion deformity and stiffness is basic skill for orthopedic surgeons [1]. When releasing the soft tissue, the important blood vessels and nerves around should be protected carefully and the deformity should not be overcorrected in order to avoid the injury of skin, vessels, and nerves caused by overstretch. Ilizarov method is a good choice to correct severe contracture deformity [2]. Graduate distraction is much safer than acute correction, which can improve the therapeutic effect and decrease the incidence rate of complications.

fusion and subtalar joint fusion, is performed to correct the deformity on joint and reconstruct the stability of joint. If there are more than one deformity sites, all osteotomies are generally performed on all the deformity sites in single stage (Fig. 1.2). Sometimes, it is necessary to open the capsule when doing periarticular deformity. Osteotome is the most commonly used tool for osteotomy in the Qinsihe orthopedic department. A sharp osteotome can effectively decrease the burn injury on bone, which is good for bone healing of osteotomy site. Continuous drilling is often performed for osteotomy on the long bone shaft. Fixation method after osteotomy: External fixation is usually for tibia and foot and ankle osteotomy, which is simple, minimally invasive, adjustable, and is good for the bone healing. Children’s tibial osteotomy can be fixed by external fixator or plaster. Femoral osteotomy is fixed by plate plus external fixator or brace. Thus, the incision is small, trauma will be less, the stress shielding is avoided maximally, and the bone healing is fast.

1.2.2 Bony Osteotomy

1.2.3 Tendon Transfer

Osteotomy is divided to bone shaft osteotomy and periarticular osteotomy [3] based on the site. Bone shaft osteotomy is performed to correct the long bone deformity, like valgus, varus, rotation, and so on. Periarticular osteotomy, like triple

Dynamic imbalance [4] exists in almost all the lower extremity deformities secondary to neurogenic diseases. If missed the early treatment, joint contracture and skeletal deformity may occur. Tendon or muscle transposition is an important

Sihe Qin, Jiancheng Zang, Shaofeng Jiao, and Xulei Qin

1.2.1 Soft Tissue Release

Fig. 1.2 Multiple osteotomies in one stage. (a) Deformities on bilateral femur and tibia; (b) Corrected by osteotomy on different sites

a

b

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method to prevent or correct deformity and reconstruct limb function. Purpose of the surgery is to transfer the force, which is not that important or even may lead to deformity, to take the place of the palsy muscle. Transferring muscle which may lead to deformity can reduce risk of occurrence of bony deformity [5]. Distal dynamic transposition means transfer the muscles across two large joints, such as muscular obliquus externus abdominis or rectus abdominis to reconstruct the function of hip flexion and knee extension function, or erector spinae and latissimus dorsi to reconstruct the function of gluteus maximus. When performing tendon transposition, the tendon will pass a totally new route [6]. Blood circulation around the route will be destroyed. On the early phase, Tendon is supplied by tissue tissue fluid and then vascular ingrowth start and adhesion happen. Tissue adhesion is common phenomenon, what we need is the minimum influence on the movement of transferred tendon [7].

1.2.3.1 Relationship Between Immobilization and Exercise After Tendon Transposition Four to six weeks immobilization after tendon transposition surgery is good for tendon healing at the new transplanted site, but adhesion will happen and influence the function of the tendon. Research and clinical observations show that early exercise after tendon transfer will not interfere tendon healing, instead will promote the vertical arrangement of new blood vessels and accelerate tendon healing, will make the adhesion looser, which will improve the sliding of the tendon. Early exercise after tendon transfer can limit adhesion formation, promote tendon healing and improve joint movement (Fig. 1.3). 1.2.3.2 The Following Factors Must Be Considered in Tendon Transfer 1. The strength of muscle for tendon transposition should be more than degree 4. When tendon drive joint to accomplish special activity, distance of tendon movement called range, distance between muscle maximum relaxation and maximum contraction called efficient range and the range of the tendon movement which can help joint accomplish the intact movement called required range. We need efficient range meet required range after surgery. 2. If the tendon is not long enough for transposition, we prefer autologous tendon or fascia to be the bridge. 3. The transposition tendon should pass through tunnel in subcutaneous fat layer. Tendon of the ankle and foot should pass peritendineum of the others. 4. The joint, transferred muscle and tendon across, should not has flexion or over extension deformities, or the deformity should be corrected in the surgery.

Fig. 1.3  Ten years follow-up of a patient underwent abdominal flexor and rectus abdominis transposition to reconstruct hip flexion and knee extension function which were satisfied when follow-up

5. Transferred muscles and tendons should pass a route as short as possible. The angle between the new route and the original one should be as small as possible and try not to change the direction of the tendon more than twice. It is better to separate the transferred tendon to a high level and avoid injuring the vessel and never around. 6. It is better to choose congenerous muscles first, then antagonistic muscle, at last the muscle far from the muscle need to be reconstructed. 7. The tension of transferred tendon should be higher than usual, because the muscles transferred, which is weaker than the original ones, may get loosen under stretch after surgery in the future. However, if the fixed tension is too high, there will be a dysfunction of deformity after surgery; moreover, muscle atrophy may occur. 8. Generally, we try not to separate a tendon and transfer part of it, because there will be an interaction between them. But, in some condition, half transposition can

1 Introduction

solve some dilemma problems, like tibialis anterior, pectoralis major, latissimus dorsi, etc. 9. There are two methods for the fixation of transferred tendon. First one is planting its end into the bone. Second one is suturing it with the palsy tendon which needs to be reconstructed. Dr. Qin prefers the second one. 10. There are many methods for the tendon suture. We should choose it according to the condition. Principle is trying to keep tendon smooth, and do not form a large induration. 11. Duration of external fixation is based on the surgical site, age of the patient, and the fixation method. When performing surgery on the lower limb and performing tendon to tendon suture, the fixator should be kept for 5–6  weeks. When performing Achilles tendon reconstruction, immobility should last for 6–8 weeks.

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joint fusion (6123 cases) (Fig. 1.4), triple fusion (2245 cases) (Fig.  1.5), Chopart’s joint fusion, and ankle fusion. When choosing ankle fusion, other joints should be reserved as possible to avoid the foot from totally losing elasticity.

1.2.5 Lengthening and Equalization for Lower Limb There are two types of length of limb discrepancy (LLD): relative unequal and absolute unequal. The gait when relative unequal is called false long limb gait. The reason is pelvic tilt secondary to the contracture of iliotibial band and glutes muscle. Iliotibial band or glutes muscle release and subtrochanter varus osteotomy can be performed to restore pelvic balance and the length of lower limb.

1.2.4 Arthrodesis Arthrodesis is important for reconstructing the stability of lower extremities, especially for the joints on foot. It is rarely performed for hip and knee. Ankle and foot are the basics for weight-bearing, the stability of which are of great importance. For children, adolescents, and patient whose condition is not good to take arthrodesis, tenodesis will be a good choice. The most common tenodesis Dr. Qin used is Achilles tenodesis for calcaneus foot, tibialis anterior tenodesis for equines foot, and tibialis posterior for foot varus deformity. Arthrodesis should be chosen carefully, because patient will lose the function of the fusion joint forever. The most common arthrodesis surgeries on foot in order are subtalar

a

Fig. 1.5  Triple arthrodesis

b

Fig. 1.4  Subtalar arthrodesis: (a) Expose subtalar joint; (b) Remove the joint surface by osteotome

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Indications: various musculoskeletal surgery below distal femur, especially for the patient with muscle atrophy due to poliomyelitis sequela. Preparation: when the surgery is completed, the incision cannot be too tight and too dense to allow blood to seep out. Where there is a dead space under the incision, a drainage tube should be placed. The incision and the bone protrusion are wrapped with a sterile cotton pad, and then the entire lower limb is wrapped with soft cotton. If a combination surgery is done and a long-leg cast gypsum is on the program, the reactive swelling may be heavier postoperatively. First, a wet wide bandage or a thick rubber tube is placed longitudinally on the front side of the lower limb, and then cast gypsum is molding. When the gypsum is solidified, the tubular plaster can be split longitudinally through pulling the bandage or rubber tube. If the limb reactive swelling is severe, the gypsum can be cut along bandage and then decompressed and expanded appropriately. The process of plaster casting (Fig. 1.7):

Fig. 1.6  Femoral subtrochanteric adduction osteotomy

If the discrepancy of lower limbs is more than 2 cm, limb lengthening should be performed. The best method for limb lengthening is widely accepted as Ilizarov method. Length and site should be decided based on the particular condition. Sometimes equal length is not the best choice, and surgical plan should carefully consider preoperatively according to the whole function of the patient. Limb discrepancy caused by hip abduction deformity should be corrected by releasing the contracture tendon or performing subtrochanteric osteotomy. Limb lengthening should be done in second stage (Fig. 1.6). If the short limb combined with muscle paralysis, it should be shorter by 2–3 cm than opposite side, which is better for walking, and limb lengthening surgery is not a good choice.

1. Pre-fabrication of 5–6 layers of plaster slab according to the thickness of the leg. 2. When the toe sags, the plaster slab should be placed from the back side and should exceed the height of the toe. 3. Wrap the limb with a plaster bandage. 4. Plaster molding by the doctors and assistants according to the three-point mechanics principles. The distribution of the main pressure points of the plaster fixation after correction of the foot and ankle deformity depends on the type of deformity and the nature of the operation. It is important to avoid compression injury on the medial and lateral malleolus and the calcaneus. For example, when the triple arthrodesis was done, a certain pressure should be given on the anterior and posterior part of the lateral malleolus, which can not only stabilize the osteotomy end, but also can reduce the bleeding of the osteotomy surface.

1.3

The Art of Minimally Invasive Surgery

Sihe Qin and Jiancheng Zang

1.2.6 Q  insihe Plaster Method for Lower Limb Deformity Common fixation methods for lower limb are plaster support, plaster clamp, and plaster cast. This section introduces the instant tubular gypsum commonly used in Qinsihe Orthopedics.

Minimally invasive surgery means achieving best outcome with minimal invasion and physiological interference. In clinical practice of Qinsihe orthopedic department, minimal invasion is the guiding concept, on the basis of which surgical skill and procedure are developed. It is very important for avoiding infection, which is 90° knee flexion deformity, the femur should be shortened with internal fixation and residual deformity is corrected gradually by Ilizarov fixator (Fig. 1.31).

1.9.7 Deformity Correction of the Knee

1.9.8 T  he Surgery for Foot and Ankle Deformity

The knee joint plays an important role in the lower limb. The function of knee is directly related to the result of the overall treatment. The general treatment principle of dysfunction of knee is to restore the matching relationship of the knee to the maximum extent, and to restore the flexion and extension function of the knee to the maximum extent, regardless of soft tissue contracture or relaxation around the knee.

The surgery for foot and ankle deformity is the most common and most complicated in orthopedics, postoperative management of which can refer to mentioned above. The goal of ankle and foot surgery is to restore a stable, painless plantigrade foot. It can be moderately adjusted according to the force line and muscle strength of lower limb. The varus, adduction or supination angle cannot be left except the angle of plantar flexion. When the external fixator

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Fig. 1.30  Application of orthosis. (a) Fixed in straight position; (b) The knee joint can be flexed with orthosis

is removed, foot ankle brace should wear with 4–6 weeks. For the instability or pain of the ankle joint, ankle guard can be used and select the heel or apply the insole according to the residual deformity of the patient (Fig. 1.32).

1.9.9 Matters Needing Attention The patient allows to encourage in 3–5  days bed-out and walking with external fixator and self-made insole, because they have obtained sufficient strength, without fear of the stability of the surgical site. For the patient underwent osteotomy and soft tissue surgery, sterile gauze and cotton pad can be used usually to evenly pressurize the operation area. On the one hand, hemostasis is suppressed, and on the other hand, the blood is squeezed out; usually the dressing was removed 1 week after surgery and the wound was free of infection (Fig. 1.33). After dressing removal, it is necessary to wrap the gauze around the pin on thigh to reduce the relative sliding between soft tissue and the pin. Other parts of pins and wires can be exposed. If there is no inflammatory exudate, no special care needed.

1.9.10 An Example Is Given to Illustrate Postoperative Management (Fig. 1.34) Wearing time of external fixator depends on the degree of deformity, the nature of the deformity, the age of the patient, and the surgical method. Usually, 80

Case (n) 1960 5268 5891 6995 6259 3874 2173 1040 705 223 60 9 2

Percentage (%) 5.69 15.29 17.09 20.29 18.16 11.24 6.31 3.02 2.05 0.65 0.17 0.03 0.01

Table 2.4  Regional distribution Nationality Chinese Russian American Indonesian Mongols Syrian Vietnamese Romanian Kazakhstan Hungarian South African Saudis Palestinian Unknown

Cases (n) 34,426 5 3 2 2 2 1 1 1 1 1 1 1 12

Table 2.5  External fixator Type Hybrid external fixator Ilizarov external fixator Unilateral fixator Taylor external fixator

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_2

Case (n) 4725 3388 64 5

Percentage (%) 13.71 9.83 0.18 0.01

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The Formation of Database

Sihe Qin, Yilan Wang, and Jiancheng Zang

2.2.1 40 Years’ Accumulation Prof. Qin Sihe has dedicated himself to orthopedics for 40 years and collected clinical documents since 1978 when he launched his career. Prof. Qin has designed corresponding

Table 2.6  Time distribution Time 1978–1979 1980–1989 1990–1999 2000–2009 2010–2017

Case (n) 2 7423 14,956 6248 5830

Percentage (%) 0.01 21.54 43.40 18.13 16.92

follow-up tables for each orthopedic surgery and filled them out with patients’ age, etiology, deformity category, degree of paralysis, operation method, etc. Those follow-up tables, together with preoperative and postoperative photographs, have been preserved properly and sorted out regularly. In the past 40 years, the follow-up tables and photographs of 34,459 cases have been collected in the database (Fig. 2.1). Most importantly, the database displays the development history of orthopedics in China, including the localization of Ilizarov technology in 1990s when it was introduced to China by Prof. Qin and the birth of Orthopedics with Chinese Characteristics. Moreover, Qin’s career has been in sync with China’s reform and opening-up since the first orthopedic case was recorded in 1978. Therefore, the database also reflects tremendous changes of Chinese society from an orthopedic perspective. Apart from academic value, the database also has important social significance and historical value. As some rare diseases may gradually disappear, the database will display distinctive historical value in the future.

6000 3000 2000 1000 500 200 100

Fig. 2.1  Domestic patients of China. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

2  The Database of 34,459 Cases

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At present, the database mainly contains surgical cases, photos, video data, macroscopic statistical analysis, and other basic statistics, so it will need much more work to accomplish systematic research and normalization. Prof. Qin and his team are looking forward to cooperating with excellent academic societies to explore Chinese orthopedic database in depth. Table 2.7  Lower limb deformity checklist in Qinsihe Orthopedics

2.2.2 Patient’s Information Form There are six types of checklist corresponding to diverse diseases in Qin’s orthopedics; the following is the ­ major  one  named lower limb deformity checklist (Table 2.7):

Hospitalization number Name

X-Ray number

Parents’ name

Marriage

Gender

Age

Hospitalization date

Profession

Cause of disease

Medical history

Age of unset

Nation

Birth order

Education

Address Phone number

QQ/WeChat/E-mail:

Intelligence

Physical growth

Nutrition

Height

cm

Weight

kg

Other disease Muscle Extensor hallucis longus

L

R

Muscle Peroneus longus and peroneus brevis

L

R

Muscle Semitendinosus and semimembrano su

L

R

Extensor digitorum

Tibialis Anterior

Gracilis

Tensor fasciae latae

Peroneus tertius

Posterior tibialis

Femoral adductor

Middle gluteal muscle

Flexor pollicis

Quadriceps

Sartorius

Gluteus maximus

Digitorum longus

Biceps femoris

Iliopsoas

Sacrospinalis muscle

Triceps surae

Muscle abdominal muscles

L

R

Latissimus dorsi

Length of limb Left___Right___ Length of femur

Left____Right____ Length of tibia Left____Right____

Lower limb deformities : (Left / Right / Both) Spinal deformity

Pelvic deformity

Joint mobility: Flexion

Hip

Knee

Ankle

Extension Internal rotation External rotation Flexion

X-ray: Walking ability : 0

Pain I

II

III

IV

V

Extension

Flexion

Extension

Sensory disturbance

Gait

Walking distance

Diagnosis Treatment target

Surgery times

Operation scheme:

External Fixator: Ilizarov Anaesthesia: Doctor’s signature:

Hybrid Orthosis:

Internal fixation: Cannulated screw Steel plate Bone grafting Remarks: date: (Sihe Qin; Yilan Wang; Jiancheng Zang)

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 tatistics of 32,659 Cases of Lower S Limb Reconstruction

Yilan Wang and Jiancheng Zang The statistics of 32659 cases of lower limb deformity correction is as follows (Tables 2.8, 2.9, 2.10, 2.11, and 2.12).

Table 2.11  International patients Nationality Russian American Indonesian Mongols Syrian

Case (n) 5 3 2 2 2

Nationality Romanian Kazakhstan Hungarian Saudis Palestinian

Case (n) 1 1 1 1 1

Table 2.12  Time trend Table 2.8 Gender Gender Male Female

Case (n) 18,896 13,763

Percentage (%) 57.86 42.14

Table 2.9  Age at surgery Age group 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 61–65 66–70 71–75 76–80 80+

Case (n) 1662 4805 5505 6658 6083 3790 2152 1023 419 277 141 77 42 14 7 2 2

Percentage (%) 5.09 14.71 16.86 20.39 18.63 11.60 6.59 3.13 1.28 0.85 0.43 0.24 0.13 0.04 0.02 0.01 0.01

Table 2.10  Domestic patients in China Province Beijing Tianjin Shanghai Chongqing Heilongjiang Jilin Liaoning Inner Mongolia Hebei Shanxi Henan Shandong Jiangsu Anhui Hubei Hunan

Case (n) 1678 152 82 75 7245 424 441 449 1512 663 3868 2538 456 1077 2900 1349

Province Jiangxi Zhejiang Fujian Guangdong Taiwan Hainan Guangxi Guizhou Yunnan Sichuan Shanxi Gansu Ningxia Qinghai Xinjiang Tibet

Case (n) 2533 513 667 447 1 49 107 150 101 293 1387 992 75 101 292 20

Time 1970s (1978–1979) 1980s (1980–1989) 1990s (1990–1999) 2000s (2000–2009) 2010s (2010–2017)

2.4

Case (n) 2 7250 13,940 5838 5629

Percentage (%) 0.01 22.20 42.68 17.88 17.24

Causes of Orthopedic Diseases

Sihe Qin, Quan Wang, Yilan Wang, Jiancheng Zang, and Baofeng Guo Prof. Qin Sihe collected and summarized preoperative, intraoperative, postoperative, and follow-up data (photos, videos, and texts) based on more than 30,000 surgical patients treated in 40 years and formed a large orthopedic medical database. According to the etiology of the patient’s disease in the database, preliminary statistics are obtained: There are a total of 202 disease types, including neurogenic diseases, genetic diseases, infectious diseases, trauma and burns, immunological metabolic diseases, tumors, vascular hematological diseases, cumulative degenerative diseases, muscle disease diseases, and other rare diseases.

2.4.1 T  he Disease Types Can Secondary to Limb Deformities 1. Limb deformities caused by central nervous system diseases Cerebral palsy Parkinson disease Encephalitis sequelae Hepatolenticular degeneration Sequela of cerebral trauma Cerebral stroke Lower limb deformity secondary to endocrine dyscrasia caused by craniopharyngioma Postoperative deformity of the intracranial cyst

2  The Database of 34,459 Cases Hydrocephalus Lower limb deformities caused by thoracic spinal cord compression Spastic lower limb deformity caused by spinal cord disease Sequelae of subarachnoid hemorrhage

2. Limb deformities caused by peripheral neurogenic diseases Spina bifida Lateral sclerosis of spinal cord Partial paraplegia of spinal cord injury Sequela of acute myelitis Sequela of arachnoiditis of spinal cord Partial injury of spinal cord secondary to ossification of posterior longitudinal ligament Spastic foot deformity secondary to cord injury caused by medicine toxicosis Obstetric brachial plexus palsy Scoliosis Ankylosing spondylitis Spinal nerve roots/injuries Sequelae of radial nerve Injury of sciatic nerve

3. Limb deformities caused by congenital diseases Congenital talipes equinovarus Congenital dislocation of the hip Developmental dysplasia of hip Congenital multiple arthrogryposis Congenital tibial curvature Congenital tibial pseudarthrosis Congenital fibula hemimelia Congenital tibial hemimelia Congenital dislocation of patella Congenital coax valgus Congenital cleft hand deformity Congenital metatarsus adduction Congenital airfoil joint Congenital constricting band syndrome Congenital vertical talus Congenital calcaneal foot Macromelia Macrodactyly Congenital syndactyly Congenital polydactyly Congenital radialis hemimelia Congenital ulnar hemimelia Congenital insensitivity to pain with anhidrosis Multiple achondroplasia Madelung’s deformity Down’s syndrome Congenital pseudarthrosis of tibia Congenital axial absence of proximal femur Congenital absence of femoral head Congenital dislocation of knee

49 Congenital talus dysplasia Congenital dislocation of the talus Congenital adduction of thumb Congenital hypertrophy of hallux Congenital adduction of anterior foot Congenital absence of anterior foot Congenital ectrodactylia Congenital dislocation of radial head Congenital ring malformation of extremities Congenital shortening of lower extremity Congenital axial defect of the calf Congenital cleft foot deformity Congenital accessory navicular bone Congenital claw toe Congenital valgus deformity of foot Congenital shortening of the toes Multiple epiphyseal dysplasia Congenital ulnar and radial cross deformity Congenital radioulnar syndesmosis Sprengel deformity Congenital thumb absence Congenital wrist flexion deformity Congenital finger flexion deformity Congenital upper limb shortening deformity Congenital clenched fist Congenital wing webbed elbow joint Dupuytren’s contracture Congenital abduction contracture of the hip Gollop–Wolfgang complex

4. Limb deformities caused by hereditary diseases Hereditary pes cavus Metaphysialaclasis Hereditary spastic paraplegia Hereditary sensory and motor neuropathy Progressive myodystrophy Familial neurofibromatosis Three functional protein deficiency

5. Limb deformities caused by bacterial infectious diseases Chronic osteomyelitis Sequelae of pyogenic arthritis Sepsis Bone tuberculosis Toxic bacillary dysentery Typhia Tuberculosis of lumbar spine Synovial tuberculosis Tuberculosis of lumbar spine Brain tuberculoma Tuberculous meningitis Choroiditis Meningitis Epidemic encephalitis type B

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6. Limb deformities caused by viral infectious diseases Sequelae of poliomyelitis Hand-foot-mouth disease Sequela of tetanus Guillain–Barre syndrome Septic pyemia Sequela of mildewed sugarcane poisoning Sequelae of poliomyelitis

7. Limb deformities caused by trauma and burns Sequelae of trauma Bone nonunion/bone defect Developmental deformities of lower limbs caused by epiphyseal injuries Sequela of empyrosis Replantation of residual deformity Sequelae of peroneal nerve palsy Electrical injury

8. Limb deformities caused by metabolic diseases Genu varum Genu valgum Osteogenesis imperfecta Lower limb deformities secondary to rickets Dwarfism Epiphysitis of tubercle of tibia Kaschin–Beck disease The sequelae of hyperparathyroidism Mucopolysaccharidosis Fanconi syndrome Melorheostosis Corticosteroid multiple osteonecrosis Subcutaneous fat atrophy Nephrotic syndrome Dwarfism Renal osteodystrophy Parathyroidoma Gigantism

9. Limb deformities caused by autoimmune diseases Rheumatoid arthritis Vastus lateralis fibromyositis Dermatomyositis Angeitides Transient synovitis of the hip Scleroderma Progressive muscular atrophy Osteochondritis Charcot’s arthropathy Gonarthromeningitis

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10. Limb deformities caused by tumors Spinal cord tumor caused nerve injury Lymphangioma Dermatofibroma Sequela of spinal meningioma Osteosarcoma Non-ossifying fibroma Fibroma around femoral artery Postoperative nerve injury of meningiomas Enchondroma Fibrous dysplasia of bone Ossifying fibroma Spina glioma Spinal fibroma Spinal angioma Intermuscular lipoma Non-ossifying fibroma Peripheral neurinoma Intracranial germ cell tumors

11. Limb deformities caused by vascular and hematological diseases Sequela of hemangioma Avascular necrosis of femoral head Hemophilicarthosis Sequelae of arteriosclerotic arteriosclerosis Sequela of popliteal artery embolism Sequelae of vascular embolism Cerebral angiitis Vascular deformity of brain Cerebral hemorrhage

12.  Limb deformities caused by accumulated injuries, degenerative diseases Knee osteoarthritis Blount disease Hallux valgus Pollex varus Flatfoot Gastrocnemius contracture Calcaneal tubercle osteitis Tenosynovitis of long head of biceps brachii External humeral epicondylitis Osteoarthritis of the ankle Progressive spinal atrophy Osteoarthritis of the canoe joint Coxitis (hip osteoarthritis) Prolapse of lumbar intervertebral disk Protrusion of thoracic intervertebral disk Dorsal carpal fascia contracture Gonarthromeningitis

2  The Database of 34,459 Cases

51

2.5

13. Limb deformities caused by muscular diseases Muscular torticollis Gluteal muscle contracture Fetal equinus deformity caused by necrotizing muscle of injection injury

Surgical Method Analysis

Sihe Qin, Quan Wang, Qi Pan, Jiancheng Zang, and Baofeng Guo

2.5.1 T  here Are More Than 200 Kinds of Surgical Method in Qinsihe Orthopedics Institute, the Data as Follows

14. Limb deformities caused by other diseases Iatrogenic lower limb deformity Spastic paraplegia of the lower extremity secondary to toxicosis of tri-ortho-cresylphosphate Complication of amputation stump Toxicosis of carbon monoxide Organophosphorus pesticide poisoning O,O-dimethyl-O-2.2-dichlorovinyl phosphate poisoning Lead poisoning Viper bite injury Bear scratches injury

2.4.2 T  op 20 Diseases in Qinsihe Orthopedics Institute Table 2.13 show the details of Top 20 Diseases in Qinsihe Orthopedics Institute.

1. Head, neck, and shoulder surgery Adventitia carotid artery dissection sympathectomy Sternocleidomastoid lysis Deltoid muscle abduction contracture release surgery Shoulder adduction, internal rotation deformity pectoralis major tendon extension lysis Congenital high scapular distraction surgery 2. Upper arm and elbow surgery Pectoralis major transfer for the deltoid Trapezius muscle transfer for paralysis of deltoid muscle Latissimus dorsi muscle transfer for paralysis of biceps brachii

Table 2.13  The list of top 20 diseases in Qinsihe Orthopedics Institute Disease Sequelae of poliomyelitis Cerebral palsy Trauma Spina bifid Genu varus/valgus Congenital talipes equinovarus Developmental dislocation of the hip Gluteal muscle contracture Hereditary sensory and motor neuropathy Congenital multiple arthrogryposis Chronic osteomyelitis Congenital fibula hemimelia Guillain–Barre syndrome Congenital tibial pseudarthrosis Encephalitis sequelae Rickets Iatrogenic lower limb deformity Muscular torticollis Sequelae of peroneal nerve palsy Sequela of cerebral trauma

Case (n) 23,310 4561 851 842 711 701 538 229 206 127 93 90 81 77 73 68 67 65 64 60

Percentage (%) 67.65 13.24 2.47 2.44 2.06 2.03 1.56 0.66 0.60 0.37 0.27 0.26 0.23 0.22 0.21 0.19 0.19 0.81 0.18 0.17

Max age (years) 71 63 84 50 67 60 48 42 65

Min age (years) 1 1 3 1 2 1 1 3 4

Average age (years) 20.60 13.11 22.41 18.25 22.21 12.56 12.76 14.73 21.74

Gender ratio (M/F) 1.43 2.12 2.05 0.84 0.18 1.99 0.31 1.76 1.82

32 52 40 47 47 39 53 63 41 56 49

1 3 1 2 2 4 4 4 2 1 6

10.93 23.21 11.05 19.80 13.27 16.49 19.60 24.56 15.78 14.87 21.75

2.17 1.21 2.75 2.00 1.08 2.04 0.74 0.63 1.40 1.28 3.61

Note. Here are some statistics of the 20 most common surgical diseases in Qinsihe Orthopedics Institute from May 25th, 1978 to December 31st, 2017

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Pectoralis major transfer for the biceps brachii Triceps brachii transfer for paralysis of biceps brachii Forearm flexor group muscle starting point upward transfer for paralysis of biceps brachii Transposition of ulnar flexor carpal muscle for paralysis of biceps brachii Elbow flexion deformity soft tissue release surgery Brachial-ulnar joint release Proximal humeral osteotomy Humeral lengthening surgery Humeral osteotomy interlocking intramedullary nail fixation Humeral epicondyle osteotomy surgery for elbow varus deformity Humeral epicondyle osteotomy surgery for elbow valgus deformity Supracondylar humeral osteotomy and lateral condyle fixation for humeral lateral condyle nonunion and elbow valgus Debridement and Ilizarov bone transport technique for humerus chronic osteomyelitis 3. Forearm and hand surgery Stripping down the starting point of the forearm flexors to correct pronation deformity Ending points of pronator teres moves laterally to correct pronation deformity Pronator quadratus lysis Radial correction osteotomy Ulnar correction osteotomy Wrist flexor tendon lengthening surgery Flexor pollicis longus and flexor digitorum profundus lengthening surgery Adductor tendon of thumb lysis Ring finger flexor superficial tendon transfer for hallux abduction reconstruction Wrist flexor tendon transfer for wrist extensor muscle Wrist flexor tendon transfer for extensor digitorum longus Extensor carpi radialis longus muscle transfer for extensor pollicis longus Extensor carpi radialis brevis transfer for extensor digitorum longus Extensor carpi radialis longus muscle transfer for flexor pollicis longus Extensor carpi ulnaris moves laterally for extensor carpi radialis Flexor carpi ulnaris transfer for flexor digitorum profundus muscle Flexor carpi ulnaris transfer for extensor digitorum communis Palmaris longus muscle transfer for extensor indicis

S. Qin et al.

Palmaris longus muscle transfer for flexor pollicis longus muscle Palmaris longus muscle transfer for abductor pollicis longus Palmaris longus muscle transfer for extensor pollicis brevis Extensor digitorum communis transfer for extensor indicis Flexor digitorum superficialis of ring finger transfer for extensor pollicis longus and extensor pollicis brevis Ilizarov traction technique for elbow flexion deformity Ilizarov traction technique for wrist flexion contracture Ilizarov traction technique for wrist extension contracture Ilizarov traction technique for the first finger webbed contracture Ilizarov traction technique for scar contracture of finger Ilizarov transverse traction webbed open technique for symphysodactylia Interphalangeal joint functional fusion at functional position Palm bone lengthening surgery (singular or plural) Metacarpal bone lengthening surgery and reconstruction for thumb stump after amputation (finger) Radius bone lengthening surgery Ulna bone lengthening surgery Wrist-hand joint dynamic balance surgery by combined tendon transfer Extensor carpi radialis longus muscle wrist joint functional fixation at functional position Wrist fusion Ulnar nerve release Debridement and Ilizarov bone transport technique for radius osteomyelitis Debridement and Ilizarov bone transport technique for ulnar osteomyelitis Ulnar lengthening and radial head reduction for old dislocation of radial capitulum Radial head resection surgery Distal ulnar and radius osteotomy Centralization and fixation for dislocation of wrist joint Ilizarov traction technique for radius bending hand (Shucking hand) Malunion of old forearm fracture, reduction, and external fixation 4. Spinal, pelvic, and hip surgery Selective posterior rhizotomy Luque rod implant surgery to correct paralytic scoliosis The head-pelvic ring spine traction to correct severe scoliosis

2  The Database of 34,459 Cases

Nail-rod system to correct scoliosis Condyle rib resection Iliac ribs suspension for paralytic scoliosis in children Iliac osteotomy and lengthening surgery, rotation osteotomy of ilium Iliac and pubic osteotomy and lengthening surgery Iliac hinge rotation osteotomy for acetabular dysplasia in children Pelvic equalization (one side of ilium shortening, the opposite lengthening) Bilateral femoral greater trochanter osteotomy to correct pelvic tilt Gluteal muscle contracture release surgery External fixator traction for iliac-hip cicatricial scars and hip abductor contracture deformity Sartorius starting point move backward with iliac bone Release of flexion hip contracture Psoas lengthening/Amputation of psoas Release the origin of rectus femoris Partially cut or release the pubic starting of femoral adductor muscle Obturator neurotomy External fixation push and traction technique for double hip adduction, internal rotation deformity Reduction of paralytic dislocation of hip and reconstruction of gluteus muscle motility Developmental hip dislocation combined surgery Femoral arthroplasty for coxa plana Chiari pelvic osteotomy Acetabular arthroplasty Transposition of the great trochanter of the femur (middle gluteal muscle stop) Subtrochanteric osteotomy of femur Proximal femur retroversion osteotomy for hip flexion deformity Proximal femur shorten and flexion osteotomy for hip extension contracture deformity Ilizarov reconstruction of the hip (pelvic support osteotomy) Hip stiffness release Hip debridement External fixation push and traction technique for hip fiber stiffness Femoral artery adventitia dissection to improve lower limb blood circulation in polio sequelae patients Releasing surgery for lateral cutaneous nerve of thigh entrapment syndrome Total hip arthroplasty 5. Muscle balance surgery of lower limb External oblique transfer for paralysis of middle gluteal muscle

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External oblique transfer for paralysis of rectus femoris Rectus abdominis transfer for paralysis of rectus femoris Sacrospinalis muscle, iliotibial tract transfer for gluteus maximus Sacrospinalis muscle combined with latissimus dorsi transposition transfer for gluteus muscle Bilateral sacral spinal muscle transfer for unilateral gluteal muscle Iliopsoas lateral displacement for paralysis of gluteus Semitendinosus transfer for quadriceps Semitendinosus and biceps femoris on behalf of quadriceps Caput longum musculi bicipitis-femoris transfer for quadriceps Caput longum musculi bicipitis-femoris moves medially to correct leg external rotation deformity Sartorius transfer for quadriceps Semimembranosus transfer for quadriceps Gracilis transfer for quadriceps Rectus abdominis insertion point moves backward to correct dynamic knee curvature deformity Posterior tibialis and peroneus longus transfer for Achilles tendon Tibialis anterior transfer for Achilles tendon Peroneus brevis transfer for Achilles tendon Flexor hallucis longus transfer for Achilles tendon Posterior tibialis transfer for Achilles tendon Peroneus longus transfer for paralysis of tibialis anterior Posterior tibialis moves laterally for paralysis of ankle dorsal flexion muscle Posterior tibialis and long flexor muscle of the toes transfer for paralysis of ankle dorsal flexion muscle, extensor hallucis longus and long extensor muscle of the toes Half posterior tibialis moves laterally for paralysis of peroneus brevis Tibialis anterior or half of it moves laterally for paralysis of peroneus tertius Half of tibialis anterior moves laterally for paralysis of extensor hallucis longus and long extensor muscle of the toes Half of extensor hallucis longus moves backward to the first metatarsal head Long extensor muscle of the toes moves backward and interphalangeal joint fusion Peroneus tertius moves medially for extensor hallucis longus or tibialis anterior Long extensor muscle transfer for Achilles tendon Peroneus brevis transfer for paralysis of posterior tibialis

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6. Thigh, knee, and lower leg surgery Middle and proximal femur osteotomy Reduction and fixation of femoral shaft fracture Debridement and Ilizarov bone transport technique for femoral chronic osteomyelitis Cortical stripping, correction, and internal fixation surgery for femoral sclerosis nonunion Multipoint osteotomy, interlocking nail combined with external fixation for femoral reverse bending deformity Iliotibial band release Lengthening of tendon biceps femoris Lengthening of semitendinosus and semimembranosus tendons Distal subcutaneous transection of tendinous tendon Semi-membranous tendon “Z” plasty Modified quadriceps arthroplasty for knee joint stiffness Ilizarov technique joint functional reconstruction for knee joint scar stiffness Common peroneal nerve release at the level of the fibula neck Surgery to release the lateral patellar retinaculum and tighten medial patellar retinaculum Combined surgical reduction for congenital dislocation of patella Extensive knee flexion release for knee flexion contracture deformity Supracondylar retroversion osteotomy of femur for polio sequelae with femoral gait pressure Supracondylar osteotomy to correct genu valgum Distal femur osteotomy and internal fixation surgery Intraarticular osteotomy surgery to reconstruct knee joint Multi-level osteotomy of femur and tibia for complex lower extremity deformity Tibial tubercle moves downward to correct knee flexion deformity of cerebral palsy Proximal tibia and fibula osteotomy to correct genu varum High tibial osteotomy combined with external fixation for knee osteoarthritis with genu varum Bilateral osteotomy of tibia and fibula to correct tibial varus deformity Posterior flexion osteotomy under tibial plateau to correct genu recurvatum Supracondylar anteversion osteotomy of femur to correct genu recurvatum External fixation in flexion position to correct paralytic severe genu recurvatum Multi-level osteotomy of tibia and fibula combined with Ilizarov technique for complex calf deformity

S. Qin et al.

Multi-level osteotomy of tibia and fibula combined with intramedullary nail fixation Dorsiflexion musle release for spastic ankle dorsiflexion Ilizarov traction technique for knee flexion deformity Ilizarov push-pull technique for genu recurvatum with anterior knee scar contracture 7. Lower limb lengthening surgery Femoral closing osteotomy and lengthening Femoral oblique osteotomy and lengthening Femoral acute lengthening and external fixation Supracondylar osteotomy of femur and lengthening Femoral stump lengthening for high amputation of thigh Femoral shortening for lower extremity equalization Distal femoral epiphyseal stimulation surgery Femoral osteotomy and lengthening combined with interlocking intramedullary nail Proximal tibia osteotomy and lengthening Tibia “z” shape osteotomy and lengthening Double-level osteotomy and bone transport of tibia Tibia osteotomy and lengthening combined with interlocking intramedullary nail Hemicortical osteotomy and transverse bone transport of tibia for treatment of foot ischemic disease Debridement of tibia and Ilizarov bone transport technique Lesion resection and intramedullary nail combined with external fixation for congenital pseudarthrosis of tibia Ilizarov technique bone transport reconstruction for treatment of tibial bone defect Transverse bone transport of fibula for treatment of large tibial bone defect Supramalleolar osteotomy and lengthening by Ilizarov technique Leg amputation and limb stump lengthening Patellar ligament lengthening Tibial tubercle medial transfer 8. Foot and ankle reconstruction and power balance surgery Lateral calcaneal lengthening Calcaneal osteotomy lengthening for regenerative reconstruction of calcaneus Mid-foot osteotomy lengthening for small foot Ilizarov bone transport technique for treatment of half tarsal bone defect Metatarsal osteotomy lengthening Distal tibula osteotomy lengthening for lateral malleolus reconstruction Opening or closing Achilles tendon lengthening Subcutaneous resection of Achilles tendon for infants Achilles tendon shortening Achilles tendon fixation

2  The Database of 34,459 Cases

Gastrocnemius aponeurosis lengthening Medial scalp release of gastrocnemius tendon Achilles tendon lengthening and peroneus longus transfer for Achilles tendon Posterior tibial tendon lengthening Release of plantar aponeurosis Subcutaneous lysis for contracture of the hallux abductor tendon Release of hallux adductor tendon Decompression of medial metatarsal posterior tibial nerve Morton neuroma resection Clawed hallux correction surgery Digitorum longus lengthening Flexor pollicis lengthening Triple arthrodesis Chopart arthrodesis Talocalcanearis joint arthrodesis Bone graft arthrodesis of talocalcanearis joint to correct valgus Arthrodesis of talocalcanearis joint through medial submalleolar incision Calcaneocuboid joint arthrodesis Talonavicular joint arthrodesis Ankle arthrodesis Ankle and talocalcanearis joint arthrodesis Interphalangeal joint arthrodesis Tarsometatarsal joints arthrodesis Interphalangeal joint arthrodesis Peritalar osteotomy and Ilizarov technique to correct pes varus Calcaneus, tarsal multipoint osteotomy combined with external fixation through small incisions to correct the foot deformities Talocalcanearis joint arthrodesis and calcaneal osteotomy combined with external fixation to correct hind foot varus deformity Aponeurotomy combined with Ilizarov traction technique to correct cavus deformity Scaphoid bone resection for treatment of extremely severe adult cavus deformity First metatarsal basal osteotomy Basal osteotomy of metatarsal bone to correct adductive deformity of forefoot Calcaneal osteotomy deformity Nonunion end cleaning and Ilizarov reconstruction technique for treatment of distal tibia nonunion Dorsalis malleolus tendon fixation surgery for drop foot Ilizarov traction technique to correct paw toe Distal peroneus longus tendon transfer for the paralysis of tibialis anterior Reduction of tendon slippage of fibula to reconstruct lateral malleolar canal

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Peroneus longus and peroneus brevis lengthening Distal peroneus brevis moves medially to build stop point of dynamic reconstruction of foot dorsiflexion Correction of the fifth toe deformity Combined operation to correct hallux valgus External fixation technique to correct spastic hallux valgus Hallux varus deformity correction Constriction of forefoot to correct sector foot with hallux valgus Shortening and constriction of congenital giant foot Middle toe of foot shortening Reconstruction of the third fibula muscle with extensor digitorum longus Extensor digitorum longus tendon binding with supramalleolar tendon for extensor hallucis longus Subcutaneous resection of tendon for contracture of extensor digitorum longus Amputation of tendon of extensor digitorum Release of anterior malleolus fascia and ankle dorsal flexor tendon to correct talipes calcaneus Medial osteotomy of distal scaphoid and Ilizarov technique to correct adolescent congenital vertical talus External fixation technique for soft flat foot—arches reconstruction surgery Rigid flat foot medial column osteotomy combined with Ilizarov technique Part of extensor digitorum longus moves backward for absence of peroneus tertius Combined orthopedic surgery and external fixation to correct talipes equinovarus Ilizarov ankle joint traction combined with osteophyte debridement for treatment of ankle osteoarthritis 9. Other limb deformity correction and reconstruction surgery Osteophytectomy Tibial tuberosity traction Osteoperiosteal decortication for nonunion Exploration and release of nerve and blood vessels Steel plate for epiphyseal arrest Epiphyseal destruction fusion Skin scar resection and soft tissue releases Incision and drainage Debridement for chronic osteomyelitis Deformity correction through combined external fixator Ilizarov knee traction technique Taylor space external fixator for lower limb deformity correction Osteofacial compartment syndrome fasciotomy Ankle canal block anesthesia and calcaneal myelin anesthesia Peripheral nerve coarctation Bone graft

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K-wire fixation Plate screw fixation Hollow nails fixation Intramedullary nail fixation Removal of internal fixation Removal of external fixator by pulling out needle Removal of foreign body Arthrocentesis Joint cavity irrigation and drainage Apodizers surgery (giant toe, polydactyl) Stump revision Shape release of linear skin contracture Congenital annular band resection and skin contracture plasty Closure of wound surface through skin puncture and stretching Reconstruction of bone mass by walking under dynamic fixation for severe lower extremity osteoporosis One-stage orthopedic surgery for hip-knee-ankle malformation

10. Non-invasive limb reconstruction and fixation Hip spica cast fixation technique Fixation through plaster of long leg of lower limb Foot ankle leg plaster fixation Elbow joint plaster fixation Wrist joint plaster fixation Drafting adjustment of ring-type external fixator Adjustment and deformity correction by combined external fixator Configuration adjustment of external fixator Plaster molding of orthopedic braces of extremities Elastic brace traction Traction and reduction of ankle anterior dislocation by external fixation for foot deformity correction

2.5.2 The Top 50 of Surgical Method The information of top 50 surgical method is in the Table 2.14 and Fig. 2.2.

Table 2.14  The top 50 of surgical method the most common used in Qinsihe Orthopedics Institute Name Achilles tendon lengthening Supracondylar osteotomy of femur Arthrodesis of talocalcanearis joint Tibia and fibula osteotomy Release of plantar aponeurosis Peroneus longus transfer for Achilles tendon External oblique transfer for middle gluteal muscle Release of flexion hip contracture Triple arthrodesis Release of femoral adductor muscle Posterior tibial tendon lengthening Release for knee flexion contracture deformity First metatarsal basal osteotomy Subcutaneous cut of gracilis tendon Tibia osteotomy and lengthening Peroneus brevis transfer for Achilles tendon

Times (n) 7772 7274 6123 4044 3626 2520 2373 2341 2245 1908 1757 1693 1364 1129 1124 1026

Posterior tibialis moves laterally

987

Sacrospinalis muscle transfer for gluteus maximus Iliotibial band release

884 881

Iliac and pubic osteotomy and lengthening surgery Posterior tibialis transfer for Achilles tendon Tibialis anterior moves backward Chopart arthrodesis Peroneus longus tendon transfer for the paralysis of tibialis anterior Posterior tibialis and long flexor muscle of the toes transfer for paralysis of ankle dorsal flexion muscle, extensor hallucis longus and long extensor muscle of the toes

847 820 813 809 746

Name Femur osteotomy Obturator neurotomy Clawed hallux correction surgery (Fig. 2.2) Tibialis anterior transfer for Achilles tendon Achilles tendon shortening Talonavicular joint arthrodesis Calcaneocuboid joint arthrodesis Interphalangeal joint arthrodesis Acetabular roof operation Calcaneal osteotomy Gluteal muscle contracture release surgery Ankle arthrodesis Semitendinosus transfer to quadriceps Gastrocnemius aponeurosis lengthening Reduction of dislocation of the hip External oblique transfer for paralysis of rectus femoris Peroneus tertius moves medially for extensor hallucis longus or tibialis anterior Femoral osteotomy and lengthening Lengthening of semitendinosus and semimembranosus tendons Sartorius transfer for quadriceps Muscles transfer for paralysis of peroneus tertius Chiari pelvic osteotomy Achilles tendon fixation Peritalar osteotomy

642

Extensor hallucis longus moves backward

Times (n) 608 597 584 562 527 516 494 494 492 486 483 449 439 321 291 283

148

283 259 231 222 205 197 196 184

2  The Database of 34,459 Cases Fig. 2.2  Qin’s procedure for Hallux toe clawing deformity correction: (a) osteotomy at the base of the first metatarsal bone; (b) 1/2 abductor pollicis tendon was removed; (c) free abductor pollicis tendon was sutured with extensor pollicis longus muscle through the hole made on the metatarsal head, so that the Hallux toe would not drop after surgery when the extensor pollicis longus tendon contract

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a

b

Extensor Hallucis Longus

Extensor Hallucis Brevis

Flexor Hallucis Longus Abductor Hallucis

c

2.6

Innovation and Application of Orthosis

2.6.1 Innovative Application of Orthosis See Figs. 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 2.10, and 2.11.

Sihe Qin, Li Zhang, and Jiancheng Zang At present, external fixator has been widely used in orthopedics and has played a great role in limb deformity correction and functional reconstruction. With the rapid development of orthosis, its application scope has been expanding. It is an innovation combined orthotics with external fixators in treatment and rehabilitation of lower extremity deformities in Qinsihe Orthopedic Institute, and it is worth popularizing and applying.

2.6.2 A  pplication of Orthosis in Qinsihe Orthopedics Institute From Jan 2015 to Dec 2016, 963 cases (1044 accessories) were assembled in our hospital, including 520 cases in male, 443 cases in female, the range of age from 1 to 65  years (Fig. 2.12).

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a

b

c

d

e

f

Fig. 2.3  Combination of orthosis and external fixator for lower limb deformity correction: (a–c) the front, lateral, and back view of the combination of orthosis and external fixator. (d–f) the front, lateral, and back view of knee joint distraction device

Fig. 2.5  Application of orthosis combined with external fixator after hip surgery: (a) front view, (b) lateral view

2  The Database of 34,459 Cases

59

2.7

 tatistical Analysis of Follow-Up S Results of Lower Limb Surgery

Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Qi Pan and Yilan Wang

2.7.1 T  he Data of 451 Cases Those Were Followed Up More Than 2 Years

Fig. 2.4  Adjustable hip abduction orthosis

a

During the period from June 2012 to June 2018, 1164 patients who undergone lower extremity surgery got more than 6 months follow-up. 451 cases were evaluated for more than 2  years (25–480  months, average time was 105.73 months), including 215 males and 236 females. The youngest patient was 4 years and 5 months, the oldest was 65 years old, and the average age was 28.84 years. According to the evaluation index, the curative effect can be judged. Definition of evaluation index was as follows: those >2.5 as excellent curative effect; those 1, good; < 1, poor Name

Gender

Address Cause of deformity Deformity : Osseous

country

Age

Age of follow-up

Phone number Soft tissue contracture

Cbined deformity

Limb shortening

Gait (preoperative) Crawling Squatting Crutches Single crutch Severe limp Moderate limp Mild limp Normal Operation procedures and times:

Remarks

Physical therapy: Reoperation:

YES No ______ years _______ months _______ days after the last surgery Unbalanced Muscle (preoperative) Evaluation of Muscle Strength transfer Surgery Balance Scores Evaluation of Deformity Correction(X-ray)

excellent

well

good

poor

3

2

1

0

excellent

well

good

poor

3

2

1

0

excellent

well

good

poor

3

2

1

0

excellent

well

good

poor

3

2

1

0

Deformity part and degree (preoperative) Deformity Correction Scores Disabled part

Evaluation of Walking ability

Improvement Scores

(Parents represent for children) Patient's Self-evaluation

Selfevaluation Scores

(E.g. nerve injury, anchyloses, severe infection, osteotomy nonunionetc.) Complications

Complication Degrees Scores

Average Scores

excellent

well

3

2

2.5 Excellent

2 well

poor

1

0

1 good

Cause of Complication:

Surgery performed by: Follow-up date:

good

Followed by:

poor

3

Application of the Ilizarov Technique Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Qi Pan, Lei Shi, and Yueliang Zhu

3.1

Ilizarov Technique in China

Sihe Qin and Jiancheng Zang It has been more than 30 years since the Ilizarov technique was first introduced to Chinese doctors and they began to learn about and develop this technology. In 1983, Dr. Guomin Tang published the first Chinese Ilizarov literature: “Epiphyseal Distraction and Limb Lengthening.” Nowadays, mainland China has already become the most active area in the world for the use of Ilizarov technology. The application and development of this technology in China has helped to transform the field, promoting the development of limb reconstruction, wound repair, and other related disciplines.

3.1.1 Introduction, Transformation, and Development In 1976, more than 400,000 patients were dead and badly injured during the Tangshan earthquake in China, which promoted the development of Chinese external fixator. Meng’s external fixator designed by Prof. He Meng is widely used in trauma management and deformity correction (Fig. 3.1). In August 1989, Dr. Sihe Qin invited Professor Krisnikov Vasilyevich, the director of the Ilizarov Center at the Jewish Autonomous Prefecture Hospital (Birobidzhan, Russia), to S. Qin (*) · J. Zang · S. Jiao · Q. Pan · L. Shi Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China Y. Zhu Kunming General Hospital, Kunming, Yunnan, China

deliver an educational lecture and teach the operative techniques of Ilizarov technology in Harbin, Heilongjiang province. In the same year, Prof. Shaochuan Pan introduced the Ilizarov technology from North America and applied it to the clinical practice of pediatric orthopedics. Prof. Qihong Li, who used to study in the former Soviet Union and was inspired by Ilizarov’s external fixation device, developed a semi-circular groove external fixator in the late 1970s. He completed animal experiments on “distraction osteogenesis” and applied it to his clinical practice. As a result, a lot of patients suffering from bone defects were healed (Fig. 3.2). Since 1993, Dr. Yansheng Wang, Dr. Long Qu from Harbin, and Prof. Tongyi Chen from Shanghai have studied Ilizarov technology in Japan, and then introduced it to China. From 1991 to 1992, there were several breakthroughs that would pave the way for the introduction and application of Ilizarov technology in China. First, Professor Shaochuan Pan published the paper “Application of Ilizarov Technology in Paediatric” in the Chinese Journal of Surgery. Second, in 1991, Prof. G.A. Ilizarov himself came to Beijing for a case consultation and gave a special lecture (Fig. 3.3). And third, in 1992, Dr. Sihe Qin signed an orthopedic cooperation agreement with the Russian Far East Ilizarov Technology Center (Fig. 3.4) and published several articles about Ilizarov biological theory and technology. In 1992, Dr. Hetao Xia developed the hybrid external fixator (Fig.  3.5). The Beijing Institute of Skeletal External Fixation Technology was subsequently established in 1994. Since then, Dr. Xia has begun to introduce and promote Ilizarov technology in mainland China with Dr. Qin. The biggest modification by Dr. Xia is that a spring was added to a threaded rod to meet the requirements of elastic distraction. He successfully combined the hybrid fixator with the Ilizarov fixator and applied the “limb lengthening over intramedullary nail” technique for the first time in China.

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_3

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Fig. 3.1  Prof. He Meng and his fixator

Fig. 3.2  Prof. Qihong Li and his fixator

In 1997, Dr. Hetao Xia, Dr. Sihe Qin, and Dr. Gang Li (from the UK) laid the foundation for the comprehensive introduction, development, promotion, and creation of Ilizarov technology in China. In 1998, Dr. Sihe Qin published his monograph of “The Surgeries of Lower Limb Deformities,” which introduced the tension-stress principle (based on Ilizarov technology) for the first time, including the methods and conclusions of animal experiments, the external fixation of the ring type, the surgical indications/contraindications, and other details. In 2002, Dr. Sihe Qin and Dr. Lei Sun lectured on “Ilizarov Technology in Orthopaedic Application” in the Chinese Journal of Orthopaedic Surgery.

In October 2003, Dr. Sihe Qin and Dr. Hetao Xia organized the first “Ilizarov Symposium” in Beijing, during which ASAMI China was established (Fig. 3.6). Dr. Qin was selected as the first president of this organization. In October 2005, Dr. Hetao Xia, Dr. Gang Li, and Dr. Sihe Qin held “The First Beijing International Forum of Limb Lengthening and Reconstruction” (Fig. 3.7), showcasing lectures about research progress and clinical applications of limb lengthening and reconstruction by domestic experts and international Faculties who came from the USA, the UK, Russia, Germany, etc. The application and achievements of Ilizarov technology in China in recent years have developed quickly.

3  Application of the Ilizarov Technique

Fig. 3.3  Prof. G.A. Ilizarov lectured in Beijing in 1991

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Fig. 3.4  Dr. Qin represented Jiamusi government signed the cooperation Agreement with health bureau of Russian autonomy state in 1992

Fig. 3.5  Dr. Hetao Xia and his fixator

In June and September 2006, Dr. Hetao Xia, Dr. Sihe Qin, and Prof. Gang Li were invited to Russia and the USA, respectively. It was the first time that Chinese orthopedic surgeons had given speeches at the Ilizarov Center in Kurgan and at the Limb Reconstruction Course in Baltimore. In 2012, Prof. Qin organized the Beijing meeting of the “International Conference on External Fixation and Bone Reconstruction” (Fig. 3.8). Professor Nuno Lopes the president of “External Fixation and Bone Reconstruction,” experts from Japan, South Korea, and the USA, and a total of 506 participants attended this meeting. This conference played

an important role in international academic communications, which helped to introduce China to the world and give them a clear view of Chinese medical practice. “Qinsihe Technical System for Deformity Correction and Functional Reconstruction of Lower Extremities” was the summation of four separate parts including the orthopedic principles of polio sequelae created by Prof. Qin in the 1980s, the Center of Rotational Angulation (CORA) published by Dr. Paley, Darwin’s Biological Theory of Evolution, and Chinese traditional wisdom. Based on observations of the situations of actual Chinese patients, distraction histogenesis

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practice of “Qinsihe Natural Orthopaedic Reconstruction” is an important sign of the assimilation of Ilizarov technology in China. Prof. Hetao Xia proposed the concept of Adaptive Stiffness Fixation (适应性刚度理念), which conforms to the biological process of fracture fixation, healing, and reconstruction, and provides practical guidance for the application of external fixation technique in clinical practice. Dr. Long Qu found that the fibrous bone tissue at the gap of the bone defect was transformed to bone during bone transport treatment. Fig. 3.6  ASAMI China was set up in 2003

Fig. 3.7  The first Beijing international forum of “limb lengthening and reconstruction” was held in 2005

Fig. 3.8 Beijing conference of “External Fixation and Bone Reconstruction” was organized by Qin in 2012

technology can be adapted to the limb deformities, defects, and dysfunctions caused by multiple professions. Inevitably, this combination led to cooperation and active contact between the orthopedic and pediatric department, the bone and joint infection department, and the neurology and vascular surgery department. This refinement of clinical and medical professions has been integrated to a certain extent under the impetus of this technical system. The proposal and great success in clinical

3.1.2 L  imb Deformity and Function Reconstruction Under Stress Control With the spread and development of Ilizarov technology across the world, a new surgical technique called “Limb Lengthening and Reconstruction” has been promoted. The treatment method is based on imitating nature, following Newtonian Mechanics, uses the principle of leverage and magnifies the artificial action of Wolff’s law through the control and transformation of mechanical stress stimulation. In combination with limited orthopedic surgery, all kinds of limb deformities and disabilities can be cured, even difficult deformities on the verge of requiring amputation can be rectified. Limb regeneration and defect repair are dreams pursued by mankind for thousands of years; and now they are finally being realized, at least to some extent. In the 1980s, with the creative application of Ilizarov’s ring external fixator, the tension-stress osteogenesis mechanism, and their magical clinical effects, Ilizarov technology defines “Modern External Fixation,” and has become known as the fourth milestone in the history of orthopedic development. Ilizarov’s innovations are not limited to his invention of the ring-type external fixation device and its original series of surgical methods (such as bone transport), but also include his discovery of the tension-stress principle, which revealed the natural attributes of regeneration and the reconstruction of living tissue, also called the “Ilizarov effect.” Modern limb lengthening techniques are also based on this biological principle, which is practiced and validated by the use of external fixation devices or internal fixation devices (intramedullary nails) of any configuration. Since then, limb lengthening and reconstruction has entered the “Ilizarov-era,” under the principles of stress control. In summary, following the principles of “stability, graduality, continuity, and blood supply,” limb lengthening and reconstruction with stress regeneration and stress control is demonstrating unique and irreplaceable advantages in clinical practice. With these principles, efficacy is greatly improved, the incidence of complications is minimized, and positive results are obtained, providing clinicians with a “golden key” to solve even the most difficult orthopedic problems.

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3.2

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 pplication of Skeletal External A Fixation in Qinsihe Orthopedics

3.3

 ow to Get the Optimized H Combination of Ilizarov Technology and Qin Sihe Orthopedic Surgery?

Sihe Qin, Shaofeng Jiao, and Jiancheng Zang Sihe Qin, Shaofeng Jiao, and Jiancheng Zang See Tables 3.1, 3.2, 3.3, 3.4, and 3.5.

Table 3.1  Total number of cases treated by external fixators Type Hybrid fixator Ilizarov fixator Monofixator Taylor spatial frame

Cases (n) 4725 3388 64 5

Percentage in total (%) 13.71 9.83 0.18 0.01

Table 3.2  Application of external fixation in different period Period 1988– 1989 1990– 1999 2000– 2009 2010– 2017 Total

Hybrid fixator 4

Ilizarov fixator 7

Taylor spatial Monofixator frame 0 0

485

138

13

0

1731

950

40

0

2505

2293

11

5

4725

3388

64

5

Table 3.3  Application of external fixation in gender distribution Gender Female Male Total

Hybrid fixator 2177 2548 4725

Ilizarov fixator 1444 1944 3388

Monofixator 31 33 64

TSF Total 5 3657 0 4525 5

Percentage (%) 44.69 55.31

Ilizarov Hybrid fixator fixator 121 109 342 261 613 498 837 591 1074 727 713 475 346 238 237 157 171 112 142 87 69 61 36 37 12 26 8 2 4 6 0 1 4725 3388

Monofixator 1 3 7 17 15 11 2 5 2 1 0 0 0 0 0 0 64

TSF 0 0 0 1 3 1 0 0 0 0 0 0 0 0 0 0 5

3.3.1 The Protocols of Clinical Practice Before surgery, system examination, overall evaluation, and designing the surgical plan need to carry out individually. During the operation, we can correct the bone and joint deformity and get dynamic balance as much as possible, and then the Ilizarov external fixator can be applied to restore the residual problem after the surgery. After removing the external fixator, a brace should be given to consolidate the correction, and follow-up should be paid attention. If the patient’s skin is extensively scarred, it can be corrected directly by Ilizarov technique.

3.3.2 T  he Optimization Combination Principle of Qin Sihe Method and Ilizarov Technology

Table 3.4  Application of external fixation in age distribution Age (years) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 61–65 66–70 71–80 80+ Total

About 80% of the limb deformities treated by the Qinsihe orthopedic department are neurogenic disability in lower extremity, and most of them are patients who have delayed or failed treatment. Such patients often have complicated dynamic imbalance, tendon fascia and skin contracture, skin scars, bone and joint deformities. Mild deformity can achieve satisfactory correction by one-stage surgery. In the severe deformities, partial correction was performed during the surgery and then using the Ilizarov external fixator to correct the residual deformities gradually, and finally the correction target can be achieved.

Total 231 606 1118 1446 1819 1200 586 399 285 230 130 73 38 10 10 1 8182

Based on experience and clinical wisdom from 40-year surgical treatment of 34,459 cases of limb deformities by Qin Sihe orthopedic, preoperative surgical plan should be designed individually. Deformity correction completed or majority correction as much as possible during surgery for mild deformities, which can reduce the time of application of Ilizarov external fixator and shorten the period of hospital stay. Pay attention to the application of brace (orthosis) to ensure the curative effect. Children with deformity are mainly performed with soft tissue release surgery; bone deformity must be performed with osteotomy in adult cases. If the bone deformity combined with dynamic imbalance, it should be done both bony osteotomy and tendon surgery during surgery simultaneously according to the patient’s condition and doctor’s technical ability.

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Table 3.5  Application of classification of diseases

Classification of diseases Poliomyelitis sequela Cerebral palsy Spinal stenosis Limbs deformity of traumatic sequelae Congenital talipes equinovarus Gonyectyposis Inherited sensory motor neuron disease Congenital fibular hemimelia Arthrogryposis multiplex congenita Congenital tibial pseudarthrosis Rhachitis Osteomyelitis Genu valgum Osteopsathyrosis Traumatic brain injury DDH Hemangioma KOA Congenital dislocation of patella Developmental anomalies of lower extremity caused by epiphyseal injury Bone defect Bone nonunion Iatrogenic anomalies of lower extremity Guillain–Barre syndrome Sequelae of septic arthritis Congenital leg length discrepancy Gluteal muscle contracture Sequela of rheumatoid arthritis Fibrous dysplasia of bone Diaphyseal aclasis Paralysis of common peroneal nerve Congenital calcaneal deformity Congenital radius dystrophia Burn and scald sequelae Multiple chondrodysplasia Encephalitis Blount ALS Congenital arthropod knee Scleroderma Congenital tibial hemimelia Congenital coxa vara Common peroneal nerve injury Hallux valgus Enchondroma Tarsoptose Multiple epiphyseal dysplasia Avascular necrosis of femur head Acute myelitis Scoliosis Familial neurofibromatosis Congenital vertical talus

Hybrid fixator 2780 593 297 163 149 53 89 9 13 12 23 17 28 26 23 41 5 13 27 15 2 11 6 21 9 2 24 9 9 7 11 4 4 4 10 10 4 7 2 3 3 5 5 8 2 6 5 4 6 3 0 0

Sum of external Ilizarov fixator Monofixator TSF fixation 1193 36 0 4009 184 1 0 778 311 0 0 608 390 10 0 563 142 0 0 291 115 2 1 171 71 0 0 160 76 0 0 85 68 1 0 82 53 1 0 66 37 1 3 64 44 0 0 61 23 0 0 51 21 0 0 47 24 0 0 47 35 1 0 77 40 0 0 45 25 0 0 38 11 0 0 38 21 1 0 37 31 20 25 9 19 26 4 14 9 10 5 11 11 10 3 3 8 5 10 9 6 4 4 1 7 3 3 3 1 4 7 7

1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

34 32 31 30 29 29 28 23 18 17 16 15 15 14 13 13 12 12 12 12 10 10 9 9 9 9 8 7 7 7 7 7

Total number 23,310 4561 842 851 701 470 206 89 127 77 68 93 241 42 60 538 55 42 54 42 35 34 67 81 49 31 229 35 22 28 64 19 20 27 15 73 15 33 15 11 10 48 16 21 10 19 19 29 29 46 9 11

Average of application of external fixation (%) 17.20 17.06 72.21 66.16 41.51 36.38 77.67 95.51 64.57 85.71 94.12 65.59 21.16 111.90 78.33 14.31 81.82 90.48 70.37 88.10 97.14 94.12 46.27 37.04 59.18 93.55 12.23 65.71 81.82 60.71 25.00 78.95 75.00 51.85 86.67 17.81 80.00 36.36 80.00 109.09 100.00 20.83 56.25 42.86 90.00 47.37 42.11 24.14 24.14 15.22 77.78 63.64

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Table 3.5 (continued)

Classification of diseases Progressive muscular dystrophy Melorheostosis Congenital absence axial section of the proximal femur Sciatic nerve injury Sepsis Spinal muscular atrophy Congenital constricting band syndrome Amputation stump Gastrocnemius contracture Osseous tuberculosis Hyperparathyroidism Meningitis Hand, foot, and mouth disease Congenital tibial dysplasia Drug-induced spinal cord poisoning Hereditary spastic paraplegia Desmofibroma Dwarfism Congenital pseudarthrosis of femur Congenital shortening of the toe Tumor-induced spinal cord nerve injury Familial talipes cavus Congenital bowing of tibia and fibula Hemophilia Organophosphates pesticides poisoning Obstetrical palsy Fanconi syndrome Osteosarcoma Bone tumor Myelogenous spasmodic lower limb deformity The giant limb disorder Coxa synovitis Hydrocephalus Tetanus Renal osteodystrophy Congenital radial head dislocation Bear scratch Vascular embolization Incomplete paraplegia of spinal cord injury The giant toes disorder Lymphangioma Craniopharyngioma Carbon monoxide poisoning Subcutaneous lipoatrophy Anhidrosis Gonarthromeningitis Congenital ulnar dysplasia Congenital deformity of absence of toes Congenital arthropod elbow scleroderma Dwarfism Perifemoral fibroids

Hybrid fixator 3 1 5

Sum of external Ilizarov fixator Monofixator TSF fixation 3 0 0 6 5 0 0 6 1 0 0 6

Total number 14 6 6

Average of application of external fixation (%) 42.86 100.00 100.00

3 1 2 2 0 2 1 3 3 4 1 2 3 2 3 0 0 1 2 1 1 3 1 1 1 1 1

3 4 3 3 5 2 3 2 1 0 3 2 1 2 1 4 4 2 1 2 2 0 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

6 5 5 5 5 4 4 5 4 4 4 4 4 4 4 4 4 3 3 3 3 3 2 2 2 2 2

16 7 9 10 7 14 18 5 35 6 4 3 20 4 8 4 8 4 6 4 3 4 20 1 1 2 2

37.50 71.43 55.56 50.00 71.43 28.57 22.22 100.00 11.43 66.67 100.00 133.33 20.00 100.00 50.00 100.00 50.00 75.00 50.00 75.00 100.00 75.00 10.00 200.00 200.00 100.00 100.00

1 1 1 1 1 2 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1

1 1 1 1 1 0 1 1 2 2 2 2 2 2 2 2 2 2 2 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1

6 2 21 2 1 3 2 3 4 4 2 2 5 2 2 2 4 2 2 3 1

33.33 100.00 9.52 100.00 200.00 66.67 100.00 66.67 50.00 50.00 100.00 100.00 40.00 100.00 100.00 100.00 50.00 100.00 100.00 33.33 100.00 (continued)

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Table 3.5 (continued)

Classification of diseases Transverse myelitis Hormonal multiple osteonecrosis Spinal nerve injuries Familial neurofibromatosis Cerebral genital tumor Cerebral angiitis Cerebrovascular deformity Cerebrovascular hemorrhage Cerebral apoplexy Down syndrome Congenital deformity of thumb Congenital forefoot adduction Congenital navicular foot Thoracic disc protrusion Hereditary chondrodysplasia Kaschin–Beck disease Arterial calcification Venomous snake bite Residual deformity of fingers replantation Malignant peripheral nerve sheath tumor Non-ossifying fibroma Hepatolenticular degeneration Ossifying fibrotherma Popliteal artery embolism Osteoarthritis of the ankle Spinal glioma Myelofibroma Intracranial cyst Madelung’s deformity Angiitis Sequelae of poisoning by moldy sugarcane Cerebral arachnoiditis Septicopyemia Parkinson’s disease Dermatomyositis Hemihypoplasia Nephrotic syndrome Injury of fetal injection Charcot’s arthropathy Congenital elevation of the shoulder blade Congenital thumb adduction Congenital forefoot absence Congenital deformity of wrist flexion Congenital calf axial defect Thoracic disc herniation Mucopolysaccharidosis Intraspinal meningioma sequelae Other infectious deformities of lower extremity Other congenital deformities of upper extremity Other congenital deformities of lower extremity Unknown diseases

Hybrid fixator 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17

Sum of external Ilizarov fixator Monofixator TSF fixation 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 1 1 1 3 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 1 0 0 1 21 1 0 39

Total number 2 1 3 9 1 1 1 1 4 1 1 1 3 1 1 10 1 1 1 1 1 2 1 1 3 1 1 1 3 1 1 1 3 1 2 2 1 1 1 1 3 1 2 1 1 1 2 47

Average of application of external fixation (%) 50.00 100.00 33.33 11.11 100.00 100.00 100.00 100.00 25.00 100.00 100.00 100.00 33.33 100.00 100.00 30.00 100.00 100.00 100.00 100.00 100.00 50.00 100.00 100.00 33.33 100.00 100.00 100.00 33.33 100.00 100.00 100.00 33.33 100.00 50.00 50.00 100.00 100.00 100.00 100.00 33.33 100.00 50.00 100.00 100.00 100.00 50.00 82.98

1

2

0

0

3

7

42.86

15

31

1

0

47

63

74.60

30

33

1

0

64

147

43.54

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Case 1: Severe Knee Flexion Deformity Due to Poliomyelitis Sequelae (Fig. 3.9)

a

b

c

d

Fig. 3.9  Qin Sihe method combined with Ilizarov technique for the treatment of severe knee flexion deformity. (a) A 19-year-old male with severe double knee flexion deformity due to poliomyelitis sequelae; (b) Preoperative clinical appearance: maximum extension of the knee joint, nearly 90°; (c) Preoperative X-ray film; (d) Knee flexion soft tissue release during the surgery; (e) Free the common peroneal nerve; (f, g) Femoral supracondylar osteotomy, femoral shortening about 5 cm; (h) Control the bone segment with hybrid external fixator, and then the

e

plate was given; (i) Application of Ilizarov knee flexion fixator to correct residue deformity over 40° during operation; (j, k) 60 days after surgery, knee flexion deformity has been corrected completely, and postoperative X-ray film; (l) 5 months after surgery, the Ilizarov fixator has been removed, the range of motion of knee: maximum extension 0°, maximum flexion 50°; (m) X-ray film; (n) 11 months after surgery, the left lower extremity protected with a brace; (o) X-ray film 11 months after surgery

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f

g

h

i

j

k

Fig. 3.9 (continued)

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l

m

n

o

Fig. 3.9 (continued)

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Case 2: Severe Knee Recurvatum Deformity Due to Poliomyelitis Sequelae (Fig. 3.10) a

b

c

d

Fig. 3.10  Severe knee recurvatum deformity due to poliomyelitis sequelae. (a) A 44-year-old female with knee recurvatum deformity due to poliomyelitis sequelae, the right knee is painful while walking, and accompanied with varus foot deformity; (b) X-ray film showed that the recoil angle is 40°; (c) Tibial plateau osteotomy above tibial tubercle; (d) Allografting; (e) The right knee joint knee recurvatum deformity

e

has been corrected; (f) Hybrid external fixator was mounted to control knee at least 30° flexion position; (g) 8  days after surgery, clinical appearance, patient was encouraged to walk with walker; (h) X-ray film 8 days postoperatively; (i) 3 months after surgery, the external fixator was removed and a brace was worn; (j) 7 months after surgery, 4 months after the brace was worn; (k) X-ray film of right knee joint

3  Application of the Ilizarov Technique

f

h

I

Fig. 3.10 (continued)

79

g

80

j

k

Fig. 3.10 (continued)

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Case 3: Severe Clubfoot Deformity Due to Spinal Bifida Sequela (Fig. 3.11) a

b

c

d

e

Fig. 3.11  Qin Sihe method combined with Ilizarov technique for the treatment of severe clubfoot deformity. (a–c) A 14-year-old male with bilateral clubfeet deformity caused by spinal bifida sequela; (b–f) Preoperative clinical appearance and X-ray film; (g) Tibialis posterior tendon Z-shape release; (h) Triple joints osteotomy and arthrodesis; (i)

With the anterior and lateral tibia incision, tibialis anterior muscle was exposed and freed; (j) Cut off the end point of tibialis anterior muscle with a sharp knife; (k–m) The tibialis anterior tendon sutured with peroneal brevis through the retinaculum extensorum; (n) Ilizarov external fixator was applied for fixation and the residual deformity correction

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g

h

i

j

k

Fig. 3.11 (continued)

3  Application of the Ilizarov Technique

l

83

m

n

Fig. 3.11 (continued)

3.4

Ilizarov Technique for the Treatment of Severe Flexion Deformity of the Knee

Jiancheng Zang, Qi Pan, Lei Shi, and Sihe Qin

3.4.1 Etiology and Clinical Manifestations 3.4.1.1 Etiology The etiology of knee flexion deformity includes congenital, metabolic diseases, acquired diseases, trauma or degenerative joint changes. Congenital polyarticular contracture, congenital wing knee deformity, congenital patella dislocation, lower extremity hemangioma, polio sequelae, hemophilia,

rheumatoid arthritis, knee suppurative infection and traumatic sequelae were included commonly (Fig. 3.12). Knee flexion deformity may be caused by simple soft tissue contracture or may be caused by anterior flexion deformity on the distal femur or proximal tibia, or combined deformities.

3.4.1.2 Clinical Manifestations The main clinical manifestations of the knee flexion contracture deformity is joint range of motion reduced or stiff. When the patient standing, gravity line falls posterior of the knee joint. The patient with less than 30° knee flexion contracture deformity causes an obvious limping gait; the patient with severe knee flexion contracture deformity cannot stand upright and usually need to take a wheelchair or squat walking (Fig. 3.13).

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b

c

d

e

Fig. 3.12  Severe knee flexion deformity: (a) Knee flexion deformity caused by poliomyelitis sequelae; (b) Congenital polyarticular contracture; (c) Congenital tibia deformity; (d) Knee deformity secondary to

hemangioma; (e) Congenital pterygoid knee joint; (f) Congenital patella dislocation and knee deformity

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85

f

Fig. 3.14  Ilizarov knee distraction apparatus

3.4.2 Preoperative Preparation

Fig. 3.12 (continued)

1. The full-length weight-bearing anteroposterior and lateral radiographs of the lower limbs and the maximal extension lateral view of lower limb were taken to measure the degree of knee flexion deformity. 2. Measuring the flexion angle of knee in X-ray film. The patient with flexion angle less than 30° can be corrected by the femoral supracondylar osteotomy and knee joint soft tissue release in one stage, but the common peroneal nerve must be dissociated. However, the patient with the flexion deformity greater than 30°, due to the neovascular limitation cannot be corrected in one stage, Ilizarov technique can be chosen for deformity correction. 3. Preassemble the apparatus according to the limb size. The configuration of the Ilizarov joint distraction apparatus mainly includes the femoral fixator and tibial fixator connected with hinges. There are one or two threaded rods at the rear or side (Fig. 3.14).

3.4.3 Surgical Processing The patient was in supine position under spinal anesthesia or general anesthesia. When the patient combined with obvious iliotibial band or biceps femoris contracture, surgical release should be performed first, so that the knee deformity can be partially corrected; when the patient with flexion deformity on distal femur or proximal tibia, the bony osteotomy should be done first, followed by Ilizarov apparatus application (Fig. 3.15). The apparatus was placed over the limb, and the hinges should march with the rotation center of the knee joint. Since the movement of the knee joint is a combination of rotation and slipping, it was determined that the rotation center of the Fig. 3.13  Bilateral severe knee flexion deformity

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a

b

Fig. 3.15  Surgical processing. (a) Surgical release of iliotibial band, biceps femoris, and common peroneal nerve; (b) Application of Ilizarov external fixation

knee joint approximately located in the axial connecting the apex of medial and lateral femoral condyles. A 1.5–2.0 mm K-wire was passed through the center of the hinge and the rotation center of the knee joint, and then the rings of the external fixator were applied with wires and pins as much as possible. The 3.5–5.0 mm pins and 2.0 mm K-wires can be used. The K-wires can be used in the lower part of the femur and at both ends of the tibia. The pins usually were used on the proximal femur and the middle part of the tibia. The number of pins or wires was chosen according to the deformity degree, the age of patient, and the primary disease.

3.4.4 Postoperative Managements The patient can practice the isometric contraction of the lower limb after surgery, and start to walk with walker 2–3 days after surgery. The local pain and swelling reaction can obviously be relieved 5–7 days after surgery. By

rotating the nut at the distal end of the bilateral hinge, the joint space was distracted by 5–10 mm to avoid the compression of the articular cartilage during the deformity correction. Starting to rotate the spring-loaded distracter on the rear of the knee joint to stretch the soft tissue and to correct the flexion c­ ontracture deformity. However, when the flexion angle is greater than 60°, the flexion contracture deformity can be corrected while the joint space is distracted. The speed of knee distraction is 3–5  mm per day, which divided into 3–5 times, the speed is also adjusted according to the pain and the X-ray film was reviewed every 7–10  days, which can detect joint space and relationship of tibia and femur to prevent joint squeezing and dislocation. When the correction of the knee deformity completed, the fixation will be fixed for another 3–4 weeks. Then the fixator can be removed, and an orthosis can be used for 3–4 weeks. During this period, the range of motion of the knee can be practiced, and the limbs can walk weight-bearing with stick.

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3.4.5 Typical Cases The patient is a 27-year-old male with severe knee deformity caused by bilateral congenital dislocation of the patella. X-ray films at the view of maximal extension of the knee joint showed dislocation of the patella, and the knee flexion deformity is about 90° (Fig. 3.16). 1. The goals and ideas of treatment: Bilateral knee flexion deformity is the cause of the patient’s inability to walk upright. Correcting bilateral knee flexion contracture deformity can achieve the goal of standing and walking, but the patient’s knee flexion contracture deformity exceeds 90°, except for the contracture of hamstring muscle; there are also popliteal fossa nerves, blood vessels, and the knee joint posterior capsule contractures, which can be solved by the Ilizarov technique. In order to facilitate postoperative care and early functional exercise, the staging surgery will be done. Do the right side first, then left. 2. Surgical plan Biceps femoris lengthening, iliotibial band release, common peroneal nerve release, lateral patellar retinaculum release, and application of Ilizarov technique. 3. Preoperative preparation: electric drill, Ilizarov distraction apparatus of knee joint. a

Fig. 3.16  Severe knee flexion deformity caused by bilateral dislocation of the patella. (a) Squat walking preoperative; (b) Maximum extension position of the knees; (c) X-ray of the knee; (d) After the right lower limb surgery, the patient can stand supported by walker and

87

4. Surgical procedure With posterior lateral incision of the lower thigh, iliotibial band and biceps femoris was exposed and released with Z-shaped respectively. Free the vastus lateralis to patellar ligament, release the lateral patellar retinaculum, then suture the incision. Ilizarov distraction apparatus can be applied for patella dislocation and flexion knee deformity. 5. Tips and tricks When releasing the biceps femoris, pay attention to revealing and protecting the common peroneal nerve and check the tension of common peroneal nerve to prevent the distraction injury. 6. Postoperative managements: The second day after surgery, the patient can practice the movement of joints. The knee deformity was started to correct 7 days after surgery. The distraction speed was 3–5 mm per day, and the dynamic change was based on the patient’s tolerance. Joint distraction could been done until the knee deformity completely corrected. During the distraction period, the patient was encouraged to stand and walk with walker gradually. When the knee deformity was corrected completely, the fixator was continuing to fix for another 3 weeks, and then be removed and maintain with brace 6–12 months. When the fixator of right lower limb was removed, the left side surgery can be done. b

orthosis; (e) 10 days after the left lower limb surgery; (f) 3 months after the left lower limb surgery; (g) 8  months after the left side surgery, 12 months for right, the patient can walk with knee orthosis

88 Fig. 3.16 (continued)

S. Qin et al.

c

d

3  Application of the Ilizarov Technique Fig. 3.16 (continued)

e

f

g

89

90

3.5

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Ilizarov Technique for the Treatment of Orthopedic Incurable Diseases

plex poly fractures and multiple malunion of post-traumatic fractures, multi-dimensional deformities of bones and joints caused by epiphysis injuries, deformities caused by congenital or infectious long bone defects, etc. These diseases are difficult to cure with classic treatments, but magical effects can be achieved with Ilizarov technology.

Sihe Qin, Shaofeng Jiao, and Jiancheng Zang

3.5.1 T  he Scope of Incurable Diseases of Orthopedics Orthopedic incurable diseases are a broad concept, usually referred to diseases in orthopedic that are very difficult to treat and have no uniform treatment method, such as coma

3.5.2 T  he Magical Effect of Ilizarov Technology on Incurable Diseases 1. Right upper limb deformity caused by scleroderma (Fig. 3.17)

b

c

Fig. 3.17  Wrist joint deformity caused by scleroderma, Ilizarov technique for deformity correction: (a) Preoperative; (b) During treatment; (c) The wrist deformity was corrected completely

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2. Lower limb deformity caused by hemangioma (Fig. 3.18) 3 . Congenital multiple arthrogryposis (Fig. 3.19) 4. Severe clubfoot deformity (Fig. 3.20) Fig. 3.18  Right knee flexion and clubfoot deformity caused by hemangioma: (a) Preoperative; (b) During treatment; (c) Postoperative

a

b

5 . Congenital dislocation of the hip (Fig. 3.21) 6. Congenital complex foot and ankle deformity (Fig. 3.22) 7. Chronic osteomyelitis (Fig. 3.23)

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Fig. 3.18 (continued)

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Fig. 3.19  Congenital multiple arthrogryposis: (a) Preoperative; (b) Right leg treatment; (c) Left leg treatment; (d) Treatment completed

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3.6

Combvination of Ilizarov Technology and Internal Fixation Technology

Sihe Qin, and Jiancheng Zang External fixation is poorly comfortable and it is difficult to carry it for patients in a long time. Ilizarov technology combined with internal fixation can give advantages to both internal and external fixation and reduce the wearing time of the external fixation.

3.6.1 I lizarov External Fixator Combined with Plate 1. The metaphyseal deformity with soft tissue contracture and bone deformity (Fig. 3.24) 2. Limb lengthening (Fig. 3.25) 3. External-fixator-assisted internal fixation (Fig. 3.26)

3.6.2 I lizarov External Fixator with Intramedullary Nail 1 . Lower extremity lengthening (Fig. 3.27) 2. Bone transport (Fig. 3.28) 3. Ilizarov external fixator with cannulated screw It was applied for subtalar arthrodesis surgery (Fig. 3.29).

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Fig. 3.20  Bilateral severe congenital clubfoot in adult: (a) Preoperative; (b) Right foot in treatment; (c) Left foot in treatment

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Fig. 3.21  X-ray film of developmental dysplasia of the hip. (a) Preoperative; (b) 14 days after surgery; (c) 48 days after surgery; (d) 27 months after surgery

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Fig. 3.21 (continued)

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Fig. 3.22  Congenital deformity: (a) Preoperative; (b) Right foot in treatment; (c) 4 years follow-up

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Fig. 3.23 Chronic osteomyelitis of the distal tibia: (a) Preoperative; (b) Intraoperative debridement; (c) End of treatment

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Fig. 3.24  Knee flexion deformity: supracondylar osteotomy and fixed with plate internal fixation to correct the anterior flexion deformity of the femur, and application of Ilizarov external fixation to correct the knee contracture flexion deformity

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Fig. 3.25  Monofixator combined with plate for tibia lengthening. Oh CW, Song HR, Kim JW, Choi JW, Min WK, Park BC. Limb lengthening with a submuscular locking plate. J Bone Joint Surg Br. 2009;91(10):1394–9

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Fig. 3.26  Supracondylar osteotomy: (a) The corrected position fixed by an external fixator; (b) The osteotomy was fixed with plate

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Fig. 3.27  Intramedullary nail combined with external fixator for tibia lengthening. [(a) The X-ray 7 days after surgery; (b) 2 cm new bone was enlengthened after surgery; (c) the external fixation was removed and intramedullary nail remained]

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Fig. 3.28  X-ray film shows that intramedullary nail combined with external fixator for bone transport

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Fig. 3.29  X-ray film showed that subtalar joint was fixed with the external fixator combined with cannulated screw, in this way,the fixator can be removed earlier

3.7

Ilizarov Techniques and Chinese Wisdom

Yueliang Zhu, Sihe Qin, and Jiancheng Zang Today the world’s civilization is comprised majorly of two parts: Western Science and Eastern Wisdom. Our physical world and daily life, food, clothing, lodging, ­communication, etc., are tightly related to scientific advancements. Science originates from the West. But Eastern Wisdom rules our psychological world. The three big religions (Christianity, Islam, and Judaism) originates from the Middle East. Buddhism originates from India, and Taoism and Confucianism originate from China. Someone is teasing that Eastern Wisdom will win eventually in human civilization. There has been 200–300 years since the first Industrial Revolution to modern days. During this period, the main scientific achievements were from the West, more specifically, the West Europe and the USA.  This phenomenon exists in medicine, of course, in orthopedics. As we all know, modern arthroplasty comes from the UK, AO internal fixation theory comes from Swiss, the intramedullary nail comes from Germany, and vertebral pedicle screw comes from France, while minimally invasive surgery and microsurgery come from the USA. Generally, the West has the big share of modern orthopedic surgery while the East makes only a little contribution. Under such background, Ilizarov techniques were born in a small town of the East and roared across the horizon in 1950s. This technique was a huge break of rules and produced uncomfortable feeling and indigestion which has lasted until today.

Yuanzhang Zhu, the founding emperor of Ming Dynasty of China, ascended the throne and gave great honors to Confucius, but had no interest in Mencius (a scholar as great as Confucius). One day he read an essay written by Mencius and echoed that these words were just his lifetime portrayal, and he exclaimed Mencius was truly a SAGE. Henceforth he gave great honors to Mencius too. Here is Mencius’ essay: “Shun rose up from the grain fields; Fu Yueh was found as a construction laborer; Chieh Ko was pulled up from his fish and salt; Sun Shu Ao from the sea, and Pai Li His from the marketplace. (These guys were all great guys who helped Kings to build a country in ancient China). Thus when God is going to give a great responsibility to someone, it first makes him suffer endurance, hunger, torture, poverty, hardworking and knocks down everything he tries to build. In this way God stimulates his mind, stabilizes his temper and develops his weak points. People will always err, but it is only after making mistakes that they can correct themselves. Only when he has been driven into a corner and desperate situation can he become creative and make a difference. The final results will show in his face and voice, then he can lead others. If a country has no legal specialists and impartial advisors inside and enemy outside, it shall perish. Henceforth we know the truth: to live in anxiety and die in pleasure.” The whole life of Ilizarov is the portrayal of this essay too. Ilizarov was born in a poor family with many sisters and brothers. When he was young, he moved several times with his parents in the large Soviet Union land and he knew people’s hard life. This experience is the same as those big guys in Mencius’ essay. At that time, the orthopedic surgeons in the Western Europe and the USA were nearly all graduated

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from formal medical collages. Ilizarov graduated only from a medical school which was quite humbler compared with western colleagues. During his study, he had to move several times due to the war. So far as we know, what he received was only rough and primary medical training. But a real hero is never necessarily related to his origin. The informal education had never hindered Ilizarov’s creation. He graduated finally in WWII and was assigned to the remote hospitals. He had to deal with large numbers of patients with extremity disability from the battlefield. In repeated daily work, he found that traditional plaster immobilization, traction, and internal fixation were inefficient to extremity deformity, infection, and defects. One day he designed a two ring structure in a spade handle. In the beginning he applied the ring supported by the Böhler splint, later he abandoned the splint and use his external fixation independently. Before he became famous, his techniques were often stolen and copied. And he was suppressed instead due to his great techniques and inventions. The road to be famous was so hard for Ilizarov. He was even not a member of communist party (and only those who had experienced that time could he really realize that a man without the identity of communist party member suffered what). But Ilizarov continued his work aloofly and proudly. Even after he had got the reputation, his work was continuously being copied in Soviet Union, Italy, and China. But he was never surpassed. He kept working until his last days. “To live in anxiety and die in pleasure”. Long lives such a great doctor! Not only Ilizarov himself but also other surgeons who were fascinated by this technique had suffered a lot. On a long road towards success, these surgeons had a deeper understanding of Mencius’ essay. Maybe it was a good thing that Ilizarov had not received formal medical education as in the west. His mind preserved original purity. Sometimes over-reading books make people dull. Without external communication and academic conferences, Ilizarov independently finished his genius design of the ring, thin K-wires, threaded rod, and hinge. It has been already 70 years since, there is no one who can really improve these four basic parts. Such genius designs might not come if he had received sufficiently formal education. It is interesting that Ilizarov techniques had got different regional styles when it was spread to the East and West. Along with Balkan peninsula, Caspian Sea, westward to Italy, the UK, France, Germany, and the USA, Ilizarov rings have become more and more strong, tough, thick, and half-pins appeared, computer-­assisted Taylor’s frame appeared, Paley’s very formal and exact principles of deformity correction appeared, and so on. These changes have distinct western characteristics of mechanical materialism. Eastward towards China, Ilizarov devices become more “Asian.” Xia modified some parts to be more small, clever, also very strong and stable. He

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invented a device for synchronization lengthening of the leg and the foot. Qin has developed relating series of tendon transfer techniques, combined the application of both external and internal fixations, and used a protocol of intraoperative quick correction combined with postoperative slow correction. As for Kurgan, the style is both west and east. The technical development continues for several generations in Kurgan. It is exactly western strict and realistic for the experiments on thousands of dogs and the tension-stress principle. As for Ilizarov hip reconstruction, transverse bone transport for extremity ischemia or brain ischemia, they are so much creative. They are just Chinese free-hand brushwork of drawing. As Gubin, the chief of Kurgan hospital, commented: “People realized gradually that Ilizarov techniques had experienced three stages: Ilizarov devices, Ilizarov techniques, and Ilizarov philosophy.” The word “philosophy” was translated to China in modern history. Before that, Chinese used “wisdom” for a broader meaning which includes “philosophy.” Chinese wisdom was deeply melted in the Spring and Autumn period (700 B.C.), the Hundred Schools of Thought (500 B.C.), and Confucius, Buddhism, and Taoism after Han Dynasty (202, B.C.). Ilizarov wisdom does not appear in only third stage, but exists all through three stages.

3.7.1 W  isdom of Ilizarov Devices: Central Fixation Circle. The circle is the most stable and flexible structure in the universe. So the planet is circle, the joint face of human boy is circle. And Ilizarov ring is circle. Axis. Without an axis, the circle collapses. As early as the Spring and Autumn Period, China had already most excellent chariots. Their wheels were the combination of circle, axis, and spokes. Ilizarov ring is a central fixation. Its circle was combined via K-wires (spokes) to bone (axis). It is stable and flexible. There appeared various parts and instruments when Ilizarov devices were spread to the West and East. And if you had got enough observation, you would have found that for nearly 70  years, with whatever innovations and scientific advancements, the four parts—holed rings, K-wires with tension, threaded rods, and hinges—had been incapably improved. Someone had already turned the rings or ­half-­rings into monolateral structure. But after careful considerations of stability and flexibility, these monolateral fixators were changed back to circular rings. Someone had already changed threaded rods to smooth sliding rods or computer-­assisted rods or even internal implants, but threaded rods remained to be the mainstream for the convenience of regulation, simplicity, and economy. In an era of such fast development of

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orthopedic equipment and instrument, these four basic parts of Ilizarov device cannot be really improved or replaced. What a surprise! Ilizarov is great not only because of his surgical devices, but also because of his unique extremity treatment principles which are based on natural biological principles—a whole new orthopedic treatment system, and he set up the industrial culture. The industrial culture is full of philosophy. When we draw back our sight, and again speculate on the “circle” and “central,” we’ll find that the two concepts cannot be overemphasized. Central fixation works by the axis and circle together. Central fixation. Orthopedics presently has three main subspecialties: spine, arthroplasty, and trauma. Each subspecialty has many hardware. Only very few of them could be called central fixation method. Spinal pedicle screw, which develops from the first (Harris rod) and second (Lushi bar) generation of fixation, is the third generation of fixation and stronger and more stable for the fusion and deformity correction. But it is off-axis. In arthroplasty, the stem of the femoral component and knee component for THA and TKA are axial, but only partially axial due to their shortness. All of plates and screws in trauma, LCP or DCP, are off-axial fixation. Classic western external fixators such as Hoffmann or Bastiani series are also mainly off-axis. The only central fixation or axial fixation in trauma area is intramedullary nail. The nail is however axial fixation with a smaller horizontal diameter than the bone. Even so, the nails win over plates as the “golden standard” for long tube bone fracture fixation. Therefore, the central fixation owns far more advantages than off-axial fixation. Then what effects will be produced by Ilizarov rings, which is axial fixation and also has a bigger horizontal diameter than bone? Actually, a fracture fixed by Ilizarov rings usually could take full weight-bearing and walking immediately after the surgery. And patients with Ilizarov rings are always encouraged to make full weight-­ bearing walk after the operation. In this respect, no other fixations are so “safe.” Circle and 360°. Ilizarov himself liked to use full rings and K-wires. Sometimes the rings and K-wires do seem too bulky and inconvenient. Some doctors endured no more and began total modifications. Half-rings, monolateral fixation, bilateral fixation, irregular fixation……, different and eccentric devices were invented. Ironically when these people tried to take “circle” away from Ilizarov fixation, the other orthopedic subspecialties were walking towards 360° simultaneously. For example, spine surgeons found the off-axial pedicle screws were insufficient for spine stability. They used cage, titanium mesh, and plates for anterior column fixation. The anterior approach and fixation combined with posterior approach and fixation together produced 360° fusion or fixation. In arthroplasty, surface replacement and stemless replacement once were used, but they lacked the

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central fixation. Postoperatively the component stability was insufficient and there were too many complications. No surprise is the declining application of off-axial artificial joint. In trauma, the tibia plateau fracture used to be fixed with single plate, later appeared two column concept with two plates fixation and finally three column theory with a 360° fixation. Then the distal radius fracture embraced three column theory too, followed by supracondylar humeral fracture, and acetabular fracture. The fractures of proximal humerus and proximal femur recently required lateral fixation as well as medial wall support. So each part of the body rushes to circle and 360° fixation. At this moment, when we review the old Ilizarov ring invented 70 years ago, we have a question: is it wrong for the large and bulky rings? So many improvements actually are retrogression. They are too much capricious.

3.7.2 Wisdom in Ilizarov Techniques: Firmness and Flexibility Tai Chi (a Chinese Kungfu) is firm and flexible. Neither single firmness nor single flexibility is good for new bone growth. The bone tissue has its elastic modulus, which is a combination of firmness and flexibility. The bone density varies according to weight-bearing and function. With its trabecular system and Haversian tubes, the bone accomplishes maximal stress bearing with a minimal weight. It is highly efficient. Stainless steel is too much firm for bone, while tree splints used by traditional Chinese doctors are too weak. It is a good attempt when the stainless steel is replaced by titanium in some implants. This change is actually a pursuit of bone elastic modulus by internal hardware. Firmness and flexibility change as time changes. In the early stage of bone union, bone needs more firmness. In the middle stage, both firmness and flexibility are needed. In the later stage, bone needs more flexibility and reclaims more stress. Ilizarov external fixators could be adjusted and controlled in out-­ patient departments. It is simple and convenient and costs less. On the contrary, the adjustment of internal fixation usually requires hospitalization and anesthesia, which costs more money and patient suffering. The first edition of AO “Manual of Internal Fixation” was published in Germany, and the second edition was translated into Chinese in 1983. A tossed stone raised a thousand ripples at that time! Suddenly Chinese doctors realized that there remained so much knowledge in the plates and internal fixation! The anatomical reduction, strong and compressive fixation, and union without callus formation, and so on, these new ideas and methods received great hailing at that time. In a few years, problems came. For those fractures with no callus, there was a high rate of nonunion or refracture after plate

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removal. And many rural Chinese doctors applied DCP with an irregular style and produced callus formation. When these fractures healed and their plates removed, the refracture rate was low. WHY? There was no answer for a long time. Finally, it was found bone has its unique modulus elasticity. Strong fixation is ignoring the “begging” of fracture bone— first strong, then flexible fixation. Disrespect the law of Wolff leads to stress shielding. Pursuit of anatomical reduction damages too much soft tissue and circulation. Non-callus union is a disobey of natural laws. Bone union requires c­ allus formation first, then the callus disappears under stress. The negation of negation makes real bone. On the basis of aforementioned failures, AO advanced a new theory “BO,” which pays more attentions to soft tissue preservation and local circulation, uses lower elastic modulus, lessens plate-­bone contacting area…. When these concepts spread from West to China, we found that Chinese ancestor doctors’ doctrine— “Balance of exercises and immobilization; Equal importance of soft tissue and bone”—had been already there for 2000  years to wait BO.  Everything returns to old Chinese wisdom. So, firmness and flexibility are wisdom and principles. And Ilizarov external fixators, based on aforementioned central fixation, are a masterpiece of firmness and flexibility! The thin wires become tough after distraction. It is strong, yet produces micro-motion which is good for bone growth. In the early stage of fixation, multi-rings, rods, and wires are used. In the middle stage, parts of the components are removed. In the later stage, most of the components are removed. At different stages, the fixation intensity changed and it is nearly synchronous with biological bone union. The fixation firmness could be adjusted in out-patient departments. Are there any internal hardwires adjusted repeatedly and conveniently? Nearly all Ilizarov techniques could be finished with minimally invasive surgery, which includes fracture fixation, deformity correction, bone lengthening, and bone transport. The insertion of K-wires, so long as to be meticulous, produces only fairly limited damage to soft tissue, bone membrane, and marrow. Except for ugliness, discomfort, and pin site infection, Ilizarov fixation has much fewer disadvantages than internal fixation. Its surgical invasion is far less than LISS, MIS, and MIPPO techniques of traumatic orthopedics. Its characteristics of central fixation, and firmness and flexibility cannot be matched by any internal fixation. Dear Ilizarov left behind the tension-stress effect: slow, steady traction of tissues caused them to become metabolically active, resulting in an increase in the proliferative and biosynthetic function. The words “SLOW” and “STEADY” are the key for a successful distraction. Ilizarov once said we had everything if we had blood circulation. These words “SLOW,” “STEADY,” and “BLOOD” are actually RULES of Ilizarov technique. Respect these rules, treatment modifi-

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cation will be always effective. Forget them, failures come. A least bit difference makes totally different results. BLOOD comes first. STABILITY emphasizes firmness. SLOW means flexibility and toughness. The three words together produces good results. On the reverse, there will be insufficient bone growth if blood circulation is not preserved, or the distraction is not slow and continuous. Instable fixation, such as improper frame configuration or pin fixation, leads to pains and pin site infections. If the distraction rate is too fast, bone will not grow. If too slow, bone will union ahead of time and lengthening is interrupted. Such phenomenon is a detailed explanation of firmness and flexibility. It is a basic philosophical law that quantitative change leads to qualitative change. Slow accumulation turns to quality change. Image that 20  years are required for a 30  cm infant becomes a 1.7 m adult. The bone and other tissues can grow to a perfect degree only by such a long time. Tai Chi is a combination of slowness and quickness. But most of time it plays slow. The alternation of spring, summer, autumn, and winter is also slow. Millions of years passed before human beings experienced from crawling to upright walking. Along with wind, the spring rain sneaks into the night and moistens everything finely and silently. Immediate fix or one-stage treatment is a style for other orthopedic subspecialties. It is not for bone transport and deformity correction. The distraction-­stress law has tight relation to treatment results. Without a deep understanding of the law, a surgeon cannot drive the technique flexibly.

3.7.3 W  isdom Among Ilizarov Philosophy: Mystery Code Mystery Code is a word from Buddhism, meaning a highly concentrated wisdom and philosophy. It is general principle, guideline, and secret. Mystery Code is headrope, while technique is mesh. Once the headrope of a fishing net is pulled out, all its meshes open. In that time, Ilizarov suddenly rose with magic effects. Hence it was repeatedly copied. And Ilizarov was bored and annoyed, he disliked answering questions from fellows in his old age. Like Chinese Kong-fu, the movements are shown, but the Mystery Code will never be disclosed to normal people. How much one can obtain through the show depends on his comprehension. Even so, Ilizarov leaves the distraction-­ stress law which is actually one of Hearty Methods of his technique series. Mystery Code is like magic code, that cannot be spread indiscriminately, but has to be inherited. Sometimes they are already made public, but ignorant people look upon them as rubbish. The secrets, when spoken out, are secrets no more. Secrets after all belong to the world, and serve for patients.

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Orthodox Ilizarov techniques come to China between 1980s and 1990s. Dr. Hetao Xia and Sihe Qin in Beijing firstly realized its charm, and they had mixed together much Eastern wisdom based on a long-time learning, application, and treatment. Xia made a systematic research on classical Ilizarov devices of Soviet Union. He also extensively studied other countries’ devices and move with the time. He made many parts to be small and exquisite, which included rings, wire-­ fixing bolts, hinges, and so on. After modifications, the whole device system is more suitable for Asian patients. In this period, Xia invented a micro-invasive osteotomy device with continuous holes, synchronizing lengthening device, minihinges, half-pin fixators, and new K-wire fixation bolts. He preserved the excellent parts of the original system and modified those stubborn and big parts, making great contributions to the Sinicization and Asianization of Ilizarov devices. Until today, the major parameters of Ilizarov devices produced by Chinese factories are all based on Xia’s research. Furthermore, Xia developed a unique three generation’s assembly fixator system—Xia’s External Fixators, which extended Ilizarov concepts in convenience and simplicity. These inventions have aroused universal interest and been acknowledged by Dr. Paley and surgeons from Japan and South Korea. On the basis of these practical experiences, Xia put forward renewed theories about regeneration, cybernetics, and adaptive firmness, which are meaningful and thought-­ provoking. He summarizes the Mystery Code of Ilizarov techniques as the following: “Treatment comes from mind. Device changes as stage changes. Body is harmonized with device. Result is harmonized with wishes. Treatment is harmonized with limbs application. Application is harmonized with exercises. Natural healing leads to optimized reconstruction.”

Dr. Xia is merciful because he discloses the secrets. “Treatment comes from surgeon’s mind.” Which mind? Surgeons’ or patients’? “Device changes as stage changes.” How? Wires penetration, frame configuration, clever and steady distribution of stress loads, these considerations are all included in this sentence. “Body is harmonized with device.” How? “Result is harmonized with wishes.” This harmony is strictly based on the treatment goal and achieved by wise adjustment of limbs and external fixators. “Treatment is harmonized with limbs application.” We should notice that it is not normal postoperative rehabilitation, but simultaneous usage of limbs and treatment. Ilizarov once said “walking is treatment.” This contains deep meaning than modern rehabilitation. “Natural healing leads to optimized reconstruction.” Exist is equal to nonexist. Exist comes from nonexist. In recent 20  years, China has few surgeons that can really understand these secrets laws of Ilizarov fixation. The quick

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spread of internal fixation by powerful associations has obscured the spread of external fixation techniques. This is a great pity! Only after long time shocking waves could gold flash among sands. Together with Xia, there is another “warrior” —Doctor Qin who has been appealing for more attentions on Ilizarov techniques for decades. As the most populous country, China has more patients of poliomyelitis, limbs deformity, cerebral palsy than other countries. Main stream of orthopedic surgery cares little about these diseases. A great number of patients cannot find a proper hospital or doctor to treat them. Tendons transfer is a technique which faces extinction. In recent years, classical orthopedic books like Campbell’s Operative Orthopaedics mention little of tendon transferring technique except for post-nerve injury reconstruction. When to do tendon release, when to do tendon transfer, which tendon is to be replaced, and which one is donor tendon, and how much tension…. An optimal choice is not easy to make, and requires long time and great quantity of clinical experience. This problem becomes more typical on the foot and ankle. There are so many tendons on the foot and ankle, and any imbalance likely leads to deformity. When Ilizarov techniques spread to the West, few surgeons pay attention to the tendon problems. They think slow and continuous correction could solve every problem. But, different tissue may respond differently to distraction. Bone’s regeneration after distraction is most steady and controllable. Nerves and vessels are most sensitive to distraction. A little bit too fast may cause palsy numb and spasm. The most stubborn tissue to distraction is tendons. Of them, the posterior tibial tendon and Achilles tendon are strong and stubborn. They yield less to blind and simple distraction. With limited release and proper transfer, these stubborn tendons could facilitate more magic treatment effects in the foot and ankle. Qin has rich experience on tendon surgery—40 years and 30,000 operations. On this basis, he develops a unique system of tendon surgery which stands by Ilizarov techniques, just like adding wings to the tiger (makes Ilizarov techniques more wonderful). Human beings have uprightly walked for millions of years, but some of functions remain its ancestral characteristics, such as lower extremity has more flexion strength than extension, more adduction strength than abduction, and more internal rotation strength than external rotation. For poliomyelitis, cerebral palsy, and other deformity, the lower extremity usually needs release of flexion tendons compensating for extension strength and release of medial tendons compensating for lateral strength. It is not a piece of cake to pick out quickly and accurately an anterior or posterior tibial tendon in a deformed foot. It is neither an easy task to pick out quickly and minimal-invasively a semitendinosus tendon from a chronically contractured knee. Qin’s tendon transfer is quick, precise, skillful, and unique. As the old saying goes,

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“To take a general’s head among thousands of enemy soldiers, is just like to take a thing within one’s own bag.” Qin’s style of tendon transfer is really something unique to the Orient. He used to do the osteotomy and do partial deformity correction immediately in one stage. The residual deformity would be treated postoperatively with Ilizarov techniques. This protocol shortens treatment period and increases patients’ comfortability. It is neither rigid nor stereotyped, but a balance of firmness and flexibility, a balance of inside and outside technique. Tendon transfer and microsurgery are the right and left arms of Ilizarov technique. They constitute a troika, a troika that can crack the most difficult and complicated challenges from trauma and deformity of the limbs. Supported by the two arms, Ilizarov techniques’ effects are doubled while the treatment period is halved. Ilizarov techniques originated from the Orient, and Qin’s tendon transfer techniques microsurgery are developed in the Orient too. On his 40 years’ experience, Qin is merciful and disclosed his Mystery Code of Ilizarov techniques:

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developed a “four obey” principle for apprentice Ilizarov doctors: K-wires VS half-pins? Obey K-wires more than half-pins. Full ring VS half-ring? Obey full ring more than half ring. Multi-planes VS mono-plane? Obey multi more than mono. Fast VS slow technique? Obey fast more than slow.

K-wires are full wires which can be fixed bilaterally on the frame. It provides steady, well-distributed and tough strength, while half-pins are only unilaterally and too rigid. If one is not sure which one is the best for a certain situation, we suggest he uses K-wires. Full ring and half-rings have their advantages and disadvantages. If one is confused, use full rings because they provide better steadiness. For one level of bone, we may use two (or more) or one ring. Multi-­ rings are more complicated but steadier, mono-ring is less steady but simpler. If one is hesitated, use multi-rings because steadiness comes first. During bone distraction and deformity correction, some surgeons use intraoperative correction and fast nut turning postoperatively, some will use traditional slow nut turning technique. If one is confused, Doctors synchronize with patients. use the slow method. These principles and suggestions are Time synchronizes with space. provided for only apprentices and novices. For them, stickExistence and non-existence originate each other. ing to these principles is helpful. After sufficient experience, Difficulty and easiness is changeable. Guided by natural force. they will finally know Mystery Code. For a master, any Regeneration for repair. devices of Ilizarov system find its proper position and they Natural reconstruction. are unobstructed. He will use the instruments at will. Doctors and patients are comrade-in-ware. Their common Skillfully and naturally, he uses Ilizarov techniques without enemy is disease. So, the treatment strategy and tactics any principles. Ilizarov devices are of characteristics of the big and steady should be union. Time changes, so changes the external fixation form. The time is exchanged for external fixator form of the West and the smart and clever of the East. But that is change as well as limb form change. Existence and non-­ artificial division, no real difference exists between the West existence originate each other. The thing that creates exis- and East. So long as one captures the inner meaning of this tence and non-existence belongs neither existence nor technique, every characteristic could be maneuvered as will. non-existence. Sometimes existence turns to be non-­ There is no real difference between internal fixation and existence, and vice versa. With distraction-stress, some bone external fixation. So long as one knows each advantage and disappears as existence, some appears from non-existence. disadvantage of the two fixations, there is no parochial prejuDifficulty and easiness is changeable. Treat firstly the easy dice. Neither neglecting nor exaggeration is good for the disease, then the difficult one. Sometimes a difficult case can development of Ilizarov techniques. Those who are not willing to recognize the greatness of be treated with easiness, sometimes a simple case is treated with difficulty. Guided by natural force. We can accomplish Ilizarov techniques are either blind in eyes or blind in heart. We should not follow the fashion blindly. When we were a great task with little effort by clever maneuvers. Regeneration for repair. Big cleverness sometimes looks like trying to de-centralize Ilizarov rings, trauma, spine, and joint stupidity. Flexibility wins firmness, slow wins fast, and that surgery are walking towards 360° fixation. When we were forgetting traditional Chinese orthopedics and worshiping is natural reconstruction. Over 70  years has Ilizarov technique spread to the East AO principles, AO turned to be BO and walking to “soft tisand West. There appear many surgical styles. Different doc- sue equals to bone, immobilization equals to exercises” (trators and different countries use different frame assemble and ditional Chinese orthopedic laws). When “harmony between different pin arrangement. This makes the junior doctors at a heaven and man, treat both symptoms and causes” were fadloss how to do the surgery. Referenced from Buddha’s “four ing from our memory and molecular biology, genetic engiobey” principle: obey law more than master, obey meaning neering, tissue engineering coming into our life, the western more than words, obey wisdom more than knowledge, obey medicine was walking from biomedical model towards thorough meaning more than half-thorough meaning, we social-psychological-medical mode. When we attached and

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abolished Eight-part essay (a literary composition prescribed for the imperial civil service examinations, known for its rigidity of form and poverty of ideas), we find SCI papers are number on Eight-part essay. No Central Country (A name for ancient China) after the Cliff Mountain battle, no Huaxia (Another name for ancient China) after the perish of Ming Dynasty. China in Chinese means “Central Country of the world,” not easily broken porcelain and chinaware. Chinese culture was twice cut in half by Yuan Dynasty and Qing Dynasty (both are not Han nationality, but ethnic minority) though, it survives and comes down in one continuous line. Given time, Chinese civilization could revive and guide the world with Chinese hardworking, intelligence, and modesty. Obeying natural laws, Ilizarov controls natural force. Natural selection leads to evolution. This is the theoretical basis for Ilizarov techniques which could cover any age, doz-

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ens of subspecialties, and hundreds of diseases. Like a chess game, Ilizarov techniques could be used with unlimited combinations. With these various combinations, surgeons could freely and skillfully treat difficult cases. To use this technique well, one must experience long-time practice, philosophical thinking, and dialectical analysis. Ilizarov techniques belong to the third Millennium. The technical localization in China has been finished with the lead of Xia and Qin. Much Orient wisdom has been integrated, and many innovations are made and acknowledged by the international peers. We have successfully bid for “Sixth International ASAMI & ILLRS.  Beijing, 2023.” However, the number of surgeons who can skillfully use and deeply understand this technique remains small in China. Ahead is a long road, Chinese surgeons should learn hard of Ilizarov techniques. With a global vision, they should set the ultimate goal as serving patients well.

4

Application of Chinese Hybrid External Fixator Jiancheng Zang, Sihe Qin, and Qi Pan

4.1

 egendary History of External L Fixation in China

Jiancheng Zang The development history of external fixation in China is very different from that of Russia and the Western countries. It originated from the Tangshan Earthquake in 1976 when the Chinese medical profession and the Western countries lacked academic exchanges during the Culture Revolution. In order to quickly treat hundreds of thousands of patients with traumatic fractures, Meng He et al., inspired by skeletal traction, had invented the “balanced traction external fixation devices” for limb fractures and mild bone deformities. The invention had been promoted nationwide with the support of the Ministry of Health. Subsequently, Prof. Li Qihong, who studied in the former Soviet Union, invented the half-ring fixator and initiated the establishment of the “Bone External Fixation Group of Chinese Medical Association Society of Orthopedics”. Xia Hetao, who has profound mechanical and engineering backgrounds, invented the hybrid external fixator. In 1992, he established the “Beijing Institute of External Fixation Technology”, which laid the foundation for the research and development of external fixation equipment and technology in China. The hybrid external fixator, which is flexible and variable configuration, wide range of indication and easy-to-learn application, has much in common with Ilizarov instruments, and skilled application of the hybrid external fixator can lay the foundation for learning Ilizarov technology. Ilizarov technology has been introduced to China for more than 20 years. In the process of localization, including the development of equipment, surgical methods, theoretical innovations, and the J. Zang · S. Qin (*) · Q. Pan Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China

creation of new disciplines, the Chinese doctors has created a series of creations and achievements that have been recognized and praised by the international academic community. Prof. Qin Sihe and Xia Hetao, with their respective medical teams, used domestic bone external fixator combined with limited surgery to treat more than 20,000 cases of traumatic limb fractures and limb deformities, and saved a number of foot and ankle deformities. It is fully proved that the Chinese external fixation device is not only low in price and complete in accessories, but also convenient in external adjustment, which can meet the clinical needs of orthopedics. At present, China is the most active area of learning Ilizarov technology in the world (Nuno Craveiro Lopes). After Ilizarov technology was introduced to China 28 years ago, there is no history of that as in Europe, North America, Japan, South Korea, etc., dispatched a large number of orthopedic surgeons to study and train in the Ilizarov Technology Center in Kurgan, but this technology can still be quickly accepted in some areas of China orthopedic community, generalized and localized, and made a series of innovations that surprised the international academic community. This situation enhanced research and promotion of the external fixation technology and laid the foundation for the introduction and development of Ilizarov technology in China. In this process, the alliance of Xia Hetao, Qin Sihe, and Li Gang developed a system for the theory and application of Ilizarov technology in China, including the aspects of clinical application, basic theory, equipment research and development; the alliance is also the basis for rapid development of the technique in China. However, due to the different medical policies of China and the different policies of provincial medical insurance, as well as the influence of AO internal fixation technology, only a few doctors in China’s main hospitals began to learn and gradually mastered Ilizarov external fixation techniques, such as Prof. Huang Lei from Beijing Jishuitan Hospital and Prof. Shu Hengsheng from Tianjin Hospital, Prof. Kang Qinglin from Shanghai, Prof. Hua Qikai from Guangxi, and several private hospitals, etc., but the related fields are often limited to traumatic sequelae. The rapid development of Ilizarov

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technology in China was promoted by “ASAMI China” and “China Limb lengthening and Limb Reconstruction Society” with textbooks, training courses, and conferences, etc.

4.2

Hybrid External Fixator

Jiancheng Zang and Sihe Qin The hybrid external fixator, invented by Dr. Xia Hetao, is a versatile external fixator with relatively independent compo-

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Fig. 4.1  Hybrid external fixator. (a) C-type fixator for pelvis; (b) O-type fixator for pelvis; (c) Fixator for intertrochanteric fracture; (d) Unilateral fixator; (e) Humerus frame; (f) Fixator for supracondylar fracture of humerus; (g) T-type fixator for humerus surgical neck fracture; (h) Ring-type fixator for humerus surgical neck fracture; (i)

nents, which could be single planar or multi-planar, that can be constructed according to the actual needs of patients (Fig. 4.1). Compared with the previous bone external fixators, it has the advantages of flexibility, light and strong adaptability. The hybrid external fixator transmits the mechanical reduction and strong fixation force on the extracorporeal connecting rod to the bones in the body, providing a good biomechanical effect for stimulating the growth of the epiphysis. The interference to the blood supply of the fracture site is slight, and the fracture healing speed is also faster than open surgery because the peri-

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Fixator for supracondylar fracture of femur; (j) Fixator for ankle fracture; (k) Fixator for tibia fracture; (l) Fixator for tibial metaphysis fracture; (m) Unilateral fixators for fore arm; (n) Fixator for distal radius fracture; (o) Fixator for floating knee; (p) Fixator for finger; (q) Fixator for elbow

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operation of hybrid external fixator is simple and more flexible than the Ilizarov external fixator, which not only achieves stable fixation, but also avoids the disadvantages of traditional fixation, such as plaster, etc.

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4.3.1 Indications 1. Basic fixation of simple ankle deformity correction such as soft tissue surgery. 2. Non-rigid foot and ankle deformity, which can be fine-­ tuned after surgery. 3. Fixed for acute correction of ankle deformity combined with lower limb deformity, and a few deformities remained postoperatively can be easily adjusted. 4. Other diseases such as ankle injury that do not require complicated adjustment postoperatively.

4.3.2 B  asic Principle of Foot and Ankle Fixation for Hybrid External Fixator

Fig. 4.1 (continued)

osteal peeling on both sides of the fracture end is minimal. The multi-planar needle fixed is to avoid loosening of the fixed needle, reduce the soft tissue stimulation around the needle track by periodic dynamic stress, and timely treat severe trauma, that can effectively reduce the incidence of infection. Hybrid external fixator can be used as a temporary or permanent treatment for complex limb fractures. In the Qin Sihe’s orthopedics, it is usually used for acute deformity correction; it is also used as an adjustable fixator by loosening clamp to adjust the configuration.

4.3

Correction of simple ankle deformity: The 3.5–5.0 mm half pins are set on the middle and distal tibia, and K-wires ranging from 3.0 to 4.0 mm are set above the ankle, then fastened by a fixed arch. The purpose is to establish a stable fixation and an orthopedic mechanical fulcrum for the ankle (Fig.  4.2). If accompanied with a correction of the lower extremity complex deformity, the whole lower extremity can be fixed after surgery, which is beneficial to the weight-bearing activities and rehabilitation exercise. Pin placement in the foot: The number and type of pins in the foot should be determined according to the specific situation of deformity corrected during the operation. The basic requirement is to meet the stable fixation and simple adjustment after surgery with the minimum number of pins. Generally, the 2.0–2.5 mm K-wires are threaded at the distal

 pplication of Hybrid External Fixator A in Ankle Orthopedics

Jiancheng Zang and Sihe Qin The application of the hybrid external fixator in the ankle orthopedics is an innovation of Chinese doctors. In the past, the ankle was immobilized by plaster after deformity correction, so there were some complications such as pressure ulcers and perspiration, because it is difficult to change once applied. The hybrid external fixator is directly connected to the calcaneus, the metatarsal bones, and the tibia to maintain the position. Once the position is found to be poor after surgery, the retaining clip can be loosened and the position can be adjusted. For example, after osteotomy, there is still a slight varus in the hindfoot, the hybrid external fixator can be loosened, then correcting the deformity and the fixator re-­fixed. The installation

Fig. 4.2  Tibia part of fixator for foot and ankle fixation

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Fig. 4.3  Wires for foot and ankle fixation

end of the forefoot and the 2.5–3.0  mm pins are used to strengthen the fixation of proximal and distal metatarsal bone. Using 3.0–3.5 mm K-wire threads the calcaneus. The pin is inserted in the medial or the lateral side of the calcaneus to prevent the sliding of the K-wire and facilitates the adjustment of residual calcaneus deformity (Fig. 4.3).

4.3.3 T  he Common Configuration of Hybrid External Fixator for Foot and Ankle The hybrid external fixator is used for postoperative fixation of the ankle and foot, and its configuration is ever-changing. The main clinical configurations are as follows: 1. The forefoot and midfoot are fixed to lower leg, and the medial side of the calcaneus is fixed to the medial side of fixator by a pin (Fig. 4.4). 2. The forefoot and midfoot are fixed to lower leg, and the lateral side of the calcaneus is fixed to the lateral side of fixator by a pin (Fig. 4.5).

Fig. 4.4  Common configuration of hybrid external fixator for foot and ankle. (a) Pattern diagram; (b) Clinical appearance

3. Fixing the forefoot and hindfoot by the fixed rod on the medial side of the foot, then fix the whole foot with the lower leg, and the pin at the lateral side of the middle foot to assist to fix (Fig. 4.6). 4. The forefoot threads the pin at the medial and the lateral side to fix with the lower leg, and the calcaneus osteotomy is only fixed with the K-wire (Fig. 4.7). 5. After fixing the medial and the lateral side of the forefoot, connect with a semi-ring arch and then connect it to the lower leg (Fig. 4.8).

118 Fig. 4.5 Common configuration of hybrid external fixator for foot and ankle, (a) Front view; (b) Lateral view

Fig. 4.6  Install program for common configuration of hybrid external fixator for foot and ankle. (a) Front view; (b) Lateral view; (c) Back view

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Fig. 4.7  The forefoot was fixed with fixator, and calcaneus osteotomy was fixed with the K-wire. (a) Front view; (b) Lateral view; (c) Back view; (d) X-ray

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Fig. 4.8  Semi-ring arch fixation. (a) Front view; (b) Lateral view

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6 . Perform osteotomy above ankle, then fixed (Fig. 4.9). 7. The medial ankle triangle is one side fixed which is often used for simple fixation after soft tissue release and tendon transfer (Fig. 4.10). 8. The medial ankle quadrilateral is fixed, since the K-wire is inserted above ankle, the strength of the lower leg support is increased, so it is stronger than the triangular fixation (Fig. 4.11). 9. The configuration of hybrid external fixator for ankle and knee deformity. Deformites of ankle, foot and knee joint should be corrected in the one surgery. The hybrid external fixator can be used for the fixation of both the knee and the ankle joints (Fig. 4.12).

4.4

 pplication of Hybrid External Fixator A in the Correction of Lower Extremity Deformity

Jiancheng Zang and Sihe Qin

4.4.1 F  ixation for Acute Correction of Femur Deformity The lower femoral deformity mainly includes valgus, varus, anterior arch, posterior arch, and rotational deformity. The valgus and varus deformities are more common, and poste-

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rior arch and rotational deformities are minor. When the patient with lower femur deformity stands and walks, the negative gravity line of the lower limb deviates from the center of the knee joint, that makes the knee joint unbalanced, which is easy to cause premature degeneration of the knee joint and osteoarthritis. Osteotomy of deformity correction: The use of simple external fixation or limited internal fixation combined with external fixator for the treatment of lower femoral deformity is a common surgical method. In the surgery, longitudinal incision on anterior medial and anterior lateral distal femur were performed. After the distal femur was exposed, the electric drill was drilled in the planned osteotomy site, then using the osteotome to make osteotomy. After the deformity was corrected, the broken end was fixed with a hybrid external fixator. If there is knee flexion deformity soft tissue releasing will be performed, the knee joint will be fixed straightly by a hybrid external fixator. The purpose of the combined application of the plate and the external fixator is: 1. The osteotomy end can obtain a more stable fixation, that can bear the weight of the patient in the early period postoperatively, to walk on the ground the second day after surgery. 2. External fixators can be removed at an early stage. After the external fixator is removed, the fixation strength of the osteotomy end is reduced in time to better achieve the “Adaptive Stiffness Principle” of postoperative management.

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Fig. 4.9  Supramalleolar osteotomy and then fixed with fixator. (a) Clinical appearance preoperative; (b) Clinical appearance postoperative; (c) X-ray

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Fig. 4.9 (continued)

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c 4 months post surgery

Fig. 4.10  The medial ankle triangle

4  Application of Chinese Hybrid External Fixator

3. The “thin and short” tibial plate can be applied in combination. Because some patients, such as the patient with pediatric paralysis sequela, have weak soft tissue in the limbs, large and thick femoral plates are prone to thigh soft tissue irritation. 4. Internal fixation can reduce the time of external fixator wear and reduce external fixation-related complications such as wire infection, pin pain, and so on (Fig. 4.13).

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4.4.2 Case Illustration The osteotomy of the tibial varus is similar to that of the femur. The hybrid external fixation also has the advantages of simple operation and stable fixation (Fig. 4.14).

4.5

 pplication of Hybrid External A Fixator After Soft Tissue Surgery and Tendon Transfer for Dynamic Reconstruction

Jiancheng Zang and Sihe Qin

Fig. 4.11  The medial ankle quadrilateral

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The soft tissue orthopedic surgery and tendon transfer are usually simple fixed with plaster or external fixator. The hybrid external fixator overcomes the disadvantages of plaster fixation, achieves stable fixation, and can realize ventilation, can observe the incision easily, and it is adjustable for some residual deformities. If external fixator was placed cross the joint after soft tissue surgery, pins showed be set in safety zone and 2–4 rods should be used for fixation. Examples are as follows:

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Fig. 4.12  The configuration of hybrid external fixator for ankle and knee deformity. (a) Pattern diagram; (b) Clinical appearance

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Fig. 4.13  Thirty-year-old female with left knee deformity due to poliomyelitis sequelae: (a) X-ray at positive lateral of knee joint showed the anterior arch valgus deformity; (b) The full-length standing radiograph shows left knee valgus; (c) Roentgenogram showed a medial approach of left femur and supracondylar osteotomy to correct the valgus and anterior arch deformities, the knee joint was fixed in the straight

position; (d) The external fixator was removed 3 weeks postoperatively, and the roentgenogram showed the callus could be seen at the osteotomy space of left femur; (e) Assisted fixation with left lower limb orthosis; (f) After 3 months, visible callus formation at the supracondylar osteotomy space

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Fig. 4.13 (continued)

4.5.1 H  ybrid External Fixation After Achilles Tendon Release for Cerebral Palsy The lower extremity deformity caused by soft tissue contracture in cerebral palsy sequelae can be corrected by soft tissue releasing in one surgery. For example, releasing equinus Achilles tendon and fixing the ankle to correct the deformity

(Fig. 4.15), but the foot fixation of the spastic cerebral palsy is different than other diseases. The experience of the Qin Sihe’ orthopedic surgery is by increasing the number of fixed pins and (or) the connecting rod to increase the stability of the fixation, so that to counteract the muscle spasm and guarantee the biomechanical strength for the patient’s early functional exercise.

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4.5.2 T  he Acute Correction of the Tendon Displacement in Neuromuscular Disease Ankle deformity caused by motor neuron disease often requires “dynamic balance” due to partial muscle strength

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loss. The surgery of this disease is tendon lysis, deformity correction, and tendon transfer surgery. The hybrid external fixator can achieve good fixation, maintain the position of the ankle joint, and let the patient to walk with load and functional exercise because of the firm and secure fixation (Fig. 4.16).

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Fig. 4.14  This patient was a 35-year-old female with left lower extremity varus deformity due to poliomyelitis sequelae. (a) The full-­ length standing radiographs; (b) The left knee lateral stress clinical view showing left tibial varus, suggesting that this patient has both skeletal malformations and joint relaxation; (c) High-level osteotomy at the proximal end of the tibia. After the incision, the osteotomy device was

used as a template to drill the hole, and the tibial varus can be corrected acutely; (d) the two parts were threaded into the screw respectively; (e) Fix the high osteotomy tibial end with a hybrid fixator, while the femoral pins were fixed across the knee to reduce the relaxation of the knee joint; (f) X-ray showed the tibial varus was corrected, and the osteotomy was fixed with K-wires transfixion

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Fig. 4.14 (continued)

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Fig. 4.15  Hybrid external fixation after Achilles tendon release for cerebral palsy. (a) Front view; (b) Lateral view; (c) Back view

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Fig. 4.16 Twenty-two-year-old male with foot deformity caused by bilateral motor neuron disease: (a) Preoperative appearance; (b–f) Bilateral calf muscle atrophy, “crane leg”-like deformity, bipedal talipes equinovarus with high cavus deformity, left foot deformity heavier; (g–j) Radiographs showed bipedal joint changes in the talipes equinovarus; (k–n) Surgical implementation of acute correction: Achilles tendon extension, plantar fascia lysis, posterior tibial tendon transfer, subtalar joint fusion, first interphalangeal joint fusion, extensor pollicis longus moved backward, tendon transfer and fixation; (o–r) Follow-up

7  months after surgery, the deformity correction satisfactory; Radiographs showed subtalar joint fusion; (s) Right side appearance, the surgical plan was written on the right leg in Chinese (t) In the second stage of the right foot, surgical implementation: the Achilles tendon release, triple joint fusion, the first interphalangeal joint fusion, the posterior tibial muscle and the first flexor longus tendon displacement instead of the extensor tendon, Ilizarov ring fixator correction; (u–w) 9 days after surgery, the ankle deformity was corrected satisfactorily; (x) Roentgenogram 9 days after surgery

4  Application of Chinese Hybrid External Fixator Fig. 4.16 (continued)

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Fig. 4.16 (continued)

4.6

 he Strategy of Hybrid External T Fixation with Internal Fixation

Jiancheng Zang and Sihe Qin Dr. Robert Rozbruch of HSS (Hospital for Special Surgery) in the United States first reported this surgical method, which is called the external fixation with aid of plate fixa-

tion. It mainly uses the “external fixation as a tool for position maintenance,” which can be adjusted by external fixation pins to obtain a good osteotomy angle and limb position, or adjustment, the doctor and other staff to reduce exposure to radiation, so that the plate is directly fixed (open or percutaneous fixation). Applying external fixator can be kept or removed after the internal fixation (Fig. 4.17).

4  Application of Chinese Hybrid External Fixator

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Fig. 4.17  Thirty-five-year-old female with rickets and bilateral lower extremity “O-leg” deformity: (a) The full-length standing radiograph shows both lower extremity varus deformity, planning osteotomies to correct femoral deformity immediately and to correct tibial deformity gradually; (b) Longitudinal incision on lateral side of left thigh, exposing the femur through the muscle interval, porous osteotomy; (c) The

distal end and the proximal end of the osteotomy were respectively fixed with pins, connecting the external fixed rod, and measure the angle through a protractor; (d) Corrected deformity to the appropriate angle, then locked the fixator; (e, f) Osteotomy end fixed with a plate; (g) Postoperative X-ray showed the femoral deformity was corrected satisfactorily

136 Fig. 4.17 (continued)

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4.7

 he Structure and Application T of Double Barrel Drill Sleeves

Sihe Qin and Jiancheng Zang Minimally invasive orthopedics is the development direction of orthopedic surgery. The external fixator is a representative of orthopedic minimally invasive fixation, but how to achieve minimally invasive osteotomy is a common problem for orthopedic surgeons. Minimally invasive osteotomy with drill and sleeve was invented in the same period by Dr. Yasui from the Japanese University of Tokushima and Dr.

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Xia Hetao from the Beijing Institute of External Fixation Technology.

4.7.1 Origin of Double Barrel Drill Sleeves Due to the rounded cross section of the femur, the drill bit easily slips off on its surface. If the two sleeves are fixed together, two holes are drilled continuously, and the two holes will be close together, so that the prototype of the double barrel drill sleeves is born (Fig. 4.18); after further processing and fixation, it is used in clinical practice and has exerted an unparalleled advantage.

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Fig. 4.18  Double barrel drill sleeves. (a) Sleeves family; (b) Hole view; (c) Front view

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4.7.2 T  he Application of Minimally Invasive Osteotomy Device 1. Cutting the skin and subcutaneous tissue with a sharp scalpel, and using hemostatic forceps to separate the soft tissue such as the muscle to the bone surface. 2. Inserting a perforated osteotomy sleeve against the bone surface. 3. Inserting the drill bit perpendicular to the bone surface and drilling. 4. Pulling out the drill bit then inserting a K-wire into the bone hole through the sleeve. 5. Pulling out the drill bit after drilling another hole. 6. Inserting another K-wire into the second bone hole through the sleeve. 7. Pulling out the first K-wire, then rotate the sleeve 180°, drilling the third hole through the sleeve, and then pulling out the drill bit. 8. Inserting another K-wire into the third bone hole through the sleeve. 9. Pulling out the K-wire in the second hole and rotate the sleeve 180° to start drilling the fourth bone hole. Looping the above steps until reaching the edge of the bone, then the narrow bone knife is inserted, and the bone can be cut by light chiseling.

4.7.3 Tips and Tricks 1. Do not swing the sleeve and the drill bit during drilling to avoid breaking the drill bit. 2. The drill bit is most easily broken once approximating the edge of the bone, so it can be changed to a K-wire. 3. After continuous drilling, the bone is easy to be broken, so it should be fixed firstly and then drilled, so that the osteotomy end is easy to control the displacement.

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4.7.4 T  he Clinical Practice of Double Barrel Drill Sleeves (Fig. 4.19)

4.8

 nited Application of Chinese Hybrid U External Fixator and Ilizarov External Fixator

Sihe Qin and Jiancheng Zang The complexity of the patient’s limb deformity and the limited choice of medical instruments, coupled with the wisdom of Chinese doctors, prompted the invention of such a “Hybrid External Fixation”. The hybrid external fixator has few components and simple structure, and can be arbitrarily constructed according to the layout of the external fixation pins. However, the postoperative correction of the residual deformity can only be corrected by relaxing the external fixator, manual reduction, often requiring two to three doctors collaborated and the patient had some pain, so it was mainly suitable for fixation after one-time deformity correction operation. The structure of Ilizarov’s annular external fixator is more complicated, and the layout of the external fixator pins needs to be considered according to the fixator configuration. It is not random, but it has the advantage of satisfactory for dynamic deformities correction after surgery. By adjusting the external fixator configuration, it can correct any deformities of the limb. For those who correct two or more deformities in the same period, if one of the deformities can be corrected acutely in the operation, the treatment can be flexibly combined to exert the advantages of both, which can reduce the difficulty of surgery and shorten the operation time and the patient treatment cycle.

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Fig. 4.19  The clinical practice of double barrel drill sleeves: (a) Femur osteotomy was performed using double barrel drill sleeves through a small incision; (b) X-ray showed the bone broken exactly; (c) X-ray showed the new born formation

Case 1 Patients with talipes equinovarus and external rotation of their legs were most commonly treated with Ilizarov external fixator. Performing osteotomy below tibial tuberosity, internal rotating the distal part; installing the hybrid

external fixator at the proximal end, and fixing the distal end to the tibial ring of the Ilizarov external fixator (Fig.  4.20). This is an excellent model of a satisfactory combination of orthopedic surgery optimization and instrument innovation.

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Fig. 4.20  Patients with talipes equinovarus and leg external rotation deformity usually fixed by external fixation after the osteotomy surgery, Ilizarov technique was used to correct the deformity of the talipes

equinovarus, and the proximal tibial osteotomy was used to correct the external rotation of the leg. (a) Simulation on the model; (b) Application on patient with talipes equinovarus and leg external rotation deformity

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Case 2 The proximal end of the femoral fixator is at the proximal end of the classic Ilizarov-type annular femoral extender. Due to the thick soft tissue, it is inconvenient to increase the fixation strength through the annular external fixation ring and the K-wires, so a half pin is added on lateral side of the thigh. The external fixation rods are connected to the thigh Ilizarov external fixation ring to improve the stability of the proximal part (Fig. 4.21). For treatment of O-leg deformity, two osteotomy sites on tibial are often needed. In order to improve the strength of

Fig. 4.21  Ilizarov ring femoral fixator with half pin at the proximal end

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Ilizarov external fixator, we respectively connect the combined connecting rods at the proximal and distal ends of the osteotomy. During the “O-leg” correction process, the hybrid fixator is loosened when adjusting, and fixed when not adjusted, to increase the strength of the osteotomy end. Or after the one osteotomy site’s correction is finished, the rod can be fixed first, and then gradually removed to reduce the overall fixation strength. Case 3 (Fig. 4.22)

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Fig. 4.22  The combination of the hybrid external fixator and Ilizarov external fixator for limb deformity. (a) Standing position, both lower extremity varus deformity in front view; (b) The full-length standing radiographs showed both tibial varus deformity; (c, d) X-ray after bilateral tibial osteotomy (c Clinical standing photo, d The full-length of the tibial roentgenogram); (e) Clinical standing picture of the patient: the external

fixation was stable, no obvious pin infection problems; (f) 7 months after surgery, radiographs showed bone healing of the tibial osteotomy, planning to remove the complex and large annular external fixation devices; (g) Removing the ring fixator connection, maintaining the position with the half pins, carefully observe the pin reaction, and take X-ray to check the bone formation of osteotomy (g), if necessary, simplify the fixator (h)

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Fig. 4.22 (continued)

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5

Lower Limb Deformities in Poliomyelitis Sequelae Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Qi Pan, Baofeng Guo, Xulei Qin, Yilan Wang, Lei Shi, Quan Wang, Li Zhang, and Xuejian Zheng

5.1

Introduction

Sihe Qin, Shaofeng Jiao, and Jiancheng Zang

5.1.1 The Epidemic History of Poliomyelitis Poliomyelitis affects more than 85% in children aged 3 months to 3 years, commonly known as infantile paralysis sequelae in China. In the age of a developing agricultural economy, this disease was only sporadic, it was thought that limb paralysis was the result of tooth-producing, gastrointestinal disorders, or fever in children. In 1840, Heine, a German doctor reported the first case of poliomyelitis. In 1890, Medin described 43 cases of poliomyelitis in Sweden during the same period, followed by a gradual report worldwide over the next few years. Pandemics of polio in Europe and North America occurred mainly in the 1930s and 1950s, and about 500,000 people suffered from polio in the United States from 1928 to 1962. In 1954, Salk et  al. invented inactivated vaccine on the basis of previous studies, and then Sabin Koprowski and Cox invented live attenuated vaccine in 1961. These two vaccines

S. Qin (*) · S. Jiao · J. Zang · Q. Pan · X. Qin · Y. Wang · L. Shi Q. Wang · L. Zhang · X. Zheng Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China B. Guo Tsinghua University Chuiyangliu Hospital, Beijing, China

were widely used in the world, thus the polio epidemic was extinguished in the developed countries in 1960s. Polio virus was eliminated in the United States in 1994, and the existence of native wild poliovirus has been confirmed in the Western hemisphere. Some new poliomyelitis still occurred in Africa, India, Afghanistan, Pakistan, and some other countries until the end of December 2003. In 2004, there was a small scale of polio epidemic in many countries of Africa, including 526 cases in Nigeria. The patients with sequela of poliomyelitis around the world are mainly found in Asian and African countries. In the United States, most of the existing polio sequelae are those older than 50  years of age, similar to Europe. They have been given systematic orthopedic treatment in their adolescence. As a result, the doctors of young and middle-­ age who experienced in the surgical treatment of poliomyelitis sequelae in Europe and the United States are absent virtually. The polio epidemic in China came much later than in Europe and in the United States. A major epidemic of polio occurred in Nantong of Jiangsu province in 1955; more than 2600 cases of polio occurred. As the spread of poliovirus is directly related to population mobility, it is first prevalent in large cities and then spread to rural areas. Therefore, polio epidemic broke out in Shanghai in 1956. The peak of the polio epidemic occurred in the late 1950s to early 1980s. In 1960, Gu Fangzhou et al. successfully developed a live attenuated poliomyelitis vaccine (commonly known as paralysis sugar pill) in the Chinese Academy of Medical Sciences by drawing on the experience of foreign countries and successively products at the Beijing Institute of Biological (Beijing Institute) and China’s medical science Kunming Institute (Kunming Institute). In 1965, the vaccination of live vaccines was popularized nationwide. In 1978, the national program of immunization for children under 7 years of age was implemented.

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_5

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Because of Chinese large population, large land area, and inconvenient transportation in remote areas, the problem of cold chain preservation, transportation, and distribution of vaccines is a complex social project, so the epidemic prevention work in rural areas is not balanced. Thus, several outbreaks still occurred in the late 1970s and 1980s. For example, several large epidemics still occurred in 1988, 1989, and 1990. Until 1994, sporadic cases which were caused by imported wild poliovirus. Still happened in some under developed area. On October15, 2000, the Chinese government submitted to the World Health Organization (WHO) Western Pacific Regional Office the progress report on “Polio Eradication in China in1999” and the “Confirmation document for Polio Eradication in China.” But other viruses of the enterovirus family can also cause diseases that are clinically and pathologically indistinguishable from poliomyelitis. Several cases of acute flaccid paralysis of lower extremities can be examined by Qin every year. In June 2003, the Ministry of Health of China issued the National Action Plan for maintaining Polio Free status for 2003–2010 and informed all parts of the country to organize and implement it seriously. The oral live vaccine immunization program was run until 2016, when a case of flaccid limb paralysis caused by oral live vaccines was reported individually. From 2017, Chinese government began to popularize inactivated vaccine immunization. Polio in China and around the world will soon become history like smallpox. Having learned the simple history of poliomyelitis epidemic and epidemic prevention in China, we can understand why there are still so many young people under 35 years who have been checked out for poliomyelitis sequelae in our outpatient clinic, and quite a few of them are yet to accept scientific, systematic treatment after 2010. But the general trend is that millions of polio patients left over in mainland China will gradually enter the middle and old age, and their surgical treatment, functional assistance, and lifestyle need doctor’s guidance. Because Chinese orthopedic science community has not held the academic conference or training course of poliomyelitis sequelae during the last 20  years, the doctors under 45 years of age hardly understand the surgical treatment for this kind of lower limb deformities! Until now, only Qin orthopedic team insist working on surgical treatment for poliomyelitis sequelae in China. Therefore, this subject of limb functional reconstruction of poliomyelitis sequelae still remains a major responsibility of medical profession (Fig. 5.1).

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Fig. 5.1  The father and his ninth son. The eight children of him are girls, the ninth child is a boy, who suffered from poliomyelitis sequelae (this photo was taken in 2004)

5.1.2 O  ccurrence and Development Factors of Lower Extremity Deformity in Patients with Poliomyelitis Sequelae The lesions of poliomyelitis are in the thoracolumbar gray matter most commonly, and the distribution of the lesions is closely related to the clinical manifestations of limb paralysis. Two years after the acute onset of the disease is recovery period; the muscle strength not recovered also cannot be recovered 2  years later, called sequelae, as a result, which will follow the whole process from childhood to adulthood to old age. The imbalance of muscle strength caused by different degrees and different ranges of muscle paralysis is obvious, which is the period of development of deformity.

5  Lower Limb Deformities in Poliomyelitis Sequelae Destruction of spinal cord anterior horn cells, irreversible degeneration

Accelerated functional decompensation after midlife

Flaccid paralysis

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Functional incapacitation

Rapid development in Deformity childhood development Slow development in adulthood

Continue to move under abnormal conditions

Limb long-term disue, non-physiological load, soft tissue contracture, muscle force imbalance

Deformity

Fig. 5.2  The causes of limb deformities and the factors affecting the transformation of deformities

Joints of children who suffered from severe muscle paralysis, were always in fixed position, because of the contracture of ligament, fascia and muscle. As the flexion advances in the body, the lower extremities are as follows: pelvic tilt, hip flexion contracture, knee flexion contracture, equinovarus and other deformities. A small number of patients presented with paralytic scoliosis and upper limb paralysis deformity. The development of muscle paralysis and bone deformity depends on the following factors: 1. The range and extent of injured neurons in the spinal cord 2. The height and width of the column of the corresponding muscle or muscle group 3. The deformity of the superior side of muscle strength caused by the imbalance of muscle strength 4. Long-term disuse and contracture of muscle and fascia 5. The stress of abnormal bearing 6. The age of illness 7. Whether lower extremity deformities got correct treatment in early stage

Therefore, patients at every stage of lifetime should consult with an experienced orthopedic surgeon to check, consult, guide, or perform orthopedic surgery. Unfortunately, because of the serious lack of orthopedic surgeons in the lower extremities and the lack of popular science propaganda, the majority people with physical disabilities lack the sense of regular examination and consultation (Fig. 5.2).

5.1.3 Physical Examination 5.1.3.1 Gait Analysis Gait is the posture when walking. The gait analysis of poliomyelitis sequelae still depends on visual observation in Qinsihe orthopedics. This method is simple and easy to carry out, does not need special equipment, and can meet the clinical practice. A walkway more than 10 m is required for the gait inspection. The main features are as follows:

1. Walking naturally This is the key point of clinical observation and physical examination. The limb deformities and dysfunction also change with the (a) Walking with shoes: Observing the same walking increase of age. Because of the movement under the non-­ way of patients as usual, walking with shoes first, equilibrium condition for several decades, the limb function which can objectively reflect the characteristics of is bound to weaken when they were entering middle age, limping and the degree of dysfunction. resulting in the degeneration of the healthy limbs, the defor (b) Walking with underwear: Observing the walking way mity of the spine and systemic dysfunction, and so on, which of the patients with only underwear, who walk back were manifested above as post-poliomyelitis syndrome and forth several times in natural posture and speed, (PPS). to observe whether the walking and the whole body

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were in harmony, the swing amplitude, the posture, and characteristics of the joints. The patients can stand with one leg and move slowly or quickly. The patients with light limping gait should be asked about their walking endurance and load walking. (c) The footprints were observed as follows: The position of the foot on the ground while walking with bare foot, the worn area of the shoe and the callus area of the foot. The squat function should be checked. (d) Walking with brace: Some patients can only walk with a brace or auxiliaries, we should observe the degree of movement disorders and the number of limbs involved in the load. For those who cannot stand and walk, their crouching-crawling and other characteristics of activities should also be observed. If the lower extremity is short or flail foot, the gait should be observed after the foot pad is kept high or the orthopedic shoe is worn. 2. Measurement of walking speed This is a practical evaluation method for gait analysis. Draw a straight line of 10  m on the ground, the ends should be marked, allow the patient to walk quickly, measure the time required for walking 10 m, and do the same test after treatment to compare the changes in functional gait. The walking function of patients over 40  years of age may decrease than young people, who should be asked whether there is any change in walking ability and style with age being changed and whether there are any degenerative changes in the deformed joints. The severe deformity and pathological gait of limbs should be photographed before and after operation to evaluate the dynamic therapeutic effect. Pathological gait is different in different patients. Patients with mild pathological gait walk at constant speed, which is similar to ordinary people; severe cases can only crawl on the ground. The most common pathological gait is walking with crutches, gluteus maximus failure, gluteus medius failure, hand on knee, halting, limping, and so on. 3 . Muscle strength examination When the patients are standing, they can be examined in 360°, including extensor muscle group, abdominal muscle group, hip group for extension, abduction, and flexion, femoris quadriceps, hamstring muscles, and so on. Then, ask the patients to sit down for muscle strength examination on foot and ankle joint.

5.1.4 Diagnosis The clinical manifestations of poliomyelitis sequelae have the following characteristics, and it is not difficult to diagnose.

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1. Flaccid paralysis or asymmetrical muscle paralysis, muscle atrophy of affected limbs, decreased muscle tone, tendon reflex weak or disappear, and no pathological reflex usually occur in lower extremities. 2. Normal intelligence, normal sensory function, normal defecation, and urine function. 3. The patients are normal at birth, it appears paralysis after a fever usually in 2 months after birth, and then the paralysis gradually improves rather than progressive aggravation or deterioration. However, some mild cases often do not have a clear fever history and can also be diagnosed after excluding other causes. 4. Limb paralysis and deformity are complex and diverse. In patients with muscular paralysis, poor blood circulation and low skin temperature were observed in the affected limbs. The differential diagnosis included lower limb deformity caused by spina bifida, deformity after peripheral nerve injury, deformity caused by sensorimotor neuron disease, and so on. The clinical manifestations are same with lower extremity paralysis deformity caused by hand-foot-mouth disease sequelae; it is needed to ask the history, but the orthopedic principle is the same.

5.2

 ata Analysis of 23,310 Cases D of Polio Sequela

Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Qi Pan, Baofeng Guo, Xulei Qin and Yilan Wang There were 34,459 patients with various types of limb deformities who had been treated in Qinsihe Orthopedic Institute. In December 2017, a surgical database was established, including 23,310 cases of polio sequela (PL), accounting for over 67% in the database. It may be the largest group of PL surgical case data in the world. On the basis of preoperative diagnosis based on medical history, clinical manifestations, and physical examination, the final decision was made by Dr. Qin Sihe (Tables 5.1, 5.2, 5.3, 5.4, 5.5, 5.6 and 5.7).

Table 5.1  Gender analysis Gender Male Female

Cases (n) 13,723 9587

Percentage (%) 58.87 41.13

Note: The reason why there are more male patients than female patients is probably that Chinese rural families have more patriarchal ideas; therefore, boys have more opportunities for their parents to provide treatment than girls

5  Lower Limb Deformities in Poliomyelitis Sequelae Table 5.5  Common surgical methods (Top 30)

Table 5.2  Age at surgery Age (years) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 61–65 66–70 70+ Maximum age Minimum age Average age

Cases (n) 687 2990 3552 4885 4834 3088 1843 802 293 188 96 33 15 2 2 71 2 20.6

Percentage (%) 2.95 12.83 15.24 20.96 20.74 13.25 7.91 3.44 1.26 0.81 0.41 0.14 0.06 0.01 0.01

Table 5.3  Time trend Time Before 1985 1985–1989 1990–1994 1995–1999 2000–2004 2005–2009 2010–2014 2015–2017

Cases (n) 200 5901 7759 3610 1791 1652 1681 716

Percentage in whole (%) 0.86 25.32 33.29 15.49 7.68 7.09 7.21 3.07

Note: Most of the polio patients were treated from 1990 to 1994. The Chinese government introduced an implementation focusing on surgical treatment of Polio patients. Qin Sihe was a young doctor and the director of Beijing Polio surgical center. The Polio patients who underwent surgery came from many provinces over the country Table 5.4  Age of the patient currently Age (years) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 61–65 66–70 >70 Maximum age Minimum age Average age

Cases (n) 0 24 83 183 269 3702 2301 2865 3204 4444 2928 2325 808 132 42 93 5 43.1

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Percentage (%) 0.00 0.10 0.36 0.79 1.15 15.88 9.87 12.29 13.75 19.06 12.56 9.97 3.47 0.57 0.18

Note: The patients with lower limb paralysis were treated recently by the application of live attenuated polio vaccine. Since 2017, the Chinese government began to promote inactivated vaccine immunization; therefore, the occasional flaccid paralysis of oral live vaccine has been avoided

Surgical methods Supracondylar osteotomy Talocalcaneal arthrodesis Achilles tendon lengthening Tibia and fibula osteotomy Release of plantar aponeurosis Peroneus longus transfer for Achilles tendon Release of flexion hip contracture External oblique transfer for paralysis of medial gluteal muscle Knee flexion release Triple arthrodesis First metatarsal basal osteotomy Sacrospinalis muscle transfer for gluteus maximus Ilium and pubic osteotomy and lengthening Iliotibial band release Peroneus longus transfer for paralysis of tibialis anterior Posterior tibialis transfer for Achilles tendon Chopart arthrodesis Claw toe correction surgery Posterior tibialis transfer laterally Tibia osteotomy and lengthening Ankle arthrodesis Achilles tendon shortening Tibialis anterior transfer for Achilles tendon Semitendinosus transfer for quadriceps Posterior tibial tendon lengthening Interphalangeal joint arthrodesis Muscles transfer for paralysis of ankle dorsal flexion muscle, extensor hallucis longus, and long extensor muscle of the toes Peroneus brevis transfer for Achilles tendon External oblique transfer for paralysis of rectus femoris Half posterior tibialis moves laterally

Cases (n) 6753 5121 4973 3239 2475 2435

Percentage (%) 28.97 21.97 21.33 13.90 10.62 10.45

2260 2249

9.70 9.65

1542 1456 961 880

6.62 6.25 4.12 3.78

847

3.63

812 719

3.48 3.08

694

2.98

654 580 540 539 513 502 466

2.81 2.49 2.32 2.31 2.20 2.15 2.00

429

1.84

425 405 401

1.82 1.74 1.72

347

1.49

285

1.22

273

1.17

Note: Through the statistics of top 30 common surgery methods, we can understand the most frequent deformities of Polio sequela, Qin Sihe orthopedic characteristics, and common optimized combinations of surgeries Table 5.6  Common pathological gait Common pathological gait Mild limping Severe limping Limping with hand on knee gait Calcaneus foot Single crutch Crutches Crawl, squat, crouch or with wheelchair Total

Cases (n) 10,070 2386 3386 683 2695 1916 649

Percentage (%) 46.22 10.95 15.54 3.14 12.37 8.80 2.98

21785

100

Note: Some patients who cannot move were not included

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Table 5.7  Clinical data of the combination of orthopedic surgery and external fixator Time (years) 1978–1989 1990–1994 1995–1999 2000–2004 2005–2009 2010–2014 2015–2017 Total

Hybrid fixator (n) 1 11 196 277 671 1156 468 2780

Ilizarov fixator (n) 6 37 66 146 301 407 230 1193

Orthofix fixator (n) 0 3 2 6 25 0 0 36

Total (n) 6101 7759 3610 1791 1652 1681 716 23,310

Note: Since 1995, the number of polio sequela surgeries with external fixator has increased significantly in Qinsihe Orthopedics Department, because severe deformed patients have grown in number, and orthopedic surgeons have got more and more experiences in the application of external fixator, especially Ilizarov technology

4. Lower extremity deformity and upper limb paralysis or deformity 5. Lower extremity severe discrepancy 6. Lower extremity deformity, structural scoliosis, and pelvic tilt

5.3.2 D  eformity Classification (Based on the Characteristic and Degree of Deformity) 1. Soft tissue contracture, bony deformity, and mixed deformity 2. Whether combined with joint dislocation or osteoarthritis 3. Extent of deformity: mild, moderate, and severe

5.3.3 Classification of Muscle Paralysis

5.3

 eformity Classification and Surgical D Principles

Sihe Qin, Jiancheng Zang, Qi Pan, and Shaofeng Jiao In orthopedic field, there is no other disease like poliomyelitis, which results in different degrees and ranges of muscle paralysis, resulting in different types of limb deformity with various and characteristic pathological gait. Orthopedic surgeons supply service to all the patients with motor system problems their job is helping patients rebuild the limb function and live without the help of others. There are more than 200 kinds of surgical methods, which must be carried out according to individual characteristics, and the postoperative rehabilitation must be carried out properly, and then maximum functional improvement can be achieved for the sequelae of different ages, different types, and deformities. Therefore, many orthopedic experts believe that the surgical treatment of poliomyelitis sequelae is orthopedic mystery and needs thorough theoretical knowledge and many years of practical experience for the treating surgeon. The following is a brief introduction.

5.3.1 D  eformity Classification (Based on the Range of Paralysis) 1. A single deformity involving only one joint, such as the ankle and knee 2. Two big joint paralysis or deformities, such as the hip and the knee, and the knee and the foot and ankle 3. Extensive paralysis of the lower extremity, involved the hip to the toe

The main muscle groups of lower extremity are gluteus muscle, quadriceps muscle, hamstring muscle, triceps muscle, and anterior tibial muscle, totally 10 groups in bilateral lower extremities. The muscle strength of each group was lower than grade 2 (including grade 2) as in the statistical range of paralysis. According to the statistics of 3033 cases, 1343 cases (43.96%) who suffered from one or two muscles paralysis (mainly including quadriceps femoris and anterior tibial muscles) were found to be the highest. There were 1791 cases who involved paralysis of three muscle groups (59.05%). The results showed that the mild-­ type polio sequelae accounted for the majority of 3033 cases, of which in 125 cases there was involvement of nine muscle groups or total paralysis of both lower limbs, accounting for 4.12%. This is only a statistical analysis of patients admitted to hospital for surgical treatment and does not accurately represent the actual incidence of severe paralysis because some patients with severe lower extremity paralysis and deformity have lost the surgical indication and were not hospitalized for surgical treatment.

5.3.4 Classification of Pathological Gait The clinical data of pathological gait of poliomyelitis sequela recorded in Qinsihe Orthopedics Institute was mentioned in Table 5.6 (Fig. 5.3).

5.3.5 Surgical Indication The objective of surgical treatment of poliomyelitis sequelae is to correct deformities, balance muscle strength, stabilize

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joints, and equalize both the lower limbs, recovery or improvement of limb function, and prevention or reduction of long-term complications. In general, to determine whether a patient with lower extremity deformity has surgical indications or not is to analyze and evaluate the requirements and conditions for deformity correction and function improvement, and whether or not to achieve the goal of operation. Some patients should be

a

treated from the view of medical treatment, but the result is not up to the requirements of the patients, so the surgical intervention should be postponed. In recent years, due to the skilled application of Ilizarov technology, surgical indications widened. Patients over 50 years of age should be treated actively if they have the requirement and condition to improve lower limb function. The indication of orthopedic surgery for lower extremities

b

c

Fig. 5.3  Pathological gait of poliomyelitis sequela. (a) Mild limping gait; (b) Severe limping gait; (c) Limping with hand on knee gait; (d) Right knee flexion deformity with single crutch; (e) Knee recurvation

with a single crutch; (f) Knee recurvation with crutches; (g) Severe flexion of the hip and knee with double crutches; (h) Knee flexion deformity with crawl and squat gait; (i) Crouching gait; (j) Calcaneus foot

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d

f

Fig. 5.3 (continued)

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e

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g

Fig. 5.3 (continued)

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h

i

j

Fig. 5.3 (continued)

is relative and needs to be determined individually by person, time, and place. For the same patient, indication of surgery is also influenced by surgeons, competency, his technical level, and overall understanding of disease sequela.

5.3.6 Principal of Operation The surgical principle for lower extremity paralysis of poliomyelitis sequela follows the principles mentioned in Chap. 1, Sects. 1.7 and 1.8, but there are some differences for the

5  Lower Limb Deformities in Poliomyelitis Sequelae

patients with lower extremity deformities that are not with muscle paralysis. 1. In the treatment for patients with severe muscle paralysis, more attention should be paid to the whole analysis of the patients, the overall needs, and then step-by-step implementation. 2. Obese patients should be encouraged for appropriate weight loss, and then surgery should be performed on them. 3. For patients who are crawling or squatting or with wheelchair, surgical treatment must have positive effect and should achieve the goal of walking after surgery, otherwise they are not suitable for surgery. 4. Bilateral lower limbs should not be completely equal in length. 5. Rational application of orthosis and assistant device. 6. Protect affected limb with moderate movement, avoid exercise excessively, otherwise there will be aggravation of muscle atrophy. 7. For patients with mild paralysis, such as quadriceps femoris paralysis with mild knee flexion, the indication of surgical treatment depends on the patients’ demand for the therapeutic effect and the technical level of the surgeon. Until now, expensive medical examinations, equipment, and new surgical instruments have been widely used in orthopedic departments, but the surgical treatment of poliomyelitis sequelae rarely requires those top medical equipment and devices. Good therapeutic effect still needs the surgeons’ dialectical thinking, the whole idea, the scientific decision, the rich practical experience, the skilled surgical technique, and the dedication to relieve patients’ suffering.

5.4

Pelvic Tilt

Sihe Qin, Jiancheng Zang, and Qi Pan

5.4.1 Overview Since humans have walked upright, the pelvis has become an important link that supports the weight of the body and transmits the gravity to lower extremities. So, pelvis is the hub of transmission of force line and the mechanical lever that maintains the balance of the body. The balance of the pelvis is the basis of the whole body’s posture. As for poliomyelitis sequelae, whether there are shoulder and neck paralysis, upper limb paralysis, spinal deformity, hip joint disease, lower extremity paralysis, joint deformity,

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or short contraction, all the above can affect the balance of pelvis, that is pelvic tilt. The pelvic tilt causes much more disease or problem than the pelvic tilt itself. When pelvic is in balance, it is possible to restore the normal weight-bearing of the lower extremities and avoid other deformities of the spine and hip secondary to the pelvic tilt. The essence of pelvic tilt is a compensatory change to maintain a new balance of pelvis when standing and walking under various teratogenic factors. The causes of pelvic tilt can be divided into three types, which is above the level of pelvis, at the level of pelvis, and sub pelvic types. Upper pelvic type is caused by paralytic scoliosis, pelvic factors are caused by pelvis and hip joint, and sub pelvic factors are caused by deformity of lower extremities and knee flexion. The pelvic type is mainly of iliotibial tract contracture and secondary to contracture around the hip joint, and the pelvic tilt is caused by the descending of the ipsilateral pelvis. The sub pelvic type is compensatory pelvic tilt, which is caused by the shortening of the lower extremity or the flexion knee deformity. Some cases with pelvic tilt are the result of two factors, such as lower extremity shortening with iliotibial tract contracture and scoliosis with hip abductor contracture.

5.4.2 Indications and Strategies of Pelvic Tilt Pelvic tilt secondary to paralytic scoliosis and lower extremity discrepancy depends on whether scoliosis and lower extremity discrepancy need to be corrected. Not all patients with pelvic tilt should be treated surgically, and not all pelvic tilt should be completely corrected. In the case of pelvic tilt, if the discrepancy of lower extremity is less than 3 cm after surgery and the contracture of the hip has been released and without condition to equalization, of less than 10° pelvic tilt is beneficial for the compensatory of the mild discrepancy of the lower limb and increase the hip stability and reduced limping gait. Old patients with severe pelvic tilt, severe lower limb paralysis and deformity, and loss of condition of landing, standing, and walking are not suitable for surgical treatment.

5.4.3 P  elvic Tilt Resulting from Paralytic Scoliosis 5.4.3.1 Pathogenesis and Clinical Manifestations The patients are with one side or bilateral sides lumbar dorsal extensor muscle and abdominal muscle paralysis due to poliomyelitis sequelae, muscle strength of bilateral erector spinae is imbalanced, and the spine (mainly lumbar vertebra) is generally bend to strong side, to the weak side

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Fig. 5.4  Pelvic tilt with scoliosis

Fig. 5.5  Tilt corrected by Axer surgery. (a) Take off fascia lata muscle. (b) Flip the fascia lata tensor; the distal iliac-tibial bundle connects with the ribs

a

the 9th rib

b

Gluteus maximus (1/3)

Tensor fascia lata

Gluteus maximus

Tensor fascia lata (1/2)

Ilio tibial tract

convex (some patients are exceptions). With the development of scoliosis, the pelvis tilts toward the convex side of the spine to compensatory upright posture (Fig. 5.4), which can aggravate the deformity of scoliosis. Severe scoliosis patients always have the problem of spinal rotation deformity, they seat only with the greater trochanter on the convex side of the spine.

The X-ray examination should preoperatively include standing view (Fig. 5.5) and traction view to determine the degree and nature of changes in lumbar and pelvic deformities. Surgical program: For preschool children, the two sides of the vertical trunk muscles should be balanced to achieve the correction of non-­ fixed scoliosis and compensatory pelvic tilt.

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For patients with normal lateral hip abduction strength, Axer surgery can be done, which is hip abductor inversion suspension (Fig. 5.5). For the pelvic tilt with fixed scoliosis, lumbar scoliosis deformity should be corrected first. The spinal fixation should span iliac bone, and the pelvic tilt gets corrected mostly with the correction of lumbar scoliosis. In the second stage, pelvic equilibrium operation such as pelvic osteotomy and iliac bone lengthening are performed to correct the residual pelvic tilt deformity.

5.4.4 Qinsihe Classification of Pelvic Tilt New classification of pelvic tilt is carried out in Qinsihe Orthopedic Institute, which according to the causes of deformity, gait characteristics, and pelvic X-ray.

5.4.4.1 Type 1: Pelvic Tilt to Affected Limb Pelvic tilt to affected limb is caused by paralytic hip in abduction and flexion contracture. When the affected limb is loaded, pelvic tilt is caused by pulling the ipsilateral iliac crest down and the contralateral iliac crest is elevated (Fig. 5.6). 5.4.4.2 Type 2: Pelvic Tilt to Healthy Limb The main causes of pelvic tilt to healthy limb are the hip abduction contracture and deformity on the side of healthy limb. Muscle paralysis on contralateral lower limb is more extensive or flail leg. The stronger the gluteus muscle and the older of the age, the more oblique of the pelvis. According to the deformity of proximal femur, it can be divided into two subtypes: Type 2a: Simple contracture type. Most of them are adolescents with mild contracture. There is no obvious bony deformities on the proximal femur and pelvis, and residual muscle strength on the contralateral lower extremities. Type 2b: Femur proximal deformity type. This type occurs in patients with pelvic tilt and long-term walking with healthy limb under single or double crutches. Except the soft tissue contracture, the secondary proximal deformity such as femoral neck stem angle became large to form hip valgus deformity. The contralateral limb is severely short, even suspended, and often associated with contralateral acetabular dysplasia or subluxation (Fig. 5.7).

5.4.5 Surgical Strategy of Pelvic Tilt 1. The above classification of pelvic tilt is simple and suitable for the choice of surgical strategy. According to this classification, different surgical methods can be used.

Fig. 5.6  Pelvic tilt to affected limb

Type 1: With anterolateral incision of the hip, the muscle group and fascia for flexion and abduction can be released to correct the deformity of hip joint. The orthopedic criterion is that the ipsilateral pelvis is motionless when the affected limb is in neutral position. It is helpful for pelvic tilt correction to walk exercise along a line in early stage after surgery. If the patient has only contracture of the abductor muscle group and no hip flexion, only surgical release of the abductor muscle can be done. Type 2a: Pelvic tilt with simple contracture, the contracted tendon release can be done. As the case combined with severe dysplasia of the affected pelvis, the gluteal muscle and fascia release and iliac bone lengthening on affected side can be carried out, iliac bone was taken for grafting.

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Fig. 5.7  Pelvic tilt type 2b

a

In this way, the soft tissue contracture can be released partially. At the same time, the affected pelvic osteotomy lengthened with bone grafting from ipsilateral iliac bone. The pelvis was in balance with the contralateral pelvis being shortened and the affected pelvis lengthened. Type 2b: Femur proximal deformity type. If the patient whose contralateral acetabular coverage is normal and the lower extremity is shorter than 5 cm, femoral subtrochanteric adduction and shorten (not >3cm) osteotomy can be done (Fig. 5.8). If the patients are with subluxation of the affected hip, they can be treated with subtrochanteric osteotomy on healthy side and contralateral hip surgery (Fig. 5.9). 2. If the patients are with severe pelvic tilt combined with coxa vara deformity on paralyzed side, the contralateral subtrochanteric adduction osteotomy and the subtrochanteric abduction osteotomy on affected side are performed, and pelvic tilt is corrected naturally after surgery. For patients with acetabular dysplasia, iliac lengthening is performed at the same time with bilateral osteotomy (Fig.  5.10), and then transposition surgery of oblique abdominal muscle or sacral spinous muscle replace gluteus muscle can be done in the second stage. 3. Pelvic tilt with knee and ankle deformities Patients with pelvic tilt combined with knee or ankle deformities on the adducted side should be corrected earlier or simultaneously. Those deformities and dysfunction affect walking, if cannot be operated at the same time, should be treated as soon as possible after pelvic tilt correction. In patients with pelvic tilt combined with gluteal paralysis, muscle transfer surgery should be carried out in the second stage in order to enhance the dynamic stability of the hip joint. In other words, the restoration of static and dynamic balance of the lower limb is the basis of treatment of pelvic tilt. b

Fig. 5.8  Pelvic tilt treated by healthy side subtrochanteric osteotomy: (a) Preoperative X-ray, pelvic tilt; (b) Subtrochanteric adduction and shortening osteotomy on right side was performed, and pelvic tilt was improved 12 months after surgery

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Fig. 5.9  Pelvic tilt treated by subtrochanteric osteotomy on healthy side and acetabular osteotomy on affected side. (a) Pelvic X-ray preoperative; (b) X-ray 3 months after surgery

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Fig. 5.10  Pelvic tilt treated by bilateral proximal femur osteotomy and iliac bone lengthening. (a) Pelvic X-ray preoperatively showed severe pelvic tilt with left hip dislocation. (b) In 25 months follow-up, X-ray showed pelvic tilt and left hip subluxation have been corrected

It is not necessary to perform special surgery for compensatory lumbar scoliosis due to pelvic tilt, which can naturally improve after pelvic tilt correction. 4 . Patient with pelvic tilt combined with severe structural scoliosis Patients with pelvic tilt combined with severe structural scoliosis of lumbar spine (Fig. 5.11) should be treated for scoliosis at the first stage, and then the pelvic tilt may be

improved naturally. Residual pelvic tilt and lower extremity deformities are corrected in second stage.

5.4.6 Pelvic Tilt of Sub Pelvic Type It is mainly caused by lower limb discrepancy. If the pelvis is oblique to the side of the short limb, lumbar vertebrae can

160 Fig. 5.11  Pelvis tilt and scoliosis: (a–c) A 33-year-old male with pelvis tilt and scoliosis. Front view, lateral view, back view. (d) Full-length X-ray of both lower limbs

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develop compensatory scoliosis. The shorter the limb, the more severe compensatory scoliosis and pelvic deformity. The development and degree of pelvic tilt will be more severe if the lower extremity is short with flexion deformity and, in a long term, can lead to secondary osteoarthritis of the spine and sacroiliac joint.

5.4.6.1 Examination of Pelvic Tilt in Sub Pelvic Type First, measure the true length of the lower limbs and calculate the number, and then check whether the pelvis can

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reach the horizontal position with the help of plantar raised blocks in the short limb (Fig.  5.12). If the pelvis is still imbalanced, the other causes of pelvic tilt should be carefully examined.

5.4.6.2 Material of Surgical Treatment With the lower limb lengthening, the knee flexion deformity correcting, the pelvic tilt will be corrected naturally. Fifty-six patients with pelvic tilt were treated followed by this classification and surgical strategy in Qinsihe Orthopedics Institute, the follow-up period was 12 months to 6 years and

5  Lower Limb Deformities in Poliomyelitis Sequelae Fig. 5.12  Pelvic tilt in sub pelvic type: (a) Pelvic tilt caused by lower extremity shortening; (b) Pelvic tilt is corrected after padding

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8 months, with an average of 2 years and 4 months. The results were as follows: based on the measurements of pelvic X-ray, 11 cases of pelvic tilt were completely corrected, of which the minimum correction was 6°; 45 cases in majority correction, the average correction was 11.2°, the average rate of correction was 78.3%. Six cases with hip subluxation preoperatively were corrected completely or partially after surgery. Twelve cases with hand on knee gait can walk with bare hands. Thirty-five cases were walking supported by crutch preoperatively, out of which 18 cases abandoned their crutches.

5.4.7 Measurement of Pelvic Tilt The measurement method of pelvic tilt has not been unified so far. The commonly used methods in Qinsihe Orthopedics Institute are as follows: 1. If the patient is in supine, lower limbs are placed at the same position, and the iliac crest should be at the same horizontal level; otherwise, the pelvis is tilted. 2. The length of the anterior superior iliac spine to pubic symphysis cartilage is measured, and the height of

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bilateral anterior superior iliac spine is measured and compared. 3. The distance between iliac crest and rib edge is measured. 4. When the patient is standing, the angle between the gravity line and iliac crest line is measured, and then the angle of pelvic tilt can be measured (Fig. 5.13). 5. X-ray examination Pelvic radiographs and full-length X-ray films of both lower extremities should be taken in standing position; if the patient cannot stand, the legs should be kept in neutral position as far as possible. The vertices of the iliac crest or the acetabular rim are perpendicular to the longitudinal axis of the trunk. Normally, the two lines meet at two right angles, and if one side presents acute angle, the contralateral pelvis moves upward. The angle between the vertex line of bilateral acetabular rim and horizontal line are inclined. The difference between the heights of the two lines is pelvic tilt distance (Fig. 5.14). The degree of pelvic tilt and bilateral limb mechanical axis can be measured on the full-­length X-ray films of both lower extremities.

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Fig. 5.15  Paralytic dislocation of the hip Fig. 5.13  Measurement of pelvic tilt at standing position

Fig. 5.14  X-ray measurement for pelvic tilt

5.5

Paralytic Dislocation of the Hip

Sihe Qin, Shaofeng Jiao, Jiancheng Zang, and Xulei Qin

5.5.1 Overview The main cause of paralytic dislocation of the hip (PDH) is extensive paralysis of gluteal muscle and relaxation of hip joint. If the iliopsoas muscle and adductor muscle group still have a certain strength, owing to dynamic imbalance, the hip joint produces flexion and adductor deformity; when the patient is walking, the posterior articular capsule is gradually

relaxed by the squeeze of the femoral head, the ligamentum teres is elongated, and finally the hip joint is subluxated or completely dislocated, which developed with age, often secondary to pelvic tilt and lumbar scoliosis deformity (Fig. 5.15). In some patients with a severe relaxation of capsule, the femoral head can come and go freely into or out of acetabulum, hence called “Walking hip.” The paralytic hip develops subluxation of hip joint gradually owing to gluteus paralysis or muscle strength imbalance, hip relaxation, pelvic tilt with abnormal weight-bearing stress, and so on, a few cases develop total dislocation of hip. Almost all adult patients are accompanied by changes of femoral neck shaft angle and anteversion angle. The older the patient is, the more significant the pathological changes are.

5.5.2 F  avorable Conditions of Surgical Correction for PDH For surgical correction and functional reconstruction of PDH, some favorable conditions can be fully utilized. 1. Muscle atrophy, blood vessel thinning, less bleeding during the operation, easy to expose the surgery site. 2. Joint relaxation of the hip with small femoral head and big acetabulum fossa; joint reduction is easy. 3. Osteoporosis. It is easy for the application of internal fixation, few complications such as femoral head necrosis and hip stiffness after surgery. 4. Most of the patients are young adults, who can perform correct functional exercises according to the doctor’s instructions. 5. The bony operation and the muscle displacement or tendon transfer can be carried out in one stage.

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5.5.3 G  rading of Paralytic Dislocation of the Hip

muscle strength and pelvic tilt caused from dislocation of the hip and then to perform surgical reduction and capsule tighten and superior acetabular osteotomy (Fig.  5.16). The transposition of the oblique abdominal muscle to medial gluteus muscle should be done as much as possible. If there is no obvious deformity in the proximal femur, it is not necessary to perform osteotomy. Good results would come owing to hip abduction being fixed at 30° position for 8 weeks after surgery. The pathological changes of acetabular and proximal femur occur in almost adult patients. The combined surgery should be done for all the pathological structures of the hip in one stage.

The pathological mechanism of PDH is different, the degree and the range of muscle paralysis of lower extremity are different, and the walking function is very different too. Therefore, we should not only focus on the dislocation of the hip preoperatively, but also the mechanical axis of the lower limb, consider the objective condition and subjective requirement of the patient, and estimate the goal of functional reconstruction. According to the age of the patients, different types, and different degrees of dislocation of hip joint of PDH, a reasonable surgical plan can be made. PDH is divided into three degrees in Qinsihe Orthopedics Institute: 1. Slight lateral dislocation of the femoral head, CE angle less than 20°. 2. Moderate dislocation, the femoral head exceeds over acetabular rim at 1/3–1/2 diameter of the femoral head. 3. Severe dislocation, the femoral head exceeds over acetabular rim more than 1/2 diameter of the femoral head, or high dislocation. Paralytic dislocation of the hip occurs gradually with the age of the patient. This grading can only reflect the degree of hip dislocation, not reflect the age of the patient, the degree of muscle paralysis, and the deformity and function of the lower extremity.

5.5.4 S  urgical Strategies and Methods of PDH 5.5.4.1 Adolescent Patients As the pathological changes of the proximal femur are mild, the purpose of the operation is to relieve the imbalance of

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Fig. 5.16  Acetabular osteotomy for paralytic dislocation of the hip: (a) A 12-year-old female, left hip paralytic subluxation; (b) The acetabular osteotomy was performed, and the external oblique abdominal muscle

5.5.4.2 The Patient with Grade I PDH with Gluteus Medial Muscle Paralysis and Without Obvious Hip Relaxation The procedure of iliac osteotomy or lengthening and transposition of the oblique abdominal muscle can be done (Fig. 5.17). 5.5.4.3 Modified Tonnis Osteotomy This procedure can increase the rotation angle of distal pelvis; thus, the coverage of femoral head can be increased effectively for hip subluxation. Considering the safety, ischial ramus osteotomy is performed with posterior incision in lateral position. And then the patient is transferred to supine position; with another iliac incision, ilium and pubis osteotomy is done, rotated, correction done, and then lengthening and grafting can be done (Figs. 5.18 and 5.19). 5.5.4.4 The PDH with Femoral Proximal Deformity For the PDH cases with abnormal femoral neck shaft angle and anteversion angle, subtrochanteric femoral osteotomy should be combined with joint reduction and acetabular arthroplasty as the surgical procedure (Fig. 5.20). The gluteal

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was transferred to the medial gluteus muscle; (c) 3 years follow-up, the X-ray showed satisfactory coverage of the left hip

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Fig. 5.17  Ilium and pubis osteotomy and lengthening for PDH with lower limb discrepancy: (a) A 19-year-old female with right hip paralysis subluxation of hip joint and gluteus muscle paralysis; (b) Ilium and Fig. 5.18  Modified Tonnis osteotomy. (a) Ischium osteotomy with posterior incision; (b) Ilium and pubis osteotomy with iliac incision

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pubis osteotomy done and lengthening fixed with plate; (c) In 1-year follow-up, X-ray showed good coverage of the hip, the difference of limb length decreased and the limping gait improved

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Fig. 5.19  Modified Tonnis osteotomy for the treatment of hip subluxation. (a) A 32-year-old female with right acetabular dysplasia and pelvic tilt. Preoperative X-ray. Modified Tonnis osteotomy was performed

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and fixed with plate; (b) In 4 months after surgery, X-ray showed good coverage and bone formation of the hip

5  Lower Limb Deformities in Poliomyelitis Sequelae Fig. 5.20 Acetabular arthroplasty and subtrochanteric osteotomy for hip subluxation. (a) A 24-year-old male with PDH. Pelvic plain X-ray preoperatively; (b) Acetabular arthroplasty and subtrochanteric osteotomy were performed, pelvic plain X-ray was taken 2 weeks after surgery

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Fig. 5.21  Chiari pelvic osteotomy: (a) A 23-year-old female with eft hip joint subluxation; (b) Chiari operation was performed; (c) In 4 years follow-up, the X-ray showed good coverage of the hip joint

muscle and fascia should be tightened with the external oblique muscle transposition simultaneously. Chiari pelvic osteotomy (Fig. 5.21) is performed in adult patients with no significant hip capsule relaxation and mild gluteal muscle paralysis. If combined with gluteus medius paralysis, sartorius muscle, tensor fasciae lata muscle strength level 4 or more, posterior replacement of anterior superior iliac spine can be done for gluteus medius muscle.

5.5.4.5 Hybrid Procedure for PDH in Adult The purpose of the hybrid procedure is to restore static stability and dynamic balance of hip joint in one stage. Therefore, two, three, or even more than four major surgeries can be done in one operation. Systematic evaluation, careful planning, and proper procedures should be done with especial emphasis to reduce surgical trauma preoperatively. Case A 33-year-old female with right lower limb paralysis due to poliomyelitis.

The muscle strength of iliopsoas, sartorius, and adductor femoris are grade 4-3, and the gluteal muscles are completely paralyzed. The hip flexion deformity is 35° preoperatively with total dislocation of the hip joint. The proximal femur is deformed without obvious deformity on knee and ankle joints. Before operation, the affected limb participated in weight-­ bearing walking. Combined surgery of hip flexion release, iliopsoas displacement for gluteal muscle, femoral head reduction, acetabular plasty, hip capsule constriction, and subtrochanteric femoral osteotomy were done. Postoperative management: The requirement of immobilization for the patient with paralytic dislocation of the hip who underwent bone surgery is to maintain the abduction of the hip joint at 30° with slight internal rotation, which is the position required after the replacement of the gluteus medius. Light and comfortable hip thermoplastics braces are fixed. On the third day after surgery, the patient was trained to exercise the isometric strength of the iliac psoas. Two weeks

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after surgery, the patient can walk with walker and under the control of hip abduction brace (Fig. 5.22). Five operations were performed in this case through a single incision. The internal and external plates of the iliac bone and the muscular attachment points of the anterior superior and inferior iliac spines were dissected. The deformity of hip flexion was corrected with the iliopsoas muscle anchorage points were free. The bone taken from the ilium

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window was used in the reconstruction of the acetabular roof, and the femoral head was temporarily fixed in the center of the acetabulum under the condition of good reduction. It was easy to measure and correct the pathological changes of the proximal femur with subtrochanteric osteotomy. Fixing the end of subtrochanteric osteotomy with external fixator and small plate can reduce the length and trauma of femoral incision. The hip joint test was performed after the completion of the bony surgery to check the stability of the hip. The iliac psoas muscle transposition replaced the gluteus medius and also eliminated the dynamic factors resulting in dislocation of the hip.

5.5.5 D  ecompensated Contralateral Hip Dislocation 5.5.5.1 Pathogenesis The name of decompensated contralateral hip dislocation was given by Qin Sihe in1990. It mainly occurs in the patients with paralysis of one leg but good alignment due to poliomyelitis sequelae. The pathogenesis is as follows: The patients are with compensatory pelvic tilt with hip abduction contracture or lower extremity shortening and walking on bilateral lower limbs, that is, the contralateral pelvis tilting upward, the affected pelvis falling. The shearing force of the contralateral femoral head moving is increased, and the CE angle of the healthy hip is decreased; this hip joint can be subluxation or dislocation. Because pelvic tilt occurs from shortening and paralysis of the affected limb, the healthy limb bears more loads during daily standing and walking, resulting in secondary acetabular dysplasia or joint subluxation or even osteoarthritis. It was named decompensated contralateral hip dislocation (Fig. 5.23). 5.5.5.2 X-Ray Examination This kind of dislocation of the hip almost occurs in healthy limb, the degree of dislocation was different such as lateral movement of head slightly, subluxation or dislocation. The shear on acetabulum rim increased with the development of pelvic tilt, the degenerative changes are inevitable over a long period of time (Fig. 5.24). These patients come to hospital most likely for pain. The case is with left lower extremity paralysis due to poliomyelitis sequelae. X-ray showed high dislocation of right hip and scoliosis.

Fig. 5.22  Clinical appearance. The hip joint abduction orthosis was taken 2 weeks after surgery

5.5.5.3 Surgical Principle If the lower limb discrepancy is >3 cm in adult patients, the affected lower extremities lengthening should be performed first, the pelvic tilt is naturally balanced after surgery, and

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Fig. 5.23  Decompensated contralateral hip dislocation: (a) A 39-year-­ old female with left lower extremity muscle paralysis, gluteus muscle fascia contracture, secondary severe pelvic tilt, right hip decompensated subluxation, walking with hip joint pain. (b) The left hip flexion contracture was released and the right pelvis Chiari osteotomy was per-

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formed simultaneously. Pelvic X-ray was taken 2 weeks after surgery. (c) In 26 months follow-up, the limping gait was obviously improved and the pain of hip joint disappeared. X-ray showed pelvis balance, good coverage on the right hip, the patient was satisfied with the curative effect

5.6.1 Overview

Fig. 5.24  Decompensated contralateral hip dislocation

then the subluxation of the hip joint will improve automatically. The hip surgery should be carried out in the second stage. If the lower limb discrepancy is 60°, the surgical procedure is as follows: posterior knee soft tissue release, common peroneal nerve release, femoral supracondylar shortening osteotomy (3–4 cm), posterior angular osteotomy and fixed

with plate, and application of Ilizarov fixator for residual deformity.

5.7.1.3 Surgical Strategy for Flexion Deformity of the Knee Surgical strategy should be determined according to the degree and the type of flexion deformity, the overall condition of muscle paralysis of lower extremity, the presence or absence of hip, foot, and ankle deformities, and the limb function. 1. Patients with simple soft tissue contracture are treated with soft tissue release, and common peroneal nerve should be released at the same time.

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Fig. 5.40  When the patient is standing, the right hip joint is extremely internally rotated, and the healthy limb is pressed on the knee of the affected limb to prevent kneeling. (a) A 34-year-old female with complete paralysis of the hip and knee accompanied by 15° knee flexion deformity, which is necessary to maintain the stability of the lower extremity when standing and walking. The right lower extremity is

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extremely internally rotated, and the healthy lower extremity is compressed on the right knee, forming a peculiar claudication gait. (b) The right femoral supracondylar osteotomy was performed to correct knee flexion deformity, and the external oblique abdominal muscle was transferred to the gluteus medius muscle. The affected limb can walk in neutral position postoperatively

2. The anterior arch deformity on distal femur or proximal tibia is corrected by osteotomy. If both, osteotomy should be performed simultaneously. 3. Patients with mixed flexion deformity should be treated with the combination of soft tissue release and bone osteotomy. 4. If the flexion deformity is >40°, the deformity cannot be corrected more than 30° at one time during the surgery. The residual flexion deformity can be corrected by Ilizarov technique. 5. Patients with genu varum, genu valgum, and external rotation of the leg should be corrected by osteotomy in the same stage. 6. Patients with flexion hip deformity must be corrected simultaneously. 7. In patients suffering from knee flexion and foot and ankle deformity, one-stage surgery should be done. In case staged, the interval between two surgeries should not exceed 1 year, so as to weight-bearing exercise.

Fig 5.41  Abnormal gait secondary to severe calcaneus foot combined with quadriceps femoris paralysis and flexion knee deformity

5.7.1.4 Surgical Risks and Complications 1. Common peroneal nerve paralysis. Common peroneal nerve paralysis is caused by too much knee flexion correction in one-stage surgery. For those with knee flexion

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Fig. 5.42  Hybrid surgery for the correction of multiple joint deformity. (a) A 15-year-old female with 35° of hip flexion and knee deformity presented hand on knee gait preoperatively. Front view. (b) Back view. (c) Left hip and knee flexion release, femoral supracondylar oste-

otomy were done and fixed with long leg plaster. (d) In 12 days after surgery, gravity line of left lower extremity was restored, and the patient walked upright with crutches. (e) X-ray showed pelvic tilt 35° preoperatively. (f) Pelvic tilt was corrected postoperatively

deformity, the fascia of the common peroneal nerve should be released in advance to avoid nerve squeezing during the processing of deformity correction. 2. Knee joint stiffness. High incidence occurs in adult or elderly patients, it should be predicted how to reduce this incidence preoperatively. 3. Osteoarthritis. Over 60° knee flexion deformity in adult whose anterior articular cartilage degenerated, suprapatellar capsule atrophy due to lack of sufficient activity. Knee stiffness (Fig.  5.43) and osteoarthritis may occur when knee flexion deformity correction is completed. mentioned above should be known by doctors preoperatively.

5.7.1.5 Muscle Transfer for Quadriceps Femoris If the patients, 1 year after knee flexion deformity correction, still feel unstable knee while walking, muscle displacement can be done to improve the knee extension function. The muscles selected for transposition are as follows: s­ emicircular muscle, biceps femoris muscle, gracilis muscle, sartorius muscle, external oblique abdominal muscle, rectus abdominis muscle, and so on. For the patients over 40 years of age, abdominal muscle transfer and connect with iliotibial bundle to reconstruct the function of flexion hip and knee extension can obtain satisfactory curative effect with no complications (Fig. 5.44).

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Fig. 5.43  Severe knee flexion deformity

5.7.1.6 Supracondylar Femur Osteotomy (Fig. 5.45) Supracondylar femur osteotomy plays an important role for effective correction of anterior arch flexion deformity of distal femur, which can restore the alignment of lower extremities and improve the walking gait. Until December 2017, 6753 supracondylar osteotomy on femur have been done in Qinsihe’s Orthopedics department, which was the most common surgery of lower extremity for poliomyelitis sequelae. The second one was subtalar arthrodesis, 5121 cases of which showed it was a scientific orthopedic routine between supracondylar osteotomy and foot stable surgery. About 4973 cases of Achilles tendon lengthening procedures included proved that there was a causal relationship between knee flexion deformity and equinus deformity in poliomyelitis sequelae. Indication Knee flexion deformity caused by anterior arch of the distal femur, with reduced femoral condylar shaft angle. Anesthesia and Posture With epidural or general anesthesia, the patient is in supine position.

Fig. 5.44  Long-term follow-up of patients after abdominal muscle transfer. Ipsilateral oblique abdominis and 1/2 rectus abdominis transposition was transferred to reconstruct the function of flexion hip and knee extension. After 5-year follow-up, the function of active hip flexion was 40°, and the muscle strength of knee extensor was three grades

Surgical Procedures 1. Incision: In patients with neutral knee flexion or combined with genu valgum, medial incision can be used for osteotomy. In patients with knee flexion and femur varus, superior lateral incision will be better. This procedure is performed along with the medial incision. 2. Surgical step: (a) A 5-cm straight incision is started from medial femoral condyle along the lower margin of medial femoral muscle, which is slightly separated from the end point of the medial femoral condyle, without touching the periosteum. Periosteal strippers are inserted on the medial and lateral sides of the femur to expose the bone to avoid damaging bursa suprapatellaris. (b) The height of supracondylar femur osteotomy is 5–7 cm above knee joint (Fig. 5.46). The method of

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Fig. 5.46  Subtalar joint arthrodesis

Fig. 5.47  Supracondylar osteotomy of the femur was performed with osteotome

Fig. 5.45  Supracondylar femur osteotomy

osteotomy depends on the degree and the type of knee flexion deformity, usually with close wedge or V-shaped osteotomy. It is best to drill out a row of holes with electric drill and then osteotomy with a sharp osteotome (Fig. 5.47). By pressing the bone, the posterior cortex is broken; the proximal end inserted into the distal end can be seen during V-shaped osteotomy, and then the knee becomes straight. (c) If knee flexion and mild genu varum are caused by distal femur deformity, the medial incision of supracondylar osteotomy can be used for deformity correction.

(d) Hybrid fixator is mounted for maintaining the osteotomy at the desirable position. A thin reconstruction plate with five holes is applied for local fixation and then is connected with tibia fixator for 4 weeks. (e) X-ray examination is not necessary for the whole process. When the surgery is completed, the depth of screw can be checked under X-ray fluoroscopy. (f) Because periosteum is not dissected, the skin can be sutured in one layer, so that drainage tube or rubber drainage can be placed in the incision. Postoperative Management Three days after surgery, the patients could get out of bed and weight-bearing with healthy limb. The external fixator can be removed 3 weeks postoperatively, and then fixed with a brace for limb protection (Figs. 5.48 and 5.49).

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Fig. 5.48  Femur supracondylar osteotomy from medial incision was fixed by reconstruction plate. (a) The space of osteotomy; (b) Plate fixation

Matters Needing Attention Supracondylar femur osteotomy is a common surgery to correct knee flexion and improve limb function. However, due to the age of the patients, the degree of muscle p­ aralysis, and knee flexion, the methods of osteotomy and the angle of deformities are different. Matters needing attention for avoiding more severe complications are as follows:

Fig. 5.49  Knee orthosis was taken after fixator removal

1 . The bursa suprapatellaris must be cared. 2. The application of external fixator. 3. In patients with moderate knee flexion and good muscle strength of gluteal muscle and triceps, about 6° flexion should be kept, so that the gait can be restored close to normal level after surgery. 4. External fixator-assisted internal fixation is very important to ensure the requirements of deformity correction. 5. For the flail leg with knee flexion deformity, the supracondylar femur osteotomy should maintain a recurvation angle at 15°~20°. 6. Adult patients with knee flexion deformity combined with anterior arch flexion of the distal femur and external rotation deformity of tibia should be corrected simultaneously and fixed with hybrid fixator. 7. For the patients with knee flexion deformity caused by mild anterior arch deformity of distal femoral, supracondylar femur osteotomy and semitendinosus muscle transfer to quadriceps femoris can be performed simultaneously, but the osteotomy must be fixed with a plate. 8. For the knee flexion deformity is >60°, most of them can be corrected by shorten osteotomy on femur in the first surgery. Ilizarov technique was applied for residue deformity correction (Figs. 5.50, 5.51, and 5.52).

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5.7.2 Genu Recurvatum

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5.7.2.1 Etiology of the Genu Recurvatum Genu recurvatum deformity is opposite to the flexion deformity of the knee. The normal range of motion of the knee joint in the sagittal plane is about 0–150°, and hyperextension is 5–10°. When the knee joint is at over extension position more than 10°, the motion of the knee joint is abnormal (Fig. 5.53). There are three causes for the genu recurvatum: b

Fig. 5.50  Tibial osteotomy for tibia torsional deformity correction. (a) Tibia external rotation deformity. (b) Tibia sub tubercular osteotomy was performed to corrected tibia torsional deformity

1. Muscle paralysis of the extensor and flexion muscles of the knee joint, that is, the knee joint lost the ability to control the center of gravity, standing upright completely rely on the interlocking of the articular ligament and the tension of the posterior articular capsule of the knee joint. The center of gravity moves forward cause knee hyperextension. In severe cases, the angle of genu recurvatum will be more than 50° (Fig. 5.54). 2. The second reason is that quadriceps femoris muscle is normal and hamstring muscle paralyzed. 3. The third type is in secondary. The patients’ muscle strength of the knee is normal, but there are congenital or acquired equinus deformities. In order to make the heel on the ground while standing and walking, the knee joint is forced to take an over extension position (Fig. 5.55).

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Fig. 5.51 Femoral supracondylar osteotomy and semitendinosus transfer to quadriceps femoris were performed simultaneously. (a) Femoral supracondylar osteotomy was performed and fixed with plate; (b) The end point of semitendinosus was cut off and dissociated; (c)

Semitendinosus was transferred to patellar ligament through subcutaneous tunnel; (d) The semitendinosus was sutured to the patellar ligament under proper tension

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Fig. 5.52  Femoral shortening osteotomy, Knee flexion release combined with Ilizarov technique for the treatment of severe knee flexion deformity. (a) Poliomyelitis sequelae in adulthood; (b) X-ray preoperatively. (c) Left knee flexion release; (d–e) Femoral shortening osteotomy by 4.6 cm; (f) The bone segment was fixed with hybrid fixator and plate; (g) Ilizarov knee fixator was applied to correct the residual deformity; (h–i) In 60  days postoperatively, the knee deformity had been

corrected, X-ray showed that the joint space was normal. (j–k) In 5 months after surgery, the external fixator was removed, the maximum extension of the knee joint was 0°, the passive flexion was 50°, and the X-ray of the knee joint was observed; (l) In 11 months postoperatively, the patient could walk with orthosis on his left lower limb; (m) X-ray showed that the structure of knee joint was normal, and the right lower limb deformity will be corrected in the second stage

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5  Lower Limb Deformities in Poliomyelitis Sequelae Fig. 5.52 (continued)

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Fig. 5.53 Genu recurvatum. A 7-year-old female with genu recurvatum

Fig. 5.54  X-ray of severe genu recurvatum (79°)

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5.7.2.2 Classification and Strategy of Surgery for the Genu Recurvatum According to the pathological changes, genu recurvatum deformity was divided into soft tissue type, bone type, and mixed type. The former is actually the early stage of genu recurvatum, and the latter is the inevitable result of genu recurvatum. Soft Tissues Type of Genu Recurvatum The muscle around knee of the patients are paralysis, with the development of the body, the deformity of genu recurvatum occur and gradually aggravated with the increase of body weight, also combined with the genu varum or genu valgum of the knee. Treatment: Mild genu recurvatum can be corrected by wearing knee flexion braces. The static and dynamic factors of genu recurvatum should be cared with surgical method. The common surgical method is posterior capsule and tendon of knee tightening and then walking exercise with an orthosis (Fig. 5.56). Bone Type of Genu Recurvatum It is more commonly found in the patients who have undergone supracondylar femur osteotomy previously. The principle of surgical correction is to correct the bone deformity by anterior osteotomy of femoral condyle with plate, and then the knee immobilized with external fixator for soft tissue contracture (Fig. 5.57).

Fig. 5.55  Talipes equinus and genu recurvatum. Overload stress from long-term standing and walking on one leg promote the development of genu recurvatum Fig. 5.56  Genu recurvatum with genu varum. (a) A 24-year-old patient with quadriceps femoris paralysis supported by the right lower limb in the genu recurvatum position. (b) Genu recurvatum with genu varum

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Mixed Type of Genu Recurvatum Mixed type of genu recurvatum is characterized by both soft tissue relaxation posterior knee and pathological skeletal changes, which is inevitable in adult patients. b

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3 . Knee joint immobilization in flexion position 4. Application of long leg brace

5.7.2.3 Osteotomy Surgery of Genu Recurvatum 1. Femoral supracondylar osteotomy. The bony angle of femoral supracondylar osteotomy is controlled by fixator, then fixed with plate, and grafted with iliac bone. 2. Tibia osteotomy anterior elevation procedure is per formed below tibial plateau and above tibial tubercle, grafted with iliac bone, and internal fixation is not necessary. 3. External fixator requires assistive performing the anterior angular osteotomy of tibia below tibial tubercle.

Fig. 5.57  The distal femur recurvation deformity secondary to supracondylar osteotomy

The pathological changes are the anterior collapse of the tibial plateau, the flat anterior femoral condyle, and the backward protrusion of the posterior margin. When formulating surgical plan and postoperative rehabilitation potocles, the following matters should be systematically examined and evaluated through an overall view. 1 . The reason and the degree of genu recurvatum 2. The extent of muscle paralysis of lower extremity and walking function 3. Whether accompanied with genu varum and foot and ankle deformities 4. The condition of ligament relaxation of the knee 5. The patient's age, job, and requirements for the treatment 6. Whether the body is obese, with or without osteoarthritis of the knee 7. Whether accompanied with deformity of spinal, pelvis, contralateral lower extremity

5.7.2.4 Soft Tissue Natural Reconstruction Using External Fixation It is unable to perform any surgery for the patients with severe genu recurvatum deformity with extensive ligament relaxation. Qin Sihe proposed a simple method that soft tissue natural reconstruction using external fixation is practical and reliable with satisfactory result (Figs.  5.58 and 5.59). The procedure is as follows: 1. Knee joint immobilization in flexion position at 60° for 30 days using external fixation. 2. The leg position is maintained at knee flexion in position of 30° by adjusting fixator 30 days after surgery, and walk weight-bearing for another 2 months. 3. After fixator removal, the long leg brace with 10° flexion is assembled. 6  months later, 0° brace was replaced for another 1 year (Fig. 5.60). The method with soft tissue natural reconstruction using external fixation was applied in 22 patients with severe genu recurvatum deformity. The effect was satisfactory including three cases repeated who did not follow the procedure of natural contracture strictly and suffered partial recurrence. Osteotomy was also needed in some patients with bony deformities.

5.7.3 E  xternal Oblique Abdominal Muscle, Rectus Abdominis Muscle, and Iliotibial Band Transfer for Quadriceps Femoris

The treatment principle is as follows: 1 . Remove all factors that cause genu recurvatum 2. Correction of bone deformity

Muscle transfer for reconstruction of quadriceps femoris is the most common surgical method for poliomyelitis quadriceps paralysis.

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5.7.3.1 Surgical Indication Adult patients with quadriceps femoris paralysis or combined with flexor hip muscle paralysis; no deformity on hip and knee joint; the muscle strength of gluteus maximus is grade 4 or above; abdominal muscle strength is normal; no structural scoliosis; lower limb alignment is normal. For female patients, it is recommended that abdominal muscle transposition should be done after childbirth. 5.7.3.2 Surgical Procedure Surgical Position The patients should be in supine position, with sterilizing ranging from breast to toe.

Fig. 5.58  Severe genu recurvatum of left leg with extensive ligament relaxation

From 1985 to 2003, 2427 cases of quadriceps muscle replacement were performed in Qinsihe Orthopedic Institute. Among them, 954 cases (39.31%) were transposition of biceps femoris and semitendinosus, 693 cases were transposition of external oblique abdominal muscle and rectus abdominis muscle to replace rectus femoris muscle, and 954 cases were transposition of biceps femoris muscle and semitendinosus muscle instead of quadriceps femoris (28.55%). Sartorius muscle transposition replaced quadriceps femoris in 418 cases (17.22%), and 362 patients were with other methods. The patients with quadriceps paralysis over 35 years of age can be treated using external oblique abdominal muscle and rectus abdominis muscle to replace the rectus femoris muscle; the good hip flexion and knee extension function was obtained after surgery, which is discussed as follows.

Incision and Procedures 1. Free removal of iliotibial tract with anterolateral thigh incision. Two or three longitudinal incisions are made from the middle part of the anterolateral thigh. Longer length iliotibial band about 5 cm width is taken out and cut into two bundles for (Fig. 5.61). 2. This incision is located below anterior superior iliac spine 10  cm. The free iliotibial band is sutured to the patella and quadriceps femoris tendon. The proximal end is led into this incision through subcutaneous tunnel of the femur. Patella sliding can be seen when iliotibial band is stretched, which demonstrates that the muscle strength can be transmitted by abdominal muscle transposition. 3. Abdominal incision. Abdominal incision is about 14  cm long from the midpoint between the umbilical cord and the anterior superior iliac spine toward pubic tubercle, through which separates the external oblique ventral muscle from the sheath of the rectus abdominis, cut off at the symphysis of the pubis, and then suture and trim as a flap. 4. With a longitudinal incision on the anterior lateral sheath of the rectus abdominis, the ipsilateral rectus abdominis muscle is exposed, longitudinal splitting of 1/2 of the lateral muscle of the ipsilateral rectus abdominis muscle to pubic and then cutting. Hypogastric neurovascular should be protected and the anterior rectus sheath should be sutured very well. 5. The leg is raised by 40° and the knee is at 0°. External oblique muscle, rectus abdominis, and iliotibial band

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Fig. 5.59  Severe genu recurvatum. (a) A 44-year-old female with severe genu recurvatum and foot varus deformity caused by poliomyelitis sequelae, presented knee joint pain during walking; (b) X-ray maximum hyperextension of the knee showed angle of genu recurvatum was 40°; (c) Tibial plateau osteotomy was performed; (d) Allograft graft; (e) Genu recurvatum deformity had been corrected; (f) The

affected knee was fixed by external fixator at least 30°; (g) In 8 days after surgery, the knee joint was fixed at 30°, the patient was encouraged to walk under crutches; (h) X-ray in 8 days after surgery; (i) In 3 months after surgery, the external fixator was removed; (j) In 7 months after surgery, the braces were worn for 4 months, continue to wear for at least 10 months; (k) X-ray in 7 months after surgery

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meet each other in the abdominal incision, sutured as “Y” under the fit tension. 6. When the tendons are sutured completely, the motion test of hip flexion and knee extension should be done to measure the tension of tendon fixation (Fig. 5.62). 7. Two absorbable lines are inserted into rectus femoris longitudinally in order to prevent rectus femoris muscle to be stretched.

5.7.3.3 Postoperative Management The abdomen and affected limb should be cared with pressure dressing, the limb is maintained at the position of 40° flexion hip and 0°extension knee with a bracket. In 7 days after surgery, moderate abdominal contractile movement and moderate passive flexion-extension exercise of knee are performed in supine position (Fig. 5.63).

Fig. 5.60  For the patients with severe genu recurvatum, permanent braces are required

5.7.3.4 Summary It is a new way for function reconstruct of quadriceps paralysis due to poliomyelitis using external oblique abdominal muscle, rectus abdominis muscle, and iliotibial band transfer for quadriceps femoris. Based on the results of 25 cases of poliomyelitis quadriceps paralysis more than 5 years followed-up, good function of hip flexion and knee extension can be obtained using external oblique abdominal muscle, rectus abdominis muscle, and iliotibial band transfer for quadriceps femoris. The strength of extensor knee is closely related to the strength of gluteus muscle; therefore, this surgery is forbidden for those with gluteal muscle paralysis. There were no complications of abdominal wall. At the early stage of muscle transposition, the affected limb is

Fig. 5.61  Surgical incision

the incision for free and fix iliotibial tract

the incision for free external oblique abdomen

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Fig. 5.62  Sartorius muscle transfer to quadriceps femoris. (a) Free the endpoint of sartorius insertion; (b) Sartorius muscle is transferred to the patellar through the subcutaneous tunnel; (c) Sartorius tendon is sutured

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with patellar ligament. (Quoted from Operative orthopedics, Second Edition Fig. 19-7-4)

accompanied by movement when they cough or sneeze in standing position. After a few years, this phenomenon gradually disappeared.

5.8

 orrection Strategy for Foot C and Ankle Deformity

Sihe Qin, Jiancheng Zang, Shaofeng Jiao, and Qi Pan Paralysis and deformity of foot and ankle are common in poliomyelitis sequela. Until December 2017, there are 19 of top 30 surgical procedures for foot and ankle deformity in the case database of Qinsihe Orthopedic Institute, such as 5111 times of talocalcaneal joint arthrodesis, 4973 times of Achilles tendon extension, 2475 times of plantar aponeurolysis, 2435 times of peroneal longus tendon transfer for the Achilles tendon, 1456 times of triple arthrodesis, and 961 times of the basal part of first metatarsal osteotomy.

5.8.1 Types of Foot and Ankle Deformity

Fig. 5.63  External oblique abdominal muscle, rectus abdominis muscle, and iliotibial band transfer for quadriceps femoris (long-term follow-­up). A 27-year-old male with left flail leg underwent surgery of right external obliquus abdominis and 1/2 rectus abdominis-iliotibial bundle transposition for function reconstruction of hip flexion and knee extension. In 5  years follow-up, the patient presented satisfactory results of hip flexion reached 40° and the muscle strength of knee extensor was grade 3 in standing position

Foot and ankle joint is easily deformed due to muscle spasms and dynamic imbalances, because it is the most stress-­ relieving with the most joints of the lower extremities, and the most complex and ingenious motor trajectory, which vary from different location, degree, extent, and different types of the deformities. The most common ones are claw toe, talipes equinus, talipes cavus, varus foot, valgus foot, and talipes calcaneus. When muscle paralysis is in short period, the deformity of foot and ankle is dynamic and flexible. With the development

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of muscle imbalance, soft tissue contracture and bony ­deformity occurred, which was divided into 10 types, including different extent and different degree of deformities.

2. Talipes cavus (commonly accompanied by foot equinus deformity) The patients with severe equinus foot weight-bearing are only with metatarsal head (Fig. 5.65). 3. Isolated varus foot deformity (Fig. 5.66) 4. Adult talipes equinovarus (Fig. 5.67) 5. Valgus foot (Fig. 5.68)

1. Talipes equinus foot (commonly accompanied by paralysis of the dorsal extensor muscles of the ankle joint) (Fig. 5.64)

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Fig. 5.64  Talipes equinus foot: (a) The lateral view of moderate talipes equinus foot deformity; (b) The front view of moderate talipes equinus foot deformity; (c) Severe talipes equinus foot deformity; (d) Severe talipes equinus foot deformity

Fig. 5.65  Appearance and X-ray of severe talipes cavus deformity (A) Drooping angle of hindfoot; (B) Drooping angle of forefoot

Talus axis

Mortise axis

First metatarsal axis

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Fig. 5.66  Appearance of right varus foot deformity (back view) Fig. 5.68  Appearance of valgus foot

6. Talipes calcaneus (Fig. 5.69) 7. Flail foot with hip flexion deformity (Fig. 5.70) 8. Claw toes (Fig. 5.71) 9. Ankle varus deformity (Fig. 5.72) 10. Severe foot and ankle deformity It is often accompied by soft tissue contracture and dynamic imbalance (Fig. 5.73).

5.8.2 D  eformity Examination and Related Problems of Foot and Ankle 1. Soft tissue contracture: We should pay attention to the extent, degree, and nature of contracture. Whether it is combined with skin scars? 2. Whether it is combined with dynamic imbalance? 3. The nature, extent, and degree of skeletal deformity. 4. Mixed deformity with various factors. 5. Surgical treatment and complications previously. 6. Whether it is combined with osteoarthritis? (Fig. 5.74) 7. Have the new problems occurred after the fusion of the foot and ankle joint? 8. The situation of foot-landing and weight-bearing area. 9. Whether combined with lower leg or knee deformity?

5.8.3 I nfluence of Hip and Knee Deformity on Foot and Ankle Fig. 5.67  Appearance of talipes equinovarus

The normal gravity line of the lower limbs is the basis of standing and walking for human body. The movement phases

5  Lower Limb Deformities in Poliomyelitis Sequelae Fig. 5.69 (a) Appearance of talipes calcaneus; (b) X-ray of talipes calcaneus in lateral view

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and regularities of the hips, knees, and ankles are uniform when walking. When the hip and knee joints are deformed, it is inevitable that the foot weight-bearing area be changed, which can increase the development of joint deformity. On the

contrary, the deformities of the foot and ankle also affect the occurrence and development of knee and hip deformity. The rules of interaction among the hip, knee, ankle, and foot deformity are as follows: • Hip flexion and knee flexion deformity promote the development of clubfoot; • Iliotibial tract contracture promote the development of talipes equinovarus deformity; • Equines foot deformity can be aggravated by genu recurvatum deformity; • Severe genu varum or distal tibia varus deformity promote the development of valgus foot deformity; • External rotation of the lower leg promotes the development of varus foot deformity.

5.8.4 Surgical Strategy 1. Isolated soft tissue contracture type: In patients with isolated soft tissue contracture, such surgery can be done including soft tissue release and tendon lengthening. For those who are combined with dynamic imbalance, tendon transposition and dynamic balance surgery can be done. 2. The patients with obvious bony deformity will be treated by osteotomy.

Fig. 5.71  Appearance of claw toes

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Fig. 5.72  Ankle varus deformity on the left side: (a–b) The front and back view; (c) The X-ray of supramalleolar varus deformity

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Fig. 5.73  Bilateral severe foot and ankle deformity. This is a 27-year-old male with bilateral foot and ankle deformity: (a–c) Talipes equinovarus, talipes cavus, and claw toes deformities; (d) X-ray in front view; (e) X-ray in lateral view

3. In patients with bony deformity and muscle imbalance on the foot and ankle, the tendon transposition should be performed at the same time with bony surgery. 4. The goal of the treatment of talipes equinovarus deformity should be determined by the type of deformity, the age of the patient, the condition of muscle spasm, whether associated with osteoarthritis, etc.

5. The calcaneus foot deformity should be corrected to planter flexion at 20–30°. 6. For the patients with multiple joint deformities on one limb, the surgeries should be done in one stage as far as possible. 7. Surgical plan designing must follow the principle of biomechanics and orthopedics.

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Fig. 5.74  The deformity with osteoarthritis

8. The ankle joint should not be fused as much as possible, the stability of ankle can be maintained by a comfortable foot ankle orthosis. 9. Application of external fixation with expand surgical indication.

5.8.5 Decision-Making for Talipes Equinovarus 1. The factors causing talipes equinovarus can be eliminated, reasonably muscle balance surgery can be done firstly, and then pay attention to the other condition of lower limb. Surgical plan for the patients with talipes equinovarus should be developed individually based on the comprehensive analysis and systematic evaluation. 2. For the talipes equinovarus without bony change, the Achilles tendon and posterior tibial tendon lengthening can be done. The anterior tibialis muscle transposition was applied for muscle balance. If the foot is with joint relaxation, the talocalcaneal joint arthrodesis should be done combined with peroneal tendon shortening. 3. The surgical procedure for talipes equinovarus with bony change are as follows: (a) Talipes forefoot varus type: Talonavicular arthrodesis and calcaneocuboid arthrodesis can be done.

(b) Talipes hindfoot varus type: Calcaneus wedge osteotomy or talocalcaneal joint fusion can be done. (c) Talipes full-foot varus type: Triple arthrodesis. In severe cases, considering the tension of the posterior tibial vessels, nerves, and skin, Ilizarov technique can be applied for deformity correction. 4. For the elder patients with severe talipes equinovarus, walking pain presented on the ankle joint due to degenerative changes of articular cartilage. Ilizarov device can be mounted for deformity correction and ankle joint space distraction, the latter adjusting can start when deformity correction is completed at same speed until the ankle joint space is 5–10 mm. The patients are encouraged to move ankle joint under non-weight-­bearing, which can effectively relieve the pain and delay the ankle joint fusion performing. 5. In patients with talipes equinovarus and external rotation of the tibia, proximal tibia osteotomy can be performed during foot deformity correction (Fig. 5.75).

5.8.6 S  urgical Treatment for Talipes Equines Retroflexion Talipes equines retroflexion of foot and ankle deformity was designated by Qin Sihe.

5  Lower Limb Deformities in Poliomyelitis Sequelae Fig. 5.75 Talipes equinovarus combined with external rotation of the tibia. (a) Tibia external rotation deformity promotes the development of talipes equinovarus; (b) Tibia external rotation deformity and talipes equinovarus deformity be corrected simultaneously

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Fig. 5.76  Talipes equines retroflexion

Eight cases with talipes equines retroflexion undergone surgery in Qinsihe Orthopedics Institute, who were mainly from remote rural area in China.

5.8.6.1 Gait Analysis Preoperatively All of the patients were able to walk with bare feet even weight-bearing with acrotarsium (Fig. 5.76), including one case with severe retroflexion whose tarsometatarsal joint involved in the weight-bearing. There are no permanent varus or valgus deformity on calcaneus.

5.8.6.2 X-Ray Examination X-ray shows the foot and ankle in extreme plantar flexion position, in which the front and middle parts of trochlea tali rotate to outside of ankle mortise. 5.8.6.3 Pathological Changes Talipes equines retroflexion deformity occurs when the dorsiflexion muscle paralysis of ankle joint combined with plantar flexion muscle normal strength and without varus or valgus imbalance.

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The affected foot presents Achilles tendon contracture only in early stage, and the entire toe is folded back when the deformity develops over 90° and weight-bearing with five toes and metatarsal head, thereby weight-bearing surface of the foot is expanded and the stability of the ankle improved obviously. Cavus deformity develops gradually and is promoted by patient walking on dorsum of the foot. The front and middle parts of trochlea tali can rotate to outside of ankle mortise, resulting in joint degeneration and hyperplasia of granulation tissue. As a result, the name of “Talipes equines retroflexion” was given by Qin Sihe based on all the pathological characteristics mentioned above.

5.8.7 Surgical Treatment The principle of surgical treatment of talipes equines retroflexion is similar to other severe deformities, including posterior medial soft tissue release, tendon lengthening, tarsal osteotomy, etc. Ilizarov technique can be applied when the foot deformity is corrected partially during surgery. Because such patients usually suffer with lower limb shortening, the 20–30° plantar foot should be retained for walking with a special wedge shoe (Fig. 5.77).

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Fig. 5.77  Qin’s method and Ilizarov technique for the treatment of talipes equinus retroflexion. (a–b) A 29-year-old female with left talipes equinus retroflexion deformity. Physical examination: extensor paralysis, muscle strength of Achilles tendon, and tibialis posterior was 4; (c) The Achilles tendon, flexor hallucis longus, and flexor digitorum longus tendon were lengthening; (d–f) The tibialis posterior was transferred to the anterolateral of the ankle through interosseous membrane of tibia and fibula. (g) Triple osteotomy; (h–i) The extensor digitorum

longus was exposed at the incision of triple osteotomy, and posterior tibialis was transferred for reservation; (j) The foot and ankle were fixed with K-wires in proper position; (k–l) The tibialis posterior was sutured with the extensor digitorum longus under proper tension; (m–n) Interphalangeal arthrodesis was performed with 2  mm K-wire. The relaxed extensor brachialis and anterior tibial tendon were sutured under proper tension to control thumb ptosis; (o) Ilizarov external fixator was applied for residual foot deformity correction

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Fig. 5.77 (continued)

5.9

Surgical Treatment for Creep-­ Squatting Cases

Sihe Qin, Shaofeng Jiao, and Jiancheng Zang Creep-squatting deformity is a special type with severe paralysis and loss of function, which is rarely reported in the literature. Patients with creep-squatting deformity cannot stand and walk, it is difficult for them to take care of themselves, learning and employment is limited, marriage is frustrated, and they have become the burden of their family and society. Therefore, such patients desire to seek treatment and change. Among the 34,459 patients treated in Qinsihe Orthopedic Institute, 681 patients with creep-squatting deformity were unable to stand up and only crawl on the ground and with wheelchairs for long distance, including 564 cases of poliomyelitis sequelae. Because some patients have lost the indication of surgery, the actual incidence is much higher than the above. The creep-squatting patients with different etiology have the same strategy of preoperative examination and surgical treatment. A brief introduction is as follows.

5.9.1 D  ata Statistics of Creep-Squatting Cases of Poliomyelitis Sequelae (Tables 5.8, 5.9, 5.10, 5.11, and 5.12) 5.9.2 Clinical Manifestation The type of movement and gait depend on the extent of muscle paralysis and the deformity on the hip and knee joint.

Table 5.8  Gender ratio of creep-squatting cases of poliomyelitis sequelae Gender Male Female Total

Cases (n) 421 260 681

Percentage (%) 61.82 38.18 100

Table 5.9  Age at surgery Age (years) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 60+ Maximum age Minimum age Average age

Cases (n) 92 249 120 92 59 40 15 10 2 0 0 2 0 60 3 13

Percentage (%) 13.51 36.57 17.62 13.51 8.66 5.87 2.21 1.47 0.29 0.00 0.00 0.29 0.00

Table 5.10  Surgical time Period 1984~1989 1990~1999 2000~2009 2010~2017

Cases (n) 116 429 70 66

Percentage (%) 17.03 63.00 10.28 9.69

Note: The majority of the cases were poliomyelitis sequelae treated before 2000, so the age at surgery was younger

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Table 5.11  Name of the disease Variety of disease Poliomyelitis sequelae Cerebral palsy sequelae Congenital multiple arthrogryposis Rheumatoid arthritis Congenital dislocation of patella Congenital talipes equinovarus Guillain–Barre syndrome Sequelae of knee joint infection Sequelae of viral spinal cord infection Hip joint skeletal flexion hip deformity Sequelae of burn of lower extremity Hereditary sensory and motor neuropathy Multiple epiphyseal dysplasia Congenital femoral defect Congenital axial defect of calf Sequelae of suppurative arthritis Toxic bacillary dysentery sequelae Congenital complex deformity of lower extremity

Cases (n) 564 74 15 6 5 4 1 1 1 1 1 1 1 1 1 1 1 2

Table 5.12  Surgical procedures Category Soft tissue contracture release, tendon lengthening

Tendon transfer and dynamic balance

Osteotomy and joint fusion

Others

Name of operation Hip flexion release Knee flexion release Iliotibial band lengthening Achilles tendon lengthening Gluteal muscle contracture release Femoral adductor release Gracilis release Plantar fasciotomy Posterior tibial tendon lengthening Tendon transfer for Achilles tendon Tendon transfer for Tibialis Anterior Tendon transfer for quadriceps Tendon transfer for gluteus muscle Tibialis anterior laterally Sacrospinous muscle transfer for gluteal muscle Modified Axer procedure Supracondylar femur Osteotomy Talocalcaneal arthrodesis Tibia and fibula osteotomy Ankle arthrodesis Triple arthrodesis Cho part arthrodesis Epiphyseal stimulation of knee

Cases (n) 306 184 30 65 10 41 23 25 16 122 14 24 65 5 3 11 167 107 69 40 21 9 16

Therefore, the surgeon should carefully observe the movement mode and limb landing, focus on the position of creep-­ squatting before surgery, and pay special attention to the degree of flexion deformity of the knee, whether there is residual muscle strength of gluteus muscle and scoliosis in patients over 30 years of age, which are helpful to judge the indication and the effect of treatment.

Patients with normal muscle strength of the upper extremity are mainly supported and driven by both upper extremities, so their upper limb muscles are more developed than those of normal people. Common types of creep-squatting gait include moving with mechanical objects, such as wheelchairs, high stools, or low stools. Moving way of creep-squatting gait includes squat moving with hands on feet (Figs.  5.78 and 5.79) moving with hand on foot in straight knee position (Fig.  5.80), creep moving with hand on wooden bench (Fig. 5.81), creep moving on knees (Figs. 5.82, 5.83, and 5.84), creep moving on buttocks (Fig. 5.85), creep moving like a baby, etc.

5.9.3 Surgical Indication In surgical indication for creep-squatting patients, the following should be clarified: 1. What is the goal of the treatment? Is it a requirement to stand and walk after surgery or simply to correct the appearance of deformities? 2. What is the situation of upper and lower extremities and spinal muscle paralysis? Is there a basic condition for standing and walking after surgery? 3. Technical ability of doctors. Whether the patients can walk with crutches after surgery? If the patient can not walk, he can lost the function of creeping. 4. If the patients have complete paralysis of the main functional muscles of bilateral lower limb, knee flexion deformity >45°, age over 30  years, or severe complicated scoliosis, incomplete upper limb paralysis, and loss of abduction capability, it is not suitable for surgery. The surgical indication for severe soft tissue contracture and bone deformity who over 40  years of age should be strictly grasped, because their postoperative adaptability is poor, and the recovery period is long. But 29 cases of creep-­ squatting patients over 30  years of age were treated in Qinsihe Orthopedic Institute, in whom the oldest was 60 years old, all of them achieved the good effect of walking upright with or without crutches after surgery.

5.9.3.1 Reflection on the Indications of Surgery The patients in creep-squatting gait with multiple joint deformities, due to extensive paralysis of lower extremity, are crawling on the ground for more than 10  years or some patients even more than 30  years. They are suffering from both physical and mental pain and eager to seek treatment. Surgical treatment is not in line with the current development trend of market medicine and technical medicine

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Fig. 5.78  Patient squat moving with hands on feet. (a) A 28-year-old female with bilateral hip flexion, knee flexion deformity squat moving with hands on feet gait 25 years. Only two groups of major functional muscles remained, and all the rest of the muscles paralyzed; (b) In 75 days after the first surgery on the left lower extremity, she can walk weight-bearing with crutches. The patient underwent four surgeries

totally; (c) In 11 years after the first surgery, she was able to upright and walk with crutches, this picture of her daughter who is already 5 years old was taken when Dr. Qin went to her home for follow-up; (d) In 28  years after the first surgery, she was still able to walk with two crutches (right 1). Her daughter had been admitted to university (right 2). The whole family took a picture with Dr. Qin at home

204 Fig. 5.78 (continued)

Fig. 5.79  Patient squat moving with hand on foot. (a) A 23-year-old female with bilateral hip flexion and knee flexion deformity presented squatting gait for 19 years; (b) She can walk upright with single crutch when four surgeries have been performed on both the lower limbs

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5  Lower Limb Deformities in Poliomyelitis Sequelae Fig. 5.80  Patient squat moving with hands on feet in straight knee position. (a) A 15-year-old male with bilateral hip flexion deformity due to extensive muscle paralysis on both lower limbs and presented squat moving with hands on feet gait preoperatively; (b) He can walk upright with crutches when bilateral hip release surgery is completed

Fig. 5.81  Patient creep moving with hand on wooden bench. (a) A 31-year-old male creeped with hand on wooden bench due to extensively muscle paralysis on both lower limbs; (b) After the treatment of two surgeries, the patient can walk upright with crutches

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because there are few reports in the English literature, and there is little need for high-tech equipment. The doctors in big hospitals in China lack training and clinical experience in the diagnosis and treatment of these patients, resulting in many patients with severe paralysis and ­deformity as they missed the best opportunity for the treatment. The experience of 681 cases of creep-squatting deformity in Qinsihe Orthopedics Institute proved most of them can walk upright successfully after surgery based on Qin’s method for lower limb deformity correction.

5.9.4 Establishment of Surgical Plan Case Illustrations (Fig. 5.86) A 24-year-old male with severe hip flexion, knee flexion, hip abduction, and rotation deformity presented squatting-­ crawling gait secondary to poliomyelitis sequela. Surgical method: Bilateral hip flexion and knee flexion release, common peroneal nerve release, subtrochanteric femoral adduction osteotomy, femoral supracondylar osteotomy, and Ilizarov technique. Treatment goal: The patient can stand and walk.

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a

b

c

Fig. 5.82  Patient creep moving on knees. (a) A 34-year-old female with 55° of flexion deformity of bilateral knee, creeping on knees for 30 years; (b) Bilateral knee flexion release surgery has been done, skeletal traction was performed until the knee flexion deformity 70

Surgical cases (n) 293 188 96 33 15 2 2

Note: 148 patients over 51 years of age were treated in this group, the oldest one was 72 years. The curative effect of the senile patients with poliomyelitis sequelae is definite due to the strict choice of surgical indication Table 5.15  Time distribution Period 1978–1982 1983–1987 1988–1992 1993–1997 1998–2002 2003–2007 2008–2012 2013–2017

Surgical cases (n) 1 2 41 52 38 49 195 251

Proportion of polio in the same period (%) 1.82 0.07 0.52 0.95 1.54 3.58 10.66 18.66

Note: The percentage of senile poliomyelitis sequelae was significantly increased after 2008.The principles of preoperative examination, evaluation, surgical treatment, and postoperative management were quite different from those young patients, which is a new problem that the Chinese mainland orthopedic surgeons should have to face Table 5.16  Application of external fixator Type of fixator Hybrid fixator Ilizarov fixator

Cases (n) 335 159

Percentage (%) 53.3 25.3

Note: Among the 629 patients who underwent surgical treatment, 484 cases were applied with external fixator, which proved the advantage of external fixation in the treatment of limb deformity of PPS

Table 5.13  Gender ratio Gender Male Female

Surgical cases (n) 274 355

Proportion in total polio Percentage (%) cases (%) 43.56 1.17 56.44 1.52

Note: Among the 23,310 cases of poliomyelitis sequelae who were treated in Qinsihe Orthopedics Institute, 13,723 were male and 9587 were female patients, the number of male patients was more than female patients. But in the senile patients, more women reported in this institute than men, maybe because Chinese children are more filial and caring for their mothers to improve their functions

Percentage (%) 46.58 29.89 15.26 5.25 2.38 0.32 0.32

Fig. 5.89  Supracondylar osteotomy of femur

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a

b

d

e

Fig. 5.90  Types of post-polio sequelae. (a) A 50-year-old female with right talipes equinovarus deformity; (b) A 57-year-old female with right talipes equinovarus deformity; (c) A 52-year-old male with flexion knee and talipes deformity; (d) A 49-year-old male with knee flexion and Fig. 5.91  Surgical treatment for PPS patient. (a) A 60-year-old male presented flail leg on left lower extremity and quadriceps femoris paralysis with knee flexion deformity 30°, squatting for 57 years preoperatively. (b) The patient could walk with crutches postoperatively

a

function of limbs weakens, and the bone and joint degeneration on the affected limbs is earlier than that of normal people. Because of the dysfunction of limbs, the amount of exercise is significantly less than others. Obesity and osteoporosis are also common, which aggravate the disability of limbs and even lead to post-polio syndrome. There are six types of PPS patients as follows (Fig. 5.90).

c

f

severe talipes deformity was walking with single crutch; (e) A 49-year-­ old female with knee recurvatum deformity was walking with crutches; (f) A 46-year-old male with flail knee and talipes deformity on the left side

b

With the improvement of the economy, the average life span of people is prolonged, in the train of their desire for improving their function. The patients got satisfactory postoperatively due to the strict control of surgical indications (Fig. 5.91). Nowadays, the number of patients with poliomyelitis sequelae over 40 years is increasing, but surgical treatment

5  Lower Limb Deformities in Poliomyelitis Sequelae

and rehabilitation for them lack of mature experience. The treatment of PPS patients still follows the principle of surgical treatment of poliomyelitis sequelae; some differences should be noted.

5.10.3 Indication The key points are as follows: 1. In patients with abnormal weight-bearing line of lower extremity, the standing and walking function can be improved without aggravating degeneration. 2. Examination of physical health, without other system disease. 3. In patients with knee flexion deformity greater than 40°, attention should be paid to avoid knee joint rigidity and common peroneal nerve paralysis. 4. The patients with mental health condition, without excessive obesity, can actively cooperate with the doctors in the treatment process. 5. There is no obvious scoliosis; the affected limb can take part in weight-bearing before surgery.

5.10.4 The Matters Needing Attention The surgical treatment of senile polio patients still follows the principle of surgical treatment of poliomyelitis sequelae in adolescents, but we should pay attention to some differences as follows. 1. Deformity correction at one stage should be moderate. Patients over 40  years of age with poor elasticity of blood vessels, nerves, and skin. In severe deformity, only a part should be corrected during the operation, and the Fig. 5.92  Achilles’s tendon fixation technique for the treatment of flail foot. (a) Surgical incision lateral view; (b) Surgical incision back view; (c) The distal of Achilles tendon was fold and fixed with fibula for maintain the ankle position in the plantar flexion

a

b

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residual deformity should be corrected gradually after surgery. 2. Mini plate can be used for bone osteotomy in acute correction, which can reduce the usage of external fixation, thereby reducing the complications of joint stiffness and osteoporosis. 3. Simple, effective, and mini invasive surgery should be performed as far as possible, for those lower extremity with multi-joint and complex deformity. It should be designed to complete the treatment in two stages of surgery. 4. The time of limb immobilization was reduced after surgery, and the favorable condition for early functional exercise was created. Rational application of orthosis can significantly improve the function and life of the residual limb. 5. Postoperative exercises should be correct and moderate. Excessive fatigue exercise will aggravate joint degeneration and residual muscle atrophy. Patients should be taught how to walk with walker or crutches before surgery to lay the foundation for early and advanced rehabilitation. 6. Tendon fixation is often used for ankle instability (Fig. 5.92). 7. The walking function of the patients with clubfoot deformity secondary to osteoarthritis is improved postoperatively (Fig. 5.93). 8. Torsional deformity of the lower leg or ankle tilt can be corrected by supramalleolar osteotomy (Fig. 5.94).

5.10.5 The Matters in Muscle Transfer Surgery for Aged PPS Patients Although the muscle elasticity decreased, but for those aged people with PPS can still achieve balance and stable joint c

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a

b

Fig. 5.93  Surgical treatment for foot and ankle deformity in aged patients. (a) A 48-year-old female with foot deformity presented pain on the ankle joint. (b) Aponeurosis plantaris release and triple arthrod-

a

b

esis were performed during operation, foot deformity was corrected, and ankle pain disappeared 6 months postoperatively

c

Fig. 5.94  The combined surgery of subtalar joint arthrodesis and supramalleolus osteotomy for the treatment of foot varus and torsional deformity. (a) A 57-year-old female with foot varus and calf torsion deformity; (b) The first metatarsal deformity; (c) The first metatarsal basal osteotomy, subtalar joint arthrodesis, and supramalleolus osteotomy were done and fixed with hybrid fixator; (d) X-ray showed degenerative changes on ankle joint preoperatively; (e) Foot and ankle

deformity was corrected satisfactorily 26  days postoperatively; (f) X-ray 26 days postoperatively; (g) The pins were removed 30 days after surgery and then fixed with plaster cast; (h) The external fixator was removed 87 days postoperatively; the patient was instructed to walk for 30 days under full weight-bearing with plaster in order to increase the strength of bone healing

5  Lower Limb Deformities in Poliomyelitis Sequelae

d

g

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e

f

h

Fig. 5.94 (continued)

with muscle transfer surgery. The most common muscle transfer surgeries in Qinsihe Orthopedic Institute are as follows: External oblique abdominal muscle substitution for the medial gluteus muscle; sartorius muscle or semitendinosus substitution for quadriceps femoris; abdominal–iliotibial transposition to reconstruct flexion hip and extension knee function; and dynamic balance of foot and ankle tendon transfer.

One of the oldest cases was a 55-year-old male patient who was unable to walk before surgery. He was followed up 5 years after surgery by sartorius muscle transfer to quadriceps femoris (he was 60 years old). The extensor knee muscle strength reached grade 3, and his walking function was obviously improved (Fig. 5.95). Note: Supracondylar femoral osteotomy was fixed with a four-hole plate, and subtalar joint arthrodesis was fixed with two cannulated screws.

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a

d

g

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c

e

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Fig. 5.95  The treatment of a PPS patient. (a–b) A 49-years-old male presented hip flexion, knee flexion, foot drop, and external rotation of the calf preoperatively; (c–d) X-ray; (e–f) Hip and knee flexion release, femoral supracondylar osteotomy, subtalar joint arthrodesis were performed, Ilizarov external fixator was installed to correct residual flexion knee deformity, the deformity of the lower extremities had been

corrected 31 days postoperatively, keeping foot 20° of plantar flexion due to lower extremities shortening; (g–h) X-ray 90 day after surgery, the fixator was removed; (i–j) long leg orthosis was applied; (k–l) In 31  months follow-up, the right lower limb deformity was corrected, and the patient could walk freely; (m–n) X-ray in 31  months follow-up

5  Lower Limb Deformities in Poliomyelitis Sequelae

i

m Fig. 5.95 (continued)

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6

Lower Limb Deformities in Cerebral Palsy Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Qi Pan, Lei Shi, Baofeng Guo, and Li Zhang

6.1

Introduction

Cerebral palsy (CP) was first reported by John Little, an English orthopedist, in 1861. It is caused due to cerebral ischemia, secondary to anoxia at the time of birth. Later, it develops into a syndrome showing dyskinesia, abnormal posture, muscle contractures, bone deformities, instability, and degeneration of joints. Spastic cerebral palsy accounts for a major group of population who need surgical treatment and rehabilitation. The basic principles for the treatment of cerebral palsy are surgery on demand, postoperative physiotherapy, and rehabilitation. The surgical plan depends on age of onset and type of deformity (bony, soft tissue, or combined). In 2008, Qin Sihe published a monograph of surgical treatment for cerebral palsy in China, which included surgical treatment and the research work of clinical practice in this field (Fig. 6.1).

6.2

 tatistical Analysis of 4561 Cases S of Cerebral Palsy

The clinical data of 4561 cases of cerebral palsy sequela in Qin Sihe Orthopedics Institute is as follows: Tables 6.1, 6.2, 6.3, 6.4, 6.5, and 6.6.

S. Qin (*) · S. Jiao · J. Zang · Q. Pan · L. Shi · L. Zhang Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China B. Guo Tsinghua University Chuiyangliu Hospital, Beijing, China

6.3

Clinical Manifestations and Classifications

The most common presentation of cerebral palsy is spastic motor disorder. However, it may also present with other types of muscle tone abnormalities and may be associated with mental retardation, personality changes, and sensory disorders such as hearing, visual, and tactile disorders. The symptoms and their severity differ according to the area and severity of brain damage and the age of child at the time of insult. The common manifestation is that of upper motor neuron injury leading to spastic paralysis, deformities, and dysfunction of extremity.

6.3.1 P  hysiological Classification and Clinical Manifestations 6.3.1.1 Spastic Cerebral Palsy (SCP) (Fig. 6.2) The symptoms are due to pyramidal tract injury in the cerebral cortex and manifest in the form of increased muscle tension, and hyperreflexia which is velocity dependent. The faster the speed of passive movements, the rapid is increase in muscle tension, and joint contracture stays for longer duration. This type accounts for about 75% of children with cerebral palsy. It is often combined with other symptoms discussed above and is suitable for surgical treatment. 6.3.1.2 Athetoid Dyskinetic Cerebral Palsy (ADCP) (Fig. 6.3) This type is due to damage of extrapyramidal system mainly basal ganglia. The patient appears aimless and has involuntary movements which would disappear

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_6

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Fig. 6.1  Different types of lower limb deformities in adult cerebral palsy

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6  Lower Limb Deformities in Cerebral Palsy

Fig. 6.1 (continued)

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Fig. 6.1 (continued)

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6  Lower Limb Deformities in Cerebral Palsy

Fig. 6.1 (continued)

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Fig. 6.1 (continued)

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6  Lower Limb Deformities in Cerebral Palsy

Fig. 6.1 (continued)

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Fig. 6.1 (continued)

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Fig. 6.1 (continued) Table 6.1  Gender ratio Gender Male Female

Table 6.3  The number of surgery every year

Cases (n) 3099 1462

Percentage (%) 67.95 32.05

Table 6.2  Age at surgery Age (years) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 >60 Maximum age Minimum age Average age

Cases (n) 667 1287 1066 833 407 196 52 40 7 3 1 1 1 63 1 13.1

Percentage (%) 14.62 28.22 23.37 18.26 8.92 4.31 1.14 0.88 0.15 0.07 0.02 0.02 0.02

Note: Among the patients with cerebral palsy operated by Qin Sihe, the number of adolescents and adults is more than that of children

Period Before 1985 1985–1989 1990–1994 1995–1999 2000–2004 2005–2009 2010–2014 2015–2017

Surgeries (n) 65 457 1049 891 542 619 657 281

Percentage (%) 1.43 10.02 23.00 19.54 11.88 13.57 14.40 6.16

Table 6.4  Statistics of birth order Parity 1 2 3 4 5 6 7 8 Abandonment or adoption

Surgeries (n) 2303 961 311 121 54 22 9 3 4

Percentage (%) 50.49 21.07 6.82 2.65 1.18 0.48 0.20 0.07 0.09

Note: In this group, the information of birth has not been recorded in 773 patients (16.5%)

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Table 6.5  Common operations Age Name of operation (1–14) Release of hip adductor 1014 Lengthening of Achilles tendon 953 Subcutaneous release of gracilis 600 705 Excision of epineurial sympathetic reticulum of common carotid artery Tibialis posterior tendon 410 lengthening Obturator neurotomy 376 Hamstring muscle tendon 221 lengthening Subtalar joint arthrodesis 147 Release of plantar aponeurosis 97 164 Gastrocnemius aponeurosis lengthening

Age (>14) 608 548 408 213

Total (n) 1622 1501 1008 918

Percentage (%) 35.56 32.91 22.10 20.13

300

710

15.57

202 313

578 534

12.67 11.71

293 122 38

440 219 202

9.65 4.80 4.43

Table 6.6  Application of external fixators (n) Period 1980–1989 1990–1999 2000–2009 2010–2017

a

Hybrid external fixator 1 5 108 479

Ilizarov external fixator 0 1 25 158

d­ uring sleep. The patient shows flickering type of muscle tone, and the intention of movement is not consistent with the end result. It affects the whole body. Head control is poor, and the patients have involuntary facial expressions. The facial muscles show irregular contractions causing strange expressions like “bared teeth,” “frown,” and “stare.” Some may also show repeated contractions of tongue and involuntary abnormal posture of trunk and upper limb. Involuntary interactions, tremors, feeding difficulties, speech disorders, and ambiguity are common. Joint contracture and their deformation are less common. It accounts for 20% of children with cerebral palsy.

6.3.1.3 Ataxia Cerebral Palsy Ataxic cerebral palsy is caused by damage to cerebellum, and most of the patients are quadriplegic. As the cerebellum is essential for coordinating muscle movements and balance, patients experience problem in coordination. It can appear alone or with other types of cerebral palsy and manifest in the form of stumbling gait, hypotonia, and abnormality of balance, coordination, and stability.

b

Fig. 6.2 (a, b) Abnormal standing posture and gait abnormality in patients with spastic cerebral palsy

6  Lower Limb Deformities in Cerebral Palsy

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Fig. 6.4  “Frog posture” in supine position of children with flaccid cerebral palsy

Fig. 6.3  The movement of limbs associated with the involuntary deviation of the head to one side in athetoid cerebral palsy

sion and stiff limbs are thought to be due to damage to globus pallidus. Hyperextension reflex causing “opisthotonus” and “lead pipe rigidity” on passive joint movement are often seen. Reflex and clonus are difficult to elicit. Growth and development are usually compromised, and overall prognosis is poor.

6.3.1.4 Flaccid Cerebral Palsy (Fig. 6.4) Patients are usually quiet, weak, stunted, and less autonomous. They are difficult to feed, slow in speaking, and sometimes inarticulate. Most of them are quadriplegic, have low muscle tone, are less autonomous, and are unable to maintain posture. When they are stimulated, muscle tone will immediately increase mainly in back extensor leading to “angle arch back” posture. The patients tend to lie supine in “frog like posture.”

6.3.1.6 Tremor Type It is characterized by irregular tremors of the eyeballs and limbs.

6.3.1.5 Rigid Type (Fig. 6.5) This type accounts for 4% of total children with cerebral palsy. The extent of cerebral lesion is usually severe. The exact site of injury is controversial and may be due to a lesion in cerebral cortex or basal ganglia. The extreme hyperexten-

6.3.2 Classification

6.3.1.7 Mixed Type It is a combination of two or more types of cerebral palsy discussed above. A combination of spastic and athetoid cerebral palsy is most common, and usually, symptoms of one type are more apparent.

This classification depends on the anatomic region of the body affected with the movement disorder. Accordingly, it can be of the following types: (1) quadriplegia,

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a

b

Fig. 6.5 (a, b) Rigid-type cerebral palsy. Opisthotonus occurs in the body during stimulation or movement

(2) diplegia, (3) paraplegia, (4) hemiplegia, (5) double hemiplegia, (6) triplegia, (7) monoplegia, and (8) total body (Fig. 6.6).

6.4

Principles of Surgical Treatment and Rehabilitation in Children

Cerebral palsy is a disability and an incurable disease. The purpose of treatment is to improve the state of motor function, reduce the secondary deformities of limb, promote the mental health development of the child, enhance the ability of self-care, and promote the ability to integrate into the society.

6.4.1 Aim of Surgical Treatment The ultimate goal of orthopedic treatment is to improve the patients’ quality of life. Of all, the most important thing is to improve the walking ability and to increase the stability of the torso. In addition, it is necessary to prevent secondary complications such as hip dislocation by doing early hip adductor release and to improve the children’s nursing care by correcting the patients’ morbid posture.

6.4.2 Surgical Strategies Once children with spastic cerebral palsy with fixed deformity, it is difficult to achieve satisfactory results by rehabilitation exercise only, and surgical treatment necessary. The basic cause of joint deformities in patients with cerebral palsy is the abnormal posture and muscle imbalance. Therefore, by principle, neurosurgery should be performed first to solve the problem of muscle spasm. Later (at least 6 months later), according to the situation (whether there are bone and joint deformity, tendon contracture, nerve surgery, etc.), it is decided whether or not to perform orthopedic surgery. The best age for surgery is 3–6 years. On the basis of rehabilitation training, selective posterior rhizotomy (SPR) needs to be performed. Peripheral nerve surgery can also be considered for mild spasm. After neurosurgery relieves muscle spasm, there is a need for secondary orthopedic surgery for rigid joint deformity, which should be performed 6–12 months after neurosurgery. Systematic rehabilitation training should be carried out before, after, and between operations. The purpose of operation is to relieve spasm and correct joint malalignment. The purpose of rehabilitation is to improve the muscle strength and joint range of movement and thereby improve the motor function and posture of child. Surgery is the premise of rehabilitation, and rehabilitation is the guarantee for the good outcome of surgery. So surgery and rehabilitation should be synchronized.

6  Lower Limb Deformities in Cerebral Palsy Fig. 6.6 Classification according to the anatomic region

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quadriplegia

paraplegia

a

paraplegia

c

b

dual hemiplegia

e

6.4.3 Surgical Treatment of Scissors Gait The most common abnormality of the lower limb in spastic cerebral palsy is scissors gait or scissors leg. In severe cases, the legs are crossed, the knee joint is flexed, and the forefoot bears weight while walking. While walking, one limb comes in front of the other. The stance phase is prolonged, swing phase is shortened, and the gait is unstable. Passive abduction of hip is difficult, and the patients are unable to move satisfactorily. If it remains for years, it may lead to secondary dislocation of the hip and rotational deformity of upper femur. It is the most common gait abnormality in adolescents and young children with cerebral palsy (Fig. 6.2a,b).

6.4.3.1 Analysis of the Common Causes It is mainly caused by spasm and contracture of hip adductor, rectus femoris, hamstring, and triceps surae muscle. 6.4.3.2 Indication for Surgery Patients with spasticity and contracture of hip, knee and ankle joint simultaneously in one or both lower limbs, are expected to achieve independence and improved walking after operation. 6.4.3.3 Strategy of Surgical Treatment First, the adductor muscle is released and the superficial branch of obturator nerve is transected to correct the adduction deformity of the hip. Then the internal rotation deformity, flexion deformity of hip and knee, and the deformities

hemiplegia

d

three limb paralysis

monoplegia

f

g

of the ankle and foot are corrected. Osteotomy should be performed at the end or as second stage.

6.4.3.4 Surgical Procedure 1. Release of adductor longus and transaction of superficial branch of obturator nerve: Position the hip and knee joint in 90°flexion. This will make the adductor longus muscle more prominent. Then cut the adductor longus muscle percutaneously near its origin on pubis. By doing so, the hip joint would gain moderate abduction, and the incision need not be sutured. If an extensive release of adductor longus or transection of superficial branch of the obturator nerve is needed, incision on the skin can be extended further. For transaction of obturator nerve, adductor longus is retracted medially. This exposes the nerve clearly on the surface of adductor brevis. Clamping of the nerve induces contractile reaction of adductor longus and brevis and confirms its identity. 1–2 cm of the nerve is then removed. 2. Subcutaneous transection of the gracilis: An assistant keeps the lower limb with hip abducted and externally rotated and knee extended. The surgeon feels the tense gracilis tendon on the medial side of lower thigh, inserts a sharp knife percutaneously under the guidance of his fingers, and cuts the tendon. This will reduce the adduction and internal rotation of hip. 3. Proximal rectus femoris release: The patient is positioned supine with buttocks slightly raised on a roll sheet. The anterior fascia of thigh and

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a­ nterior superior iliac spine are cut through the lower segment of anterior iliofemoral approach. The lateral femoral cutaneous nerve should be protected. The interval between sartorius and the tensor fascia lata muscle was found at the level of anterior superior iliac spine. The sartorius and tensor fascia lata muscle were retracted medially and laterally, respectively. If there is difficulty in exposure, the sartorius can be transected from the anterior superior iliac spine. Deep in this interval, direct head of the rectus femoris can be seen taking origin from the anterior inferior iliac spine. The direct head is then separated from the reflected head of rectus femoris muscle to find out the extension of the common rectus femoris tendon in a Z shape. 4. Percutaneous Gastrocnemius Aponeurosis resection: It is indicated for isolated gastrocnemius muscle contracture without involvement of soleus muscle. The clinical manifestation is that the equinovarus deformity appears in knee extension and disappears in knee flexion. Keeping the patient in supine or prone position, the assistant maintains knee in extension and ankle in dorsiflexion, thereby tensioning the gastrocnemius aponeurosis. The medial bundle of gastrocnemius aponeurosis is first cut with a sharp knife at the musculotendinous junction in an oblique fashion. The lateral bundle is then cut in different planes to allow the ankle dorsiflexion by 10° without suturing the incision. 5. Postoperative management Long leg plaster cast is used to immobilize knee in full extension, ankle in 10° dorsiflexion, and both hip in 45° abduction. The plaster is kept for 4–6 weeks. 6. Common complications There is a risk of excessive reduction in muscle strength after tendon resection. So, the indications are limited to children who can walk independently. The purpose of tendon transfers is to restore the muscle balance. However, for spastic muscle imbalance, it is difficult to predict the postoperative results and the possibility of overcorrection is higher. Overcorrection can lead to opposite deformity, so partial tendon transfers are more reliable in children with cerebral palsy. Good plaster is an important prerequisite to achieve satisfactory results after soft tissue surgery for cerebral palsy. In general, tubular plaster cast is used. Otherwise, problems such as correction insufficient and soft tissue compression by plaster are likely to occur.

6.4.4 Typical Case (Fig. 6.7) 6.4.5 Contraindication of Surgical Treatment 1 . Significant athetotic movement of hands and feet. 2. Exaggerated hyperextension reflex producing opisthotonus. 3. Limb deformity caused by torsional spasm. The above types should be treated by a neurosurgeon.

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6.4.6 Rehabilitation Principle Rehabilitation is fundamental in the treatment of cerebral palsy. It has a key role to alleviate the adverse effects of brain damage on the affected limbs and to improve the function, motor power, communication skill, and self-care. It encourages the patient to strive for education (normal education or special education) and self-care. Rehabilitation should be started immediately after diagnosis of cerebral palsy. It requires long-term persistence and systematic training to improve and maintain the relative normal movement level of limbs. The principles of rehabilitation include: 1. Early detection and treatment. When the motor system of infants is still developing, early detection and correction of abnormal movement would achieve good results. 2. Promote normal motor development and inhibit abnormal movement and posture. According to the law of child’s motor development, functional training, step by step, helps children to attain the correct movement. 3. Comprehensive treatment. A combined method should be used for comprehensive and diversified care of children. In addition to the treatment of dyskinesia, speech disorder, mental retardation, seizure disorder, and behavioral problems also need simultaneous intervention, to improve their ability in daily life and social interaction and to attain an occupation in the future. 4. A combination of family training and physician’s guidance. Rehabilitation is a long-term process; short-term hospitalization cannot achieve satisfactory results. Many treatment methods need to be carried out in the family. Parents and doctors should work together to develop a treatment plan and evaluate its outcome. Improper methods followed by the family are corrected under the guidance of the doctor.

6.5

 rinciples and Procedures for Surgical P Treatment in Adult

Due to their poor economic status, many patients in China with cerebral palsy fail to receive systematic rehabilitation in childhood. Therefore, permanent and severe limb deformities often develop during growth. These patients generally need orthopedic treatment in adulthood. As patients get older, their ability to compensate for deformity decline and finally disappear, giving rise to secondary deformities. The key to the treatment of adult cerebral palsy is to identify the main problem. Just presence of a chronic disability may not require surgical treatment. In order to design an effective treatment plan, surgeon should focus on what the patient needs and what functions have been lost recently.

6  Lower Limb Deformities in Cerebral Palsy

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a

b

c

d

Fig. 6.7  An 8-year-old female with spastic cerebral palsy had severe hip flexion, adduction and internal rotation, and knee flexion deformity. The surgical procedure included bilateral iliopsoas, rectus femoris, adductor longus and gracilis muscle release, bilateral transection of anterior branch of obturator nerve, and percutaneous aponeurotic lengthening of bilateral gastrocnemius muscle. The order of release is from top to bottom (from hip joint to ankle and foot). (a, b) Preoperative examination showed “cross leg (scissors step)”. (c, d) X-ray examination

showed bilateral hip dysplasia, subluxation, and both hip adductions. X-ray showed hip dislocation aggravated by 5% while the hip joint is in adductive position. (e, f) After operation, both limbs were immobilized with plaster; 1 week after operation, the child was assisted to practice standing. (g) The hip abduction bar was removed 3 weeks after operation. (h) After 3 months, the child was told to walk exercise. As a result, hip adduction and internal rotation deformity were corrected. (i) X-ray showed subluxation of both hip joints was reduced

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e

g

f

h

bilateral iliopsoas, rectus femoris, adductor longus and gracilis muscle release, bilateral transection of anterior branch of obturator nerve, and percutaneous aponeurotic lengthening of bilateral gastrocnemius muscle.

i

Fig. 6.7 (continued)

6  Lower Limb Deformities in Cerebral Palsy

6.5.1 Clinical Treatment Strategy Adult patients with spastic cerebral palsy often have significant deformities; most of them being due to fixed muscle contracture. The common deformities are hip adduction, knee flexion, and equinovarus. The range of spastic deformity varies from unilateral gastrocnemius contracture to multilevel soft tissue contracture and skeletal malalignment. The scissors gait progresses from childhood until adolescence and adulthood. A large number of patients show mild to severe flexion of hip and crouch gait along with adduction deformity, which seriously affected walking. Therefore, the purpose of the treatment at this stage is to correct contracture, restore the anatomical structure of bone and joint near normal, avoid secondary painful osteoarthritis, and treat painful osteoarthritis at the end. Tendon transfer is also commonly used to restore muscle balance. The indication of total tendon transfer should be evaluated carefully as its postoperative results are difficult to predict. Over correction is more likely and may lead to opposite deformities. Partial tendon transfer is more reliable and hence preferable. Good plaster immobilization is an important step to obtain satisfactory result after soft tissue surgery. The operating surgeons should apply the plaster themselves. It is easier to handle and manipulate the deformity in plaster when patients are under anesthesia and good muscle relaxation.

6.5.2 Principles of Surgical Treatment 1. For severe spasms, selective posterior rhizotomy (SPR) is performed in children aged 6–12  years. However, the complications of (SPR) in adult patients are relatively high. The local spasticity can be alleviated, and satisfactory results can be obtained by doing multilevel peripheral nerve muscle branch resection. 2. The spasm of local muscle group can be alleviated by the resection of selective nerve branch. For those complicated with soft tissue contracture and joint deformation, limited orthopedic procedures, such as tendon lengthening, are performed. For the ones with severe deformities of bone and joint, soft tissue surgery must be performed simultaneously with bony procedures in order to achieve satisfactory results (Fig. 6.8). External fixation after surgery can reduce surgical trauma and improve outcome (Fig. 6.9). If the patient has multiple joint contracture and bony deformity, it should be corrected in stages.

6.6

Application of Qin’s Plaster Technique

Many types of polymer cast material are being used in orthopedics currently and have shown the advantages of portability, resistance to breakage, resistance to water, and not blocking X-rays. However, gypsum (plaster of Paris) cannot

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be completely replaced from clinical practice because of its low cost and good plastic properties. Orthopedic surgeons are skilled in various gypsum fixation techniques, which is one of the basic prerequisite for good results of reconstruction surgery and lower limb function.

6.6.1 Indication for Gypsum Application 1. In the early stage of cerebral palsy, deformities can be avoided by controlling the limbs in functional position, and some deformities such as equinovarus, equinovalgus, and knee flexion can be gradually corrected by using gypsum. If the knee deformity cannot be corrected by brace, the joint can be immobilized in a plaster in mild flexion for 3~6 months. This also helps in standing and walking and can correct the knee flexion deformity partially or completely. 2. In addition to internal fixation or external fixation, short-­ term immobilization with gypsum in the position needed can alleviate pain and limb swelling and is helpful for early nursing care. 3. Some deformities after surgery can only be fixed with plaster to keep limb in required functional position. 4. Muscle spasms can be relieved under anesthesia and limb immobilized in functional position with long leg plaster. The child can then walk in the plaster for 6 weeks until it is removed. It has been found that spasms can be alleviated and joint deformities can be corrected (Fig. 6.10). 5. Gypsum can be used as a model before making brace (Fig. 6.11).

6.6.2 Q  in’s Method of Plaster Fixation of Lower Limb and Doctor’s Advice on Gypsum 6.6.2.1 Indication Patients undergoing bilateral adductor muscle release and obturator nerve transaction can be immobilized with plaster on both lower extremities. A cross bar can be applied to control the lower limb rotation (Fig. 6.12). The foot is maintained in a functional position in a tubular cast after correction of spastic clubfoot by transecting peripheral nerve branch (Fig. 6.13). 6.6.2.2 Doctor’s Advice on Gypsum Once the gypsum is solidified, red and blue color pencils are used to write out: 1 . The name of operation; 2. The date and time of applying gypsum; 3. The date when walking with or without putting weight can be started and other issues needing attention. The doctor’s advice on gypsum is written so that doctors, nurses, patients, and family members of the patients can see it clearly after surgery.

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Achilles tendon lengthening, tibialis posterior tendon lengthening

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Fig. 6.8  Surgical strategy for severe equinovarus deformity in adults with cerebral palsy. (a) A 21-year-old female with right spastic hemiplegia with equinovarus deformity. (b) Weight bearing on right foot. (c) The X-ray showed right equinocavovarus deformity. (d) Triple arthrodesis with first metatarsal base osteotomy for correction of metatarsal head prolapse. (e) Achilles tendon lengthening, tibialis posterior tendon lengthening, and plantar aponeurosis release. (f) The center of the incision should span the calcaneocuboid joint. (g) Calcaneus, calcaneocuboid, and talonavicular joints were exposed, and appropriate bone wedges

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7 days after operation it can be weight bearing, fixed for 100 days Achilles tendon lengthening, first metatarsal base osteotomy, Triple arthrodesis

were removed. (h) Three 2 mm K-wires were used to fix the osteotomy. (i) The surgery was completed, and severe equinovarus was corrected. The cavus deformity was corrected satisfactorily, and the whole operation time was 40 min. (j, k) The ankle was fixed in neutral position in a plaster cast, and the patients could walk on seventh day after surgery. All deformities of the foot were corrected in one stage. If the patients were treated with Ilizarov technique, they could have retained the talonavicular and calcaneocuboid joints, and this would have avoided the surgical wound. But the treatment time and cost would have increased

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Fig. 6.9  Correction of severe equinovarus deformity in adults with cerebral palsy. (a) A 25-year-old male with bilateral severe equinovarus deformity. (b) X- ray showed increased femoral neck shaft angle on both sides. (c) Left foot varus deformity. (d) After epidural anesthesia, the equinovarus deformity disappeared. The distal part of tibialis posterior muscle was cut, and Achilles tendon was lengthened. (e) The distal half of tibialis posterior muscle was guided through the interosseous

membrane and brought to the anterolateral side of foot. (f) The ankle joint was maintained in neutral position with an external fixator, and the transferred posterior tibial tendon was sutured to the peroneus brevis tendon and surrounding periosteum under proper tension. (g, h) The residual adduction deformity of foot was corrected by external fixator in postoperative period

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equinovarus

Fig. 6.9 (continued)

6.6.2.3 Typical Cases 1. Immobilization of limb in plaster following soft tissue surgery corrects “deformity chain” of cerebral palsy in one stage. Also, postoperative exercise can be started early (Fig. 6.14). 2. Achilles tendon lengthening with release of tibial nerve constriction for correction of spastic clubfoot with ankle clonus, postoperative plaster fixation, early restoration of movement (Fig. 6.15).

3. Complex combined deformities with hip flexion, knee flexion, and planovalgus foot can be immobilized using tube cast after removal of external fixation to start early functional exercise (Fig. 6.16).

6.6.2.4 Combination Method Bilateral lower extremity deformities in cerebral palsy can be corrected by combining plaster and external fixator according to the severity of deformity (Fig. 6.17).

6  Lower Limb Deformities in Cerebral Palsy Fig. 6.10 Three-point fixation principle for long leg cast. (a) Area above the knee joint, the anterior and outer sides of the leg are used as fixed point, and the anterior aspect of ankle is used as the moving point. (b) After completion of plaster, doctor’s advice can be mentioned on gypsum

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6.7

 pplication of External Fixation A in Severe Knee Flexion Deformity

6.7.1 Common Causes 6.7.1.1 Dynamic Imbalance Dynamic imbalance is a muscle imbalance around the knee joint, due to spasm or contracture of the hamstring, weakness of the quadriceps and spasm, or secondary contracture of the hip flexors.

6.7.1.2 Static Imbalance During the growth of children, the persistent flexed posture of knee can lead to secondary contracture of posterior capsule and ligaments. It may even lead to the developmental changes of the osseous structure around knee, resulting in a fixed flexion deformity of the knee joint. 6.7.1.3 Lever Arm Dysfunction Internal rotation of femur, external rotation of tibia, and instability of the subtalar joint lead to valgus, external

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Fig. 6.11  Plaster mold. (a) The wet plaster bandage is wrapped around the leg. (b) The straps are placed. (c) The plaster is molded. (d) Bandage strip is pulled and the plaster mold is cut. (e) Gypsum mold is formed

r­otation, and dorsiflexion of foot. This causes excessive ­excursion in the foot angle while walking and the reduction of the distance between heel and metatarsal head. Thus, the knee extension torque of the ground reaction force and the stability of the knee joint in the stance phase are reduced, resulting in crouch gait.

6.7.1.4 Iatrogenic Factor The calcaneus gait (true dynamic ankle dorsiflexion deformity) produced by excessive lengthening of the Achilles tendon can shift the ground reaction force behind the knee in stance phase leading to secondary crouch gait.

6  Lower Limb Deformities in Cerebral Palsy

6.7.2 Ilizarov Technique for the Correction of Severe Lower Limb Deformity in Cerebral Palsy 6.7.2.1 Ilizarov Technique for the Correction of Severe Flexion Contractures of the Knee in Cerebral Palsy 1. Knee joint distraction fixator (Fig. 6.18) 2. Typical case (Fig. 6.19)

Fig. 6.12  The hip joint was kept in abduction with a plaster after bilateral hip adductor release

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6.7.3 C  orrection of Patella Alta in Cerebral Palsy It is common to have patella in a high position in patients with spastic flexion deformity of knee. In order to maintain the stability of knee joint, the quadriceps femoris continues to contract strongly, forcing the patella to move up gradually and the patellar tendon to be elongated. This weakens the knee extension power of quadriceps femoris and forms a vicious cycle. The longer the course of the disease, worse is the knee flexion deformity. If the knee flexion deformity reaches 50 degrees, and patella reaches a certain height, the deformity is relatively fixed. As the knee flexors are contracted on both sides of the patella, the function of vastus medialis and vastus lateralis muscles is weakened, and contracture of the hamstring tendon is aggravated. In this type of knee flexion deformity, patella alta must be corrected simultaneously. The patella is pulled back to normal position, and the relaxed patellar tendon is shortened, so that after surgery the knee extensor lever arm increases. The knee joint is then stable, and patients can walk upright. The knee flexion deformity gets corrected, and recurrence is rare. The patella distractor can be applied satisfactorily in clinic. Spastic fixed flexion deformity >40° with patella alta, length of patella ligament >1.5 cm of long axis of patella, age more than 12  years. No incision is made. Only Ilizarov fixator is applied, and the distractor is adjusted gradually after operation. In the process of correcting

The leg was kept in plaster for 50 days

Bilateral obturator nerve branch selective resection.

Fig. 6.13  Selective peripheral nerve branch resection and tendon release. The ankle was immobilized with plaster in neutral position. Bilateral obturator nerve and percutaneous sural nerve transaction was

performed. The leg was kept in plaster for 50 days, and the hip joint was maintained in abduction. The patient could walk from fifth day after surgery

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Transection of superficial branch of bilateral obturator nerve and gracilis release.

Fig. 6.14  Soft tissue release combined with gypsum technique for one-stage correction of hip adduction, knee flexion, and clubfoot deformity in patients with cerebral palsy. (a) Fixation in the position of hip joint abduction after the operation. (b) Doctor’s advice on gypsum

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Partial transection of gastrocnemius muscle and branch of tibial nerve

Fig. 6.15  Deformity correction of spastic clubfoot. (a) Clubfoot before operation. (b) Partial transection of gastrocnemius muscle and branch of tibial nerve. (c) Long leg plaster immobilization

knee flexion, the patella moves down simultaneously and reaches to its normal position in 2 weeks. Then the patellar ligament is exposed for shortening as the second operation. The patellar extender is maintained for 6  weeks until the patellar ligament heals firmly and then removed (Fig. 6.20). If the patient is an adult with a higher patella upshift, it is better to gradually pull the patella, tighten the patella liga-

ment on the second stage, and replace the extensor plaster or brace (Fig. 6.21). In an adult with patella alta, it is better to gradually pull the patella and tighten the patellar tendon in the second stage. Limb should be kept in a plaster or brace (Fig. 6.22). Supracondylar osteotomy should be performed simultaneously to correct the anterior bowing of distal femur during the first or second stage (Fig. 6.23).

6  Lower Limb Deformities in Cerebral Palsy

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bilateral rectus femoris release

Fig. 6.16  Application of tube cast. (a) Preoperative crouch gait. (b) Hybrid external fixator. (c) Functional exercise with gypsum after fixator removal

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Fig. 6.17  Combination method of plaster and external fixator. (a) Complex deformity with combination of scissors gait, hip flexion, knee flexion, bilateral thigh adduction, and clubfoot in spastic cerebral palsy.

(b) After soft tissue release, left lower extremity with hybrid external fixator and right lower extremity with long leg plaster cast

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Fig. 6.18  Knee joint distraction fixator. (a) Before distract. (b) After distract

6.8

Functional Exercise

Spastic type is the most common type of cerebral palsy and is the main indication for orthopedic surgery. Surgery aims to relieve muscle spasm and contracture, reduce muscle tension, correct bone and joint deformities, stabilize joints, balance muscle strength, increase joint motion, facilitate nursing, increase self-care ability, and improve quality of life. Some children miss the best recovery time because they do not receive reasonable treatment before the age of 3. Orthopedic surgery should be followed by proper motor rehabilitation, and early functional training after surgery cannot be overemphasized. To guide the rehabilitation training of patients, there should be good cooperation between doctors and patients. On the one hand, full play should be given to the subjective initiative of patients, whereas on the other hand, doctors should have a high sense of responsibility, to guide patients, to start training in time, and to closely observe for any complication. If any complication arises, they should respond and do needful readjustment on time. Most of the orthopedic surgeries for cerebral palsy are minimally invasive. It maintains a stable local environment to promote bone and soft tissue healing. At the same time, it maintains the orthopedic position, by internal and external fixation or plaster cast. But the immobilization due to surgery should not affect the rehabilitation. As soon as the operation is finished and the gypsum solidified, the red and blue pencil is used to write the operation name, the date of plaster application, the date of weight bearing, walking, and so on. This will make other doctors, nurses, patients, and their families know about the rehabilitation plan easily and effectively. For patients with internal or external fixation, doctors are required to explain to the patients and

family members at an early stage that active and passive physical activity can be carried out under stable fixation conditions and to direct and demonstrate the magnitude and intensity of movement. During early bed-rest, limb muscles should be rested with equal length. Because the contracture of flexor muscles of lower extremity is more obvious, early exercises for the strength of dorsal lumbar and gluteus muscle in prone position is more helpful to improve the abnormal posture. Generally, when the condition is stable at 3 days after operation and plaster or external fixation is firm, training to stand off the bed and to walk can be started with walking aids. The early exercise can prevent bedsore, venous thrombosis, urinary tract infection, and other complications and can improve cardiopulmonary function, increase vital capacity, promote systemic blood circulation, promote gastrointestinal peristalsis, increase appetite, and prevent constipation. Early training of muscle coordination and re-establishment of dynamic balance can let patients improve their standing and walking ability and increase their confidence in further rehabilitation and treatment. The external fixator is usually removed 4 weeks after soft tissue surgery and then plaster or brace is applied. Postoperative plaster generally does not exceed 8 weeks. The external fixator of the ankle and foot can be removed after 8 to 10  weeks of soft tissue surgery or calcaneal osteotomy. When fusion of the subtalar joint or middle tarsal joint is performed, the external fixation lasts for 12  weeks till the bone healing is certain. The external fixation should be strong enough to overcome the persistent muscle spasm of the limb. After external fixation or plaster removal, the correction should be maintained for 6–8  weeks by brace (Figs. 6.24 and 6.25).

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Fig. 6.19  Correction of severe flexion deformity of bilateral lower extremities in cerebral palsy with Ilizarov technique in stages. (a) A 11-year-­old male, with severe knee flexion and hip adduction deformity. (b) Crouching with both hands on the wall before operation. (c) X-ray film showed subluxation of right hip and knee flexion, but the patella was in normal position. (d) After lengthening of hip adductor and iliopsoas muscle, Ilizarov fixator was applied to correct severe flex-

ion deformity of knee joint. (e) After 50 days of operation, the flexion deformity of knee was completely corrected, the fixator was removed, and the long leg plaster cast with knee in full extension was given. (f) The patient can walk upright in plaster. The same operation was performed on left side in the second stage. Finally, the bilateral hip adductions and flexion deformities are corrected satisfactorily

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Fig. 6.19 (continued)

6  Lower Limb Deformities in Cerebral Palsy

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Fig. 6.20  Ilizarov technique for the correction of flexion deformity of cerebral palsy with patella alta. (a) Male, 13 years old, paraplegic spastic type, bilateral severe flexion, and clubfoot deformities in lower extremities. (b) X-ray showed that the patella was displaced in a high position. The knee joint flexion deformity was corrected with the patella being pulled down. (c) Two steel wires run across the patella and were mounted to a pull rod. (d) Flexion deformity of the knee joint was being

corrected in the process of traction. Walking exercise was carried out with double crutch. (e) X-ray examination of knee joint showed that knee flexion deformity had been corrected, patella had been moved down, and patella ligament was constricted under local anesthesia. (f) Six months after surgery, X-ray films were taken in the local hospital of the patient. The flexion deformity was completely corrected, and the patella was moved down to the normal position

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Fig. 6.20 (continued)

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6  Lower Limb Deformities in Cerebral Palsy

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Fig. 6.20 (continued)

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Fig. 6.21  Ilizarov technique for correction of knee flexion deformity with patella alta in cerebral palsy. (a) A 13-year-old male with spastic paraplegia having bilateral severe knee flexion and clubfoot deformity. (b, c) X-ray showed patella alta. The knee flexion deformity was corrected, and patella was pulled down. Two stainless steel wires were passed across the patella and were mounted on a pull rod. (d, e) Flexion

deformity of the knee was being corrected in the process of traction. Walking exercise was carried out with double crutch. X-ray showed correction of knee flexion deformity and patella in normal position. (f) Three months after surgery, the flexion deformity was completely corrected, and the patella was moved down to the normal position. When the fixators were removed, the patient could wear casting

6  Lower Limb Deformities in Cerebral Palsy

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Fig. 6.21 (continued)

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Bilateral rectus femoris lengthening and short-contraction of the ligamentum

Fig. 6.21 (continued)

Weight bearing 5 days later, fixed for 45 days

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Fig. 6.22  Correction of severe knee flexion deformity with patella alta in adults with cerebral palsy. (a) A 23-year-old male, with spastic cerebral palsy having bilateral hip adduction and knee flexion deformity with a crouch gait. (b) The relationship between head and acetabulum was normal on both sides. (c) There was anterior bowing of bilateral distal femur with patella lying superiority. (d) The bilateral rectus femoris and adductor longus were released, and then bilateral Ilizarov fixator was applied. (e) After operation, the flexion deformity and the

patella alta were corrected simultaneously. Lateral view showing knee flexion and mounted extender for high patella. (f) Six weeks after the first operation, the patella ligament was plicate, and the long leg cast was applied. But the bilateral anterior bowing was not corrected. (g) The patient was walking on the ground. (h, i) After fixator removal, long leg brace was worn to exercise walking. (j, k) X-ray 11 months after surgery showed patella returned to normal position and new endpoint of displaced tibial tubercle was healed

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6  Lower Limb Deformities in Cerebral Palsy

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Fig. 6.23  Supracondylar femoral osteotomy was performed to correct knee flexion deformity in adult patient with cerebral palsy

Fig. 6.24  Lying prone and strengthening gluteus muscle, dorsal lumbar muscle, and upper limb

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6  Lower Limb Deformities in Cerebral Palsy Fig. 6.25  The patient is walking with walker: (a) front view; (b) back view

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Complex Deformity Correction and Functional Reconstruction of Lower Limbs Jiancheng Zang, Sihe Qin, Gang Li, Shaofeng Jiao, and Qi Pan

7.1

 efinition and Classification of Limb D Dysfunction

Jiancheng Zang and Sihe Qin 1. Definition (Fig. 7.1) Any lower extremity deformity combined with one of the following features is considered as complex deformity of lower limbs. (a) One or two of the hip, knee, and ankle have severe deformities, the affected limb loses the upright walking ability. (b) Polyarticular deformity of both lower extremities or severe deformity of the bone, accompanied with bone nonunion and/or defects. (c) Combined with extensive muscle spasms or sensory disturbances. (d) Lower limb compound deformity with severe scoliosis and pelvic tilt. (e) Extensive skin scar contracture, lower limb discrepancy greater than 10 cm. (f) Severe osteoporosis, hip and knee stiffness. (g) Long-term bone and joint infection or combined with nonunion, bone defect. (h) Lower extremity deformities associated with brittle bone disease, hemangioma/ischemic disease. (i) Patients with severe complications or multiple surgical failures of previous treatments. (j) Lower extremity deformity failed classical orthopedic surgery treatment and facing risk of amputation.

2. Preoperative examination and evaluation. (a) Preoperative physical examinations shall include causes, time, extent, and range of deformity, as well as muscle spasm, malformed nature, and interdisciplinary characteristics. (b) The age and previous surgical treatment of the patients. (c) Pathological gait should be videotaped. (d) Preoperative evaluation should include the psychological and mental state of the patients, their understanding of the surgery, and expectation for the surgical outcome. (e) Do necessary imaging examinations (X-ray, CT, and MRI) after physical inspection. (f) For the patients with complicated bone and joint deformities, it is recommended to have 3D printing of the deformity before surgery. 3. Classification of Qin Sihe for lower limb complex deformity. The grading is based on whether or not the patients can walk upright and the ability of the lower limbs to drag the body movement. (a) Severe independent claudication. (b) Walking with a cane or assembly brace. (c) Walking with crutches or walking aids. (d)  Can complete crawling and squatting down movement. (e) Rely on wheelchairs when walking.

7.2

 urgical Indications and Related S Issues

J. Zang · S. Qin (*) · S. Jiao · Q. Pan Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China

Sihe Qin, Gang Li, Shaofeng Jiao and Jiancheng Zang

Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China

1. Preoperative examinations and evaluations of the patients The conditions of these patients varied as mentioned before. A particular note is that for those lower limb complex deformity disabled patients, the surgeries shall not cause more harm or worsen their existing disability.

Qinsihe Orthopeadics Institute, Beijing, China G. Li Chinese University of Hong Kong, Sha Tin, Hong Kong

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_7

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cogential bilateral patellar dislocation

Fig. 7.1  Complex lower limb deformities. (a) Genu valgum deformity secondary to hyperparathyroidism; (b) Bilateral lower limb deformity secondary to Blount’s disease; (c) Genu valgum secondary to low phosphorus rickets; (d) Knee flexion deformity secondary to congenital bilateral patellar dislocation; (e) Genu valgum deformity secondary to

epiphyseal injury of distal femur; (f) Severe flexion deformity secondary to suppurative infection of knee joint; (g) Congenital pterygoid webbed knee joint; (h) Complex deformity of knee joint caused by congenital epiphysis dysplasia of knee joint; (i) Congenital pseudarthrosis of tibia; (j) Right tibia shortening deformity with nonunion

7  Complex Deformity Correction and Functional Reconstruction of Lower Limbs

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2. Self-evaluation of doctors Include overall planning, technical skills, doctor– patient communication ability, predicting surgical outcome and avoiding surgery risks abilities. 3. Evaluation of team quality and medical condition Do you have a team to handle the necessary conditions for after surgery care? 4. Whether there are indications for surgery requires to clarification on these following questions: (a) Do the surgeon understand the patient’s pathological condition and limb deformity progression? Whether the evaluation of functional status is complete, accurate, and objective? Do the surgeon have experience in the treatment of this type of disability? (b) Whether the patients have conditions to correct deformity and improve function? How many surgical treatments needed to achieve desired therapeutic goals? (c) Whether the patients agree to the therapeutic time and outcome, and their mental state can cope with the

treatment, and whether these expectations are consistent with what doctors predict? (d)  Whether we can avoid surgical risks and severe complications? (e) Whether the long-term management after surgery and doctor–patient communication are comprehensive? (f) If the auxiliary equipment, rehabilitation, etc. can be properly coordinated? The doctors must be objective and fair about themselves and their team to ensure the efficacy of surgery. ‘Know yourself and know your enemy, and you will never be defeated’—Sun Tzu’s Art of War.

7.3

 urgical Strategy for Multiple Joint S Deformities

Sihe Qin, Gang Li, Jiancheng Zang and Qi Pan

7  Complex Deformity Correction and Functional Reconstruction of Lower Limbs

7.3.1 T  ry Best to Correct Multiple Deformity of One Side of Lower Limb at First Stage Surgery Create conditions for upright walking for the patients. If the deformity cannot be completely corrected during surgery, then install the Ilizarov external fixation to correct the residual deformity postoperatively. Those who need different stages of surgeries should correct the hip and knee ­deformities first, and then the ankle deformities. Soft tissue release surgery should be performed concurrently with bone deformity correction surgery. For limb lengthening and lower extremity reconstruction surgery for joint deformity correction, which should be arranged in the same period of lower extremity reconstruction surgery or after implementation. External fixation can be used for slow correction by traction. Dynamic reconstruction of the ankle can be performed simultaneously with the ankle deformities correction surgeries.

7.3.2 Lower Limb Paralysis and Deformity For the patients who cannot stand walking before surgery, the first surgery shall be on the less deformed lower limbs. Whereas for the patients who can walk upright before surgery, the first surgery shall go for more severe lower limb. Those who need staged surgeries should arrange rationally. The second surgery on the same leg should not interfere with the outcome of the first surgery. It is best for one doctor to complete the treatment plan for the patient.

7.3.3 T  hree Principles of Qin Sihe for Deformity Correction and Functional Reconstruction of Lower Limb Deformity 1. Walking. Encourage patient to walk early and walking is part of the treatment. The surgical method selection is based on whether it can create conditions to allow patient walking early. 2. Two lines. Restore the mechanical axis of lower limbs and hip-knee-ankle normal anatomical articular line. 3. Balance. First, bone surgery shall regain balance between bone quality, strength, and stiffness, eliminating stress shielding. Second, rebuild lower limb static and dynamic balance. Third, to rebuild patient’s physical and mental health.

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7.3.4 Postoperative Management The post-surgery care directly affects the efficacy of treatment. Especially for external fixators, correct management procedures could effectively prevent complications. 1. Get out of bed early after surgery. Patients shall walk with crutches 3–5  days after surgery. The weight bearing on the fixator depends on the strength of the limb. Generally, most of the external fixation can bear 0.5–1 times the patients’ body weight. Patients may experience different degree of pain under loading, the doctor should encourage the patients to overcome, exercise within the range of pain tolerance, and take oral painkillers if necessary. 2. Joint motion exercise Joint motion exercise shall start as soon as possible. Flexion and extension of joints should be encouraged, active and passive exercise to maintain the maximum range of joint motion. There will be pain during the movement, and patients may take painkillers. 3. Pin care Prevent pin track infection and reduce pin track discharge. For tibiae anterior region and the ankle where soft tissues are less, no need to dress the wound and apply disinfectant. For other part of the leg where soft tissues are thicker, use gauze-pressed to prevent the soft tissue sliding against the pins, which can reduce the exudation and infection caused by the needle stimulation. 4. External fixator adjustment to correct residual deformities Adjustment of external fixator shall start to correct residual deformities 5–7  days after surgery. As bony deformity correction the lengthening speed shall not exceed 1 mm/day, in 4–6 steps. The speed for soft tissue lengthening can be faster as long as it does not affect the skin blood supply. 5. Regular X-ray examination Take an X-ray 5 days post-surgery to check the deformity correction and if the angle and depth of the needles and screws are appropriate. If there is no residual deformity, the X-ray can be taken 2–3 months after surgery to check bone healing. If residual deformity needs to be corrected after surgery, X-ray shall be taken biweekly to check the alignment of the osteotomy and callus formation. After the correction of the deformity, X-ray can be taken every 2 months to follow bone healing. 6. Removal of external fixator For patients with only soft tissue deformities correction, once the deformity is corrected, continue the external

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fixation for 3–6 weeks and then loosen the external fixator; if the deformity does not rebound, the external fixator can be removed. For bony deformities correction, the external fixator can be removed once the osteotomy is healed. 7. The use of orthosis After the external fixator is removed, orthopedic braces shall be used routinely to maintain the effect and prevent recurrence of deformity.

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7.3.5 Case Illustration An 18-year-old male with complex deformities of both lower limbs caused by hereditary low phosphorus rickets. Tibial anterior arch deformities and femoral varus deformities were presented on admission. Multiple tibial osteotomy was performed in one stage (Fig. 7.2).

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Fig. 7.2  Multiple tibial osteotomy for anterior arch deformity correction. (a) Clinical appearance preoperatively; (b, c) Preoperative X-ray films of tibia and femur; (d) Left tibia V-shaped osteotomies were performed to correct the deformity at one stage; (e–g) Intramedullary nail was applied; (h, i) X-ray fluoroscopy showed satisfactory position for deformity correction; (j, k) The anterior arch deformity of left tibia was

corrected; (l) The anterior arch deformity of right tibia was corrected by the same surgical method; (m) Hybrid external fixation was mounted; (n, o) Two weeks after surgery, he has begun to walk with walker on the ground; (p, q) X-ray of AP view and lateral view 2  weeks after surgery

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7.4

 orrection of Lower Limb Deformity C with Imbalanced Muscle Strength

Sihe Qin, Shaofeng Jiao, and Jiancheng Zang

7.4.1 Overview Neuromuscular lesions often cause bone and joint deformities, combined with muscle force imbalance, such as polio

sequelae, spina bifida sequelae, lower limb deformity secondary to peripheral nerve injury, and limb deformity under hereditary sensory motor neuron disease. The common feature of these conditions is dual dysfunction of bone and soft tissue, whether it is a bone deformity caused by muscular imbalance, or a tendon soft tissue contracture secondary to skeletal deformity. Taking together, systemic design is critical for good outcome of complex lower limb deformity correction.

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7.4.2 H  ip Deformity Combined with Muscle Strength Imbalance 1. Gluteus medius paralysis combined with paralytic dislocation of the hip For gluteus medius paralysis caused by polio sequelae or congenital spina bifida, if combined with hip dislocation, obliquus externus abdominis transfer can be used to reconstruct the gluteus medius following surgical reduction of the hip, which can increase the hip stability, prevent recurrence of dislocation, and improve the patient’s swing gait.

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Typical case: female patient, 23  years old, with sequelae of bifida sacrum, received meningocele repair at 4 years old. She had left gluteus medius paralysis combined with hip dislocation and left foot valgus deformity. The following surgeries were applied: left iliopsoas muscle extension, hip open reduction, acetabular capping, hip joint capsule tightening, femoral subtrochanteric derotation osteotomy, gluteus medius reconstruction by obliquus externus abdominis transfer, and calcaneus and talus joint fusion. Left foot deformity was well corrected postoperatively, and gait was improved significantly (Fig. 7.3).

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Fig. 7.3  Therapy of gluteus medius paralysis combined with paralytic dislocation of the hip: (a) Move with walker aid pre-operation, left foot valgus, and transverse incision scar can be seen in the lumbosacral region; (b) preoperative X-ray, left hip joint dislocation, and sacral ver-

tebrae plate defect; (c) Dissecting obliquus externus abdominis during operation; (d) Wearing abduction brace to maintain left hip joint abduction after surgery; (e) Left hip X-ray post-surgery

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Fig. 7.4  Reconstruction of gluteal muscle with bilateral sacrospinalis transfer

Ipsilateral sacrospinalis

Contralateral sacrospinalis

Iliotibial band

Greater trochanter

Sacrospinalis is fixed in the greater trochanter

2. Treatment of gluteal muscle paralysis by reconstruction of  gluteal muscles with bilateral sacrospinous muscle transfer The hip joint is not stable when gluteal muscles (gluteus maximus and gluteus medius) are paralyzed, affecting the patients’ gait. Reconstruction of gluteal muscle function through bilateral sacrospinalis transfer could increase hip stability, provide walking power, and improve gait. The distal ends of bilateral sacrospinalis were used to fix the femoral trochanter through the iliotibial band, and the direction of muscles were the same as the posterior side of the gluteus maximus and the gluteus medius (Fig.  7.4). After the muscle transfer, it can produce a ­pulling force similar to that of the gluteus maximus and part of the gluteus medius, which stabilizes the hip joint during abduction. 3. Treatment of gluteal muscle paralysis by reconstruction of gluteus medius with ipsilateral sacrospinalis plus obliquus externus abdominis transfer The paralyzed gluteus medius can also be reconstructed using the ipsilateral sacrospinalis together with obliquus externus abdominis transfer (Fig.  7.5), which has the advantage of gaining more muscle strength than that of a single muscle, and the muscle strength could reach to level 3 or above (Fig. 7.6).

Fig. 7.5  Reconstruction of gluteus medius with ipsilateral sacrospinalis and obliquus externus abdominis combined transfer

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obliquus externus abdominis

Fig. 7.6  Fifteen years follow-up after reconstruction of gluteus medius with ipsilateral sacrospinalis and obliquus externus abdominis combined transfer. The muscle strength was greater than grade 3. When the muscle contracted, the subcutaneous contour was clearly visible

7.4.3 K  nee Deformity Combined with Imbalanced Muscle Strength The knee joint moves in two directions: flexion and extension. The contraction of popliteal muscle causes the knee joint to flex, and quadriceps contractions make the knee joint straight. In addition, gastrocnemius contraction can also ­produce the power to flex the knee joint, but when the calf is fixed, the gastrocnemius contraction pulls the femoral condyle backward, making the knee joint tend to be straight and stable. The stability of the knee joint when it straightens is the basis for walking upright without support, so correcting the deformity of the knee joint to enable it to straighten and reconstruct the knee extension function is the goal of knee deformity correction.

1. Rebuild knee extension function through reconstruction of quadriceps with semitendinosus and biceps femoris long head combined transfer (a) Indications: Quadriceps paralysis, hamstring muscle strength reaches grade 4 or above, no knee deformity when flexed, or applying knee deformity correction concurrently. Hips and ankles are free of deformities, or the deformities may be corrected at the same time. (b) Surgical procedure (Fig. 7.7): Make the incision at the posterior medial of the lower thigh and expose the proximal end of the biceps femoris, separate the medial and lateral head, and free the long head along the muscle gap toward distal end; Make incision at the fibular head and reveal the insertion of biceps femoris muscle; Continue to free biceps femoris long head subcutaneously to the insertion of fibular head, cut off the long head, and withdraw it from the proximal incision; Protect the common peroneal nerve and lateral collateral ligament when dissecting muscles and tendons; Make incision at the medial lower thigh and reveal the semitendinosus muscle and free it to the distal end; Incise below the medial condyle of the tibia and reveal the semitendinosus muscle insertion, cut off the insertion and free it to the proximal end, then taken it out from the proximal incision for standby use; Make transverse incision at the patella distal polar and reveal the patella and patella ligament. From this incision, make channels toward the posterior medial and posterolateral incision of the lower thigh subcutaneously and lead the long head of biceps femoris muscle and semitendinosus to the anterior patella incision through the channel; Extend the knee joint and fold back the patellar ligament which traverses the distal patella polar from semitendinosus, and fixed it with the patellar tendon with appropriate tension. For testing tension of the tendon junction site, the suture shall not break when the knee flexion reaches 45°, whereas the two muscles are not loose when the knee extends; Suture the incision; Use an external fixator or plaster to secure the knee joint in the extended position. (c) Postoperative management: Begin to lift the leg on the second day after operation; on the third day, walk with crutches, and the lower limb can carry some weight; The plaster can be removed 4  weeks after surgery, then the knee flexion and extension exercise can start gradually, and slowly increase the range of motion from small to large; 8 weeks after surgery, the knee joint slowly reach the maximum flexion position. (d) If one side of the hamstring muscle is paralyzed, such as the biceps femoris muscle paralysis or semitendinosus paralysis, and the muscle strength of the other side is above grade 4, then the unilateral muscle can be transferred to rebuild the quadriceps. For example,

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Fig. 7.7  Semitendinosus combined with biceps femoris long head transfer to rebuild quadriceps: (a) Make incision at the long head of biceps femoris; (b) Dissect the long head of the biceps; (c) Free the long head of the biceps femoris to the proximal end; (d) Incision to

Fig. 7.8  Sixteen  years follow-up of rebuild knee extension function surgery through reconstruction of quadriceps with semitendinosus and biceps femoris long head combined transfer, knee extension muscle strength > grade 3

expose semitendinosus; (e) Transfer the semitendinosus and the biceps femoris long head to the anterior patella incision, and fix them at the distal femurs through a bony tunnel; (f) The diagrammatic drawing of tendon suture through bony tunnel

the semitendinosus transfer to rebuild quadriceps or biceps femoris muscle transfer to rebuild quadriceps. (e) The long-term follow-up effect of this operation is significant, and the muscle strength of knee extension can reach level 3 or above (Fig. 7.8). 2. Sartorius muscle transfer to rebuild quadriceps femoris (a) Indications: Strength level of sartorius muscle shall be grade 4 or above. (b) Surgical procedure: Incise at the posterior medial lower thigh and reveal the sartorius muscle, then free the muscle to the distal and proximal ends. Pay attention to protect the saphenous nerve that is close to the muscle and localized deep in the sartorius muscle; Make incision at tibial medial condylar, reveal the pes anserinus tendon,

276 Fig. 7.9  Rebuild quadriceps with sartorius muscle transfer: (a) Anatomy of the sartorius muscle; (b) Schematic diagram of the surgical procedure

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anterior superior spine

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tibial tubercle 3

and continue to free the sartorius muscle toward distal end to the insertion. The insertion of sartorius muscle is short, so the tibia periosteum can be peeled off to increase the length of the insertion tendon, then cut off it, and pull it out from the proximal incision; Incise at the anterior patella, expose the distal patella polar and patellar ligament, lead the sartorius muscle to the anterior patella incision through the subcutaneous tunnel, and straighten the knee joint. Fix the sartorius muscle with patellar ligament at the distal patella polar (Fig. 7.9). (c) Precautions for surgery: Protect the saphenous nerve from damage when freeing the sartorius muscle. The sartorius muscle should be freed to the proximal end of the muscle as much as possible to reduce the steering angle during transfer. (d) Postoperative management: Same as above. 3. Rebuild hip flexion and knee extension function through reconstruction of quadriceps with rectus abdominis and obliquus externus abdominis combined transfer (a) Indications: Iliopsoas, flexors, and sartorius are paralyzed, or muscle strength less than grade 2. (b) Surgical procedure (Fig. 7.10): Two to three longitudinal incisions on the lateral of the thigh, reveal the iliotibial band, cut the bundle of about 2 cm wide, and free the band to the distal end until the knee joint level; Then free the band toward the proximal end to the femur great trochanter and cut off for standby use; Make the abdominal incision, expose the obliquus externus abdominis and rectus abdominis, cut the aponeurosis of the obliquus externus abdominis about 3 cm wide, free to the distal end toward the pubic bone, cut off the insertion, also free the aponeurosis to the proximal end to the rib arch, and pay attention to avoid damage to the deep vascular and dominating nerves of the external oblique muscle; Then free the abdominal muscle at the bottom of the rectus abdominis, and cut the insertion of the rectus abdominis inside the pubic symphysis; Because the insertion of rectus abdominis is very short,

it can be cut with a pubic periosteum to facilitate tendon anastomosis. Pay attention to avoid damage to the deep cone muscle; Then raise the lower limb, maintain the hip flex and knee extended position, lead the iliotibial band through the rectus femoris, suture and fix the aponeurosis of obliquus externus abdominis with the rectus femoris tendon, and suture the distal end with the patellar tendon; Suture the abdominal wall sheath and incision, and the abdomen was pressure bandaged. (c) Postoperative management: Maintain the limb lifted post-surgery and maintain the hip flexion at 30° and knee straight for 6 weeks (Fig. 7.11); Begin to practice abdominal muscle contraction on the second day after surgery, do flexion, and extension movement of the knee while the hip flex at 90°. Keep the ­abdominal belt on after dressing change to maintain abdominal compression to prevent abdominal hernia; 2  weeks after surgery, the patient could walk with crutches while the hip is maintained at a flexed position (bend down or use bandage to lift the limb) (Fig. 7.12); Return to normal position walking 8 weeks after surgery.

7.4.4 A  nkle Deformity Combined with Muscle Strength Imbalance The muscles of the ankle and foot can be divided into four groups according to the direction of joint movement: the ankle extensor muscle group, the flexor muscle group, the valgus muscle group, and the varus muscle group. These four groups of muscles counter balance to each other, to maintain muscle strength balance, and normal shape and function of the foot and ankle. When one or several groups of muscles are paralyzed, the balance is broken, which will cause ankle deformity. In the early stage, posture deformity can be easily corrected. Over time, the bone and joint structure changes and develops into a fixed deformity. Hence for ankle deformity correction, the balance of the muscle strength should be restored to prevent the recurrence of the deformity.

7  Complex Deformity Correction and Functional Reconstruction of Lower Limbs Fig. 7.10  Reconstruction of quadriceps with rectus abdominis and obliquus externus abdominis combined transfer: (a) Surgical incision; (b) Cut the iliotibial band; (c) Obliquus externus abdominis, rectus abdominis, and iliotibial band anastomosed at the proximal end; (d) Anastomose the distal end of the iliotibial band and patella ligament

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Fig. 7.11  Position in bed at the early stage after surgery (reconstruction of quadriceps with rectus abdominis and obliquus externus abdominis combined transfer)

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Fig. 7.12  Practice walking after surgery (reconstruction of quadriceps with rectus abdominis and obliquus externus abdominis combined transfer)

1. Reconstruction of the dorsiflexion and ectropion function of the foot. (a) Reconstruction of the dorsiflexion and ectropion function of the foot by tibialis posterior anterolateral transfer Indications: Tibialis anterior is paralyzed, muscle strength of extensor hallucis longus and extensor digitorum longus is less than grade 3; tibialis posterior muscle strength is greater than grade 4; calf triceps muscle strength is greater than grade 4; no bony varus deformity or concurrent deformity correction. Surgical procedure (Fig. 7.13): A medial supramalleolar incision at the tibia posterior margin is made to expose the posterior tibial tendon; a medioposterior incision at the scaphoid nodule is made to expose the insertion of the posterior tibial tendon which is severed and extracted from the supramalleolar incision; a lateral supramalleolar fibula anterior incision is made to incise the deep fascia. Transfer the posterior tibial tendon to the anterior lateral malleolar through the tibia interosseous membrane; Incise at the lateral dorsal foot and reveal the third peroneal muscle. Make a channel

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through the tendon sheath to the lateral supramalleolar incision, and the posterior tibial tendon is introduced into the instep incision; the ankle joint is placed in a mild dorsal extension position, and then suture the posterior tibial tendon and the third peroneal muscle with appropriate tension. The ankle joint is fixed to the orthopedic position by a combined external fixator. Tips and tricks: Pay attention to avoid damage to the posterior tibial nerves and blood vessels; the passage between the tibia and fibula should be sufficiently spacious; if the third peroneal muscle is absent or the tendon is too thin, the distal tendon of the tibia short muscle should be exposed. The posterior tibial muscle and the short peroneal muscle are sutured. Postoperative management: Begin to practice the contraction movement of the transferred muscles since the second day after surgery, and encourage the patient to practice the ankle joint extension movement. Three days post-surgery, walk with the crutches is allowed, and the limb is able to walk with weight; Keep the external fixation or the plaster for 8 weeks; after the external fixation is removed, protect the foot with an ankle brace for another 2 months. (b) Anterior placement of posterior tibial muscle to rebuild extensor pollicis longus and extensor digitorum longus Indications: Paralysis of anterior tibial muscle, extensor hallucis longus and extensor digitorum longus; tibialis posterior strength greater than grade 4; triceps surae, flexor hallucis longus, flexor digitorum longus strength greater than grade 3; non-bone varus deformity or concurrent deformity correction. Surgical procedure (Fig.  7.14): A medial supramalleolar incision at the tibia posterior margin is made to expose the posterior tibial tendon; a medioposterior incision at the scaphoid nodule is made to expose the anchor point of the posterior tibial tendon which is severed and extracted from the supramalleolar incision; the posterior tibial tendon is split into two bundles for use; a lateral supramalleolar fibula anterior incision is made to incise the deep fascia, and a pathway is made from the medial supramalleolar incision to lateral supramalleolar anterior margin incision via the tibiofibula, via which the two bundles of posterior tibial tendon are drawn to anterio-lateral side of the ankle; a dorsal lateral incision is made to reveal the extensor digitorum longus tendon; a dorsal medial incision is made to reveal the extensor hallucis longus tendon; a pathway is made respectively to

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Fig. 7.13  Reconstruction of the dorsiflexion and ectropion function of the foot by tibialis posterior anterolateral transfer: (a) Incision to expose the posterior tibial muscle; (b) Incision to expose the posterior tibial muscle; (c) Dissect the insertion point of tibialis posterior muscle; (d) The posterior tibial muscle is moved to the lateral side, and the third

peroneal muscle tendon has been revealed on the back of the foot; (e) The posterior tibial muscle is sutured to the third peroneal muscle insertion (the patient also received the calcaneus osteotomy and the first tibial base osteotomy); (f) Surgery completed

the supramalleolar lateral incision via the two tendon sheaths, and one bundle of the posterior tibial tendon is drawn to the dorsal lateral incision and dorsal medial incision; one bundle of the posterior tibial tendon is stitched to the extensor digitorum longus tendon by appropriate tension; the other bundle is stitched to the extensor hallucis longus tendon; the incisions are then stitched. The ankle joint and toes are fixed at the dorsal flexion position with combined external fixation device.

Postoperative management: The same as reconstruction of the dorsal flexion and extroversion function by anterior lateral displacement of the posterior tibial tendon (above). (c) Peroneus longus tendon distal retraction method for reconstruction of anterior tibial muscle functions Indications: Paralysis of anterior tibial muscle, extensor hallucis longus and extensor digitorum longus strength less than grade 3; paralysis of posterior tibial muscle; calf triceps, flexor hallucis longus, and

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for extensor hallcius longus tendon for extensor digitorum longus tendon

Fig. 7.14  Anterior placement of tibialis posterior for extensor pollicis longus and extensor digitorum longus: (a) Percutaneously cut off the anchor point of the posterior tibial tendon; (b) The posterior tibial muscle is removed (the plantar fascia is severed percutaneously at the same time); (c) The posterior tibial muscles are split into two bundles;

(d) The two bundles of posterior tibial muscles are displaced to the lateral side and will be stitched with the extensor hallucis longus tendon and the extensor digitorum longus tendon (hematogenous osteomyelitis is conducted concurrently)

flexor digitorum longus strength greater than grade 3; peroneal longus strength greater than grade 4; no equinovarus deformity or concurrent deformity correction. Surgical procedure (Fig. 7.15): A lateral supramalleolar incision (incision 1) about 10  cm is made to reveal the peroneus longus and cut it in a Z shape; incision 2 is made at the fifth metatarsal base to expose the distal end of the peroneus longus, and cut off peroneus longus; the dorsal incision 3 is made between the first and second metatarsal base, and a thread is drawn from incision 2 to incision 3 along the peroneus longus tendon sheath pathway with the hemostatic forceps, which draws the peroneus longus to the dorsal incision 3; the malleolar antero-superior incision 4 is made to expose the anterior tibial tendon, and the peroneal tendon is drawn to incision 4 along the tibial anterior tendon sheath; then the peroneal longus proximal end is drawn to incision 4 subcutaneously; upon dorsal flexion of the ankle joint,

the peroneus longus tendon is stitched in the incision 4. Fixation with plaster or combined with external fixation device. Postoperative management: On postoperative day 2, contraction of the transposed muscle is allowed, and the patient is encouraged to practice the ankle joint dorsal flexion movement. On postoperative day 3, the patient may walk with crutches and bear weight on the operated limb; maintain the position with external fixation device for 8 weeks; after removing the external fixation device, use the ankle brace for another 2 months. 2. Reconstruction of the flexor and extensor function of the ankle (a) Reconstruction of Achilles tendon by posterior tibial muscle combined with the peroneus longus Indications: Paralysis of calf triceps; the posterior tibial muscle and peroneus longus strength greater than grade 4; no bony deformity or concurrent deformity correction.

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Fig. 7.15  Peroneus longus tendon distal retraction method for reconstruction of anterior tibial muscle functions: (a) Skin incision; (b) Free peroneal longus muscle, that is cut in the Z shape at the junction of tendon and muscle belly, and the distal end is extracted from the fifth

metatarsal base incision; (c) The distal end of the peroneus longus is drawn to the dorsal incision 3 by thread; (d) The direction of the displaced peroneus longus; (e) End of the surgical procedures

Surgical procedure (Fig. 7.16): The media supramalleolar incision at the tibial posterior margin reveals the posterior tibial tendon; the scaphoid nodule medio-posterior incision reveals the ending point of the posterior tibial tendon, which is severed and extracted from the supramalleolar incision for use; an incision is made at the lateral supramalleolar peroneal posterior margin to expose the peroneus longus; the fifth metatarsal base incision reveals the distal end of the peroneus longus, which is severed and extracted from the lateral supramalleolar incision for use; an arc-shaped incision is made at the calcaneal tuberosity to reveal the ending point of the calcaneal tendon,

and the posterior tibial muscle and the peroneus longus are drawn respectively to the ending point of the calcaneal tendon subcutaneously; upon plantar flexion of the ankle joint, the peroneus longus tendon is transversed through the calcaneal tendon ending point and folded back before being stitched to the posterior tibial tendon; the incision is sutured. Fix with plaster or hybrid external fixator. Postoperative management: On postoperative day 2, the contraction movement of the transposed muscle starts, the patient is encouraged to practice the ankle joint dorsal flexion movement. On postoperative day 3, the patient may walk with crutches,

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Fig. 7.16  Replacement of Achilles tendon by posterior tibial muscle combined with the peroneus longus: (a) Incision; (b) Posterior tibial muscle and peroneus longus incised; (c) The posterior tibial muscle and

peroneus longus are subcutaneously transfer to the Achilles tendon; (d) The peroneus longus is crossed across the Achilles tendon ending point and folded back for stitching with the posterior tibial tendon

with feet raised (Fig. 7.17), and the operated limb may walk with weight-bearing; fixation with the external fixator or plaster for 8  weeks; after the external fixator is removed, ankle brace is used intermittently for 3 months; wearing the high heel for more than 1 year to prevent the Achilles tendon loosening. If either of the posterior tibial muscle and the peroneus longus is paralyzed and the muscle strength of the other muscle is greater than grade 4, a single muscle may be transposed to replace the Achilles tendon. (b) Replacement of Achilles tendon by anterior tibial muscle transposition Indications: Paralysis of calf triceps; paralysis of the posterior tibial muscle and peroneus longus; extensor digitorum longus and extensor hallucis longus strength greater than grade 3; no bony deformity or concurrent deformity correction surgery. Surgical procedure: The malleolar antero-superior incision at the tibial lateral margin reveals the ante-

rior tibial tendon; the medial incision of the medial cuneiform bone reveals the anterior tibial tendon ending point, which is cut off, and is taken out from the supramalleolar incision for use; the arc-shaped incision of the calcaneal tuberosity reveals the ending point of the Achilles tendon; a pathway is made from the malleolar anterior incision to the Achilles tendon ending point along the tibial lateral margin, and the anterior tibial tendon is drawn via this pathway to the Achilles tendon ending point; upon plantar flexion of the ankle joint, the anterior tibial tendon is sutured to the calcaneal tendon ending point; the incision is sutured. Fix with plaster or combined external fixator. Postoperative management: Same to that of replacement of Achilles tendon by the posterior tibial muscle combined with the peroneus longus. (c) Transfer of flexor halluces longus and flexor digitorum longus for reconstruction of Achilles tendon Indications: Paralysis of calf triceps; paralysis of posterior tibial muscle and peroneus longus and brevis, and anterior tibial muscle; flexor digitorum longus and

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7.4.5 Foot Eversion Function Reconstruction 7.4.5.1 Lateral Transposition of the Anterior Tibial Muscle 1. Indications: Foot inversion deformity, peroneal muscle paralysis; anterior tibial muscle strength greater than grade 4; calf triceps muscle strength greater than grade 3; no bony deformity or concurrent deformity correction at the foot ankle. 2. Surgical procedure (Fig.  7.18): The malleolar antero-­ superior incision at the tibial lateral margin reveals the anterior tibial tendon; the medial incision of the medial cuneiform bone reveals the anterior tibial tendon ending point, which is cut off, and is taken out from the supramalleolar incision for use; the dorsal lateral incision reveals the third peroneal tendon, and via this tendon sheath, the anterior tibial tendon is drawn to the dorsal lateral incision; upon dorsal eversion of the ankle joint, the anterior tibial muscle is sutured to the third peroneal muscle tendon; the incision is sutured. Fix with plaster or combined external fixator. 3. Postoperative management: Similar to that of anterior lateral transposition of posterior tibial muscle for reconstruction of dorsal flexion and eversion function.

Fig. 7.17  Heel raised up

flexor hallucis longus strength greater than grade 4; no bony deformity or concurrent deformity correction at the foot ankle. Surgical procedure: The medial supramalleolar incision at the posterior margin of the tibia reveals the flexor digitorum longus and flexor hallucis longus tendon; the medial thenar incision reveals the distal end of the flexor digitorum longus and flexor hallucis longus, which is cut off, and taken out from the medial supramalleolar incision for use; the arcshaped incision of the calcaneal tuberosity exposes the ending point of the Achilles tendon, and the flexor digitorum longus and flexor halluces longus are drawn to the ending point of the Achilles tendon; upon plantar flexion of the ankle joint, the flexor digitorum longus tendon is transversed through the calcaneal tendon ending point and folded back to be sutured with the flexor hallucis longus tendon; the incision is sutured. Fix with plaster or combined external fixator. Postoperative management: Same to that of replacement of Achilles tendon by the posterior tibial muscle combined with the peroneus longus.

7.4.5.2 Replacement of Peroneus Brevis with Posterior Tibial Muscle 1. Indications: Foot inversion deformity, peroneus paralysis; anterior tibial muscle strength greater than grade 4; calf triceps muscle strength greater than grade 3; foot and ankle without bony deformity or concurrent deformity correction. 2. Surgical procedure (Fig. 7.18): The medial supramalleolar incision at the tibial posterior margin reveals the posterior tibial tendon; the medial posterior incision at the scaphoid tuberosity exposes the ending point of the posterior tibial tendon, which is cut off and taken out from the medial supramalleolar incision for use; the lateral supramalleolar incision at the peroneal posterior margin reveals the peroneus brevis; the posterior tibial muscle is guided to the lateral incision closely along the tibial posterior margin; the lateral malleolar anterior inferior incision reveals the distal end of the peroneus brevis, and the posterior tibial muscle is guided to the distal end via the peroneus brevis sheath, and sutured to the peroneus brevis; the incision is sutured. Fix with plaster or combined with external fixator. 3. Postoperative management: Same to that of anterior lateral transposition of posterior tibial muscle for reconstruction of dorsal flexion and eversion function.

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Fig. 7.18  Later transposition of the anterior tibial muscle, take 1/2 posterior tibial muscle to replace peroneus brevis: (a) Take 1/2 posterior tibial muscle; (b) Take anterior tibial muscle; (c) Use hemostatic forceps to transfer the 1/2 posterior tibial muscle to the lateral peroneus

brevis incision; (d) The posterior tibial tendon transfers to the lateral side; (e) The posterior tibial tendon and the peroneus brevis tendon are stitched distally; (f) The anterior tibial tendon and the third peroneal muscle are sutured distally

7.4.6 R  econstruction of the Foot Inversion Dorsal Flexion Function

2. Surgical procedure: The lateral supramalleolar incision at the peroneal posterior margin reveals the peroneus longus; the fifth metatarsal base incision reveals the distal end of the peroneus longus, which is cut off and taken out from the lateral supramalleolar incision for use; the malleolar anterio-superior incision at the tibial lateral margin is made to expose the anterior tibial tendon; the medial incision of the medial cuneiform reveals the ending point of the anterior tibial tendon; the peroneus longus tendon is guided to the anterior tibial muscle proximal incision subcutaneously and

7.4.6.1 Replacement of Anterior Tibial Muscle by Peroneus Longus 1. Indications: Foot eversion deformity and analysis of anterior tibial muscle and posterior tibial muscle; peroneus strength greater than grade 4; calf triceps muscle strength greater than grade 3; foot and ankle without bony deformity or concurrent deformity correction surgery.

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then guided to the ending point of the anterior tibial muscle via the anterior tibial muscle sheath; upon dorsal flexion of the ankle joint, the peroneus longus tendon is stitched to the anterior tibial muscle ending point; the incision is sutured. Fixate with plaster or combined with external fixator. 3. Postoperative management: On postoperative day 2, the contraction movement of the transposed muscle is allowed, and the patient is encouraged to practice the ankle joint dorsal flexion movement. On postoperative day 3, the patient may walk with crutches, and the operated limb may walk with weight-bearing; fixation with the external fixator or plaster for 8 weeks; after the external fixator is removed, wear the ankle brace intermittently for 3 months.

7.4.6.2 Replacement of Anterior Tibial Muscle with Extensor Hallucis Longus 1. Indications: Foot eversion deformity, anterior tibial muscle, posterior tibial muscle paralysis; extensor hallucis longus and extensor digitorum longus strength greater than grade 4; calf triceps muscle strength greater than grade 3; foot and ankle without bony deformity or concurrent deformity correction. 2. Surgical procedure: The dorsal talonavicular joint incision or malleolar anterio-superior incision reveals the

Fig. 7.19  Various foot & ankle deformities

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anterior tibial muscle and extensor hallucis longus tendon; upon dorsal flexion of the ankle joint, the extensor hallucis longus tendon is strained toward the distal end, and the anterior tibial tendon is strained to the proximal end, then these two tendons are sutured; Incisions are stitched. Fixate with plaster or combine with external fixator. After the operation, the contraction of the extensor digitorum longus tendon replaces the contraction of the anterior tibial muscle. 3. Postoperative management: Similar to replacement of anterior tibial muscle with peroneus longus.

7.5

Correction and Functional Reconstruction of Complex Ankle Deformity

Sihe Qin and Jiancheng Zang More than two kinds of ankle deformity, or deformity with different nature, soft tissue contracture combined with bone and joint structure abnormality, or other conditions that are prohibitory to bone and soft tissue healing, such as infection, large areas of skin soft tissue scars, and vascular and nerve abnormalities (Fig. 7.19).

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Fig. 7.20  Soft tissue release, elongate the posterior tibial tendon, use the sharp knife to loosen the Achilles tendon, plantar fascia, and abductor hallucis

7.5.1 Q  in’s Basic Strategy for the Correction of Ankle Deformity 1. To obtain comprehensive information of patients with individualized surgery plan following systematic evaluation before surgery. 2. Preparation and test of appropriate external fixation devices before surgery. 3. Use tourniquet during operation to insure operative field clean. 4. Surgical procedure: release the tendon, to correct soft tissue contracture, perform osteotomy to correct bone deformity. 5. Install the external fixator to correct residual deformities.

7.5.1.1 Specific Procedures 1. Soft tissue release: Ankle deformity is often accompanied by varying degrees of soft tissue contracture, including skin, fascia, ligaments, tendons, nerves, blood vessels, etc. Surgical release of the contracted fascia, ligaments, and tendons (Fig. 7.20) can instantly correct partial deformities, but the skin, nerves, and blood vessels cannot be released and shall be protected during surgery. 2. Muscle strength balance: Muscle force imbalance is an important cause of the occurrence and development of ankle deformity. Long-term ankle and foot deformity can also cause imbalance of muscle strength. Therefore, muscle force balance surgery is important to correct the ankle deformity and avoid the recurrence of the deformity (Fig. 7.21). 3. Osteotomy: Bone deformity requires osteotomy correction. The wedge osteotomy or curved osteotomy is performed to correct the bony deformity according to the angle and direction of the deformity, then restore normal or near-normal morphology. 4. Limited joint fusion to retain the elasticity of the foot: When muscle paralysis and walking are affected by ankle instability, it is necessary to stabilize the joint through joint fusion; but the foot joint is important for foot flexion. Excessive joint fusion will diminish the foot flexibility,

Fig. 7.21  The longus muscle of fibula is displaced, and the distal end of the tendon is divided into two bundles to replace the extensor hallucis longus and the extensor digitorum longus

which is not favorable for standing and walking. Therefore, it is necessary to retain the elasticity of the foot as much as possible through limited joint fusion accordingly.

7.5.2 Application of Ilizarov Technology For complex ankle deformity, if the surgery is forcedly corrected, complications such as flap necrosis, nerve or vascular injury, and repeated osteotomies may occur. These difficulties may be avoided when Ilizarov technology is used and the risk is greatly reduced. Limited deformities can be corrected intraoperatively according to soft tissue conditions, and then using Ilizarov external fixation device (Fig. 7.22) to correct the residual deformity gradually post-surgery. The use of Ilizarov technique could reduce the surgery difficulty and improve the therapeutic effects.

7.5.3 Postoperative Management 1. In the early postoperative period (1–3  days), the blood flow of the flap in tension side and the skin sensation of the foot should be monitored to avoid the ischemic necrosis and nerve damage caused by excessive correction. 2. X-ray is performed 1 week later to check the joint structure and the depth of the half needles. 3. Ilizarov external fixator is adjusted to correct the deformity 1  week after surgery, and the adjustment speed is according to the tension of the skin and soft tissue on the tension side. The distraction strength adjustment shall not cause obvious pain in patients. 4. Adjust the pulling direction according to the deformity. 5. The needle track requires careful care to avoid infection. 6. Patients can walk with weight-bearing 2–3  days after surgery.

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Fig. 7.22  The deformity was partially corrected in the surgery, and the Ilizarov external fixation was used to correct the residual deformity

7. The fixation is used to maintain the position after the deformity is corrected and retained till bone healing, and the external fixation device is removed. 8. The orthopedic brace should be used for 1–3 months after the external fixation devices are removed.

7.5.4 Application of  Orthotic Braces The use of the orthotic brace at the foot and ankle plays a very important role in maintaining correction outcome. The orthopedic braces are custom-made according to the deformity. Patients with normal or near normal muscle strength and ankle range of motion should customize ankle brace which could fix the ankle in the coronal and move in sagittal plane. Patients who need to maintain overall stability of the ankle should equip with ankle protection brace. The ankle brace is worn for 1–3 months according to the deformity of the patients. Some patients can extend the wearing time.

7.5.5 Typical Case A patient, male, 20 years old, suffered from a large area of soft tissue defect in the right leg caused by a traffic accident

at the age of 3. After surgery, the patient gradually developed strephexopodia and calf shortening deformity, which were gradually aggravated. Physical examination: the middle and lower 2/3 of the right leg were covered by scars, with external rotation deformity and valgus deformity of the right foot, weight-bearing walking at the inner ankle, and thumb flexion contracture deformity. Vascular color Doppler ultrasound indicated only the existence of tibial anterior artery, not the tibial posterior artery. X-ray showed right calf is shortened and abnormal ankle structure (Fig. 7.23). 1. Treatment goals: Objective: During primary treatment, use microsurgical skin flap transplantation to reduce the back side of the lower leg scar, the secondary correction of external rotation deformity and valgus deformity of the right foot, then perform leg lengthening to recover the length of right leg. Planning: The patient has extensive bony scar on the right leg, external rotation deformity, and valgus ­deformity of the right foot, and the tibial posterior artery has been damaged. In order to ensure correction safety, the scar tissue at the back of the lower leg should be replaced by skin flap transplantation first. In the secondary treatment, the ankle osteotomy with

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d Fig. 7.23  Ilizarov technique combined with limited surgical treatment for complex ankle deformity: (a) Preoperative appearance; (b) Preoperative X-ray; (c) Preoperative ankle X-ray; (d) Postoperative calf free flap transplantation (e) Surgical implementation of ankle osteotomy, occipital joint osteotomy, interphalangeal toe joint fusion, Ilizarov

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small incision and Ilizarov technique is used to correct the ankle deformity. The proximal of the tibia was lengthening by osteotomy at phase III treatment. This section describes only the phase II treatment of the ankle deformity correction. 2. Surgery plan: The right ankle osteotomy, articulation talonavicularis osteotomy, interphalangeal joint fusion, and Ilizarov method. 3. Preoperative preparation: Drill, sharp narrow osteotome, and Ilizarov ankle orthopedic device. 4. Surgical procedures: A 2 cm small incision was made at the anterior medial, medial, and lateral sides of the ankle, anterior tibial artery should be protected. The ankle joint had incisions by three incisions: front, inside, and outside. Then the medial incision was to expose articulation talonavicularis, and the articular

cartilage was cut off with an osteotome, and wedgeshaped osteotomy was made to correct the valgus deformity, and the foot and ankle was fixed with a 2 mm K-wire. After the joint is exposed by dorsal incision of the interphalangeal joint, the articular cartilage is resected with a osteotome and then coaptate the end of osteotomy to correct the flexion deformity. A 2  mm  K-wire was used for fixation. The incision was closed, and the Ilizarov external fixation was applied. 5. Tips and tricks: Three small incisions for ankle osteotomy are used to protect the anterior iliac vessels, making osteotomy easier, less traumatic, and safer. When installing the external fixator with wires, take care to avoid damaging the anterior tibial artery. Only the ankle joint osteotomy was performed during surgery, and the valgus deformity should not be corrected to prevent skin necrosis.

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6. Postoperative management and quality control: Use walking aids to practice walking 5 days after the surgery. The external fixator was adjusted to correct abduction deformity and valgus deformity of foot 7 days after the surgery. After the correction, change the connection structure of leg ring and foot external fixation frame, and start to correct the external rotatory deformity of the foot. Then, the external fixator structure was changed again to correct dislocation of feet, and finally the axis of ankle and leg is restored. Keep the pin tract dry and prevent infection. After the deformity was corrected, the fixation was maintained for 2  months, and the external fixator was removed and then fixed with a brace for 6 months.

7.6

 reatment of Severe Limb Deformity T Suggested Amputation

Sihe Qin, Shaofeng Jiao, and Jiancheng Zang

7.6.1 Introduction Severe lower limb deformities, especially foot and ankle deformity, such as adult severe ankle and foot complex deformities, co-infection or long-term unhealed foot and ankle deformity caused by foot ulceration of weight bearing area, ankle and foot defect caused by lack of blood circulation, are difficult to achieve satisfactory therapeutic effects by traditional treatments, which seriously affect the quality of life of patients. Traditionally, orthopedic surgeon often choose amputation and then install the prosthetic to improve the quality of patient’s life. However, the limb loss caused by amputation will bring great obstacles to the patient’s psychology, body, daily life, and work and cause complications such as phantom limb pain and stump ulcer which leads to endless pain. Also most patients and families are reluctant to accept amputation because of Chinese cultural traditions. Ilizarov technique combined with the orthopedic surgery of Dr. Qin Sihe have treated more than 100 cases of foot and ankle deformities that are close to amputation, restoring satisfactory shape and walking function, bringing hopes to patients and their families. Moreover, the treatment is not so complicated with low risk.

3. With severe blood circulation obstacle or insufficiency of the foot 4. Chronic osteomyelitis of the foot, extensive scar attached to bone 5. Bone defect after severe open injury with large area of soft tissue scar or chronic osteomyelitis 6. Severe complex deformity of the knee or calf after repeated surgical treatment failure, affecting walking function. The etiologies of these patients are different, the types of deformities and clinical manifestations are different, but their common feature is that severe deformities seriously affect their standing and walking function. Due to poor soft tissue conditions in these patients, it is difficult to correct deformities and restore weight-bearing function using traditional surgical methods such as osteotomy and soft tissue release (Fig. 7.24); or chronic osteomyelitis, ulcers that are difficult to heal or repeated relapse (Fig. 7.25), and prolonged disease seriously affect the patient’s physical and mental health. X-ray examination can show the deformity of the bones and joints (Fig. 7.26), and the structure and defect status of the foot joints, which provides a reference for surgical plan.

7.6.3 Preoperative Evaluation No matter how complicated the deformity is, after evaluating the relationship between the deformity and dysfunction, the ultimate goal of surgery is to correct deformities, cure infections, restore lameness, and rebuild the weight-bearing function of the foot.

7.6.4 Surgical Treatment Principles and Methods

The definition of severe limb deformity suggested amputation:

7.6.4.1 Principles of Surgical Treatment The ultimate goal of treatment is to correct deformities, cure infections, preserve limb and foot, restore lameness, and maximize the patient’s walking function. However, due to the contraction of soft tissue or the presence of infection, it poses a great risk if not treated properly such as infection or limb ischemic necrosis. Therefore, the treatment principle should be limited soft tissue release and deformity correction, even leaving soft tissues deformity correction at later stage. After the surgery, the Ilizarov technique is used to slowly correct the deformity, to reduce the risk. The deformity is corrected safely by slow traction under close surveillance, and for patients with ulcers, strict aseptic surgery should be carried out. For patients with severe deformity of the foot and ankle, surgery reconstruction should be divided into several stages.

1. Severe and complicated deformity of the foot and ankle, with previous surgical treatment failure, cannot bear weight 2. Severe ankle deformity with sensory disturbance and skin ulcer

7.6.4.2 Surgical Methods 1. Severe osteomyelitis of the lower extremity, infection of the bone segment: Remove infected bone and use bone transport technique to repair the bone defect; open wound drainage; if

7.6.2 C  linical Manifestations and X-Ray Features

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Fig. 7.24  Severe complex deformity of the foot

Fig. 7.25  Foot and ankle deformity with ulcer

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2 . When inserting a half pin, it is better to check under X-ray, avoid passing contralateral cortical bone too far, hurting the contralateral blood vessels or nerves. 3. If the deformity is severe, the ankle Ilizarov external fixator should be used. Put the tibial support ring first, then the hind foot fixation ring and the forefoot ring, respectively, finally connect all parts according to the deformity correction needs.

7.6.4.5 Postoperative Management 1. Raise the operated limb, and pay attention to limb feeling and blood supply. 2. Encourage patients to move actively during bed rest to improve the circulation of the limb. 3. 3–5 days after surgery, encourage patients to stand up and gradually walk with weight-bearing. 4. 7–10  days after surgery, start adjusting the external fixator gradually to correct the deformity and adjust the external fixator configuration as needed. 5. During the deformity correction and external fixation, the patient is encouraged to exercise weight-bearing walking.

7.6.5 Prevention and Treatment of Complications Fig. 7.26  X-ray shows bone and joint deformity

necessary, temporarily shorten the limb, to cure the infection first, then repair the bone defect, correct the deformity. 2. Complex foot and ankle deformity without infection or ulceration: Release soft tissue first according to the type of deformity. For example, when treating varus foot, release sacral muscle, flexor digitorum, flexor longus, aponeurosis, etc. and release the tibia muscle when it is valgus foot. Then carry out the osteotomy of the ankle joint, the subtalar joint or the triple joint according to the bone structure of the deformity. Finally install the Ilizarov external fixators to maintain the position.

7.6.4.3 Ankle Deformity with Ulcers 1. If the ulcer is located outside the surgical incision area, first disinfect the ulcer with iodophor, cover the wound with gauze, cover the wound with a sterile film, and then completely disinfect the limb to complete the operation. 2. If the ulcer is located within the incision site, the disinfection may be performed according to (1), finish the part of operation which is outside the ulcer area (such as extension of the posterior tibial muscle), suture the incision, and then remove the ulcer directly to complete the part of operation which is in the ulcer area. 3. After the surgery is completed, install the Ilizarov external fixation. Refer to the first section of this chapter for the installation procedure. 7.6.4.4 External Fixation Installation Precautions 1. Avoid damage to the anterior tibial artery, the pin should be inserted slowly to avoid skin burns.

1. At the end of the surgery, check the skin tension and color. If the skin tension is high or the skin turns white, the external fixator should be relaxed to avoid skin necrosis. 2. During deformity correction, check the local skin tension, blood supply, and sensation, to avoid blisters and skin necrosis owing to excessive skin tension. 3. Keep the pin track clean and prevent infection.

7.6.6 Fixator Removal 1. After the deformity correction is finished, keep the external fixer firmly fixed. 2. Determine the removal time of the external fixator according to the healing condition shown by X-ray. 3. After removing the external fixator, make an individualized orthopedic brace to maintain the position. After the external fixation is removed, the brace can be worn for 3–6 months.

7.6.7 Typical Cases 1. Female patient, 22  years old, suffered from severe left foot trauma when she was 5  years old. The lameness gradually formed a special eversion, foot torsion deformity, and the calf shortened by 9 cm. The patient did not agree to amputation (Fig. 7.27). 2. Male patient, 26 years old, bilateral foot deformity caused by spina bifida, severe talipes equinovarus deformity left side, accompanied by ulceration of the foot-bearing area (Fig. 7.28).

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Fig. 7.27  Left foot severe deformity: (a, b) Preoperative appearance; (c) Preoperative X-ray; (d) Surgical treatment use distal tibial shortening followed by fixator installation, gradual correction by traction. X-ray showed osteotomy and traction site; (e, f) Because of shortening of the affected limb, the second stage of the treatment was tibial length-

ening. The first postoperative follow-up was at 15 months. The ankle deformity was basically corrected, and the lower limbs were equal in length. The patient can walk with full weight-bearing. (g) The lateral radiograph showed the ankle joint fusion, and the structure and shape of the foot were restored

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Fig. 7.28  Severe clubfoot with large ulcer: (a) Appearance on admission. (b) Surgical procedure: Achilles tendon, tibial posterior tendon release, flexor tendon, and flexor longus tendon release; trigeminal osteotomy; Ilizarov foot fixation and surgical removal of ulcer tissues. (c) 28 days after the surgery, the deformity correction was achieved; the posterolateral medial incision healed well, the lateral dorsal incision

still had strip-like clean wounds, but granulation tissues were evident. (d) 4 months after surgery, the external fixator was removed, the deformity was corrected, and the ulcers healed. (e) 2 years after treatment, the deformity was corrected, the ulcer did not relapse, and the foot functioned well. (f) 11 years follow-up

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Clinical Data of Congenital Fibular Hemimelia and Tibia Hemimelia Sihe Qin, Jiancheng Zang, Xulei Qin, Shaofeng Jiao, Lei Shi, and Qi Pan

8.1

Introduction

Sihe Qin, Jiancheng Zang, and Xulei Qin A total of 1837 cases of congenital limb deformity were treated in Qinsihe Orthopedics Department, accounting for 29.2% of huge data of limb deformity and disabilities, which includes 34,459 cases covering 202 kinds of diseases and 59 kinds of deformity. Among the top five diseases, 701 cases were congenital talipes equinovarus, 538 cases were congenital dislocation of the hip, 127 cases were congenital multiple joint contracture, 89 cases were congenital fibular hemimelia, and 77 cases were congenital pseudoarthrosis tibia.

8.1.1 W  hy Do Humans Suffer from So Many Congenital Limb Deformities? It may be related to the evolution from primitive life to human beings. Paleontological fossils show that the “prokaryotes” appeared on the earth about 3.6 billion years ago, with prokaryotes evolved into “eukaryotes” and that cells occurred after about 1  billion years. Since then the speed of species evolution has accelerated. Vertebrates appeared about 500 million years ago; apes evolved from monkeys in the old world about 30 million years ago; humans separated from apes about 7  million years ago and walked upright on 2  ft toward the evolutionary avenue of Homo sapiens. Thus, it is a peculiar phenomenon that the closer the verS. Qin (*) · J. Zang · X. Qin · S. Jiao · L. Shi · Q. Pan Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China

tebrates evolve to Homo sapiens, the shorter the transition period of vertebrates becoming “new s­ pecies,” and thus the structural limb defects and deformities are associated with evolution, development, and bipedal upright walking. In species living in nature, the “genes” that cause limb deformities are ­optimized for elimination, and in human society, the inheritance and spread of diseased genes are allowed. In the market economy society, with the increase of the reproductive age, young women choose to marry men with wealth and status. However, these people are not necessarily strong in their body and genes. This is one of the reasons resulting in so many children with poor physical quality and deformities.

8.1.2 D  eformity Category and Clinical Manifestations See Figs. 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9, 8.10, 8.11, 8.12, 8.13, 8.14, 8.15, and 8.16.

8.1.3 T  he Principle for Congenital Lower Limb Deformity Correction 1. Soft tissue contracture deformity. There is no obvious skeletal deformity in infant stage, such as congenital talipes equinovarus, and joint contracture. Manual massage and orthotics are used to treat this deformity. After 1 year of age, distraction is used to correct the deformities, such as Ilizarov technique, as far as possible without open surgery. 2. Skeletal deformity in children, bony osteotomy can be done. For severe deformity, Ilizarov technique can be used for deformity correction. 3. Complex deformity can be treated individually.

Qinsihe Orthopeadics Institute, Beijing, China © Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_8

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Fig. 8.4 Macrodactylia

Fig. 8.5  Congenital vertical talus

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Fig. 8.6  Congenital multiple epiphyseal dysplasia

Fig. 8.7 Achondroplasia

Fig. 8.8  Arthrogryposis multiplex congenita

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Fig. 8.9 Polydactylia

Fig. 8.10  Congenital fibular hemimelia

Fig. 8.11  Tibial hemimelia

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8  Congenital Deformity of Lower Limb Fig. 8.12 Congenital absence of proximal femur

Fig. 8.13  Congenital tibial curvature

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Fig. 8.14 Congenital absence of left anterior foot

Fig. 8.15  Congenital flattened valgus foot

4. Whether or not amputation for severe lower limb disability depends on the patients’ demands. The characteristic of Chinese culture is that most of their families are willing to adopt limb salvage therapy. Satisfactory limb shape and functional reconstruction results can achieve in majority of lower limb deformities using the combination of Qin Sihe orthopedic strategy, Ilizarov technique, and assistive product (Fig. 8.17).

8.1.4 T  he Experience and Wisdom of Qin Orthopedics in Lower Limb Deformity Correction 1. Macroscopically prediction, systematic assessment, deformity correction individually. Bony osteotomy and muscle transposition should be combined. 2. Contracture tendon is released subcutaneously with a “sharp knife,” it will be a minimal invasive surgery without a strip like scar.

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Fig. 8.16 Congenital dislocation of the right knee joint

3. All the tendon lengthening in open surgery, the tendon should not be sutured or sutured only with 1–2 stitches. 4. The subcutaneous tissue of the incision is usually not sutured, and skin and subcutaneous tissue are sutured together. 5. When the deformity is corrected completely, orthosis should be worn routinely to prevent deformity reoccurrence. 6. The patient with complex deformities is a child, the family members must understand that the need for surgical treatment at different stages of age, so they must regularly seek follow-up, evaluation, and surgical treatment. 7. The barriers between pediatrics and orthopedics should be pushed aside. The treatment of a sick child from childhood to adulthood is best handled by one surgeon.

8. Clinical database should be established to facilitate follow-up. 9. “Stress Transformation” is the greatest secret for doctors to control the whole process of limb deformity correction and functional reconstruction. At present, only the external fixation represented by Ilizarov technology can achieve this goal. 10. To guide clinical practice of limb deformity correction from the perspectives of evolutionism, auxanology, social medicine, and ecological medicine and from the perspective of natural philosophy, so as the human body’s ability of self-organize, self-rebuild, and self-­ compensate be mobilized.

308 Fig. 8.17  The treatment of congenital arthrogryposis. (a) The patient was a 6-year-old male with knee flexion and clubfoot deformity due to congenital arthrogryposis; (b) Ilizarov frame was applied during the operation, and the knee flexion and clubfoot deformity were corrected gradually. 90 days postoperatively, the right lower limb deformities were corrected; (c) Ilizarov frame was applied on left leg. The deformity was corrected at 13th day after surgery. After that, Ilizarov fixator of the right lower limb was removed and applied with orthosis; (d) The patient can walk with orthosis12 months after first surgery; (e) 7 years follow-up, the alignment of affected limb was good, the deformity did not recur. His family and Dr. Qin posed for a picture

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8.2

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 ongenital Deformity of Hip C and Knee Joint

Sihe Qin, Shaofeng Jiao, and Jiancheng Zang

8.2.1 Congenital Dislocation of the Hip Congenital dislocation of the hip (CDH), also known as developmental dysplasia of the hip (DDH), is a major disease of limb deformities in children. In 2003, China officially replaced CDH with DDH. DDH is a developmental disorder of the hip associated with birth, characterized by abnormal hip structure at birth and deterioration during postnatal development, ranging from instability to dislocation of the hip. Posterior dislocation type in DDH is common. The lesions involve acetabulum, femoral head, capsule, ligament, and adjacent muscles, leading to joint relaxation, subluxation, or dislocation. Neglected DDH can cause hip flexibility decline, joint pain, gait abnormalities, limb length discrepancy, osteoarthritis, and other symptoms in the late stage.

8.2.1.1 Clinical Data of DDH in Qinsihe Orthopedics Institute See Table 8.1. There are a lot of literatures about the conservative and surgical treatment of DDH. In this section, we only introduce Ilizarov pelvic support osteotomy. 8.2.1.2 Ilizarov Pelvic Support Osteotomy Prof.G.A Ilizarov creatively combined subtrochanteric abduction osteotomy with distal femoral adduction osteotomy and lengthening, which solves the problem of residual genu valgum deformity and lower limb discrepancy after traditional abduction osteotomy. It is called Ilizarov hip reconstruction, and Dror Paley calls it pelvis support osteotomy (PSO). Table 8.1  Clinical data of 538 cases of DDH in Qinsihe Orthopedics Institute Category Gender Age (years)

Time

Fixation Side

Item Male Female 1–14 15–44 >45 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Left Right Bilateral

Cases (n) 128 410 393 101 44 119 223 129 67 34 31 201 184 153

Percentage (%) 23.79 76.21 73.05 18.77 8.18 22.12 41.45 23.98 12.45 6.32 5.76 37.36 34.20 28.44

Introduction Although Ilizarov pelvic support osteotomy has changed the anatomy position of the proximal femur, it has been proved by clinical application that the pain on hip can be relieved, and the limping gait can be improved obviously. A natural and effective functional reconstruction strategy is provided for patients who are not suitable for artificial hip replacement. If the operation design is reasonable and the surgery is correct, the lower limb function postoperative will be better and better. Operative Principle Ilizarov pelvic support osteotomy works owing to proximal femoral segment supporting pelvis due to the extreme adduction of the hip joint and valgus osteotomy at proximal end of the femur. In the extreme adduction of the hip joint, the greater trochanter of the femur moves distally and laterally, forming a dynamic structure of the lever force system and increasing the tension of the abductor muscle to eliminate the Trendelenburg gait. In addition, the valgus knee and limb shortening were gradually corrected after the middle osteotomy of the femur with Ilizarov technique. It not only retains its own hip joint but also restores the force line and length of the affected limb, eliminates hip pain, and corrects limp gait. Preoperative Examination and Design The X-ray should be taken preoperatively. Based on the maximum adduction radiography of the patient in supine position, the first osteotomy point can be determined at the contact point between the femoral shaft and the ischial tubercle of the affected limb and the adduction angle can be determined. If the hip adduction was 40°, plus 15° of overcorrection, the total abduction osteotomy angle was 55°. The second osteotomy point should be the point intersecting the vertical line that passes through the apex of the first osteotomy with the middle and distal femur (Fig. 8.18). Experiences in Surgical Management 1. Minimally invasive osteotomy with external fixation is the important step for bone healing. 2. For the patient obese in adults, proximal femoral osteotomy can be done and then fixed with plate. 3. Strict follow-up to the end of recovery, a doctor should be fixed. 4. According to the degree of callus mineralization, gradually simplify the external fixator. When patients walk freely for 3 weeks, no bone deformity occurs, patients are without discomfort, the external fixator can be removed, and then they can safely walk with crutches. Typical Cases Case 1 See Fig. 8.19.

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Fig. 8.18  Ilizarov hip reconstruction. (a) Femoral osteotomy; (b) Femoral lengthening and adduction gradually; (c) Lower limb mechanical axis and length meet the requirements of treatment

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Fig. 8.19  Ilizarov hip reconstruction surgery. (a) A 27-year-old female with the absence of right femoral head and dislocation of hip joint caused by infection in juvenile. (b) The maximum adduction angle of femur was 27°, and the angle of proximal abduction osteotomy was “27 degrees + 15 degrees = 42 degrees.” (c, d) The first osteotomy point was located by X-ray during operation. (e) With 10 cm incision, the proximal femur was exposed, drilling osteotomy with electric drill. (f) Two 5 mm pin was inserted at 42° to the proximal and distal part of the first osteotomy. (g) The femur was completely cut off with an osteotome. (h, i) The distal femur was abducted, and the distal end was inserted into the proximal end and displaced inward 1/2 at the same time. (j, k)

Application of plate with 42°. (l–n) The second osteotomy was performed with 1 cm skin incision. (o, p) A modified Ilizarov ring external fixator was applied at the second osteotomy. (q, r) 7  days after the operation, bone lengthening of second osteotomy was started at the rate of 1 mm/d. The lengthening rate was slowed down at a speed of 0.6– 0.7 mm/d. After confirming that the callus grew uniformly and well, the femur was lengthened slowly and externally, then gradually adducted and lengthened until the force line of the affected limb returned to normal and the length of both lower limbs was equal. (s, t) 83 days after surgery, the callus mineralized well and the force line of the lower limbs was good, waiting for the callus to be completely mineralized

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Fig. 8.19 (continued)

Case 2 A 24-year-old female with wobbly gait due to bilateral congenital dislocation of the hip without treatment history. Left hip presented moderate pain during long distance walking. Pelvic support osteotomy on the left side was performed after completing the relevant examination (Fig.  8.20). The patient could walk with crutches 5  days after surgery, and the fixator was adjusted for femur lengthening and distal varus deformity correction from 7 days after surgery. When the axis of the right lower limb was restored, the lengthening stopped and the fixator was removed after bone healing.

8.2.2 Congenital Dislocation of the Patella As a rare congenital deformity, it is also called congenital lateral dislocation of the patella, because patella lateral dislocation is the most common due to the biomechanical characteristics of the knee joint.

8.2.2.1 Clinical Data of Congenital Patellar Dislocation in Qinsihe Orthopedic Institute See Table 8.2. 8.2.2.2 Clinical Manifestation The patient with lateral dislocation of the patella presents knee flexion, valgus, and torsional deformities, which gradually aggravates with age because the patella cannot be repositioned in adulthood (Figs. 8.21 and 8.22). 8.2.2.3 Treatment 1. Surgical treatment is the only option for congenital patellar dislocation. 2. Surgical plan. Operative plan should be designed individually based on the cause, age, and degree of dislocation. All pathological factors leading to dislocation of the patella should be corrected in one stage by combined surgery including genu valgum deformity correction, the patellar ligament transposition, the

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Fig. 8.20  Ilizarov hip reconstruction surgery. (a) Preoperative clinical appearance, left Trendelenburg sign positive; (b) X-ray showed bilateral dislocation of hip joint; (c) Ilizarov hip reconstruction surgery (pelvis support osteotomy) on the left side has been done, and X-ray

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18 days postoperatively; (d) Clinical appearance 252 days postoperatively, the mechanical axis and the length of lower limb were restored; (e) X-ray after fixator removal; (f) Trendelenburg sign negative postoperatively; (g) Postoperative clinical appearance

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Fig. 8.20 (continued)

Table 8.2  Clinical data of 54 cases of congenital patellar dislocation Category Gender Age (years)

Time

Fixation

Side

Item Male Female 1–14 15–44 >45 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Others Left Right Bilateral

Cases (n) 29 25 25 25 4 5 8 5 36 12 27 15 13 13 28

Percentage (%) 53.70 46.30 46.30 46.30 7.40 9.26 14.81 9.26 66.67 22.22 50.00 27.78 24.07 24.07 51.86

Note: This group included 54 cases who have undergone surgery, in which 29 cases were over the age of 15 years. Most of them were misdiagnosed or failed in previous treatment and developed genu valgum or flexion deformity. The patients with bilateral severe deformity secondary to congenital dislocation of the patella, losing the standing condition, can only squat on the ground

lateral capsule release, medial capsule constrict and so on. The end of the surgery is that no patellar dislocation occur in a passive knee extension and flexion. 3. Application of external fixator. This is the mature experience of deformity correction in Qinsihe Orthopedics Institute. If there is still residual knee flexion deformity after surgery, Ilizarov ring external fixator can be applied for further correction. If the deformity has been completely corrected, the hybrid fixator can be used to fix the knee joint. The patient can control the position of the knee while walk weight bearing.

8.2.2.4 Typical Cases Case 1 A 28-year-old male with severe knee flexion and valgus deformity due to bilateral patellar dislocation; he moved on the ground with creep and squat gait (Fig. 8.23). Case 2 A 48-year-old male with knee flexion, valgus, and torsional deformity secondary to total dislocation of the right patella. The combined surgery was done including quadriceps arthro-

8  Congenital Deformity of Lower Limb Fig. 8.21  The patient with knee flexion and external rotation deformity due to dislocation of patella

Fig. 8.22  Lateral dislocation of the right patella

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plasty, femoral supracondylar osteotomy, and patellar ligament inward displacement fixed with hybrid external fixation. At a follow-up of 16 months, the patient could walk upright, with good range of motion and without pain on the knee (Fig. 8.24).

8.3

Congenital Foot Deformity

Sihe Qin and Jiancheng Zang

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Fig. 8.23 The treatment for congenital patellar dislocation: (a) Preoperative squatting gait; (b) Preoperative flexion contracture deformity of both knees; (c) Maximum extension of both knees in prone position; (d) Preoperative X-ray in AP view; (e) X-ray of both knees in lateral view at maximum extension position; (f) Soft tissue release of right knee joint; (g) Application of Ilizarov fixation; (h) Gradual distraction for residual deformity; (i) Walking with crutches; (j) X-ray during distraction; (k) External fixator was removed when lower

8.3.1 Clubfoot (Talipes Equinovarus) Clubfoot, a common congenital foot deformity, occurs in approximately 1–3‰. Boys are more common, accounting for 70%, and bilateral morbidity is about 50%. The disease is characterized by varying degrees of pathological changes in muscles, tendons, ligaments, bones, and articular capsules of not only foot and ankle but sometimes vascular and nerves changes around the knee joint and often associated with

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extremity deformity was corrected completely, a long leg brace was worn after fixator removal, and left knee surgery was done in same time; (l) Walking with braces; (m) Quadriceps arthroplasty, patellar reduction, and patellar ligament transfer surgery has been done on right side; (n) Application of hybrid external fixator postoperatively; (o) X-ray showed patellar reduction on the right side; (p) 10 months after third surgery, the patient can walk upright; (q) Clinical appearance 10 months after third surgery

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10 months after surgery

10 months after surgery

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Fig. 8.23 (continued)

developmental acetabular dysplasia or dislocation of the hip, spina bifida, torticollis, and many other congenital deformities. The etiology and pathological changes of clubfoot have not been fully understood, and there are no uniform criteria for the classification and treatment (Fig. 8.25).

8.3.1.1 Clinical Data of 701 Cases with Clubfoot in Qinsihe Orthopedics Institute See Tables 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, and 8.9. 8.3.1.2 Clinical Manifestations Most of the patients with clubfoot presents as follows: (1) hind foot varus, (2) middle foot cavus with plantar aponeurosis contracture, and (3) forefoot adduction and supination.

The affected side with muscle atrophy and normal sensation develops worse than the healthy side. The talar head protrudes in the lateral side of the dorsum of the foot. Thickened bursa and callosity can be seen in the weight-bearing area. When examining, it should be determined whether the clubfoot is rigid or flexible, and whether there is a dynamic imbalance or not. Radiographic Evaluation: The development of the hip and lumbar vertebrae can be observed in X-ray AP view of the pelvis. For the ankle and foot, the AP and lateral view X-rays are enough. Computed tomography (CT) is not routinely used except for the elder patients and the patients with severe deformities. The relationship between tibia, calcaneus, talus, and cuboid can be distinguished clearly (Fig. 8.26).

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Fig. 8.24  Correction of knee joint complex deformity caused by congenital dislocation of the patella. (a) A 48-year-old male with flexion and torsion deformity on right knee; (b) X-ray axial view of patella; (c) Full-length X-ray of the lower limbs; (d) Patellar retinaculum surgery of lateral release and medial tightening, femoral supracondylar osteotomy, and application of external fixator; (e) The mechanical axis of right lower limb restored; (f, g) Femoral supracondylar osteotomy with double plate; (h) The endpoint of patellar tendon was displaced inward

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and sutured under appropriate tension; (i) The patient walked under crutches 17 days after surgery; (j) X-ray 17 days after surgery showed patella was in good reduction, and the valgus deformity of femur was corrected; (k) The external fixator was removed 22 days after operation, and the X-ray showed normal axis of the lower extremities; (l) 16 months after surgery, the knee joint was in good arrange of motion without pain and swelling, and no patella dislocation occurred when the knee was in full flexion; (m, n) X-ray 16 months after surgery

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Fig. 8.24 (continued)

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Fig. 8.24 (continued)

Fig. 8.25  Neglected congenital talipes equinovarus in adulthood

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Fig. 8.25 (continued) Table 8.3  Gender ratio of clubfoot cases who underwent surgery in Qinsihe Orthopedics Institute Gender Male Female

Cases (n) 467 234

Percentage (%) 66.62 33.38

Table 8.4  The age of clubfoot cases who underwent surgery in Qinsihe Orthopedics Institute Age group (years) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55

Cases (n) 233 137 113 71 67 32 19 11 7 8 1

Percentage (%) 33.24 19.54 16.12 10.13 9.56 4.56 2.71 1.57 1.00 1.14 0.14

Table 8.4 (continued) Age group (years) 56–60 >60 Maximum age Minimum age Average age

Cases (n) 2 0 60 1 12.56

Percentage (%) 0.29 0.00

Note: About 218 cases were patients over 16 years of age, accounting for 31.1%, which demonstrates that many neglected clubfoot cases in this group Table 8.5  Surgical cases vary with year Period (years) Before 1990 1990–1994 1995–1999 2000–2004 2005–2009 2010–2014 2015–2017

Cases (n) 87 135 106 86 113 118 56

Percentage (%) 12.41 19.26 15.12 12.27 16.13 16.83 7.98

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327 Table 8.9  Application of external fixator of clubfoot group in Qinsihe Orthopedics Institute (n)

Table 8.6  Deformity sides of clubfoot cases Bilateral Left Right

Cases (n) 289 205 207

Percentage (%) 41.23 29.24 29.53

Table 8.7  Parity of the patients with congenital foot deformity 1 2 3 4 5 6 7 8 Infanticide or adoption

Cases (n) 307 139 72 11 7 2 2 3 5

Percentage (%) 43.79 19.83 10.27 1.57 1.00 0.29 0.29 0.43 0.71

Note: 153 cases (21.82%) lack the record of parity

Table 8.8  Surgical procedures for clubfoot in Qinsihe Orthopedics Institute (n)

Plantar aponeurolysis Achilles lengthening Triple arthrodesis Anterior tibialis tendon transfer Posterior tibialis tendon lengthening First metatarsal osteotomy Calcaneus osteotomy Subtalar arthrodesis Supramalleolus osteotomy Posterior tibialis tendon lateral transfer Calcaneocuboid arthrodesis Cho part arthrodesis Tendon transfer for dorsiflexion of ankle and hallux and extensor digitorum Talonavicular arthrodesis Interphalangeal arthrodesis in hallux

1–14 (years) 249 141 62 156

>14 (years) 118 103 129 33

Sum 367 244 191 189

Percentage (%) 52.35 34.81 27.25 26.96

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19.83

28 34 29 38 32

53 22 19 9 13

81 56 48 47 45

11.55 7.99 6.85 6.70 6.42

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8 3

14 9

2.00 1.28

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4 4

9 4

1.28 0.57

8.3.1.3 Conservative Indications and Options Flexible Clubfoot Ponseti method of serial manipulation and long-leg casting with or without percutaneous Achilles tenotomy is successful in infants or young children (less than 18 months) with clubfoot. Limited surgery should be done when the serial casting fails or residual deformity remains.

1995–1999 2000–2004 2005–2009 2010–2014 2015–2017 Total

Hybrid fixator 10 19 56 48 16 149

Ilizarov fixator 0 6 24 68 44 142

Sum 10 25 80 116 60 291

Rigid Clubfoot Ponseti method is not recommended because midfoot break or rocker bottom foot can occur.

8.3.1.4 Surgical Principle for Clubfoot in Qinsihe Orthopedics Institute Clubfoot with Mild Joint Stiffness The Achilles tendon and posterior tibial tendon are lengthened through mini incision, and the plantar fascia is released subcutaneously using a sharp knife. The distal tibial osteotomy should be performed when the patient is having tibial rotational deformity also and then it should be fixed with mini fixator (Fig. 8.27). Club Foot with Severe Joint Stiffness In addition to the above procedures, the flexor hallucis longus tendon and flexor digitorum longus tendon should be lengthened simultaneously to achieve partial deformity correction during the surgery. The Ilizarov external fixator was applied and adjusted slowly after surgery until the deformity of foot was completely corrected, the child could walk satisfactorily with the external fixator.

8.3.1.5 Qin’s Correction Principle for Clubfoot in Children (45 1980–1989 1090–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Wire + cast Internal fixation Left Right Bilateral

Cases (n) 8 3 8 3 0 1 2 2 6 7 0 4 0 4 3 4

Percentage (%) 72.73 27.27 72.73 27.27 0 9.09 18.18 18.18 54.55 63.63 0 36.36 0 36.36 27.27 36.36 Fig. 8.30  The medial plantar protrusion

on the dome of talus, and the plantarflexion of the calcaneus. Haveson indicated that the diagnosis could be made by the relationship of the calcaneus, talus and cuboid, the ­dorsiflexion of the forefoot and the plumpness of the soft tissue in the tarsal region of the sole.

8.3.2.4 Surgical Principle for CVT Patient The treatment of CVT is difficult due to the complex pathological anatomy and neuromuscular or chromosomal abnormality. The aim of the treatment is to restore the anatomical relationship between talus, navicular, calcaneus, and cuboid and recover the weight-bearing ability and plantigrade function. Limited surgical release with Ilizarov technique is a simple and effective way to treat CVT.  The younger the patient is, the better the postoperative effect is. For the elderly patients, it is necessary to perform triple arthrodesis and soft tissue contracture release. 8.3.2.5 Surgical Methods Minimally invasive surgery with Ilizarov technique is a new option for the treatment of CVT, which including percutaneous tendon release and gradual distraction correction of the navicular-talus dislocation. This method, with minimal invasion and low postoperative reaction, avoids many complications such as skin necrosis of incisions.

The procedures of surgical methods were described as follows: 1. Soft tissue surgery. The patient was in the supine position. The surgery was performed when the foot was kept tightened by an assistant including subcutaneously release of the anterior tibial tendon, the extensor hallux longus tendon, the extensor digitorum longus tendon, and the fibular tendon on the lateral malleolus. 2. Application of Ilizarov fixator. The Ilizarov fixator preassembled was applied with K-wires and pins (Fig. 8.34).

8.3.2.6 Postoperative Management 1. The external fixator start to be adjusted on 3–5 days postoperatively. The foot arch can be reconstructed by pressing down the forefoot and hindfoot based on the center of head of the talus. 2. Deformity correction is performed at the rate of 3  mm/ day divided into three times. The speed of distraction should be adjusted according to the extent of pain. 3. The external fixator should be kept for 6  weeks until deformity is corrected completely, and the child can be told to walk positively with foot arch pad attached to the external fixator.

8  Congenital Deformity of Lower Limb Fig. 8.31  The midfoot touches the ground

Fig. 8.32  Severe forefoot valgus and external rotation deformity in adult CVT

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8.3.3.1 Clinical Data of 10 Cases with Branchymetatarsia in Qinsihe Orthopedics Institute See Table 8.11. 8.3.3.2 Clinical Manifestation Plantar callosity, floating toe, arch collapse and hallux valgus. Adjacent normal toes tend to migrate into the space vacated by the floating toe. Metatarsal pain occurs in adult patients, which is caused by abnormal weight-bearing in forefoot. It is an important factor for medical treatment, in which the metatarsal lengthening is the only option. It can be diagnosed by anteroposterior and oblique X-ray radiograph, on which we can evaluate the length and nature of shortening.

Fig. 8.33  X-ray shows the vertical talus and the dorsolateral dislocation of the navicular on the talus

8.3.2.7 Typical Cases The patient was a 5-year-old male with bilateral congenital vertical talus. The surgery was done with tendons release and Ilizarov fixation. The fixator was started to adjust the forefoot and hindfoot to relocate mid-tarsal and subtalar joint on 5 days postoperatively. The patient was asked to walk with crutches. When deformity correction was completed, the fixator was kept for 4 weeks, and then replaced with cast for another 4 weeks (Fig. 8.35).

8.3.3 Congenital Brachymetatarsia Congenital short toe deformity is commonly seen in branchymetatarsia, which is a relatively rare developmental deformity and largely hereditary, accounting for 0.02– 0.05%. It often affects female and makes young patients bear a heavy psychological burden due to ugly appearance (Fig.  8.36). Besides, shortened metatarsal easily forms a painful plantar callus to affect the foot weight-bearing and cause floating toe to hinder shoes wear.

8.3.3.3 Strategies, Methods, and Procedures Metatarsal lengthening, also known as callus lengthening, is the most common procedure in clinic. The lengthening of the metatarsal can be done by unilateral fixator and Ilizarov circular external fixator. The monolateral fixator is simple and portable (Fig. 8.37), but can only be used for single metatarsal lengthening. The Ilizarov fixator is more complex and bulky (Fig. 8.38), but it can be used for multiple metatarsus lengthening. Metatarsal Lengthening Using Unilateral Fixator 1. The patient is in the supine position Under the monitoring of image intensifier, the tarsometatarsal and metatarsophalangeal joints are identified by fine needle to determine the contour of the metatarsal shaft. The mini unilateral external fixator with 2.0  mm diameter pins is used as the lengthening device. It is put on the top of the metatarsal, and the pin is directly placed by an electric drill. The pin clamp hole on the fixator is used as the guide device. First, two pins at the proximal and distal ends are penetrated to determine the position of the fixator, and then the remaining two pins are penetrated again. The fixator is 5 mm away from the skin. Osteotomy site is located between the middle two pins. In order to prevent the splitting of the metatarsus, we first drill several holes in the osteotomy site using a 1.5 mm K-wire and then make the osteotomy perpendicular to the long

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Fig. 8.34  Surgical procedure of CVT patient. (a) Extensor tendon release subcutaneously; (b) Peroneus release subcutaneously; (c) Ilizarov fixator was applied with wires and pins. One wire should be

located at the neck of talus to match the hinge of fixator, which serve as the rotation center of ankle joint; (d) The tibia ring was mounted; (e) Lateral view during surgery; (f) Front view during surgery

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Fig. 8.35  Ilizarov technique for CVT patient. (a) Preoperative clinical appearance; (b) Application of Ilizarov external fixator; (c) Foot arch appeared 3 weeks postoperatively; (d) Clinical appearance when exter-

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nal fixator was removed; (e) Casting; (f) Clinical appearance when cast was removed; (g) Keep walking with ankle–foot orthosis

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axis. Finally, the image intensifier is used to confirm the pin position and the osteotomy. A 1.2 mm K-wire is temporarily used to fix the interphalangeal and metatarsophalangeal joints to prevent the dislocation in the processing of metatarsal lengthening. Metatarsal Lengthening Using Ilizarov Lengthening Method The longitudinal incision, 0.5  cm, begins in the middle of metatarsus. The subcutaneous tissues and deep fascia are dissected and the extensor tendon is retracted medially or laterally. With the periosteum is exposed and peeled off, several holes along the cross section can be predrilled with 1.5 mm K-wire. And then the external fixator preassembled is mounted, and osteotomy is done.

Fig. 8.36  4th–5th toe right side with branchymetatarsia

Table 8.11  Data analysis of 10 branchymetatarsia (n) Category Gender Age (years)

Time

Fixation

Sides

Item Male Female 1–14 15–20 21–30 31–40 >40 1981–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Unilateral fixator Internal fixation Left Right Bilateral

Cases (n) 1 9 0 2 6 2 0 0 0 6 4 4 5 1 3 3 4

Percentage (%) 10.00 90.00 0 20.00 60.00 20.00 0 0 0 60.00 40.00 40.00 50.00 10.00 30.00 30.00 40.00

8.3.3.4 Tips and Tricks One-stage lengthening with bone graft has not been adopted by author because of the complications such as metatarsophlageal stiffness, re-fracture, and the re-absorption of the graft bone. Metatarsal lengthening, especially for the fourth one, which is short and small, requires skilled surgical tips. Once the placement of pins fails, there is no chance to rescue. Preoperative communication between surgeons and patients is necessary. The appropriate fixator should be selected according to the patient’s condition to effectively distract the short metatarsal. 8.3.3.5 Postoperative Management Antibiotics are given routinely for 1 day after surgery. The lengthening begins at 7th day postoperatively at a rate of 0.15 mm per time and 4 times a day. When the distraction completed, the K-wire fixed in the metatarsophalangeal joint can be removed. X-ray should be taken every 2 weeks. The external fixator can be removed once the callus was completely ossified. During the lengthening, the pin tract should be clean and dry. The application of alcohol is not necessary. Patients can walk on foot postoperatively as long as the pain can be tolerated. When the lengthening is done, all the screws on the fixator should be tightened to allow full weight-­ bearing walk for 2 hours or more per day. When the K-wire for the metatarsophalangeal joint is removed, the metatarsophalangeal joint and the interphalangeal joint should be moved passively to prevent the joint stiffness. Metatarsal lengthening should keep moving forward rather than sinking and floating.

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Fig. 8.37  Unilateral mini fixator

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Fig. 8.38  Ilizarov external fixator

8.3.3.6 Complications Pin Tract Infection Preventive measures include keeping the pin clamp 5  mm away from the dorsum of the foot, keeping the skin around the pin dry from soaking in water. Frequent alcohol sterilization is not necessary around the pin. The K-wire in the metatarsophalangeal should be removed as early as possible if it is infected. Over- or Under-lengthening Under-lengthening will affect appearance, and over lengthening will destroy foot arch to cause metatarsalgia. The head of the 4th metatarsal with the proper length is on the arc parabola formed by the five metatarsus, or simply, it is between the head of the third and the fifth metatarsal. In 10  days after lengthening stops, abnormal lengthening can be adjusted through lengthening or shortening. If the final length is not enough but the callus is hard, it is not necessary to undergo any treatment because only the appearance is affected. Metatarsophalangeal Stiffness Metatarsophalangeal stiffness is common because the flexor and extensor digitorum tendons are tightened when lengthening starts. The K-wire crosses through the metatarsophalangeal and interphalangeal to prevent joint dislocation which will also lead to joint stiffness. Prevention and treatment: The K-wire should be pull out as long as the lengthening completely, and joint function can be restored with time. Metatarsophalangeal Subluxation If the metatarsal lengthening is over and the metatarsophalangeal is not fixed by K-wires, joint subluxation will

come with the tendons tightened. Therefore, for overlengthening, the wire should be routinely inserted longitudinally to fix the metatarsophalangeal joint and the time of removing should be postponed. This complication can be avoided by using the Ilizarov fixator with K-wire through the phalanges.

8.3.3.7 Typical Cases Case 1 A 24-year-old female with right fourth branchymetatarsia, she suffered from psychological burden and shoe wear difficulty due to floating toe and painful callus. Bilateral fourth metatarsal lengthening was performed. Bony lengthening started at 7th day after surgery at a rate of 0.15  mm per time and 4 times a day. After 35  days, 1.5 cm lengthening was got and K-wire through the metatarsophalangeal was removed. The radiology showed that the fourth metatarsal head was located on the arc formed by the 5 metatarsal heads. After 3 months, the new bone was well ossified and the external fixator was removed. The appearance of the feet improved, and the function of the metatarsophalangeal and interphalangeal joints were normal (Fig. 8.39). Case 2 A 36-year-old female with branchymetatarsia presented with bilateral first toe, accepted bilateral first metatarsal lengthening surgery for ugly appearance (Fig. 8.40). Case 3 A 25-year-old female with bilateral 1st and 4th branchymetatarsia and the 2nd and 3rd mallet toe. Metatarsal lengthening in 1st and 4th toe were performed using Ilizarov semicircular fixator (Fig. 8.41).

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Fig. 8.39 Congenital branchymetatarsia on the right foot. (a) Preoperative clinical appearance; (b) X-ray preoperatively; (c) Postoperative clinical appearance; (d) X-ray postoperatively; (e) X-ray

8.4

Congenital Pseudarthrosis of the Tibia

Sihe Qin and Qi Pan Congenital pseudarthrosis of the tibia (CPT) involving the distal tibial and ipsilateral distal fibula. The incidence of the disease is about 1/250,000 of the surviving newborns. Generally, it produces anterior angulation of the tibia, pathological fractures and pseudarthrosis, in which 50–90% with neurofibromatosis, presenting skin and bone damage.

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showed 1.5 cm lengthening; (f) Postoperative clinical appearance after fixator removal; (g) X-ray postoperatively showed good bone formation in lengthening area

Congenital pseudarthrosis of the tibia is difficult to cure as local developmental disorders. The patients who failed several surgeries eventually suffered from disability due to limb deformity, shortening, and weight-bearing difficulties. As of December 2017, 81 cases of congenital pseudarthrosis of tibia had been treated in Qinsihe orthopedic. Since 2000, the number of cases has increased significantly, and abundant clinical experience has been obtained, and a scientific and effective process for surgical treatment and postoperative management has been formed. At present, the cure rate of one stage surgery with comprehensive surgical methods is over 90%. The final rate was close to 100%.

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Fig. 8.40 Congenital branchymetatarsia in bilateral first toe: (a) Preoperative clinical appearance; (b) Predrilling prior to osteotomy; (c) Osteotomy after installing of the external fixator; (d) Postoperative instant photo; (e) Clinical appearance 7th day postoperatively; (f) X-ray postoperatively; (g) 45th day postoperatively; (h) 100th day postopera-

tively, the K-wire in hallux was removed; (i) X-ray 135th day postoperatively, good bone formation in lengthening area and the external fixator can be removed; (j) Clinical appearance 7th month postoperatively

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Fig. 8.41  Bilateral congenital branchymetatarsia on 1st and 4th toe: (a) Preoperative clinical appearance; (b) Preoperative X-ray; (c) Incision for osteotomy; (d) external fixator was applied and osteotomy was done; (e) X-ray postoperatively; (f) 26th day postoperatively; (g) 46th day postoperatively, the K-wire in hallux and fourth

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toe have been removed; (h) X-ray 90th day postoperatively; (i) 1st and 4th metatarsal osteotomy and lengthening; the 2nd and 3rd proximal phalangeal shortening; (j) Metatarsal lengthening with Ilizarov fixator; (k) X-ray postoperatively; (l) Follow-up 3 year for left foot and 1 year for right foot

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8.4.1 Clinical Data

Table 8.12  Clinical data of congenital pseudarthrosis of the tibia in Qinsihe orthopedics institute

See Table 8.12.

Category Gender

8.4.2 Clinical Manifestations

Age (years)

The appearance of the leg in CPT patient is normal at birth, but the deformity of anterior tibial bend gradually appeared. Fractures usually occur after minor trauma. Although the fractures were treated regularly, they still did not heal and gradually angulated forward. Short leg, soft tissue contracture, foot deformity, weight-bearing difficulty of the affected limbs, and skin of trunk and limbs often had milk coffee spots. X-ray examination showed that the middle and distal 1/3 part of the tibia was curved forward, angular, cystic, and pseudo-joint formation, the bone end became thin, tapered, and sclerotic, the medullary cavity became atresia, the bone cortex became thinner, the bone atrophy and the distal tibial joint surface became deformed, the fibula in a pseudo change at the same time or just bend deformity, and usually the leg was shortened.

Time

Fixation

Side

Item Male Female 1–14 15–44 45–59 >60 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator External and internal fixation Left Right Bilateral

Case (n) 42 39 52 28 1 0 1 3 30 47 69 12

Percentage (%) 51.85 48.15 64.20 34.57 1.23 0.00 1.23 3.70 37.04 58.03 85.19 14.81

43 35 3

53.09 43.21 3.70

8.4.3 The Principles of Surgical Treatment The surgical principles of congenital pseudarthrosis of the tibia in Qinsihe orthopedics are as follows: pseudo-joint and

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its surrounding sclerotic soft tissue (periosteum) resection, intramedullary nail fixation to maintain the tibial axis, iliac bone graft, application of Ilizarov external fixator, tibia osteotomy, and tibial lengthening.

8.4.4 Surgical Procedures 1. Pathological tissue resection The whole lesion of bone and soft tissue (especially periosteum) was excised thoroughly, tibia and fibula end dressing into a cross section, and fixed with a titanium intramedullary nail across the ankle joint to maintain the normal axis of the tibia. 2. Iliac bone graft If the patients have failed to perform multiple surgeries in the past, bone graft should be taken from ilium; if necessary, the graft will be bound with catgut, and then suture incision. 3. Proximal tibia and fibula osteotomy for bone lengthening. The cortical osteotomy was performed on the proximal tibia and fibula for bone lengthening.

8.4.5 Application of Ilizarov External Fixator The external fixator should be designed and preassembled, and its configuration should meet the requirements of “proximal tibial lengthening and compression.” The proximal and distal parts of the tibia are fixed with two groups of full wires. The middle part can be threaded with half pin, and the ankle joint must be fixed across. The fixed strength must meet the requirement that the patients can walk in full weight bearing.

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external fixator can be removed. Then, an orthosis should be wearing for 3–6 months. According to Qinsihe’s experience, the success rate of one-stage operation including intramedullary fixation combined with Ilizarov technique and so on, which can reach more than 90%. If there was delayed union or poor bone remodeling in the pseudarthrosis, we can still carry out secondary operation, bone grafting, re-fixation, and other comprehensive means to achieve the cure results.

8.4.7 Typical Cases Case 1 A 12-year-old woman with congenital pseudarthrosis of right tibia who underwent surgery in a local hospital at the age of 3 years but failed. There were fibular pseudarthrosis, distal valgus of the pseudarthrosis, and right calf shortening (Fig. 8.42). The patient underwent surgical resection pseudarthrosis and dredge medullary cavity when deformity was corrected. The tibia was fixed with K-wire intramedullary temporary crossed the ankle joint and a frame for tibial osteotomy and tibia lengthening. After surgery, the patient could move knee and hip joints in bed. After 5 days, he can walk weight-bearing with double crutches; 7th day after surgery, the proximal tibia began to restore the length of the right leg; the intramedullary nail can be pulled out when the lengthening is completed and external fixation will be maintained until bone healing. Case 2 See Fig. 8.43.

8.5

 ongenital Fibular Hemimelia C and Tibia Hemimelia

Sihe Qin, Shaofeng Jiao, and Xulei Qin The tibial lengthening was started with a rate of 4 times a day, 0.25  mm every time from 7th day after surgery. The proximal tibial osteotomy and lengthening to form a proper compression for the tibial pseudarthrosis area. It was the most effective way to promote bone healing by encouraging the operated limb to walk weight-bearing. When the lengthening part of the tibia and the pseudarthrosis of the tibia reach the clinical healing standard, the affected limb must walk under full load for more than 2 months before the

8.5.1 Congenital Fibular Hemimelia Congenital fibular hemimelia is the most common long bone deficiency, followed by hypoplasia of the radius, femur, tibia, ulna, and humerus. It is also known as fibula hemimelia, congenital deficiency of the fibula, paraxial

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Fig. 8.42  Ilizarov technique for the treatment of congenital pseudarthrosis tibia. (a) Preoperative clinical appearance, right lower extremity with angular deformity; (b) X-ray showed right tibial and fibular pseudarthrosis; (c) X-ray showed that the tibia was corrected in good align-

ment and fixed with intramedullary nail and external fixator. (d) 80 days after surgery, lateral view. (e) 80 days after surgery, back view. (f) The appearance at 14th month after surgery, the bone healed well, and the Ilizarov fixator was removed. (g) X-ray at 14th month after surgery

fibular hemimelia, and hypoplasia of the fibula. Congenital absence of the fibula has a wide spectrum of clinical presentation ranging from minor hypoplasia of the fibula to complete absence, also including hypoplasia of the foot, tibia, and femur in severe cases. It is commonly accompanied by tibial anterior bowing, foot drop, and valgus deformity secondary to the triceps surae and peroneus muscle shortening.

8.5.1.3 Clinical Manifestation According to specific types fibular hemimelia presents varies commonly leg length discrepancy, equinovalgus deformity, knee flexion, femoral shortening, instability of ankle and knee, ankle stiffness, and lateral absence of ankle joint and so on. Although equinovalgus is more common, equinovarus foot and calcaneus valgus deformity are also reported. The clinical main problems are leg length discrepancy and instability of foot and ankle joint. Asymmetric dwarf is commonly presented in bilateral congenital absence of the fibula (Fig. 8.44). The classification of congenital fibular hemimelia proposed by Achterman and Kalamchi is devised to distinguish the fibula hypoplasia (type I) and the complete absence (type II). Type I is subdivided into IA and IB according to the extent of the deficiency of fibula. In type IA, the proximal fibular epiphysis is in distal of tibial growth plate while the distal fibular growth plate is in proximal of the dome of

8.5.1.1 Clinical Data of Congenital Fibular Hemimelia and Tibia Hemimelia See Table 8.13. 8.5.1.2 Etiology The exact cause of congenital fibular hemimelia remains unclear. Hypotheses include vascular dysgenesis resulting failure of the embryo to form a satisfactory blood supply, genetic factors, and intoxication.

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Fig. 8.43  The treatment of congenital pseudarthrosis tibia. (a, b) The patient was a 19-year-old female with congenital pseudarthrosis tibia who has failed in three surgeries. An angular deformity on left leg and coffee spots on her back. (c) Preoperative X-ray. (d, e) The surgery of pseudarthrosis resection, proximal tibiofibular osteotomy, application of intramedullary nail, and Ilizarov external fixator were performed.

The bone formation on proximal lengthening and pseudo-joint area were healed at 16th month after surgery, but the distal tibia remained valgus deformity. (f, g) Ilizarov external fixator was removed at 16th month after surgery, and the distal valgus deformity was corrected and the intramedullary nail with appropriate length was replaced and fixed with hybrid external fixator. (h) X-ray at 5th day after surgery

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Fig. 8.43 (continued)

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Table 8.13  Data analysis of congenital fibular hemimelia and tibia hemimelia in Qinsihe Orthopedics Institute Category Deformity Gender Age (years) Time

Fixation

Side

Item Congenital fibular hemimelia Congenital tibia hemimelia Male Female 1–14 15–44 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Internal fixator Left Right Bilateral

Fig. 8.44  Different types of congenital fibular hemimelia. (a) An 8-year-old male with the absence of the left fibula; (b) A 6-year-old male with right fibula absents and tibia proximal anterior arch deformity. (c) A 9-year-old male with the absence of right fibula and lateral three toes of foot; (d) A 11-year-old female with the absence of distal left fibula; (e) A 2-year-old male with the complete absence of right fibula and fifth toe of foot; (f) A 2-year-old male right fibula dysplasia and absence of lateral 3–5 toe of foot

a

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Cases (n) 10 90 72 28 73 27 0 6 35 59 86 13 1 36 62 2

talus. In type IB, there is partial absence of the fibula, which accounts for 30–50% of its length. Lateral femoral condyle hypoplasia and cruciate ligaments laxity can also be seen in type IB. Bowing of the tibia is classically described in type II deficiency. Ball and socket ankle joints are commonly present in the type IA group. There is a stable tibiotalar joint with an apparently normal distal tibia with complete absence of the fibula in some type ΙΙ. However, severe deformity of ankle is also observed in type ΙΙ, including complete instability of tibiotalar joint, talocalcaneal union, and absence of lateral rays in the foot.

8.5.1.4 The Goal of Treatment The relevant clinical deformities are documented, and a ­prediction of leg length discrepancy can be made in the first evaluation. The management of a child presenting with congenital

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absence of the fibula is based on predicted leg length discrepancy and severity of the foot deformity. A patient predicted minimal leg length discrepancy, corrective thick insole should be the best choice, and epiphysiodesis of the contralateral limb can be done before maturity. It is possible to correct well the severe leg length discrepancy and foot deformity by application of Ilizarov technology in recently years although there is complete absence of the fibula.

8.5.1.5 Operation Procedures 1. Spinal anesthesia or general anesthesia. 2. The patient is in supine position. A small incision is made after limb sterilized at osteotomy plane preoperatively; drilling holes with double sleeves, and then Ilizarov external fixator is mounted; osteotomy with an osteotome at the drilling site; finally, suture the incision. 8.5.1.6 Tips and Tricks Absence of the proximal fibula has minimal effect on limb function. However, absence of the distal fibula forming lateral malleolus often results in ankle instability, most commonly leading to severe ankle valgus deformity and lateral ankle dislocation. The treatment is as follows: Orthosis is used to maintain appropriate position of foot and tibia; Osteotomy of the distal tibia may be used to correct deformities; Fusion of tibiotalar joint; Fibula lengthening is often performed to reconstruct lateral malleolus if there is partial absence of the fibula. Ilizarov technology is beneficial for the treatment of severe foot valgus deformity.

The entire treatment and maintenance process of congenital fibular hemimelia almost continue until bone mature. Therefore, the doctors should make a systematic plan for patients and their families and must let them know the characteristics of the disease, the application of technical p­ rinciples, and treatment process, in order to be able to understand and cooperate. For the young adults with severe tibial shortening and foot deformities, limb lengthening is required. Because of the absence of fibula and the presence of a strong fibular retinaculum, tibial lengthening is more difficult and problematic than that of the normal leg, the technique of locking nail combined with external fixator should be adopted.

8.5.1.7 Postoperative Management 1. The patients can walk with walker 3–5  days after surgery. 2. X-ray should be taken and the fixator started to adjust at the 5th to 7th day postoperatively. 3. Pin tract care. 4. Pay attention to the correct walking function exercise. 5. Pay attention to joint function exercise in the process of limb lengthening. 6. When the predetermined lengthening length is reached and anatomical axis restored, the external fixator remains fixed. The rigidity of fixation is reduced gradually, and the fixator can be removed after the bone is healed. If there is combined internal fixation, the fixator can be removed early and appropriately.

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8.5.1.8 Complication The Ilizarov method is minimally invasive and safe as one of the new ways to cure many problems. The complications postoperatively should also be closely observed and resolved in time. 8.5.1.9 Typical Cases Case 1 An 8-year-old female presented with limb shortening and clubfoot valgus deformity due to congenital fibular hemimelia; her right leg shorted by about 6.5 cm; lateral growth of the fifth toe of the right foot affected shoe wear; X-ray showed absence of the right fibula, shortening, the anterior tibial arch, fusion of the calcaneus and talus, absence of the fifth metatarsus, and absence of the fourth

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Fig. 8.45  Congenital fibular hemimelia. (a–d) Preoperative clinical appearance, this girl patented right leg shortening by 6.5  cm, equinovarus deformity, toe deformity and right foot fifth toe lateral growth; (e, f) X-ray showed absence of right fibula, shortened anterior tibial arch, fusion of calcaneus and talus, absence of the fifth metatarsal, and fusion of the base of the fourth and fifth proximal phalanges. (g–i) The surgery in first stage included right fifth toe resection, peroneal muscle

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and fifth metatarsal. The proximal phalanges were fused at the base. Five days after surgery, the deformity of foot was corrected and then the tibia lengthening started. After bone healing, the external fixator was removed. In the second stage, the calcaneal osteotomy and supramalleotomy were performed, and Ilizarov technique was applied to correct valgus deformity of the foot (Fig. 8.45). Case 2 The patient was a 12-year-old female presented with left lower limb shortened by 8 cm, foot valgus, and limping gait due to congenital fibular hemimelia. During the surgery, the fibular band was released, Achilles tendon was lengthened,

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lengthening, Achilles tendon lengthening, tibial osteotomy and lengthening; (j) X-ray postoperatively; (k–n) Postoperative clinical appearance; (o–q) Functional exercise with external fixator postoperatively; (r) The fixator was removed 10 months after surgery; (s, t) Valgus foot deformity; (u–w) Calcaneal osteotomy and supramalleolar osteotomy were performed in the second stage surgery

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the fibular brevis was placed to posterior tibial muscle, and tibial osteotomy was done (planned to lengthen 8 cm), and intramedullary nail was implanted into the medullary cavity (Fig. 8.46).

8.5.2 Congenital Tibia Hemimelia

and thickening, and there is often a scar or depression on the crooked top. It can be accompanied by Achilles tendon contracture, sometimes there is no Achilles tendon, but a hard mass of fibrous tissue is difficult to lengthen in the operation. Deformities are easy to recur postoperative, so it should be placed overextension in a long term. Ten cases underwent surgery in Qinsihe Orthopedics department.

There are two types of congenital tibia hemimelia: complete absence and incomplete absence. The ipsilateral limb is often associated with other deformities, such as dysplasia of the hip, shortening of femur, and absence of fibula. The most common sign is that the tibia bending, shortening

8.5.2.1 Etiology and Pathogenesis Congenital tibia hemimelia is usually sporadic despite reports of familial autosomal dominant or recessive inheritance, with tibial hemiplegia as a component of at least four specific syndromes, such as three phalangeal-poly phalan-

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Fig. 8.46  Ilizarov fixator combined with intramedullary nail for the deformity correction of congenital fibular hemimelia. (a–c) A 12-year-­ old female with left leg shortening by 8 cm, hallux valgus deformity, and absence of the fourth toe. (d, e) Left fibula band was released and the Achilles tendon was lengthened. (f, g) Fibula brevis was transferred to posterior tibial muscle. (h) Tibia osteotomy. (i, j) An intramedullary nail was implanted into the tibial medullary cavity. (k) Application of

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Ilizarov ring fixator; (l) The fixator was started to adjust from 5 days after surgery at the rate of 1 mm/day in 4–6 times, this photo was taken at 7th day after surgery. (m) X-ray at the 15th day after surgery. (n) X-ray findings at 125th day after surgery showed the limb were prolonged by 8  cm, and the callus formation in the prolonged area was good. (0) 15  months after surgery, the external fixator had been removed. (p) X-ray15 months after surgery

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geal syndrome (Werner syndrome), tibial hemiplegia, foot duplication, hand or foot splitting syndrome, and triangle head syndrome. The determined cause is not clear.

8.5.2.2 Clinical Manifestation The affected leg presents shortened deformity, which can touch the fibula head displaced to the proximal end and without the basic structure of the knee joint. The foot is characterized by severe varus deformity accompanied with hind Fig. 8.47  The treatment of congenital tibial hemimelia. (a) A 5-year-­old male with right lower limb flexion deformity 95°and shortening by 18 cm; (b, c) X-ray showed that the distal femur forked, the tibia was completely absent, and the right femoral fork osteotomy was performed at 1.5 years of age; (d) Application of Ilizarov; (e) Knee joint was straight 45 days after surgery; (f) The patient walked freely with orthosis; (g) X-ray 6 years and 3 months after surgery, fibula has been significantly thickened; (h) Full-length X-ray of both lower extremities showed right lower extremity shortened by 13 cm when he was 12 years old; (i) Knee distraction and fibula lengthening were performed; (j, k) Clinical appearance 4.5 months with limb lengthening; (l) X-ray showed the callus grew well; (m–o) 3 years follow-up, functional recovery was good; (p–r) In 2017, 18 years after first surgery, the patient was hospitalized again due to malunion suffered from road accident 3 years ago. X-ray showed that the proximal fibula recurvation deformity; (s–u) Femoral supracondylar osteotomy and proximal fibula osteotomy for correction and lengthening was done. 8 months after surgery, the patient can stand with assisted by fixator and thigh braces, which for preventing soft tissue contracture knee joint, X-ray showed that the proximal fibula deformity has been corrected and bone formation was good in lengthening area

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foot stiffness. Although proximal tibia cannot be displayed on X-ray in elderly children, proximal tibial primordia can also be touch. The patients can also present deformity combined knee flexion and femur hypoplasia.

8.5.2.3 Typical Cases Case 1 (Fig. 8.47) A 5-year-old male with severe knee flexion and shortening deformity of the right lower limb due to congenital tibia

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hemimelia. X-ray showed that the distal of right femur was forked deformity, the tibia was absent, and the fibula was intact. At the age of 1.5  years, the lower femur underwent surgery with resection of the medial bifurcation. At the age of 3 years, the posterior soft tissue release was performed to correct the deformity of knee flexion, and the lower fibula was placed in the hind foot to correct the varus foot deformity. Knee flexion recurs with age postoperatively, and the patient was admitted to hospital again in June 12, 1999 (5 years old). Physical examination: Right lower limb shortened by 18  cm and knee flexion deformity at 95°can be seen preoperatively. His knee joint formed from fibula head and lower femur in anterior and posterior dislocation. Muscle strength was as follows: muscle strength of quadriceps femoris was 0, flexor knee was 3, toe flexor extensor was 3, and the rest of the foot were 0. X-ray examination: The hip joint was normal; the tibia was completely absent. The distal femur was clubbed and the fibula was slender, and be a sliding joint each other. The fibula head can be placed in the center of the distal femur at the flexion knee 95°, and the talus was absent. On June 16, 1999, the patients underwent surgery of knee flexion deformity correction with Ilizarov technique, and the lower femur and fibular head were attempted to form a knee joint. According to the length and circumference of the affected limb, a knee fixator with joint hinges was designed and preassembled. Under the control of the frame, the distal

femur and the fibula head constitute a bony structure like knee joint capable of passive flexion and extension. The distraction of the knee was started to adjust from 5 days after surgery. The patients could get out of bed and walk weight-bearing partially with healthy limb under crutches in the distract process. The initial speed for ­distraction was 3–4 mm/day, gradually slowed down to 2 mm/day until the knee straight. The knee joint was in position of 35° 45 days and straight 59 days postoperatively, the patient was encouraged to walk with fixator until fixator removal 6 months later. In June 2002, the deformity presented posterior dislocation of the fibula and knee flexion at 35°. The Ilizarov fixator was applied for deformity correction with the same method. The patient can walk bare-hand 18 months after surgery; a new joint formed by fibular head and distal femur were in a good position, of which the bone significantly developed thickening. In even more than 2 years of walking with a fixator, no obvious infection occurred due to proper wire care. Five years and three months follow-up was obtained postoperatively (September 2004, the patient was 10 years old). X-ray showed that the femur and fibula were developed and significantly enlarged, the fibula had a trend of tibial ossification. The patient could walk with orthosis more than 3 kilometers freely without discomfort. Whole affected limb was well developed, the discrepancy of both lower limbs did not increase during walking. Fibular head had stabilized

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in the middle of the knee and no longer produced anterior and posterior dislocation or even the moderate passive knee extension and flexion movement. The patient was asked to continue to walk with orthosis. In December 2006, the patient was 12.5  years old and underwent the surgery of fibula lengthening and knee distraction due to limb shortening by 13  cm and slight knee dislocation.

a

Case 2 A 15-month-old male with left leg shortening and foot varus deformity due to congenital tibial hemimelia. He could not stand and walk independently. X-ray showed that most of the left tibia was absent and fibula was curved. Surgery was done included tendon release and installation of Ilizarov fixator for deformity correction to restore the ability of standing and walking independently (Fig. 8.48).

b

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Fig. 8.48  The treatment of congenital tibial hemimelia. (a, b) A 15-month-old male with left leg shortening and foot varus deformity due to congenital tibial hemimelia. X-ray showed that most of the left tibia was absent and ankle varus deformities; (c–f) Posterior tibial muscle lengthening, Ilizarov fixator was mounted during surgery, and the residual deformity was corrected gradually postoperatively; (g) The deformity of the ankle was corrected 16  days after surgery; (h) The external fixator was removed 3 weeks after surgery, and then a long leg

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plaster was applied. The kid was encouraged to walk full weight-­ bearing; (i) The plaster was removed after 2 months. He can walk with an orthosis; (j) X-ray 2 months after surgery showed that the residual deformity of the ankle was still presented and the brace was used to maintain control. With the body growth, there will be a deformity recurrence, and the patient may undergo multiple surgeries to achieve the goal of treatment

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8.6.3 Clinical Manifestations

Shaofeng Jiao, Xulei Qin, Lei Shi and Sihe Qin

Macrodactylism usually occurs after birth, while other fingers or toes are normal. One or more fingers or toes can Congenital macrodactylism is one of the rare deformities be seen, but not necessarily all fingers. Tsuge has reported that can be presented in all extremities. Congenital macro- localized hypertrophy, involving only distal fingers. With the dactylism deformities characterized by enlarged finger or toe growth and development of children, giant fingers gradually volumes, as well as hypertrophy of the entire lower extrem- grow up. Because the lesion is mostly located on one side of ity. Odd foot shape, difficulty in wearing shoes, and weight-­ the finger, in addition to the whole huge finger, the common bearing are indications for surgery. side of excessive growth, the finger is curved to the side of the deviation. The disease is characterized by the proliferation of bone and adipose. Giant fingers or toes not only affect 8.6.1 Clinical Data of Congenital the shape of hands and feet but also affect their functions. If Macrodactylism (Table 8.14) the lesion is located in the carpal tunnel, there will also be nerve compression symptoms. Macrodactylism is mainly the accumulation of fibrous adi8.6.2 Etiology and Pathogenesis pose tissue, often occurring in the lateral or metatarsal surface. Asymmetric hypertrophy results in joint tilt, and metacarpal or The pathogenesis of macrodactylism is still under study, and metatarsal involvement also appears as excessive growth. The extension of the fibrous tissue from the toe to the anterior part no conclusion has been reached. Macrodactylism (giant finger or toe) shows the prolifera- of the foot will result in lateral expansion. Hypertrophic tissue tion of fibrous adipose tissue. The more prominent feature of mainly occurs on the metatarsal surface of the foot (Fig. 8.49). macrodactylism is hypertrophy. Most of the hyperplasia of the involved fingers or toes occurs in the volar side, so there may be neurogenic etiology. 8.6.4 X-Ray and Imaging Examination The main pathological manifestation of macrodactylism is hyperplasia and accumulation of adipose tissue accompa- For deformed limb with giant toe, CT and three dimensional nied by enlargement of corresponding bones, joints, and soft reconstruction were performed routinely before operatissues (Fig. 8.49). tion. The length and width of affected the phalanges have Because the growth and metabolism of any tissue in the increased, and foot changes were more common. human body are controllable, there may be lack of inhibitors There are two types of macrodactylism syndrome. of local growth of limbs, or the expression of local factors One is static type, which occurs at birth, but increases proout of control, in the patients with macrodactylism, resulting portionally with other fingers or toes. The other one is proin excessive growth of a part of the limbs. gressing type, which grows much faster than normal ­fingers Table 8.14  Clinical data of congenital macrodactylism in Qinsihe Orthopedics Institute Category Gender Age (years)

Time

Fixation

Side

Item Male Female 1–14 15–44 45–59 >60 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Plaster Left Right Bilateral

Cases (n) 2 2 1 3 0 0 0 1 0 3 2 0 2 2 2 0

Percentage (%) 50.00 50.00 25.00 75.00 0 0 0 25.00 0 75.00 50.00 0 50:00 50.00 50.00 0

Fig. 8.49  Clinical appearance of giant second toe on the left foot

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or toes. The pathological tissue of hypertrophy is mainly the infiltration of adipose tissue.

8.6.5 Surgical Strategy Preoperative overall evaluation and system analysis can make correct surgical decision and prepare corresponding surgical instruments to ensure the success of surgical correction. The goal of treatment for macrodactylism is to create painless, beautiful feet that can comfortably wear shoes. When toe enlargement is not serious, phalangeal epiphyseal block of diseased bone and microsurgical constriction of corresponding nerve branches can be considered to control its excessive growth. When the macrodactylism reaches close to adults, complex surgery such as toe shortening or toe removal can be done.

8.6.6 Surgical Procedures 8.6.6.1 Toes Shortening Procedure Surgical Methods The dorsal incision can be made along the toe; it will be a long incision or multiple small incisions along the metatarsal and phalangeal bones. Then, the fibrous adipose tissue can be removed, pay attention to protection of digital nerves, vascular bundles. Osteotomy should be performed at the neck of metatarsal bones. Referring to the length of the other metatarsal bones, the superfluous part of the metatarsal bone was shortened and the epiphyseal plate of the metatarsal head was fused. If necessary, the operation of any phalanges should be performed until the toes are shortened to normal length. Along the axis of toe, a K-wire was inserted from toe to the base of the metatarsal bone. When hemostasis is performed completely, the incision was sutured intermittently and the foot was fixed by tubular plaster.

8.6.6.2 The Procedure for Toe and Metatarsus Removal It is suitable for the treatment of hypertrophic giant toe except the first toe. Removal of a toe, a metatarsal bone, and associated soft tissue can narrow the width of the foot, shorten the length of the foot, and facilitate the patient to wear appropriate shoes to walk.

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Surgical Method The incision line is drawn from the toe tip to the base of the metatarsal bone. Removal of metatarsal and adjacent phalanges, as well as hypertrophic soft tissue nearby, carefully protects the neurovascular bundles supplying the adjacent toes. After appropriate resection of soft tissue, the incision was closed by conventional intermittent suture, and the forefoot was bandaged under pressure. Factors to Ensure Successful Surgery This kind of surgery must be performed under clear anatomy with tourniquet. If the operation lasts more than 1 h, the tourniquet can be used multiple times. As long as the anatomy is clear, the blood vessels and nerves of the toes will not be damaged, and the serious complications of toe ischemic and necrosis can be avoided. Postoperative Management Pressure dressing until wound healing, and then walking orthosis should be wore, asking patients to follow up regularly.

8.6.7 Typical Case 1. A 22-year-old male with macrodactylism on left foot had undergone multiple soft tissue excisions. Preoperative examination: On admission, he was examined for the second, third, and fourth toes enlarged, combined with severe hallux valgus deformity, and the second toe straddled the first. Compared with the right foot, the forefoot is obviously wider and thicker, which seriously affects the function of wearing and walking. 2. Surgical goal: Recovery of the length and size that is similar with the healthy side, so that the patients can wear ordinary shoes to walk. 3. Surgical plan: Excision of hypertrophic second toe and metatarsal bone, correction of hallux valgus deformity, application of Ilizarov external fixator for transverse compression to constriction of the forefoot. 4. Surgical procedures: Resection of the second metatarsal and second toe, removal of the osteophyte of the first metatarsal head, subthalamic osteotomy for hallux valgus deformity correction, and compressive constriction of the forefoot with Ilizarov technique (Fig. 8.50).

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a

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Fig. 8.50  Treatment of macrodactylism. (a–e) The patient was a 22-year-old male with giant toe on the left foot. The clinical appearance preoperative; (f) The second toe and metatarsal bone were removed; (g, h) Correction of hallux valgus with metatarsal head osteotomy, and

d

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then fixed with external fixation; (i–o) Application of Ilizarov external fixator; (p) Postoperative imaging examination; (q–u) Clinical appearance and the X-ray of the affected foot at 17 months follow-up, both the feet were equal width and equal length

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Fig. 8.50 (continued)

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8.7

 ongenital Constricting Band C Syndrome

8.7.1 Clinical Data (Table 8.15)

Sihe Qin and Jiancheng Zang

8.7.2 Clinical Manifestations

Congenital constricting band syndrome (CCBS) is a rare clinical syndrome with unclear etiology. Complete or incomplete soft tissue depressions around the limbs can be seen at birth, mostly in the legs, toes, forearms, fingers, and occasionally in the trunk, and deformities secondaries can be unilateral or bilateral.

In clinical practice, it is often divided into four degrees: • Degree 1: The band is embedded only under the skin and has no obvious effect on limb development. • Degree 2: The band is deep into the fascia and does not affect the blood circulation of the distal part of the body.

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Table 8.15  Clinical data of limb deformity caused by congenital constricting band syndrome in Qinsihe Orthopedics Category Gender Age (years) Time

Fixation

Side

Item Male Female 1–14 >14 1980–1989 1990–1999 2000–2010 2010–2017 Ilizarov fixator Hybrid fixator Bandage Left Right Bilateral

Cases (n) 4 6 10 0 2 0 3 5 3 2 5 4 6 0

Percentage (%) 40.00 60.00 100.00 0 20.00 0 30.00 50.00 30.00 20.00 50.00 40.00 60.00 0

• Degree 3: The band is deep into the fascia, affecting the circulation of the distal limbs. The swelling and color changes of the extremities can be seen. It can also be accompanied by nerve compression or injury. • Degree 4: Congenital amputation.

8.7.3 Goals and Ideas of Treatment The main purpose of treatment is to remove the bandage compression, to improve the shape and function of the limbs, so that the limbs can developed normally. Surgical release is the only choice of treatment, for that bundle compression of blood vessels, and nerves should be under surgical treatment earlier.

8.7.3.1 Surgical Procedures 1. Surgical method The surgical method is to release the constricting band completely with Z-shaped plasty. The traditional point of view is that the band release should be divided into 2–3 stages to prevent flap necrosis and affect the blood supply of the limbs. With the improvement of medical technique, it is possible to do Z-shape plasty in one stage, which can reduce the surgical period, shorten the time of treatment, and achieve good physical development. 2. Surgical procedure (a) The surgery is performed under tourniquet control, and multiple “Z”-shaped incisions are made along the annular groove.

( b) As the band is in deep, it is necessary to remove the skin of the circular sulcus and then make a “Z”-shaped plasty. (c) Subcutaneous soft tissue release. Then, the deep structure should be carefully determined, and the fascial tissue of the entrapped tendon, blood vessel, and nerve should be thoroughly released. (d) Flap revision, incision irrigating, and hemostasis when tourniquet is relaxed. (e) Suture the triangular flap alternately and place a rubber drainage under the skin routinely (Fig. 8.51).

8.7.4 Tips and Tricks The operator should review the anatomy of the limb and its adjacent relationship and design the incision before surgery. Annular groove with mild compression of the extremities can be completed in one stage. But deep annular sulcus, in order to avoid affecting the limb circulation, should be staged in surgery; each time to deal with half the circumference of the annular sulcus, the two surgeries should generally be 6  months later. The surgical operation should be gentle, and there will be no complications.

8.7.5 Typical Case The patient is a10–year-old female with circular constricting band on right thigh The band release and “Z”-shaped plasty were performed in March 2016 (Fig. 8.52).

8.7.6 T  he Band Release with Transverse Incision For patients with flabby skin, a transverse incision can be performed for the constricting band release, the upper and lower sides of the incision can be sutured directly. Thus, the scar of incision is smaller (Fig. 8.53).

8.7.6.1 Typical Case A 12-year-old female with constricting band, which was released through a transverse incision (Fig. 8.53).

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Fig. 8.51  Suture the triangular flap alternately

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c

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Fig. 8.52  Congenital constricting band syndrome. (a, b) The circular band is on the right thigh; (c–f) The circular band was released with Z-shaped plasty; (g, h) The annular sulcus disappeared 15 weeks follow-up

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Fig. 8.52 (continued)

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Fig. 8.53  Constricting band on the distal thigh, which was released through a transverse incision. (a) Constricting band on the distal thigh; (b) Transverse incision was used; (c, d) Constricting band was released through a transverse incision; (e, f) Incision sutured

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Lower Limb Deformity Caused by Hereditary and Metabolic Diseases Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Quan Wang, Xulei Qin, Qi Pan, and Lei Shi

9.1

 ower Limb Deformity Caused L by Hereditary Sensorimotor Neuropathy (Charcot–Marie–Tooth)

Sihe Qin and Jiancheng Zang Hereditary sensorimotor neuropathy (Charcot–Marie–Tooth, CMT) is a progressive, neuromuscular atrophy syndrome a

which is known clinically as Peroneal muscular atrophy or hereditary motor sensory neuropathy (HMSN); it is the most common autosomal dominant genetic disorder in the peripheral nervous system (Fig. 9.1), most of which occur in childhood and adolescence. In the United States, with an incidence of about 1/2000, it is the most common cause of cavus deformity in children.

b

Fig. 9.1  Charcot–Marie–Tooth’s disease is an autosomal hereditary disease. (a) Three generations of inheritance; (b) Twin disease S. Qin (*) · J. Zang · S. Jiao · Q. Wang · Q. Pan · L. Shi · X. Qin Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China © Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_9

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9.1.1 Clinical Data of Limb Deformity

Due to the combination of intrapedis and extrapedal muscle weakness, imbalance of muscle strength is the main cause of foot and ankle deformity in Charcot–Marie–Tooth disease.

Charcot–Marie–Tooth disease often occurs in infancy. Its clinical features are chronic progressive muscle weakness and muscular atrophy of the distal extremities with only slight or no sensory disturbance. A long period of unbalanced muscle strength will cause bone and joint deformity of the foot changed from flexibility to stiffness. The clinical manifestations of ankle deformity include cavus and varus, claw toe, muscle atrophy of distal extremity, pain under metatarsal head, unstable gait, foot fatigue, and difficulty in wearing common shoes (Fig. 9.2). Therefore, CMT disease should be suspected in patients with progressive, no obvious inducement of cavus and varus, claw toe, crane-leg deformity, and unstable gait (Fig. 9.3).

Table 9.1  Gender ratio of limb deformity of hereditary sensorimotor neuropathy in Qin Sihe Orthopedics Institute

Table 9.4  Walking index of limb deformity of hereditary sensorimotor neuropathy in Qin Sihe Orthopedics Institute

206 patients have undergone surgery in Qin Sihe Orthopedics Institute until December 2017; the clinical data is as follows: (Tables 9.1, 9.2, 9.3, 9.4, 9.5, and 9.6).

9.1.2 C  linical Characters of Foot and Ankle Deformity

Gender Male Female

Cases (n) 133 73

Percentage (%) 64.56 35.44

Note: In this group, the number of males was significantly higher than females

Table 9.2  Age at surgery Age group (year) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–60 >60 Maximum age Minimum age Average age

Cases (n) 4 23 36 43 43 23 11 9 7 4 2 1 65 4 21.7

Percentage (%) 1.94 11.17 17.48 20.87 20.87 11.17 5.33 4.37 3.40 1.94 0.97 0.49

Walking function index 0 I II III IV V uncertain

Cases (n) 1 7 11 16 8 56 107

Table 9.5  Abnormal side Sides Left Right Bilateral

Cases (n) 14 8 184

Percentage (%) 6.80 3.88 89.32

Table 9.6  Deformities of lower limbs of hereditary sensorimotor neuropathy in Qin Sihe Orthopedics Institute Abnormal part Foot and ankle deformity

Percentage (%) 0.49 3.40 5.34 7.77 3.88 27.18 51.94

Percentage (%) 0.97 2.43 5.83 21.84 49.51 2.43 16.99

Note: The preoperative walking function index was formulated by Qin Sihe, and the specific evaluation methods are presented in Sect. 1.4, Chap. 1

Table 9.3  Annual operating volume Period 1983–1987 1988–1992 1993–1997 1998–2002 2003–2007 2008–2012 2013–2017

Cases (n) 2 5 12 45 102 5 35

Knee joint deformity Calf deformity

Abnormal type Equinus Calcaneus foot Pes varus Pes valgus Cavus Anterior foot adduction Claw toe Genu varum Genu valgum Laterotorsio crura Internal tibial torsion

Cases (n) 116 2 153 2 69 3 14 2 7 8 5

Percentage (%) 56.31 0.97 74.27 0.97 33.49 1.46 6.80 0.97 3.40 3.88 2.43

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arcuate foot, claw toe, drooping foot, and tendon reflex weakening or disappearing. 3. Electromyogram (EMG) shows neurogenic damage; peripheral nerve motor conduction velocity was slower; median nerve motor nerve conduction velocity was less than 38  m/s; and positive family history could further support this diagnosis. Nerve biopsy, genetic diagnosis was helpful for diagnosis and classification.

9.1.4 P  rinciples and Procedures of Surgical Treatment

Fig. 9.2  Cavus foot caused by Charcot–Marie–Tooth disease

9.1.3 X-Ray Features of Ankle and Foot The X-ray film should include all metatarsal, phalangeal, and ankle joints. The anterior and posterior radiographs mainly show varus foot and metatarsal adduction, and talus rotation on ankle joint (Fig.  9.4); the lateral radiographs show typical cavus deformity, first metatarsal sagging, metatarsophalangeal dorsal extension, and metatarsal flexion of interphalangeal joints. Degenerative changes in tibial talus joints, triple joints, and metatarsal tarsal joints can be seen in older patients (Figs.  9.5 and 9.6); the calcaneal axial films show calcaneal varus deformity. Diagnosis: 1. In childhood or adolescence, both lower limbs appear weak, difficult to walk, and progress slow. 2. The distal muscle atrophy of both lower extremities is typical with crane-like deformity, often accompanied by

For the treatment of ankle deformity, orthotic shoes or orthosis can be used in combination with physiotherapy; surgical treatment can be performed for those with severe dysfunction and advanced deformity or severe deformities. The principle of operation is to correct foot and ankle deformities and to reconstruct the muscle balance of foot and ankle. There are three kinds of operations: soft tissue surgery, osteotomy, and joint stabilization. Soft tissue surgery included plantar fasciolysis and tendon release or transfer surgery; the tendon release surgery included tendon lengthening or transfer of Achilles tendon or gastrocnemius, extension or transfer of extensor digitorum tendon, transfer of long tendon of fibula, transfer of posterior tibial tendon, transfer of flexor digitorum tendon, etc. Osteotomy included basal metatarsal osteotomy (Fig. 9.7), middle tarsal joint osteotomy (Fig. 9.8), and calcaneal osteotomy (Fig. 9.9). Arthrodesis includes interphalangeal fusion, triple arthrodesis, and subtalar arthrodesis. In addition, non-osteotomy and osteotomy can be used to correct foot and ankle deformities with Ilizarov technique. Non-­osteotomy is suitable for children under 8 years of age. It can remove contracture, correct foot deformity, and reconstruct the biomechanical elasticity of foot by stretching joint and soft tissue, and osteotomy is suitable for children over 8  years old, combined with bony surgery (supramalleolar, forefoot, hindfoot or both.) In the foot and ankle deformity of Charcot–Marie– Tooth disease, the cases with cavus foot deformity occupies a high proportion of children, accounting to 78%. Coleman block test could determine the relationship between forefoot and hind foot and whether the hind foot was flexible or stiff. When Coleman block test proves that the deformity of the hind foot is flexible, the surgery should be limited to the forefoot and be feasible for soft tissue surgery or osteotomy. If Coleman block test is confirmed as a rigid deformity in a young patient, the osteotomy of the hindfoot should be considered. The first

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b

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Fig. 9.3  Foot deformity caused by Charcot–Marie–Tooth disease. (a) A 39-year-old female with clubfoot deformity; (b) a 14-year-old male with severe cavus foot deformity; (c) a 21-year-old male with right foot varus deformity; (d) a 18-year-old male with right foot varus deformity

and left foot valgus deformity; (e) a 20-year-old male with bilateral clubfoot deformity; (f) a 15-year-old male with foot cavus and varus deformity; (g) a 18-year-old female with heel varus deformity; (h) a 23-year-old male with right foot varus deformity

Fig. 9.4  Anteroposterior position

Fig. 9.5  Lateral position

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Fig. 9.6  Axial position of calcaneus

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b

Fig. 9.7  Metatarsal basal osteotomy surgery. (a) Basal cuneiform osteotomy of metatarsal; (b) Closed osteotomy space

388 Fig. 9.8  Osteotomy of middle appendage joint for cavus: (a) Equinus and cavus; (b) Surgical incision; (c) Exposure of the attached middle joint; (d) Removal of middle appendage joint with wedge-shaped osteotomy, fixation with K-wires

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talonavicular joint

calcaneocuboid joint

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Fig. 9.9  Calcaneal osteotomy surgery. (a) Incision of osteotomy; (b) Calcaneal displacement after osteotomy

9  Lower Limb Deformity Caused by Hereditary and Metabolic Diseases

metatarsal or calcaneal osteotomy combined with limited soft tissue release can obtain satisfactory results. Osteotomy of dorsal extension of three metatarsal bones and osteotomy of the middle tarsal joint can be performed where the adduction of the forefoot is obvious. In a patient whose degenerative changes in the ankle, forefoot, and hind foot result in rigid deformities or other surgical failure, triple fusion can be applied as a suitable surgical method to correct deformities. In addition, claw toe is also more common in Charcot– Marie–Tooth disease. Soft clawed toes are feasible for soft tissue surgery, such as extensor digitorum tendon extension, flexor digitorum tendon anterior transfer, metatarsophalangeal joint, or interphalangeal joint release; rigid claw toes need arthrodesis. For those with simple hallow toe claw, the first metatarsal neck can be raised by placing the tendon of the extensor hyphalus on the neck of the first metatarsal bone, and the distal head of the tendon of the extensor longus is sutured to the dorsal soft tissue of the proximal phalangeal bone. K-wire was used to fix the interphalangeal joint in extensional position (Modified Jones’s surgery), and the claw-like deformity of the other four toes could be corrected by transposition of the total extensor digitorum (Hibbs surgery) to correct the deformity. Transfer of posterior tibial tendon to the first or second wedges when combined with foot pendulous deformity. If the tibial anterior muscle strength is normal and other extensor muscles are weak, the tendon of the anterior tibial muscle should be placed lateral side to avoid causing foot varus deformity.

9.1.5 Expected Therapeutic Objectives and Advantages of External Fixators The goal of the treatment is to restore a pair of feet that are close to normal in shape and function. They should not only correct the deformities, but also preserve the elasticity of the feet as much as possible, prevent the recurrence of the deformity, and focus on protecting the triceps muscle of the calf from weakening muscle strength. For patients whose Achilles tendon strength has weakened, the ankle metatarsal flexion of 5–10° should be properly preserved to increase the driving force of the foot forward while walking. In order to maintain the orthopedic position and provide a stable environment for soft tissue healing, plaster can be used after soft tissue release or tendon transposition, and internal fixation (K-wires, screw, plate) combined with ­plaster is also used to protect bone healing. Gypsum fixation is not conducive to the observation of incision, but there is a risk of skin necrosis under gypsum compression.

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The external fixator acts directly on the bone through the pin technique. The exposure of the skin incision is helpful to observe, reduce the irritating pruritus of the skin, and improve the comfort. Ilizarov ring external fixator with three-dimensional adjustment can arbitrarily change the configuration, which has unique advantages for the treatment of complex and severe ankle deformities.

9.1.6 Surgical Procedure and Risk Avoidance 1. The hybrid external fixator is mainly used for the fixation of mild to moderate deformity that can be corrected acutely during surgery (Fig. 9.10). (a) When the operation completed, 3–3.5  mm  K-wire with 10–15 cm is inserted through from the anterior edge of fibula perpendicular to the longitudinal axis of tibia. The wire is intermittently inserted from the muscle space to avoid penetrating the muscle and injury to the anterior tibial artery. The speed of inserting should be controlled, then fixed with semicircular arch. Friction is avoided to produce thermal injury. Perpendicular to tibia is put through a diameter 4–4.5  mm pin and is fixed with semicircular arch from the anterior medial tibia to the hemicyclic arch. The attention is paid to the depth of the pin, avoiding neurovascular injury. (b) Put a 2.5–3.0 mm K-wire from the medial part of the first metatarsal head to the second metatarsal head to penetrate the second metatarsal head, and then put a 3.5 mm pin to penetrate the contralateral cortex through the medial calcaneal tubercle. The first metatarsal head is pushed upward to correct the deformities of the lower and adductive metatarsal bones, and the cavus deformity is corrected at the same time. (c) Correct the equinovarus deformities with dorsal extension of the ankle and the subtalar joint, and then fix the semicircular arch of the fore foot, hind foot and the lower leg with two rods, respectively, to form a stable, triangular fixed structure on the medial side of the ankle and foot. At the base of the first metatarsal, a 3–3.5 mm pin is used to strengthen the fixation of the forefoot, and a 3–3.5 mm pin on calcaneal to strengthen the fixation of hindfoot. (d) The base of the fifth metatarsal or the lateral cuboid bone is inserted into a 2.5–3 mm K-wire or pin and fixed with a rod to the tibial semicircular arch. 2. Ilizarov ring fixator It has powerful function and is mainly used for severe foot and ankle deformity correction. It is for the deformity that cannot be corrected acutely due to the limitation

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Fig. 9.10  Common configuration of hybrid external fixator

of skin, nerve, blood vessel, and other soft tissues. The residual deformities are dynamically corrected by Ilizarov external fixator. (a) According to the circumference of the lower leg, the external fixator with proper size is prepared before operation. After surgery, the external fixator is applied into the lower leg or ankle and foot, and the space of the external fixator is adjusted so that the calf and foot are in the middle of the external fixation structure. The ankle hinges are located at the center of the ankle rotation, and the assistant maintains a stable relative position to the limb (Fig. 9.11). (b) From the place 1  cm of medial or lateral calcaneal tubercle, put a wire for calcaneus semicircle fixation, pay attention to the angle of the wires and pins, avoid the ankle canal injury. (c) Distal tibia is fixed with the second wire from the lateral to medial side (Fig. 9.12). (d) Through the neck of the first to fifth metatarsal bone, put the third pin or fix oliver wire on the metatarsal half ring or its rear joint; the wire must be pierced through the first and fifth metatarsal bones with second and third metatarsal bones (Fig. 9.13). (e) Fix two pins in proximal tibia ring, one pin in distal ring (Fig. 9.14) and reinforce another pin at the base of metatarsal bone. (f) The posterior lateral and posterior medial calcaneus are fixed with pins, respectively (Fig. 9.15). (g) A pin is inserted on the neck of talus and connected to the ring of distal tibial. (Fig. 9.16).

Fig. 9.11  Assistant maintains stability of relative position between external fixator and limb

Fig. 9.12  Distal tibia is fixed with the second wire

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Fig. 9.13  Fixation of metatarsal through wire

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Fig. 9.16  A pin (red arrow) is inserted into talus and connected to the distal tibial ring

9.1.7 Postoperative Management

Fig. 9.14  Strengthened fixation with half pin

Fig. 9.15  Posterior lateral calcaneus and posterior medial fixation with two half pins

1. Operated limb should be elevated at 20–30° within 12 h, the extremity sensation, movement, and blood flow should be observed carefully. For patients with obvious abnormalities, relax the bandage as appropriate, or change the fixed position. 2. One day after surgery, patients are encouraged to have active and passive movements in bed to improve the circulation of affected limbs. 3. Within 3 days after surgery, pay attention to the appropriate use of analgesic drugs to reduce the discomfort. 4. 3–5 day after surgery, patients are encouraged to weight-­ bearing gradually depending on the condition of the operation. 5. 7 days after surgery, the dressing is removed, the wound and wires are exposed, and then X-ray film should be taken; observe the wires and pins, alignment, joint position, and the deformity angle. 6. The patients with severe deformity should be fixed with Ilizarov external fixator. The fixator is adjusted gradually to correct the deformity from 7 to 10 days after surgery. X-ray films are taken regularly to observe the correction of the deformity. The configuration of the external fixator is adjusted to the desired position, and then locked to facilitate the bone healing or changed to the elastic configuration to facilitate the restoration of joint movement.

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9.1.8 Functional Exercise

9.1.11 Typical Cases

1. During the period of deformity correction, patients should be encouraged to exercise under walker. 2. The patient undergone tendon transposition surgery should be encouraged to start exercising the active movement of the displaced muscle after the anesthesia has subsided. 3. Pay attention to toe passive and active exercises.

1. The patient was a 22-year-old male with bipedal deformity due to lower motor neuron disease, bilateral leg muscle atrophy, “crane-leg” deformity, bipedal equinovarus varus and cavus deformity, and severe left foot deformity. After admission, the surgery was performed in stages. The postoperative result of deformity correction was satisfactory (Fig. 9.17). 2. This patient was a 14-year-old male with severe equinovarus deformity caused by Hereditary Spinal Muscular Atrophy. At the first stage, bipedal surgery was ­performed, started to correct equinovarus deformity at 7th day after surgery. Bipedal deformity was corrected satisfactory 34  days after surgery. External fixator was removed 3 months postoperatively (Fig. 9.18).

9.1.9 Complications 1. To avoid the injury of tendon, nerve, and vessel when wire piercing. 2. For severe deformity, the skin tension and skin color should be observed at the end of the operation. If the skin tension is greater and the skin is white, the external fixator should be relaxed in time to recover the deformity until the skin is ruddy so as to avoid serious complication of skin flap necrosis. 3. During the correction of the deformity, pay attention to observe the local skin tension, blood flow, listening to the subjective feelings of the patients, in order to avoid blisters, even skin necrosis and other serious problems due to excessive skin tension. 4. In the process of correction of equinus deformity, regular X-ray should be taken and rechecked. If dislocation tendency of ankle joint is found, joint hinge position should be adjusted in time to prevent dislocation of ankle joint. 5. Keep pin tract clean and dry to prevent infection.

9.2

 ower Limb Deformity Caused L by Osteogenesis Imperfecta

Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Quan Wang, Xulei Qin, and Qi Pan The incidence at which fractures occur in patients with osteogenesis imperfecta (OI) decreases gradually in adolescence. For the deformities caused by repeated fractures and malunion, the axis of limbs can be restored by osteotomy, and the walking function of the patients can be improved.

9.2.1 Clinical Data of Lower Limb Deformity 9.1.10 Fixator Removal 1. The duration of external fixator wearing is determined by the disease and operation of deformity correction. 2. The external fixator is removed at 6–8  weeks after soft tissue surgery. As for osteotomy surgery, the time of fixator removal is determined by bone healing condition, usually 10–12 weeks. 3. After fixator removal, individualized orthotic braces should be made at the same time to maintain the orthopedic position and to protect the affected limbs; walking can be started under braces for 1–2 months.

See Table 9.7.

9.2.2 P  athological Characteristics of OI in Adult The incidence of fractures in adult OI patients decreased significantly, but often accompanied with multiple parts and multiple planar deformities, which became the main causes affecting lower limb function.

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Fig. 9.17  A 22-year-old male with bipedal deformity caused by hypomotor neuron disease. (a–e) Preoperative clinical appearance showed that equinovarus varus changes in the bipedal bone joints; (f–h) the operation was performed as follows: Achilles tendon lengthening, plantar aponeurosis release, posterior tibial muscle transposition, subtalar joint fusion, interphalangeal joint fusion, posterior displacement of extensor longus muscle. Hybrid fixator was applied. (i, g) At 7 months after the left foot surgery, the clinical results showed that the correction of the deformity was satisfactory. (k) X-ray showed subtalar joint

i

fusion was done. (l) At the second stage, the right foot underwent Achilles tendon lengthening and plantar aponeurosis release, triple joint fusion, the interphalangeal joint fusion, transposition of the posterior tibial muscle, and flexor hallus longus muscle for hallux extensor longus and extensor digitorum muscle. (m–o) Satisfactory result of foot and ankle deformity correction was achieved at 9 days after surgery. (p) X-ray films were taken at 9 days after operation and followed up until 1 year postoperatively (q, r, s). The correction of bilateral ankle deformity was satisfactory. (t, u) X-ray film at 1 year postoperatively

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Surgical plan in Chinese

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h Fig. 9.18  A 14-year-old male with hereditary spinal muscular atrophy. (a, b) Preoperative severe equinovarus deformity; (c, d) Bilateral posterior tibial muscle lengthening and plantar aponeurosis release, first metatarsal basal osteotomy, triple joint osteotomy, and Ilizarov fixator were applied. (e) At the end of surgery, Ilizarov fixator was mounted. (f) One week after operation, X-ray showed that the osteotomy ends were closed well, and then pulled out the K-wire and started to adjust the fixator to correct the equinovarus deformity; (g) 15 days after surgery,

i foot deformity was improved by 80%; (h) 26 days after surgery, most of the foot deformities were corrected; (i) During the treatment, both feet weight-bearing; (j, k) After 34 days, satisfactory correction of bipedal deformity; (l–n) 3 months after surgery, the patient returned to hospital to remove the fixator, he was able to walk freely with double crutches; (o, p) After fixator removal, he could walk with braces; (q–s) The bone healing of the triple joint was good and the deformity correction was satisfactory

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9  Lower Limb Deformity Caused by Hereditary and Metabolic Diseases Table 9.7  Data statistics of lower limb deformity secondary to OI in Qin Sihe Orthopedics Institute Category Gender Age (years) Time

Fixation∗

Side

Deformity

Item Male Female 1–14 15–44 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Internal fixation Left Right Bilateral Hip Knee Ankle and foot

Case (n) 26 16 11 31 2 15 25 19 22 9 0 0 42 0 42 0

Percentage (%) 61.90 38.10 26.19 73.81 4.76 35.72 59.52 45.24 52.38 21.43 0.00 0.00 100.00 0 100.00 0.00

*Note: Some patients were fixed with mixed fixation

Fig. 9.19  Lower limb deformity secondary to OI

9.2.3 Clinical Manifestation 1 . Obvious multiple limb deformities (Fig. 9.19). 2. The blue sclera. 3. Triangular head, broad forehead, prominent zygomatic bone with relatively small mandible.

9.2.4 X-Ray Characters The severe OI cases present with multiple multidimensional deformities on femur and tibia, rare and translucent bone trabeculae, thinning cortical and relatively large medullary cavity, slender mid bone and dilated ends, and sometimes multiple old fractures can be seen (Fig. 9.20).

Fig. 9.20  X-rays of lower extremities secondary to OI

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9.2.5 Diagnosis and Treatment According to clinical appearance and X-ray characteristics, it is not difficult to diagnose. For the deformities, osteotomy can be done and then fixed with an external fixator. The juvenile patients should wear braces for a long time to prevent the recurrence of the deformity.

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osteotomies with Ilizarov external fixator were performed. After two stages of surgical treatments, lower extremity deformities were corrected completely.

9.3

 evere Osteoporosis with Limb S Deformities

Sihe Qin, Jiancheng Zang, and Xulei Qin

9.2.6 A  pplication of Ilizarov Technique in OI Deformity Development of the deformities of lower extremity in OI patients basically stopped or slowed down after the ossification of the bones in the adult period, which should be corrected reasonably. Because the deformities of lower extremities in such patients were severe and complicated, most of the deformities could not be corrected at one stage. According to the author’s experience, Ilizarov technique could be used to correct the deformities safely and ­satisfactorily (Fig.  9.21). Patients with severe and complicated deformities of lower extremities should be corrected in stages or parts in order to reduce surgical trauma and facilitate osteotomy healing (Fig. 9.22). Because of the longtime of bone healing and weak strength of the osteotomy in such patients, the external fixator should not be removed too early (Fig. 9.23).

9.2.7 Typical Case A 30-year-old male with multiple deformities of lower extremities caused by OI.  He had lost the function of standing and walking preoperatively. He could only walk a short distance with wheelchair. X-ray showed bilateral femoral varus, bilateral tibial varus, and anterior arch deformity (Fig. 9.24). At the first stage of operation, the right femoral trochanter valgus osteotomy was performed with plate fixation. The proximal and distal tibial osteotomies were performed and fixed with intramedullary nail and Ilizarov fixator. The deformity was corrected after surgery, and the patient could walk with the walker. At the 12th month after surgery, the external fixator was removed. At the second stage of operation, the left subtrochanteric osteotomy was performed with plate, as well as tibial

Up to now 34,459 cases of limb deformity have been treated in Qin Sihe orthopedics Institute, 23,310 cases of them are poliomyelitis sequelae. These patients suffered from muscle paralysis, atrophy. Some cases had no weight-­bearing and walking for decades. Almost all of them were accompanied by different degrees of bone and muscle wasting, atrophy, and osteoporosis. Under the guidance of the theory of orthopedic natural reconstruction, Qin Sihe summed up a set of principles for correction of lower extremity deformities with osteoporosis, which is simple and effective. So far, all cases have been successful.

9.3.1 A  Thin Reconstruction Plate for Internal Fixation of Femoral Shaft Osteotomy Supracondylar femoral osteotomy was fixed with a 5–6 holes reconstruction plate combined with limited external fixation for 3–4  weeks. For those with soft tissue flexion contracture, cross-knee fixation was performed (Fig. 9.25).

9.3.2 Correction of Tibial Deformity Preferred ring external fixation, combined with elastic intramedullary nail if necessary and extended intramedullary nail fixation (Fig. 9.26).

9.3.3 S  evere Foot and Ankle Deformity with Severe Osteoporosis Several small incisions were used to cut the bone and partly correct the deformity. The Ilizarov ring external fixator was used to correct the residual deformity (Fig. 9.27).

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Fig. 9.21  Correction of knee valgus deformity secondary to OI. (a) Bilateral severe genu valgum deformity and knee collision while walking; (b) Preoperative full-length X-ray of the right lower extremity; (c) Supracondylar osteotomy of distal femur, proximal and distal tibial

osteotomies were performed and Ilizarov external frame was installed. (d) At the end of the treatment, the lower extremity gravimetric line and anatomic axis were restored satisfactorily. (e, f) Postoperative clinical appearance

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Fig. 9.22  Staged surgery for severe deformities due to OI. A 26-year-­ old male with bilateral severe and complex lower extremity deformity secondary to osteogenesis imperfecta. (a) Preoperative clinical appearance; (b) X-ray preoperatively; (c) Clinical appearance after the first-­

stage surgery; (d) X-rays shows Ilizarov frame and hybrid fixator were installed; (e) Clinical appearance after the second-stage surgery; (f) X-ray postoperatively

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Fig. 9.23  Bilateral severe deformities of lower limb due to OI. (a) A 24-year-old male with bilateral severe deformities due to OI, preoperative clinical appearance; (b) Preoperative X-ray film shows thin cortical bone, bilateral middle and distal tibia deformity; (c, d) (3–4) The left femur osteotomy was performed and fixed with intramedullary nail and external

fixator. The middle and distal tibiofibular osteotomy was performed and fixed with Ilizarov frame. The deformities of bilateral lower extremities were corrected 34 days after operation. (e) Clinical appearance15 months after surgery, the external fixator was removed partially, which is beneficial to bone mineralization. (f) X-ray 15 months after surgery

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Fig. 9.23 (continued)

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Fig. 9.23 (continued)

a

b Fig. 9.24  Multiple deformities of lower limb secondary to OI. (a) Preoperative clinical appearance, the patient presents multiple deformities of bilateral lower extremities. (b) Preoperative X-ray; (c) Femur

and tibia on right side were radiographed 4  days after operation; (d) Clinical appearance 15  days after surgery; (e) Clinical appearance 12 months after surgery; (f) X-ray 12 months after surgery

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Fig. 9.25  A 25-year-old male with left knee and hip flexion deformities: (a) Preoperative appearance, femoral pressure gait; (b) Preoperative X-ray showed knee flexion contracture; and (c) Subtrochanteric osteotomy and supracondylar femoral osteotomy were performed. (d) Supracondylar osteotomy was fixed with a reconstruction plate and a

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cross knee joint external fixator. At 24  days after operation, the left lower extremity deformity was corrected. (e) At follow-up of 12 months after operation, the weight-bearing line of the left lower extremity malformation was corrected

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Fig. 9.26  A 6-year-old male with left congenital pseudarthrosis of tibia: (a) Severe shortening of left lower extremity and anterior angular deformity before operation. (b) X-ray films before operation, osteoporosis, anterior angle 90°. (c) Pseudoarthrodesis excision, intramedullary needle fixation, and Ilizarov external fixation were performed. At 5 months

after operation, the deformity was corrected and high support brace was used for walking. (d) At 8 months after operation, X-ray film showed pseudarthrosis healing. (e) After 19  months’ follow-up, the angular deformity of the left leg was completely corrected. (f) At 19 months after operation, X-ray films showed bone union at pseudarthrosis site

The principles of treatment for severe osteoporosis after multiple internal fixation of traumatic fractures are: try to protect the patient’s bones from excessive stress on lower extremities with accessories that can carry weight, such as plaster or external fixators to assist in the walking and exercise of the affected limbs. During the course of walking exercise, the improvement of osteoporosis is measured regularly and the fixation method is changed accordingly. Bone remodeling is achieved with regulation of time and intensity conversion of stress stimulation. Even in pathological fractures, such as osteofibroid proliferation, satisfactory bone reconstruction can still be achieved.

9.3.4 Clinical Case (Fig. 9.28) 1. A 55-year-old female with post-traumatic femoral fracture who had undergone five internal fixation operations. The fracture still had not healed. X-ray showed that the right femoral intramedullary nail was fixed and the broken ends of the fracture had not healed. The bone cortex was thinned, and the bone was osteoporotic. The intramedullary nail was removed in the local hospital and hybrid external fixator was applied. After 11  months of fixation, the fracture still did not heal and osteoporosis was further aggravated. Bone resorption occurred at the broken ends.

9  Lower Limb Deformity Caused by Hereditary and Metabolic Diseases Fig. 9.27  A patient with fibrous dysplasia complicated with dislocation of left hip joint and deformity of the left proximal femur. (a) X-ray showed at 3 months after internal and external fixation of osteotomy, bone healing at the osteotomy site was satisfactory postoperatively. Due to osteoporosis, external fixation pin became loosened. (b) In order to obtain more stable fixation of osteotomy, the hip plaster had to be used. (c) After 4 weeks of fixation, it was replaced by external fixation of orthosis. (d) X-ray films reviewed

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2. Preoperative design: Osteoporotic bone became nonunion which was considered to be caused by a stress blocking effect due to an excessive number of pins of external fixators. In the view of loosening of the steel needles of the external fixator, the original external fixator had been removed and fixed with the pins again. The cross K-wires were put at the broken ends to increase the stability. 3. Surgical scheme: removal of external fixator and resuscitation of needle fixation.

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4. Postoperative management: the walking with body weight-bearing was carried out after the operation. The osteoporosis was obviously improved at 26 months after the operation, but due to the loosening of the pins, the open surgery was carried out to have the broken end cleaned up and bone graft again. The plate was applied together with cross K-wire and cross knee external fixator to fix the fracture. At 3 months after the operation, the external fixator was removed to replace the lower

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Fig. 9.28  Osteoporotic bone nonunion: (a) Femoral fracture fixed with intramedullary nail, bone nonunion, and osteoporosis; (b) After removal of intramedullary nail, the external fixator replaced. 8  months after operation, nonunion, and the external fixation pins loosened; (c) At 11 months after surgery, osteoporosis aggravated and bone resorption; (d) The external fixator was removed and fixed again, and the stability was increased by intersecting the needle at the end of the fracture. After 19 months, osteoporosis was obviously improved, but the fracture still did not heal; (e) 19 months postoperatively, the appearance; (f) After

22  months, osteoporosis was improved and fracture did not heal; (g) After 26 months, osteoporosis was improved, fracture did not heal, but external fixation wires or pins became loose; (h) The bone graft, plate, K-wires, and combined external fixator were used; (i) Postoperative X-ray films; (j) The external fixator was removed at 3 months after surgery, and the long leg brace was used to protect the external fixator; (k) After removal of the external fixator, the X-ray films showed that the callus at the fracture end grew well and the osteoporosis was obviously improved

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limb orthosis for continuous weight-bearing ­walking. X-ray showed an increase in bone mass and an improvement in the condition of osteoporosis.

9.4

 ower Limb Deformity Caused L by Rickets

Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Xulei Qin, and Qi Pan

9.4.1 Etiology and Pathogenesis 9.4.1.1 Introduction Rickets is a group of metabolic bone diseases with abnormal mineralization of bone matrix caused by multiple etiology and different pathogenesis. The main manifestation of rickets is the lack of growth and mineralization of epiphyseal cartilage in children. It should be distinguished from osteomalacia, which is caused by the defective mineralization of new osteogenic matrix during bone reconstruction in adults. The clinical characteristics of the two are similar.

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9.4.1.3 Pathogenesis The occurrence of rickets is often the result of multiple factors, in which vitamin D deficiency or metabolic disorder is the most important factor and the most direct cause of bone mineralization disorder. It is also the most common type of ricket found in many developing countries. Hypophosphatemia, too much mineralization inhibitor, etc., leads to the abnormality and structural disorder of bone matrix such as collagen fibers, and can also inhibit the normal mineralization of bone.

9.4.2 Clinical Manifestations and Examination Points Rickets is characterized by a lack of growth and mineralization of epiphyseal cartilage in children, which occurs before closure of the growth plate of the long bone, and is the most evident in the rapidly growing parts of the bone (skull, ribs, and long bones). Orthopedic clinical patients with osteoarticular deformities have obvious characteristics.

1. Bone pain: Long-term load or joint movement of muscle tendon affects the periosteum of sensory nerve terminal and causes the bone pain. It can develop into severe systemic bone pain. 9.4.1.2 Etiology 2. Myasthenia: Myasthenia is a typical symptom of hypo 1. Vitamin D deficiency or metabolic disorders phosphetamic rickets, characterized by weakness and (a) Inadequate nutrition or absorption disorders: diet hypotonia, increased muscle weakness and bone pain deficiency, insufficient sunshine, digestive system during movement and walking, leading to duck walking, diseases lameness, difficulty in hair combing, sitting up, turning (b) Metabolic deficiencies: liver and kidney diseases, over, etc. After oral administration of phosphorus prepapseudohypoparathyroidism, genetic diseases ration, it significantly improved. (c) Abnormal vitamin D and metabolite receptors: 3. Fractures: Severe osteomalacia can lead to scoliosis, mainly seen in genetic diseases (such as vitamin-­ humpback deformity, short stature, and mild trauma can dependent rickets, VDDR) (Fig. 9.29) lead to pathological fractures, especially multiple rib (d) Increased metabolism and excretion: Taking anticonfractures, sometimes not perceived by the patient. vulsant drugs, nephrotic syndrome, peritoneal dialy- 4. Hypocalcemia: Abdominal swelling, easily frightened, sis, etc. head sweating, delay in height growth, twitching, and so on. 2. Phosphate deficiency (a) Too low diet of phosphorus or too much aluminum In laboratory biochemical examination, the blood calcium hydroxide and phosphorus levels were diversified, for example, the (b) Genetic hypophosphatemic rickets (Fig. 9.30) blood calcium was normal and the blood phosphorus was (c) Hypophosphatemic rickets (starting from adults) decreased in hereditary hypophosphatemic rickets. (d) Chronic renal disease and other systemic genetic When the blood calcium was decreased, then the blood disorders phosphorus was normal in rickets of the calcium deficiency. (e) Tumor factors The level of parathyroid hormone in rickets patients with 3. Metabolic acidosis secondary hyperparathyroidism was increased in addition to (a) Renal tubular acidosis the decrease of alkaline phosphatase (Alp) in other types of (b) Osteomalacia, renal glycosuria, amino acid urine, rickets. Vitamin D determination can be used to differentiate and hyperphosphaturia syndrome osteomalacia from different types of rickets.

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Fig. 9.29  Vitamin-dependent rickets. (a) A 46-year-old female with rickets underwent surgery by Dr. Qin 28 years ago. When 28 years of follow-up, the gravity line and function of both lower limbs were nor-

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mal, she brought her 18-year-old son to ask treatment; (b) Windswept deformity of both lower limbs; (c, d) X-ray of bilateral lower limbs

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Table 9.8  Data analysis of lower limb deformity secondary to Rickets in Qin Sihe Orthopedics Institute Category Gender Age (year)

Time

Fixation∗

Item Male Female 1–14 15–44 45–60 1980–1989 1990–1989 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Taylor fixator Internal fixator

Case (n) 29 41 23 43 4 8 17 10 35 39 24 3 23

Percentage (%) 41.43 58.57 32.86 61.43 5.71 11.43 24.29 14.28 50.00 55.71 34.29 4.29 32.86

Note: Some patients were fixed with mixed fixation

9.4.4 Treatment Protocols

Fig. 9.30  Mother (right) and her daughter (left)

9.4.3 C  linical Data of Lower Limb Deformity Caused by Rickets There are 70 cases of rickets deformity in Qin Sihe Orthopedics Institute; data statistics are as follows (Table 9.8):

The aim of the treatment of limb deformity secondary to rickets is to correct the deformity, to restore the load line of the lower limb, to improve the function of the lower limb, and to improve the quality of life. The most common deformities of the lower extremity of rickets were bilateral varus deformities of leg (O-shaped deformity). The positions of femoral, tibial, and fibula deformities were determined by means of physical examination and full-length X-ray film of lower extremity. Because the deformity is formed during the epiphyseal growth, the deformities with torsion occur at the same time in the coronal plane, sagittal plane, and horizontal plane. Therefore, by simply drawing the line on the X-ray film, abnormal situation cannot be truly reflected with mechanical axis and anatomical axis. In the case of bilateral severe deformities, we may first consider restoring the force line of the lower limb, that is, the osteotomies of the femur and the tibia and fibula at the same stage. The femoral osteotomy is usually located in the middle and distal segments. Because of increased soft tissues on the thigh, it is suitable for application of internal fixation instead of external fixation. The lower limb severe varus deformity presents “banana” shape, accompanied by torsion. The incidence of complications will be significantly increased in acute correction. It is appropriate to correct gradually with Ilizarov technique. If there is mild deformity on both legs, we may consider performing corrective surgery on both legs simultaneous, which is more favorable for rapid recovery after surgery.

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9.4.5 Tips and Tricks 9.4.5.1 Correction of Thigh Deformity Femur deformity was mainly located in the middle and distal segments, accompanied by varus and anterior arch deformity. Because of the short and thick thigh, the balloon tourniquet could not be used. At the beginning of surgery, a 4.5 to 5.0  mm pin was inserted vertical to the femoral shaft below the greater trochanter, and then the rubber tourniquet was applied. Another pin was inserted vertically and parallel to articular surfaces at the lateral condyle of distal femur. Close wedge osteotomy was performed with a sharp narrow osteotome. The deformity could be corrected by simultaneous valgus and extension with moderate shift of distal fragment, and then fixed with a wire to increase the local stability of both bone segments. When the femoral deformity corrected, the pins were connected with hybrid fixator, the position of femur was checked by X-ray fluoroscopy, and then the fixator was tightened in satisfactory position. A plate with 6–7 holes was placed on the lateral posterior side of the femur for further fixation. The temporary fixator was removed when the plate was applied completely. 9.4.5.2 Correction of the Calf Deformity There is multiple plane deformity of both tibia and fibula in rickets sequelae. In order to obtain good effect, the proximal and distal tibiofibular osteotomies are usually performed with minimal incision. The common peroneal nerve should be exposed clearly when performing proximal fibula osteotomy. Because of multiple osteotomies on the calf, the deep fascia should be cut with surgical scissors to prevent osteofascial compartment syndrome, and the drainage strip should be placed in each incision of osteotomy.

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stage, thick rings were used for frame to ensure early weight-bearing after surgery.

9.4.6 Postoperative Management The postoperative management procedures are similar with other kind of lower extremity surgery. The hinges of external fixation must match with osteotomy site during the adjustment process base Paley principle. Regular X-ray examination should be performed to check limb alignment of lower extremity.

9.4.7 Complications 1. Early complications: The early complications involve common peroneal nerve palsy, osteofascial compartment syndrome, etc. 2. Intermediate complications: During the treatment, there is axial deviation, insufficient or excessive correction needed detecting in time and corrected by adjusting the external fixator. 3. Late complications: Delayed union or refracture after fixator removal.

9.4.8 Typical Cases

9.4.5.3 Drug Therapy The phosphate and vitamin D was given orally, but blood calcium and phosphorus should be detected to prevent hypercalcemia and urinary calculi.

Case 1 A 25-year-old female with severe O-shaped deformity caused by low-phosphorus rickets; X-ray film of lower extremity showed bilateral lower limb varus deformity. Surgical plan: The deformities of lower extremity will be treated in staged surgery. At the first stage, the surgeries for right side can be performed, which includes femoral valgus osteotomy and ­proximal and distal tibiofibular osteotomy. The deformity correction for left side can be done at the second stage with same procedure (Fig. 9.31).

9.4.5.4 Design of External Fixator The Ilizarov frame was applied for tibiofibular deformity correction, which should be preassembled preoperative according to the circumference and the length of calf which was fixed on tibia and fibula with wires and pins. When ­bilateral deformities were corrected at the same

Case 2 A 12-year-old female with O-shaped lower limb deformity secondary to rickets. X-ray showed bilateral proximal and distal tibia bending deformity. Bilateral tibia and fibula osteotomy was performed, and Ilizarov technique was applied for deformity correction (Fig. 9.32).

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Fig. 9.31  Severe O-shaped limb deformity secondary to rickets: (a) Preoperative clinical appearance; (b) X-ray preoperatively; (c) Left lower limb underwent surgery at the first stage; (d) Femur osteotomy with lateral longitudinal incision of thigh; (e) V-shaped osteotomy was performed; (f) One pin was inserted at distal lateral femur; (g) Femoral osteotomy segment was temporarily fixed with hybrid fixator; (h) Application of plate; (i) A drainage tube was applied in the incision; (j)

Common peroneal nerve; (k) The fibula osteotomy was done at the junction of fibula head and neck; (l) The distal fibula osteotomy was performed with a small incision; (m) Tibia osteotomy was done and deep fascia was released simultaneously; (n) lower limb deformity right side was corrected partially 64 days after surgery; (o) X-ray was taken 70 days after surgery; (p) Clinical appearance 253 days after first surgery for right side and 180 days after second surgery for left side

9.5

9.5.1 C  linical Data of Achondroplasia in Qin Sihe Orthopedics Institute

Achondroplasia

Jiancheng Zang and Sihe Qin Achondroplasia is a kind of congenital developmental abnormality due to a defect of endochondral ossification, which mainly affects the long bone. The clinical manifestation is a special type of dwarf-short limb dwarf (Fig. 9.33). But they have good mental and physical development.

A total of 16 cases of achondroplasia were treated in Qin Sihe Orthopedics Institute. The statistical analysis was as follows: (Table 9.9).

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Fig. 9.32  The treatment of severe O-shaped limb deformity secondary to rickets using Ilizarov technique: (a) Preoperative clinical appearance; (b) Preoperative X-ray film; (c) Ilizarov fixation was applied for

deformity correction; (d) X-ray 3  weeks after surgery; (e) X-ray 4 months after surgery

9.5.2 Etiology

9.5.3 Clinical Manifestation

Achondroplasia is an autosomal dominant hereditary disease. Most of the patients died of stillbirth or neonate, and the parents of most of the patients were normal, suggesting that it may be the result of spontaneous gene mutation. Molecular genetics showed that the gene encoding fibroblast growth factor receptor had a point mutation and was located on the short arm of chromosome 4.

At birth, the child’s torso is found to be out of proportion to the limbs, the head is large and the limbs are short, and the torso is normal. The proximal end of the limb is shorter than the distal end, such as femur, fibula, humerus, ulna, and radius. This feature becomes more obvious with age, and gradually forms dwarf deformity. The facial features include nasal collapse, mandibular protrusion, and broad forehead. The middle finger

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a

b

height 120cm

Fig. 9.33  Achondroplasia: (a) Dwarf, genu valgum; (b) Dwarf, genu varum

and the ring finger are wide apart,; this type of hand is called trident hands (Fig. 9.34). It may have flexion contracture of the elbow joint and dislocation of the radial head. The lower extremity is short and curved as arcuate. The muscle is especially bloated. The length of the spinal column is normal, but there can be a deformity of thoracic kyphosis in infancy. Intelligence is not affected generally. Deformity of lower extremities occurs in different degree under the effect of weight-bearing stress. Surgical correction is mainly for lower extremities.

9.5.4 Goal and Idea of Treatment The aim of treatment is to correct the deformity of lower extremity and improve limb function by orthopedic surgery. Secondary knee and ankle deformities such as flexion, varus, and valgus of the two joints are the main causes of lower extremity dysfunction, which can be improved by orthopedic osteotomy. Femoral osteotomy should be fixed with plate, and tibia and fibula with external fixation. Some patients have

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Table 9.9  Clinical data of achondroplasia in Qin Sihe Orthopedics Institute Category Gender Age (year) Time (year)

Fixation method

Bone deformity∗

Item Male Female 1–14 15–44 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Internal fixator Hip Knee Ankle and foot

Cases (n) 5 11 7 8 1 1 2 12 4 9 3 5 15 4

Percentage (%) 31.25 68.75 46.67 53.33 6.25 6.25 12.50 75.00 25.00 56.25 18.75 33.33 100.00 26.67

Note: Some patients suffered from compound deformity

Fig. 9.34  Trident hand

psychological problems due to short limbs and short stature. They can increase their height by limb lengthening. The common surgical methods are tibial metaphyseal osteotomy and femoral lengthening and so on. However, attention should be paid to prevent the complications of limb lengthening surgery.

9.5.5 Typical Case Case 1 A 23-year-old male with congenital multiple achondroplasia, presented as short stature, posterior process of thoracic vertebrae, trident hand, flexion deformities of both hips and knees, and external rotation deformities of both legs. X-ray film showed bilateral bulging of proximal tibia, femur trochanter, and femoral condyle. Both distal femur and proximal tibia had anterior arch deformity and bone fusion of upper and lower tibiofibula (Fig. 9.35).

1. The main factors affecting the lower limb function were the deformities of hip flexion, knee flexion, and lateral rotation of the lower limbs. The aim of the treatment was to correct the deformities of hip and knee flexion and to improve the gait. Deformity of hip flexion is mainly caused by soft tissue contracture. Deformity of knee flexion co-exists with bone deformities of distal femur and proximal tibia and contracture of hamstring muscle. Patients have no desire to increase the body height. Therefore, soft tissue release combined with osteotomy should be applied to correct the deformity. Both soft tissue deformities and bone deformities need to correct at the same time. Patients with bilateral simultaneous surgery trauma were not conducive to early exercise and walking, so the legs should be treated by stages. 2. The surgical plan included release surgery of the right hip flexion, biceps femoris tendon lengthening, iliotibial tract release, retroversion osteotomy of femoral condyle, osteotomy and internal rotation of tibial tubercle, and hybrid external fixation. 3. Preoperative preparation: electric drill, sharp osteotome, hybrid external fixator, etc. 4. The surgical procedures were as follows: With anterior incision of hip joint, exposure of crista iliac, stripping of internal and external plate of iliac bone, excision of the origin of sartorius muscle, Z-shaped lengthening of the origin of rectus femoris, exposure of the iliopsoas tendon, and Z-shaped lengthening. These operations significantly corrected hip flexion deformity. The incision was sutured. The lateral incision of lower thigh exposed the iliotibial tract and had Z-shaped lengthening, and tense lateral femoral muscle septum was cut off. Biceps femoris tendon was exposed and had Z-shaped lengthening. The common peroneal nerve was released at the head of the fibula and protected. The fibula was cut off under the head of the fibula and the incision was sutured. An anteromedial incision was made to pull the medial femoral muscle and expose the distal femur. The anterior femoral supracondylar wedge osteotomy was made with osteotome to correct the deformity of distal femoral anterior arch and was fixed with a steel plate. After the incision of tibial tubercle, the tibia was exposed and cut off. The distal end of the osteotomy was turned inward and backward, and the deformity was corrected and fixed with hybrid external fixator. The femoral pin was fixed with external fixator across the knee joint, and then the incision was sutured. 5. Postoperative management: Hip pad was raised to maintain the hip joint in extension position. At the second day after the operation, leg lifting exercise was begun. In the prone position, the knee joint was pad raised and the hip was pressed to correct the deformity. At the 7th day after the operation, walking exercise was begun under the walking aid. At the 2nd week after surgery, the external

9  Lower Limb Deformity Caused by Hereditary and Metabolic Diseases

fixator of the knee joint was removed and the knee joint was pressed to further correct the flexion deformity. Then the external fixator was locked. After satisfactory correction, the knee joint was fixed for 4 weeks, and the external fixator of the leg was removed. Knee joint brace was made to maintain the knee joint at the maximal elongation position; 3 months after the tibia osteotomy healed, the external fixator was removed. 6. Tips and tricks: When the tendons of iliopsoas muscle are lengthened, attention should be paid to avoid the injury to the femoral nerve. While the biceps femoris tendon is lengthened and fibula osteotomy is performed, attention

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should be paid to protect the common peroneal nerve and avoid the injury. The common peroneal nerve should be released when genu valgum and knee flexion are corrected by osteotomy under the fibula head. The tibial nerve and the common peroneal nerve should not be stretched to avoid the injury to the tibial nerve and the common peroneal nerve. 7. Left limb surgery was done with same procedure above at the second stage (Fig. 9.36). 16 cases of surgical treatment proved that the ability of bone healing after osteotomy was not significantly different from that of normal people.

a

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c

Fig. 9.35  Achondroplasia. (a) Preoperative clinical appearance; (b) Trident hand; (c) Preoperative X-ray radiography of the knee joint; (d) Release of the right hip flexion, release surgery of knee flexion, supra-

condylar femoral osteotomy, and subtuberculous tibial osteotomy were performed. The appearance 10 days after surgery; (e) 80 days after surgery; (f) X-ray films 4 months postoperatively

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Case 2 See Fig. 9.37. This case was provided by Dr. He Tao Xia, Dr. Aimin Peng, and Dr. Yilian Han.

9.6

 ower Limb Deformity Caused L by Melorheostosis

Sihe Qin, Shaofeng Jiao, Xulei Qin, Qi Pan, and Jiancheng Zang Melorheostosis is a rare and unknown bony sclerosing disease that can invade one side of the limb. It was first reported by Leri in 1928, also known as Leri’s disease. Because the hyperplastic bone flows from top to bottom along the backbone, like wax tears on the surface of a candle, it was also called wax tears like bone disease. Although this disease is a rare disorder of bone development, it can be diagnosed according to the characteristic changes of X-ray and pathological examinations. Fig. 9.36 Clinical appearance after the second-stage surgery: (a) 10 days after surgery; (b) 81 days after surgery; (c) At the end of treatment, the X-ray films after the removal of the external fixator

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9.6.1 Data Analysis Qin Sihe orthopedic team has treated four cases of lower extremity deformity of melorheostosis in which three cases were female and one case male. Their ages were 7 years old, 14 years old, 21 years old, and 25 years old. Two cases had simple clubfoot deformities and one case had knee valgus, respectively. One case had knee varus combined with equinovarus deformity.

9.6.2 Etiology and Pathogenesis The cause of the disease is unknown and the main pathological changes are the proliferation of the internal and external membrane of bone and irregular sclerosis. The new bone accumulates and the bone contour is deformed on the diaphysis, but the swelling of the bone is rarely seen. No malignant changes or pathological fractures were found in the diseased bone. There is no family history and

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Fig. 9.36 (continued)

a

c

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Fig. 9.37  Ilizarov technique for short stature. (a–h) Male, 18  years old, 129 cm in height before surgery, 33 cm was lengthened on lower limbs in 5 years, his final height was 162 cm; (i) 10 years follow-up, he

c

has married and took a photo with his wife by the river. (j) The photo showed he (left 2) and his family

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d

g

Fig. 9.37 (continued)

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Fig. 9.37 (continued)

no hereditary disease. This disease can occur from children until old people, but mostly occur in patients from 5 to 20 years of age.

9.6.3 Clinical Manifestations There is generally no obvious symptom in the early stage of the disease. 1. Pain is a common complaint of the disease. Local pain and limited physical activity have exaberation and remission episodes with activity level such as relief or disappearance of symptoms during rest, Symptoms worsen during activity. 2. There are motion disorders and deformities caused by thickening of joints or thickening of surrounding soft tissues. Some patients have limping or difficulty in squatting, etc. 3. Affected limbs are thicker and shorter than normal and may present asymmetrically, segmentally, or completely due to early epiphyseal closure. Long tubular bones often present varus or valgus deformities when lesions involve the diaphysis and epiphysis (Fig. 9.38). 4. Symptoms of the skin: When nerves compressed, sensory disturbance and dysfunction may occur. When blood vessels are squeezed, the limb may present with soft tissue edema, tight or erythema.

9.6.4 X-Ray In the long tubular cortex, there are sclerosing bone strips or plaques, which are continuous or intermittent, extend from the proximal side to the distal side, mostly confined to one side of the bone cortex, and can also wrap around the whole bone cortex. The surface of the bone is uneven, looking like wax oil that melts and drips. The density of bone is as high as the ivory. The bone structure around the proliferative bone is normal, and the medullary cavity becomes narrow when the hyperplasia is excessive. In cancellous bone, irregular and linear plaques of bone hyperplasia can also be seen. In the early stage, the proximal part of the bone was not involved and eventually reached into the epiphysis and across the joint into the other shaft. The lesions of short tubular bone and epiphysis are similar, showing that there are spots or stripes in the bone, which are not easy to cause contour changes, and most of the joints are not affected. Even if the bone at both ends of the joint has obvious accumulation of new bone, the articular surface remains smooth. Bone deposition is common in soft tissue nearby (Fig. 9.39).

9.6.5 Pathological Diagnosis The proliferation of internal & external membrane of bone, irregular sclerosis, the accumulation of new bone on the diaphysis, the deformation of outline, the increase of

9  Lower Limb Deformity Caused by Hereditary and Metabolic Diseases

Fig. 9.38  Left lower limb deformity caused by melorheostosis

Fig. 9.39  X-ray of Melorheostosis

osteoblast activity, and the decrease of osteoclast movement in the lesion site, with the presentation of new bone formation. Under the microscope, the hardy canal of the diseased bone is distorted and deformed, as well as the lamellar layer is tightly arranged and deformed. The trabeculae and the medullary cavity may be replaced by the fibrous tissue.

9.6.7 Typical Case

9.6.6 Treatment Goal Osteopathy itself does not need to be treated, but the deformity caused by it often affects the motor function of lower extremities. Orthopedic surgery can be used to correct the deformity of bone and joint, and the limb function of patients can be improved significantly.

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A 21-year-old female with left genu varum and equinovarus deformity caused by melorheostosis. When she was 6 years old, she had been corrected by Achilles tendon lengthening surgery in the local hospital. The deformity recurred after operation, and gradually aggravated, which seriously affected the patient’s walking. On admission, examination reveals: severe limping gait, left genu varus, and left severe equinovarus deformity. X-ray film showed continuous lacrimal bone sclerosis of left lower limb from iliac bone, pubic bone, femur, tibia, and ankle; it looked like wax oil that melts and drips. Foot and ankle equinovarus deformity (Fig. 9.40). 1. Treatment objective: Correct left knee varus and equinovarus foot deformity, restore weight-bearing function, and restore normal alignment of the mechanical axis of left lower extremity.

426 Fig. 9.40  Left lower limb deformity caused by melorheostosis. (a) Preoperative appearance, genu varum, and equinovarus deformity left side. (b) X-ray showed that continuous lacrimal bone sclerosis on the left iliac bone, pubic bone, femur, tibia, and ankle. (c) Preoperative full-length X-ray film of both lower extremities showed left genu varum deformity. (d) Fibula osteotomy. (e) Achilles tendon release. (f) Subtuberculum tibial osteotomy. (g) Install external fixator. (h) At the 16th day after surgery, the genu varum was corrected, and the equinus deformity was improved. (i) At the 28th day after surgery, the mechanical axis of the left lower limb returned to normal. (j) The knee and ankle deformity were corrected 58 days after surgery. (k) X-ray showed the bone healed at the tibial osteotomy site. The external fixator was ready to be removed at the180th day after surgery. (l) X-ray at the 180th day after surgery. (m) At 27 months follow-up, the mechanical axis of the left lower limb returned to normal, but there was still a limb length discrepancy. (n) At 42 months follow-up, the mechanical axis of the left lower limb was normal

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b

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Fig. 9.40 (continued)

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l

m

Fig. 9.40 (continued)

n

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2. Surgical procedures: Percutaneous release surgery of Achilles tendon, triple joint osteotomy, osteotomy of tibial tuberculus valgus, and external fixation. 3. Surgical preparation: Ilizarov external fixator, sharp osteotome, electric drill, double sleeve drill, drilling assisted osteotomy device, etc. 4. Surgical steps: The lateral incision of the fibula head and neck exposed the common peroneal nerve for retraction and protection, then the fibula was cut in the fibula head and neck junction with osteotome, the incision was sewed. The partial fibers of the Achilles tendon were severed with a sharp osteotome in different planes. The Ollier incision exposed the articular cartilage of the three joints which were cut off with a bone osteotome, and the partial foot varus was corrected. The osteotomy was fixed temporarily with a 2 mm K-wire. After this through a small incision under the tubercle of the tibia was exposed, a row of holes was drilled horizontally with the aid of a double-sleeve drill device, then the tibia was cut off with a sharp osteotome and the incision was sutured. Ilizarov external fixator for the leg was installed with wires and pins. 5. Tips and tricks During the fibula osteotomy, the common peroneal nerve should be protected to avoid injury. At the time of triple joint osteotomy, the length of the foot should be preserved by minimizing the excision of the bone. During the osteotomy of the tibia and foot, the bone will be too hard and sharp osteotome is used for osteotomy to avoid excessive thermal injury. 6. Postoperative management At the 5th day after surgery, the function of walking was started with the help of walker, and at the 7th day after operation, the external fixator was adjusted to correct the equinovarus deformity, first to correct the varus and adduction of the forefoot, and then to correct the equinus. At the same time, the medial rod of the external fixator of tibia was lengthened to correct the tibial varus deformity. The pin tract infection was prevented. The traction speed of the foot and ankle deformity was 3–5 mm per day so that the patient could tolerate it. After correction, the external fixator of foot and ankle remained fixed for 2  months, and the external fixator was fixed until the bone healed. After the external fixator removal, the brace was applied to support the ankle joint for 6 months.

9.7

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 ower Limb Deformity Caused L by Hemophilia

Sihe Qin, Shaofeng Jiao, Xulei Qin, Lei Shi, and Jiancheng Zang Hemophilia is a sex-linked recessive hemorrhagic disease. According to the difference of the deficiency of coagulation factors, it can be divided into three types: type A (lack of viii factor), type B (ix factor deficiency), and type c (lack of xi factor). There is a marked tendency of bone and joint bleeding. Type C is autosomal dominant inheritance. Both men and women have the disease. This type of cases is rare with mild bleeding and rare involvement of bone and joint. Hemophilic arthropathy is a joint disease complicated with hemophilia and mainly hemarthrosis and ankylosis. It usually occurs in the joints with more movement and gravity, such as knee, ankle, elbow, and hip. Joint hemorrhage is the most common and characteristic hemorrhage, as well as the most common cause of disability, especially in severe patients. Bleeding often occurs after injury or prolonged walking and exercise. The bleeding repeated so that the joint bleeding cannot be completely absorbed, the enzyme released by white blood cells leads to synovial fibrosis and hyaline cartilage decomposition, causing chronic synovitis, articular cartilage degeneration, and joint surface erosion. It causes subarticular bone erosion and joint space stenosis. It lasts several years to result in joint stiffness, deformed contracture, disused muscle atrophy, and osteoporosis.

9.7.1 Clinical Manifestation Hemophilic arthropathy is the most common in the knee joint, which is often leading to flexion contracture of the knee joint and making the patient gradually lose the function of standing and walking.

9.7.2 Treatment For the treatment of hemophilia deformity, the cooperation between departments of hematology and orthopedic surgery is needed. 1. It is necessary to supplement the lack of factors and increase the concentration of coagulation factors in blood

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9.7.3 Typical Case

Fig. 9.41 Hemophilia arthrosis, X-ray film shows severe joint damage

to prevent the bleeding that is difficult to control during and after operation. 2. If the joint destruction is severe (Fig.  9.41), the best treatment is still joint replacement or joint fusion. If comprehensive assessments of the patient’s age, degree of osteoporosis, economic situation, and other factors show that the patient is in good condition, artificial joint replacement can be implemented to restore joint function. Arthrodesis is the ultimate treatment, for patients with poor conditions. The direct implementation of joint fusion can restore standing and walking function.

1. A 21-year-old male with bilateral severe equinovarus deformity secondary to hemophilia could not walk before operation. His daily life needs wheelchair support. The X-ray films showed that the equinovarus deformities in bilateral ankle and foot joints (Fig. 9.42). 2. Treatment objectives and ideas: The patient’s treatment objectives are to correct bipedal deformities so that the patient can walk weight-bearing. Surgical ideas are as follows: on the basis of blood coagulation factor supplementation, minimally invasive osteotomy, limited soft tissue release combined with Ilizarov technology are chosen to correct ankle and foot deformities and to achieve treatment objectives. 3. Surgical plan: Bilateral Achilles tendons are released subcutaneously. Tendons of posterior tibial muscle are lengthened; triple osteotomy is performed and fixed with Ilizarov ring. 4. Preoperative preparation: coagulation factor, electric drill and Ilizarov external fixator and sharp osteotome, etc. 5. Surgical steps: With posterior tibial incision above the medial malleolus, posterior tibial tendon was exposed and performed Z-shape lengthening. The incision was sutured. With the dorsolateral arc incision of the foot, three joints were exposed. After the articular cartilage was cut off with an osteotome, the wedge-shaped bone osteotomy was performed. Equinovarus deformity was corrected partially, and then suture this incision. With dorsal extension of ankle joint, Achilles tendon was released with sharp knife percutaneously. Finally, Ilizarov external fixator was performed. 6. Tips and tricks: Preoperative monitoring shows that blood coagulation function returns to the normal. Percutaneous release of Achilles tendon is performed at different levels to avoid complete transection of Achilles tendon. Triple osteotomy should be performed to remove bone as little as possible. The residual deformity is corrected by Ilizarov external fixation after surgery. 7. Postoperative management: On the next day after surgery, operated legs should be elevated and function excises on bed. On the 5th day after surgery, walking practice was done under the walker. On the 7th day after surgery, the external fixator was adjusted to correct the residual varus deformity of the foot and ankle. When deformity correction was completed, the external fixator was fixed until removal 3 months postoperatively.

9  Lower Limb Deformity Caused by Hereditary and Metabolic Diseases Fig. 9.42 Bilateral equinovarus deformity caused by hemophilia: (a) Preoperative wheelchair support for walking; (b) X-ray films of the foot and ankle; (c) 59 days after surgery, walking with walker; (d) X-ray films at 39 days after surgery; (e) 4 months and 10 days after surgery, the external fixator was removed and the foot and ankle deformity were corrected; (f) The patient was walking with ankle foot orthosis

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Fig. 9.42 (continued)

e

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Traumatic Sequelae of Lower Limb Sihe Qin, Jiancheng Zang, Yilan Wang, Shaofeng Jiao, Xulei Qin, and Qi Pan

10.1 Clinical Data Sihe Qin, Jiancheng Zang, and Yilan Wang There were 700 patients with traumatic sequelae who had undergone surgery in Qinsihe Orthopedic Institute, accounting for 0.2% of the total number of lower extremity deformities database. The statistical analysis is as follows: (Tables 10.1, 10.2, 10.3, 10.4, 10.5, 10.6, and 10.7).

10.2 Clinical Manifestations Shaofeng Jiao, Xulei Qin, and Jiancheng Zang Traumatic deformities of lower limbs affect the appearance and function. Different type, location, and severity correspond to different manifestations. Some patients suffer from delay in treatment or improper treatment at the first time. Limb deformities cause dysfunction through the following aspects: 1. Abnormalities of articular surface lead to traumatic arthritis due to inappropriate gravity conduction. 2. Rotational and/or angular deformities affect the balance and gait of lower limbs. 3. Limb deformity causes abnormal movement of the adjacent joint.

Table 10.1  Gender ratio analysis Gender Male Female

Case (n) 459 241

Percentage (%) 65.57 34.43

Table 10.2  Age at surgery Age (year) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–60 61–70 71–80 >80 Maximum age Minimum age Average age

Case (n) 7 46 85 116 116 91 60 57 43 38 24 15 1 1 84 3 27.1

Percentage (%) 0.10 6.58 12.15 17 17 13.01 8.57 8.15 6.15 5.43 3.43 2.15 0.14 0.14

Note: This table shows that men are significantly more than women, and patients aged 16–25 years account for one third

Table 10.3  Case undergone surgery

S. Qin (*) · J. Zang · Y. Wang · S. Jiao · X. Qin · Q. Pan Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China

Period 1978–1982 1983–1987 1988–1992 1993–1997 1998–2002 2003–2007 2008–2012 2013–2017

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_10

Case (n) 2 13 61 47 69 64 194 250

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Table 10.4  The sides of deformity analysis Sides Left Right Bilateral

Cases (n) 335 312 53

Percentage (%) 47.86 44.57 7.57

Period 1988–1992 1993–1997 1998–2002 2003–2007 2008–2012 2013–2017 Total

Table 10.5  The location of deformity analysis Location Hip joint Femur Knee joint Tibia and fibula Ankle, foot, and toe

Case (n) 35 78 211 137 424

Frequency 5.00 11.14 30.14 19.57 60.57

Hybrid fixator 2 5 12 14 44 57 134

Ilizarov fixator 1 0 7 31 141 183 363

Unilateral fixator 3 1 0 1 3 1 9

4. Limb discrepancy is caused by limb deformity or bone defect. 5. Muscle power imbalance causes joint deformity and even bone deformity.

Note: Some cases have 2–3 deformities Table 10.6  Data analysis of surgical procedure Type Bony surgery

Category Joint fusion

Osteotomy

Limb lengthening Others Not bony surgery

Soft tissue release

Tendon transfers

Others

Name of surgery Two joint arthrodesis Triple joint arthrodesis Subtalar joint arthrodesis Calcaneocuboid arthrodesis Talonavicular arthrodesis Ankle joint arthrodesis Interphalangeal joint arthrodesis Tibial and fibula osteotomy First metatarsal osteotomy Femoral osteotomy Osteotomy around the talus Super malleolus osteotomy Calcaneus osteotomy Tarsal joints osteotomy Pelvic internal osteotomy Thigh Calf Bone transport surgery Greater trochanter surgery Stiff knee release Achilles tendon lengthening Plantar fascia release Posterior tibia muscle lengthening Iliotibial band release Knee flexor release Femoral adductor release Hamstring lengthening Toe flexor lengthening Gastrocnemius aponeurotic lengthening Posterior tibia muscle outward Anterior tibialis outward Tendons transfer to Achilles tendon Tendons transfer to quadriceps Tendons transfer to extensor digitorum tendon Quadriceps arthroplasty Obturator nerve branch cutting Debridement Achilles tendon shortening

Frequency 10 78 54 7 9 3 27 72 35 26 26 44 31 3 4 35 21 10 2 31 156 55 71 6 3 16 4 21 4 32 24 7 3 20 29 3 3 2

These common reasons also can lead to limb dysfunction as follows: 1 . Fracture nonunion, malunion 2. Muscle imbalance due to muscle and/or nerve injury 3. Scar contracture 4. Joint stiffness deformity due to long-term fixation or lack of exercise 5. Limb deformities due to the growth speed difference of the bone after the epiphyseal injuries

10.2.1 Pelvic Fracture Malunion The main manifestations are pelvic tilt, limited hip joint activity, and limb length discrepancy (Figs. 10.1 and 10.2).

10.2.2 Thigh Traumatic Sequelae Thigh trauma sequelae are mainly characterized by femoral bone defects, thigh shortening, nonunion, or malunion.

10.2.2.1 O  pen Femoral Fracture with Bone Defect See Fig. 10.3. 10.2.2.2 Nonunion of Femoral Fracture See Figs. 10.4, 10.5, and 10.6. 10.2.2.3 Malunion of Femoral Fracture See Fig. 10.7.

10.2.3 Traumatic Sequelae of Knee Traumatic sequelae of knee are mainly characterized by joint deformities including knee varus and valgus, knee flexion, knee recurvatum, knee stiffness, and knee dislocation.

10  Traumatic Sequelae of Lower Limb

a

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b

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Fig. 10.1  Malunions of pelvic and hip fractures: (a) Pelvic tilt (right down); (b) Scars on the buttock; (c) Pelvic plain X-ray

Fig. 10.2  Malunion of femoral neck fracture

10.2.3.1 Genu Valgum See Fig. 10.8. 10.2.3.2 Genu Varum See Fig. 10.9. 10.2.3.3 Knee Dislocation See Figs. 10.10 and 10.11. 10.2.3.4 Knee Stiffness See Fig. 10.12.

Fig. 10.3  Open femoral fracture with bone defect

10.2.3.5 Knee Flexion Deformity See Fig. 10.13.

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Fig. 10.4  Femoral nonunion

Fig. 10.5  Femoral nonunion

Fig. 10.6  Femoral nonunion

10.2.3.6 Knee Recurvation Deformity

10.2.4 The Traumatic Sequelae of Calf The traumatic sequelae of calf are mainly characterized by tibial bone defect, calf shortening, bone nonunion or malunion.

10.2.4.1 Bone Defect After Open Tibial Fracture 1. Bone defect at the proximal tibia segment (Fig. 10.14) 2. Bone defect at the tibial middle segment (Fig. 10.15) 3. Bone defect at the tibial distal segment (Fig. 10.16) 10.2.4.2 Tibial Malunion See Fig. 10.17.

10  Traumatic Sequelae of Lower Limb

Fig. 10.7  Malunion of femoral fracture

Fig. 10.8  Traumatic genu valgum deformity (right)

Fig. 10.9  Traumatic genu varum deformity (left)

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438 Fig. 10.10  Traumatic tibial posterior dislocation

Fig. 10.11  Traumatic tibial anterior dislocation

Fig. 10.12  Traumatic knee stiffness

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Fig. 10.13  Traumatic knee flexion deformity

Fig. 10.14  Traumatic bone defect at the proximal side of the right tibia

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Fig. 10.15  Traumatic bone defect at the tibial middle segment

Fig. 10.16  Traumatic bone defect at the tibial distal segment

10.2.4.3 Nonunion of Tibial Fracture 1. Nonunion at the proximal tibial segment (Fig. 10.18) 2. Nonunion at the middle tibial segment (Fig. 10.19) 3. Nonunion at the distal tibial segment (Fig. 10.20)

10.2.5 The Traumatic Sequelae of Foot and Ankle The traumatic sequelae of foot and ankle are mainly characterized by complex ankle deformities such as ankle varus, valgus, clubfoot, and so on.

10.2.5.1 Ankle Varus Deformity See Fig. 10.21. 10.2.5.2 Ankle Valgus Deformity See Fig. 10.22. 10.2.5.3 Rigid Clubfoot See Fig. 10.23.

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10.2.5.4 Ankle Valgus Deformity See Fig. 10.24. 10.2.5.5 Other Ankle Deformities See Fig. 10.25.

10.2.6 Multiple Deformities The traumatic and complex lower limb deformities are mainly characterized by deformities in multiple joints and multiple dimensions (Fig. 10.26).

10.3 Preoperative Assessment and Correction Strategies of Deformities Sihe Qin and Jiancheng Zang The following conditions must be considered when a surgeon faces skeletal deformities: 1. Location 2. Alignment 3. Rotation 4. Limb length 5. Articular surface 6. Angulation 7. Muscle strength 8. Soft tissue condition Fig. 10.17  Tibial malunion

Fig. 10.18  Nonunion at the proximal tibia

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Fig. 10.19  Nonunion at the middle tibia

Fig. 10.20  Nonunion at the distal tibia

Fig. 10.21  Ankle varus deformity

Is there any deformity in nearby joints? Can it be corrected? For children under 9 years, it should be assessed whether the deformity is consistent with the direction of joint movement, whether it can get corrected during the growth and development period, and whether the epiphysis is damaged

or not.The main purpose of deformity correction is to reconstruct patient’s function and improve limb appearance. For traumatic arthritis, in severe cases, the joints should be fused or replaced to relieve pain.

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Fig. 10.22  Ankle valgus deformity

Fig. 10.23 Clubfoot

Fig. 10.24  Ankle valgus deformity

10.3.1 Preoperative Assessment As for the patient who can stand and walk, the gait and general appearance of the lower limbs should be observed

firstly to make a general judgment on the overall axis and the function of lower limbs. Then physical examinations from pelvis to foot including the shape of the bone, deformity present or not, point of deformity, and some other

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Fig. 10.25  Other ankle deformities

characters should be carried out. Finally, muscle strength and range of joint motion should be checked. For patients who cannot walk, all other examinations except for gait are needed. Finally, all the results of comprehensive examinations are summed up. Patients’ requirements for treatment are solicited. Then it is predicted whether the

current orthopedic means can significantly improve the function of the lower limbs. It is important for doctors to rightly assess their technical skills and determine whether they have the ability to formulate and accomplish an orthopedic plan. This is critical in determining the success or failure of the operation.

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Fig. 10.26  The traumatic and complex lower limb deformities

10.3.2 Deformity Correction Strategy

10.4.1 Introduction

1. Soft tissue contracture Tendon contracture should be corrected by Z-shaped lengthening; the contracture of skin, fascia, nerve, blood vessel, and other tissues should be corrected by Ilizarov technique. 2. Long bone deformity The strategies refer to the “Paley principle” for deformity analysis, find the center of rotational angle (CORA), select the best site for osteotomy, install the Ilizarov fixator to correct the deformity gradually. 3. The foot and ankle deformity is more complicated, in addition to soft tissue contracture combined with bone deformity and muscle imbalance. Therefore, the correction strategy should include soft tissue release, osteotomy, and limited joint fusion and muscle balance surgeries. On the one hand, the stable weight-bearing function is rebuilt; on the other hand, the elasticity of both feet is retained.

Traumatic and infection sequelae of lower extremity are divided into the following categories:

10.4 C  orrection Methods for Different Deformities Sihe Qin and Jiancheng Zang

1 . malunion after traumatic fracture 2. bone and joint deformity caused by scar contracture 3. bone and joint deformity caused by ischemic muscle contracture after vascular injury 4. bone and joint deformity caused by muscle imbalance as incomplete central or peripheral nerve damage 5. joint deformity caused by early closure of the epiphysis resulting from trauma or infection 6. joint deformity caused by septic arthritis 7. complex lower limb deformities caused by severe complex injuries, and so on

10.4.2 Correction Methods for Different Deformities 10.4.2.1 Malunion After Traumatic Fracture The deformity site, deformity angle, and the parameters of shortening and rotational displacements are confirmed. According to the Paley’s principle, you can determine the CORA, perform minimally invasive osteotomy, and correct the deformities with fixators.

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10.4.2.2 B  one and Joint Deformities Caused by Scar Contracture Tendon contracture can be corrected by Z-shaped lengthening; the contractures of skin, fascia, nerve, blood vessel, and other tissues (Fig.  10.27) should be corrected by Ilizarov technique.

Fig. 10.27  Knee flexion deformity caused by contracture of burn scar

Fig. 10.28  Foot and ankle deformity caused by ischemic muscle contracture as popliteal artery injury during the arthroscopic surgery

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10.4.2.3 B  one and Joint Deformities Caused by Ischemic Muscle Contracture After Vascular Injury The most common deformity caused by ischemic contracture is clubfoot (Fig.  10.28). The soft tissues are extensively contracted, including tendons, fascia, ligaments, joint capsules, etc.

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If the patients with deformity less than 2 years, surgical methods mainly include posterior tibial tendon and Achilles tendon lengthening and distraction by Ilizarov frame. Patients with deformity more than 2  years usually have secondary skeletal deformities and need to add bone osteotomy or joint fusion such as calcaneus osteotomy and subtalar joint or triple joint fusion.

10.4.2.4 B  one and Joint Deformities Caused by Muscle Imbalance After Incomplete Central or Peripheral Nerve Injury Long-term muscle imbalance can lead to structural changes in the bones and joints (Fig.  10.29). Surgical treatment of deformity correction and muscle balance should be done in the same period. Muscle balance surgery usually be done on the basis of osteotomy. 10.4.2.5 J oint Deformity Caused by Early Closure of the Epiphysis Resulting from Trauma or Infection (Fig. 10.30) The deformity caused by early epiphyseal closure usually presents skeletal deformity, and osteotomy is the only surgical method for adult patients. However, this type of deformity commonly occurs in the part close to the joint, and the center of angulation and rotation of the deformity always close to the articular so the osteotomy site should be as close as possible to the joint. This case below shows good alignment restored with distraction osteogenesis postoperatively as the osteotomy site at the distal part of tibia and fibula. 10.4.2.6 J oint Deformity Caused by Septic Arthritis in Infants Great influence of joint function could occurred when bone and joint was fusion at abnormal position (Fig. 10.31). The purpose of o­ peration is to correct deformity and make the joint fusion at functional position. Joint deformity is inevitable secondary to soft tissue contracture in a long term, including nerve and blood vessel contractures. Ilizarov technique with distraction correction after osteotomy is a good way for the treatment of joint deformity. 10.4.2.7 C  omplex Lower Limb Deformities Caused by Severe Complex Injury Limb salvage was the main purpose for severe compound injury of the lower limbs in the early stage. The early palliative treatment usually left the complicated deformity (Fig. 10.32). The operation method may involved in soft tissue release and multiple osteotomies and so on. Ilizarov technology is the

Fig. 10.29  Calcaneus varus foot deformity (right side) caused by sciatic nerve injury

“killer” or “lifeboat” for the treatment of such complex deformities.

448 Fig. 10.30  Ankle varus deformity caused by medial epiphyseal injury of the distal tibia

Fig. 10.31  Knee joint fusion at the flexion position caused by septic arthritis

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Fig. 10.32  Severe compound injury in the right lower extremity, complicated limb deformities such as knee stiffness, calf shortening, and clubfoot deformities after limb salvage treatment

10.5 L  ower Limb Deformities Caused by Bone and Joint Tuberculosis Sihe Qin and Shaofeng Jiao Limb deformities and dysfunction with articular destruction caused by bone and joint tuberculosis always be delayed in treatment or affect epiphyseal growth in childhood. The treatment of this kind of limb deformities should follow the orthopedic principle mentioned above. If tuberculosis is still active, it is necessary to enhance the patient’s immunity and to give regular anti-tuberculosis treatment. Braces or external fixators would be applied to prevent the development of limb deformities.

10.5.1 Typical Cases A 39-year-old male with tibiofibular valgus deformity due to tuberculosis infection on the left fibula at the age of 6. Valgus deformity was gradually developed on the distal tibia, even undergone surgical debridement and anti-tuberculosis treatment (Fig. 10.33). 1. The valgus deformities presented on left ankle. The X-ray films showed ankle tilt with bone defect in about three-­fifth the area of the middle part of the right fibula. 2. Surgical plan: According to the analysis of CORA, the osteotomy should be performed at the 6–8 cm level above the ankle joint; the deformity was gradually corrected by Ilizarov external fixator.

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Fig. 10.33  A 39-year-old male with ankle valgus deformity due to tuberculosis at the age of 6. (a) Left ankle valgus deformity preoperatively; (b) X-ray preoperatively; (c) Surgical implementation of super malleolus osteotomy fixed with Ilizarov fixator; (d) Foot and ankle

deformity was corrected and limb length recovered at the 64th day after surgery; (e) X-ray after correction; (f) Ankle and foot orthosis was applied after fixator removal; (g) X-ray at the 97th day postoperatively

3. Preoperative preparation: The relevant configurations of Ilizarov external fixator, electric drill, sharp osteotome, and other conventional instruments should be prepared. 4. Surgical procedures: The longitudinal incision about 2 cm was made at 5 cm above the lateral malleolus. When the fibula was exposed, osteotomy can be done horizontally, and the incision was sutured. The anterior medial longitudinal incision about 1cm above medial malleolus was given. A row of transverse holes was made in the tibia parallel to the ankle surface with an electric drill. The Ilizarov external fixator was mounted with wires and pins, and then osteotomy was done and the incision was sutured.

5. Tips and tricks: The tibial osteotomy line should be parallel to ankle joint surface and the distal ring should also be parallel to that. 6. Postoperative management: The patient was encouraged to practice physical exercise of ankle joint flexion and extension postoperatively. X-ray should be taken at 5 days postoperatively, and then the external fixator was started to be adjusted to correct ankle valgus deformity. At the same time, the patient could walk with partial weight-bearing assisted by crutches.

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When the deformity was corrected satisfactorily, the external fixator was fixed until bone healing. Ankle foot orthosis should be given when the fixator was removed 3 months later; the affected limb resumed normal walking function.

10.6 L  ower Limb Deformity Caused by Septic Arthritis Jiancheng Zang and Sihe Qin Improper treatment of septic arthritis results in joint destruction in childhood, which always develops into secondary deformities of lower limb although the infection has been cured.

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10.6.1 Septic Sequelae of the Hip 10.6.1.1 T  he Hip Joint Is Fused at the Deformed Position of Flexion and Abduction (Fig. 10.34) 1. A 42-year-old female with severe limping gait and pelvic tilt; she suffered from purulent infection of the left hip joint when she was 15 years old. The left hip was fixed at a position of flexion, abduction, and external rotation. X-ray film showed that bony fusion of the left hip joint. 2. Surgical plan: The hip deformity was corrected to the function position of hip flexion 10°–15°, abduction 5°–10° with hip osteotomy surgery, which was fixed with a mini plate and hybrid external fixator. 3. Surgical procedures: With lateral incision of left hip, through the subcutaneous tissue and deep fascia, the glu-

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Fig. 10.34  The treatment of flexion and abduction hip deformity. A 42– year-old female with left hip flexion, abduction, and external rotation deformity due to purulent infection of the hip 27 years ago. (a) Front view preoperative; (b) Lateral view preoperative; (c) Pelvic X-ray preopera-

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teus medius was separated and the hip joint was revealed. Proximal femur osteotomy was performed with osteotome. The hip deformity was corrected to maintain the function position of hip flexion at about 10°, abduction at about 15°, and then fixed with a hybrid external fixator and a mini plate. Finally, the incision was sutured. 4. Tips and tricks: Attention should be paid to avoid sciatic nerve injury during the incision exposure and osteotomy. Attention should be paid to the soft tissue tension of the anterior side of the hip during deformity correction. If there is soft tissue contracture, appropriate release should be given. 5. Postoperative management: At the 5th day after surgery, the patient could walk weight-bearing partially. The external fixator was removed at the 6th week postoperatively. The treatment was terminated when the patient could walk without crutches at the 12th week postoperatively. Total hip replacement could be considered when pelvic tilt was corrected completely and walking weight-bearing for 1 year.

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10.6.1.2 T  he Right Hip Stiffness with Femoral Head Collapsed (Fig. 10.35) 1. A 29-year-old female with hip flexion and adduction deformity suffered from septic arthritis of the right hip at age of 1 year. X-ray showed the femoral head deformity and defect, serrated change of acetabular bone, and bending deformity of the proximal femur. 2. Surgical plan: Abduction and extension osteotomy on the right proximal femur and fixed with plate and external fixator. 3. Surgical procedures: A lateral incision on right proximal femur was made to cut the skin, subcutaneous tissue, deep fascia and tensor fascia, pull the lateral femoral muscle forward, and reveal the bone of proximal femur. Many holes were drilled below femoral lesser trochanter with an electric drill. The distal end of the osteotomy was abducted and extended to correct the deformities acutely. The hybrid external fixator and a plate were used to fix the osteotomy ends. Finally, the incision was sutured. 4. Tips and tricks: Attention should be paid to avoid the sciatic nerve injury during incision exposure and osteotomy.

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Fig. 10.35  A 29-year-old female with right hip deformity due to purulent infection of the hip joint at the age of 1. (a) Preoperative clinical appearance; (b) X-ray preoperatively; (c) Postoperative clinical appearance; (d) X-ray at 2 weeks postoperatively

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5. Postoperative management: At the 5th day after surgery, the patient could walk weight-bearing partially under double crutches. The external fixator was removed at 6  weeks postoperatively. The treatment was terminated when the patient could walk without any help at the 12th week postoperatively.

10.6.1.3 H  ip Dislocation and Stiffness at Adduction Position (Fig. 10.36) 1. A 30-year-old female with limping gait and left hip stiffness at adduction position due to purulent infection at the age of 10. X-ray radiographs showed that the acetabulum was small and shallow, the femoral head was enlarged and deformed, the femoral neck shaft angle was reduced, and the joint space was narrow. 2. Surgical plan: Femoral subtrochanter osteotomy was performed and fixed with Ilizarov external fixator. 3. Preoperative preparation: Ilizarov external fixation device and related instruments, double barrel drill sleeves, electric drill, narrow osteotome, etc. 4. Surgical procedures: A lateral incision about 10 cm of the thigh was made below the greater trochanter. The skin, fascia, tensor fascia was cut, and the muscle tissue separated with the hemostat to reach the femur. A row of holes of the femur was made with an electric drill. Ilizarov external fixator was applied with

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wires and half pins and the rings were connected by threaded rods after osteotomy. Finally, the incision was sutured. 5. Tips and tricks: The osteotomy plane should be determined under fluoroscopy. Attention should be paid to avoid the drill bit broken when predrill is performed for osteotomy. 6. Postoperative management: The patient can walk with crutches on the ground at 3–5 days postoperatively. The threaded rods of the external fixator were adjusted to correct the proximal varus and flexional deformities at the 7th day postoperatively. The external fixator should be fixed when the correction of the femoral deformity was satisfied. The patient was encouraged to walk with the fixator until bone healing.

10.6.2 Septic Sequelae of the Knee 10.6.2.1 S  evere Knee Flexion Deformity (Fig. 10.37) 1. A 23-year-old female with severe knee flexion deformity due to purulent infection at the age of 5. As improper treatment, the secondary hip and knee deformities occurred, which seriously affected walking in

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Fig. 10.36  The patient was a female of 30 years old, whose left hip joint with deformity had purulent infection at the age of 10. (a) Preoperative clinical appearance; (b) Full length standing AP view radiographs preoperatively; (c) Three-dimensional reconstruction CT

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of the pelvic; (d) Femoral subtrochanteric osteotomy was performed and fixed with Ilizarov fixator; (e) Postoperative clinical appearance; (f) Full length standing AP view radiographs at 17 months follow-up; (g) Appearance at the 32th month postoperatively

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Fig. 10.37  A 23–year-old female with severe knee flexion deformity due to septic sequelae: (a) Preoperative clinical appearance; (b) Full length standing AP view X-ray radiographs preoperatively; (c) X-ray of knee in lateral view preoperatively; (d) Clinical appearance at the 7th day after surgery; (e) AP and lateral X-ray at the 7th day postoperatively; (f) Most of the knee deformity was corrected at the 84th day postoperatively; (g) The fixation was simplified; (h) Full length stand-

ing AP view X-ray radiographs at the 7th month postoperatively; (i) Second-stage operation for biplane lengthening of the knee joint and below tibial tuberosity; (j) The lower limbs were in equal lengths at the 23th month after the second surgery; (k) The external fixator was removed and protected with a brace 3 years after the first surgery; (l) Full length standing AP view X-ray radiographs after fixator removal

jumping gait. X-ray films showed that knee joint was fused in extremely flexion position.

2. Surgical plan: It was staged surgery, in which knee joint osteotomy was done and applied with Ilizarov method first of all.

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3. Preoperative preparation: Sharp osteotome in different widths, Ilizarov external fixators, and related instruments. 4. Tips and tricks: The neurovascular posterior tibial should be protected when osteotomy is performed. The close wedge osteotomy on anterior side of the knee is done as large as possible, so that the knee deformity can be corrected to at least 90° during operation. 5. Surgical procedure at the first stage: The fused knee joint was exposed with a longitudinal incision anterior of the knee joint. The close wedge osteotomy was performed with an osteotome. Then the contralateral osteotomy ends were pressed to correct knee deformity partially. The incision was sutured and the Ilizarov fixator was applied with wires and pins. 6. Postoperative management: The knee deformity was corrected at the speed of 3–5 mm/day from the 5th day after surgery. The speed was slowed down while the soft tissues were tight, which depends on whether the patient could tolerate the pain or not. The knee deformity was corrected with slow distraction for 3 months, and then the fixation was simplified until removed at 7  months postoperatively. 7. Surgical plan for the second stage: Limb lengthening with Ilizarov technique at two levels of the knee joint and the proximal tibia. 8. Preoperative preparation: The Ilizarov frame was provided. This configuration was designed as a biplane structure for two level lengthening. Others included double barrel drill sleeves, a narrow osteotome, and so on.

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9. Surgical procedure: Common peroneal nerve was protected when performing the proximal fibula osteotomy. The tibia was drilled with an electric drill and then cut with a narrow osteotome. Finally, Ilizarov external fixation device was mounted. 10. Tips and tricks: The callus in the site of knee osteotomy could still be distracted. Common peroneal nerve should be carefully protected to avoid injury. 11. Postoperative management: The distraction was started from the 7th day postoperatively at the speed of 2/3 mm/ day in knee joint plane and 1 mm/day in tibial tuberosity plane. The lower limbs were equal in length after 14 cm left limb lengthening. The patient walked with double crutches during the distraction process.

10.6.2.2 S  evere Compound Deformity of the Knee (Fig. 10.38) 1. A 16-year-old male with severe complex knee deformity due to septic sequelae in infant. X-ray showed knee joint subluxation and proximal tibial varus deformity, proximal fibula dislocation with recurvatum deformity. 2. Surgical plan: Proximal tibial and fibula osteotomies, and fixed with Taylor Spatial Frame. 3. Preoperative preparation: Taylor Spatial Frame, electric drill, osteotome, etc. 4. Surgical procedure: With the proximal lateral incision of fibula, the common peroneal nerve was exposed and separated. Fibula osteotomy was performed and then incision was sutured. Tibia osteotomy was performed with the

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Fig. 10.38  A 16-year-old male with severe complex right knee deformity caused by infantile suppurative arthritis. (a) Preoperative clinical appearance. (b) X-ray AP and lateral view of the right knee preoperatively. (c) Three-dimensional CT reconstruction. (d) Deformity correc-

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tion with Taylor SF. (e) X-ray AP and lateral radiographs postoperatively. (f) The deformity was significantly corrected at 23 months follow-up, but there was still a residual short deformity on the calf. (g) X-ray AP and lateral radiographs at 23 months postoperatively

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mini incision below tibial tuberosity, and Taylor SF was mounted with wires and pins. 5. Tips and tricks: Attention should be paid to protect the common peroneal nerve during the fibula osteotomy. The Taylor SF is fixed across the knee joint for tibiofibular deformity correction and the knee joint distraction. 6. Postoperative management: The Taylor SF was adjusted according to the program or prescription from the 5th day after surgery. The crutches were loaded with ­weight-­bearing walking during the distraction period. The external fixator was removed when bone healing. a

1. A 31-year-old male with distal tibia valgus deformity suffered from osteomyelitis at the age of 4. AP and lateral X-ray radiograph on admission showed the fibula absence with ankle tilt. 2. Surgical plan: Wedge-shaped osteotomy was performed at the distal tibia and fixed with an Ilizarov external fixator. 3. Preoperative preparation: Ilizarov external fixator, sharp osteotome, electric drill, etc.

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10.6.3 Septic Sequelae of the Knee (Fig. 10.39)

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Fig. 10.39  A 31-year-old male with ankle valgus deformity caused by juvenile osteomyelitis. (a) Preoperative clinical appearance; (b) AP and lateral X-ray radiographs preoperatively; (c) Distal fibula osteotomy; (d) Distal tibial osteotomy; (e) A wedge-shaped bone block; (f) The valgus deformity was corrected partially and fixed with K-wires; (g)

Installation of the Ilizarov frame; (h) Further correction for residual valgus deformity form 8  days after surgery; (i) AP and lateral radiographs at the 8th day after surgery; (j) The external fixator was removed at 4 months postoperatively, and AFO was applied

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4. Surgical procedure: With the distal incision above lateral malleolus, the distal fibula was revealed and osteotomized. The anterior medial longitudinal incision on the distal tibia was made and the corresponding area of distal tibia was removed. The osteotomy ends were connected with the valgus deformity partially corrected, and then fixed with an Ilizarov external fixator through wires and pins. The incision was sutured. 5. Tips and tricks: The tibial osteotomy line should be parallel to the ankle joint as much as possible. When osteotomized, care should be taken to protect the posterior tibial neurovascular. 6 . Postoperative management: At the 5th day postoperatively, the crutches were used to carry weight-bearing walking. The external fixator was adjusted to correct the residual deformity after 7  days. The external fixator was fixed when deformity was corrected completely, and was removed when the bone healed, and then ankle foot orthosis should be worn for 3 months.

10.7 L  ower Extremity Deformities with Extensive Skin Scar Contracture Jiancheng Zang and Sihe Qin

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Soft tissue scars caused by skin and soft tissue infections and trauma (including burns) will gradually contract during repair and reconstruction. As the tissue elasticity is poor, it often causes stiff bone and joint deformities. Moreover, these scar tissues have poor blood supply. If they were peeled off extensively, scar skin necrosis is liable to occur. Therefore, the scar tissue should not be peeled off and kept the connection to the tendon or other tissues under it. Ilizarov technology can improve the blood supply of scar tissue during tissue distraction and transform it into normal skin. Some cases suffered from lower limb deformities with scar show as follows.

10.7.1 Hip Deformity Caused by Scar Contracture (Fig. 10.40) 1. A 24-year-old female was injected in the left buttock at the age of 10. Unfortunately, infection occurred. After debridement, scars were formed and caused hip deformity. At the age of 10, her left hip activity had been limited. Hip abduction deformity, pelvic tilt, and limping aggravated gradually. X-ray radiographs showed the left iliac dysplasia and normal hip structure. 2. Surgical plan: The scars on the left hip should have Z-shaped release and be fixed with an external fixator. 3. Preoperative preparation: Electric drill, external fixator.

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Fig. 10.40  The patient, a 24-year-old female, suffered from hip abduction deformity caused by left hip scar: (a) Appearance preoperative; (b) Local appearance of the buttocks; (c) Full length standing AP view radiographs preoperative showed pelvic tilting to the left down; (d) Appearance at 13 days after surgery; (e) Appearance at 27 days after

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surgery; (f) Full length standing AP view radiographs at 27 days postoperative, pelvic tilt was corrected; (g) Appearance at 5  months and 20  days after surgery; (h) Full length standing AP view radiographs postoperative at 5  months and 20  days, pelvic tilt was corrected completely

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4. Surgical procedure: An incision along the line of skin scar was made to loosen the subcutaneous scar tissue until to the iliac bone, and separate the adhesion between the scar tissue and the normal tissue. A Z-shaped incision at the distal end of the incision was made to cut the flap. It was staggered and sutured, and the drainage tube was placed inside the incision. The hip joint was fixed by a hybrid external fixator with pins setting on the proximal femur and the iliac bone at an abduction position for relaxing the skin incision. 5. Tips and tricks: After admission, surgery should be performed on the patient for scars release and an external fixator which is gradually adjusted to an internal rotation position of the hip joint should be fixed, so that the normal skin can repair the scar tissue until the hip abduction deformity is corrected. Then, the hip is kept fixed for 6 weeks. During the fixed period, the external fixator is intermittently loosened for functional exercise of the hip joint. At 5 days after the operation, the patient can walk under the assisting device.

10.7.2 Knee Deformity Caused by Thigh Scar Contracture (Fig. 10.41) A patient, male, 41 years old, suffered from knee recurvation deformity. In his right thigh, anterior soft tissue was infected at the age of 3, and scars were formed resulting in recurvation contracture of the right knee joint. The patient showed a limping gait on admission, extensive scars on the front of the thigh, the quadriceps atrophy, knee flexion, and extension activity between 40° (extension) and 10° (flexion); the motion ranges of hip and ankle joints were normal. After the operation of quadriceps release, the maximal flexion could only reach 0° due to the large skin tightness, and–then the Ilizarov knee joint frame was installed to distract gradually from the 7th day after surgery. After 200 days of slow distraction, the knee flexion of the patient reached about 95°. After 20 days of fixation, the exercise of flexion and extension was started, and the leg was still fixed at maximal flexion position after the exercise. The external fixator was removed after 1 month’s exercise. Exercise was continued every day with a CPM machine. At 19 months follow-up, the range of motion of the knee was 0°–70°; his walking function was restored to normal.

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10.7.3 Ankle and Foot Deformity Caused by Calf Scar Contracture (Fig. 10.42) A 14-year-old male suffered from a clubfoot deformity with scar contracture. A large area of soft tissue injury in the left lower extremity was caused by a car accident 2 years ago. The wound was repaired by a skin graft and finally healed. Unfortunately, there was almost scar tissue from the upper middle part of the thigh to the distal end of calf. Secondary clubfoot deformity developed from bad to worse, affecting walking function. At the time of hospitalization, the left clubfoot deformity reached a degree of Dimeglio III with severe limping. The operation of subcutaneous Achilles tendon lengthening was performed and fixed with an Ilizarov frame. At the 5th day after surgery, the clubfoot deformity was corrected and the ankle joint was distracted firstly. After the deformity was corrected, the external fixator was removed after 6 weeks of fixation, and the ankle foot brace was assembled intermittently for 3 months to prevent deformity recurrence and get better function.

10.8 F  oot and Ankle Deformity Caused by Ischemic Muscle Contracture Jiancheng Zang and Sihe Qin

10.8.1 Introduction Ischemic muscle contracture (also known as Volkmann contracture). Irritable muscle contracture of the lower leg is common in cases such as tibia and fibula fractures, vascular injury, severe soft tissue contusion, casting or small splint to fix the fractures, and so on. In recent years, it is common in the complication of internal fixation for tibial fracture. Soft tissue ischemia, hypoxia, edema, and pressure rise in the calffascia usually form Osteofascial Compartment Syndrome (OCS). With improper treatment at the early stage, ischemic necrosis of the calf muscles and neurological dysfunction will occur. Later, ischemic muscle contracture, muscle fibrosis, local access to lumps, and fixed deformity and function obstacle of the ankle joint usually caused by muscle contracture. Because the soleus muscle, the posterior tibial muscle, the flexor digitorum muscle and the flexor digitorum longus muscle in the posterior fascia of the calf are surrounded by a

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Fig. 10.41  A 41-year-old male suffered from genu recurvatum contracture caused by the soft tissue scar on the anterior thigh. (a) Appearance preoperative; (b) The patient could not bend his right knee completely; (c) Passive recurvation of the knee joint reached up to 45°; (d) X-ray lateral view preoperative showed knee recurvation deformity of 22°. CT scan showed that the knee joint space was normal; (e) The longitudinal incision on the middle and distal thigh was made. The operation showed the quadriceps muscle was replaced by fiber scar tissue. (f) The knee joint could only reach 0° position after scar tissue was fully released; (g) Ilizarov knee joint frame was mounted after the incision was sutured; (h) AP and lateral radiographs at the 20th day after

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surgery showed that knee flexion was about 10°; (i) On the 40th day after surgery, knee flexion reached up to 20°; (j) AP and lateral radiographs at the 40th day after surgery showed knee flexion was about 20°; (k) Knee flexion was about 45° on the 76th day after surgery. (l) X-ray radiographs at postoperative 76 days; (m) The knee flexion was about 95° on the 200th day after surgery; (n) AP and lateral radiographs at the 200th day after surgery; (o) The patient took the device to exercise on the 220th day after surgery; (p) The active flexion and extension range of the knee joint is 0–70° after 19 months postoperatively. (q) The muscle strength for knee extension reached Grade 4 at 19  months follow-up

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dense, inelastic connective tissue fascia, and located in the deep layer, it is not easy to find early after OSC. The degree of muscle necrosis and contracture is often heavier, and it is easy to form equinus, talipes equinovarus, and claw toe deformity. At the late stage of OSC, pathological changes and ischemic lesions increase edema of joint, joint capsule, ligament, fascia, and necrotic muscles, all of which develop extensive contracture, and the ankle joint becomes stiff and deformed. The combination of Qinsihe surgical method with Ilizarov technology can obtain satisfactory results.

10.8.2 Type of Foot and Ankle Deformities and Clinical Manifestations Common types of foot and ankle deformities are rigid clubfoot and equinocavus deformity. It is usually combined with different degrees of claw-foot deformity and aponeurosis contracture. Due to the early implementation of decompression, the scar is often located around incision. In severe ischemic contracture, the blood vessels, nerves, joint capsules, and ligaments of the affected limbs have different degrees of pathological changes. The nerve fibers accompanying the muscles are also denatured to varying degrees due to ischemia and hypoxia. Later, the nerves and blood vessels are compressed by the scar tissue, the blood circulation and neurotrophic conditions of the affected foot are poor, the subcutaneous fat is thinned, and the elasticity of skin is reduced, and the weight-bearing area is prone to skin ulcers that are not easy to heal. X-ray photographs show the patient who suffered severe ischemic muscle contracture and with long-term disease period have the narrow space of the ankle joint, soft tissue calcification, and disused osteoporosis.

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The spacing movement increases tension on the soft tissue posteriorly resulting in tissue regeneration and thereby slowly and continuously correcting the foot deformity. The severe contracture of posterior tibial muscle and the flexor digitorum longus muscles should be corrected at the same time. If there is hammer toe deformity, the toe joint fusion can be performed simultaneously during the operation. The Achilles tendon do not need to suture. As the posterior ankle joint capsule is not released, the foot deformity can be corrected only partially. The skin and subcutaneous tissue is sutured together in one layer, and then the Ilizarov external fixator is applied with wires and pins.

10.8.5 The Step for External Fixator Application and Avoiding Surgical Risk According to the degree and type of foot deformity, the circumference of the calf and the size of the foot, the individualized fixator with three-dimensional adjustable function should be assembled (Fig.  10.43). Also, the corresponding 2–2.5  mm  K-wires, fixing clamp, nut, wrench, and other installation instruments should be prepared at the same time. An epidural anesthesia is used for surgery. For Z lengthening of Achilles tendon, tibialis posterior, and the long flexor tendons, a longitudinal incision between the medial border of tibia and the Achilles ten-

10.8.3 Surgical Treatment Principles and Classic Surgical Methods The classical orthopedic surgeries, such as Achilles tendon lengthening and medial soft tissue release, can not give an effective correction. The damage due to skin incision and soft tissue release is extensive, which increases the degree of scar contracture and compromise the vascularity of foot. The triple joint osteotomy by removing a large wedge of bone can cause the foot to shrink. Further more, it can increase the stiffness of ankle joint.

10.8.4 The Advantages and Principle of Ilizarov Technology Because same three-dimensional structure between the ankle joint, and the Ilizarov frame and they are connected with cross-­wires. So, the frame is adjusted by the push-pull device in anterior, posterior, medial, and lateral in three dimensions.

Fig. 10.43  The configuration of external fixator and the wires position for foot and ankle deformity correction

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don is made. The contracture of plantar fascia is released subcutaneously. If the deformity of clubfoot cannot be corrected effectively after lengthening of these tendons, it indicates that extensive contracture also occurred in the joint capsule and its surrounding area. The Ilizarov fixator should be applied in this situation to correct residual deformity. If the patient with rigid clubfoot deformity and obvious skeletal changes, limited osteotomy and partial correction of varus deformity should be performed during operation. Fixing the osteotomy with two or three 2.0 mm K-wires temporarily will make it convenient to apply the Ilizarov frame. It will also avoid the movement at the osteotomy site during distraction process. The application method should follow the principle of Ilizarov technique. The prepared frame is placed over the lower leg and foot. The two rings are fixed to the tibia by the 2 mm wire, and then hinge is aligned with ankle joint center of motion. Fix the half rings on calcaneus and forefoot and connect the forefoot and tibia rings with a spring-loaded rod. All the deformities including equinovarus and adduction can be correct by this three-dimensional device simultaneously. During the operation, the deformity can be corrected partially by stretching medial soft tissues.

4 weeks. After 4 weeks, the fixator can be removed and an ankle foot orthosis can be used for 12 weeks.

10.8.6 Postoperative Management and Prevention of Complications

Case 2 The woman was 41 years old with right rigid clubfoot caused by ischemic muscle contracture suffered from popliteal fossa vessels injury during knee arthroscopic surgery. Achilles tendon lengthening and tibialis posterior muscle lengthening were performed, and Ilizarov external fixator was mounted during the operation. The right clubfoot deformity was corrected gradually after surgery. Follow-up at 4  years and 7  months showed that the foot deformity was completely corrected and with good function (Fig. 10.45).

The threaded rods can be slowly adjusted to correct residual deformities from the 5th to 7th day after surgery. The abduction and varus deformity of the foot can be corrected by adjusting medial and lateral rods. The threaded rods with spring on the calcaneus can produce a continuous pushing and pulling force on the calcaneus; similarly, the spring rod in front of leg can produce a continuous pulling force over ankle joint, thereby gradually correcting equinus foot deformity. In clubfoot, the order of correction should be adduction, varus, and then equinus deformity. The speed of distraction should be determined by the tension of local skin and the condition of neurovascular structures. Attention should be paid to the sensation and vascularity of the toes in the process of distraction. The initial distraction can be faster, and then middle and late stage should be slowed down. In the process of gradually correcting the foot deformity, patient should be encouraged to walk with appropriate weight-bearing. X-ray should be done regularly to monitor the deformity correction and to prevent displacement of the ankle joint. When the deformity is corrected satisfactorily, the patient can walk full weight-bearing with fixator for

10.8.7 Typical Cases Case 1 A 31-year-old female, with stiff clubfoot deformity due to open injury of the right lower leg combined with popliteal artery injury 3 years ago. She was managed by open reduction and internal fixation of distal tibia with plate and screw. Due to long ischemic time, some of the calf muscles were already necrotic before the artery was repaired in emergency. After debridement and decompression of the calf muscles, the equinovarus deformity appeared gradually, and with time the deformity aggravated and stiffness increased. The right tibialis posterior and the Achilles tendon were lengthened during surgery. The deformity was corrected partially. Then the Ilizarov fixator was applied for further distraction. The distraction was started on the 7th day after surgery. All deformities were corrected satisfactorily by 28 days after surgery. After keeping the fixator for 1 month, it was removed and ankle foot orthosis was given for another 3 months (Fig. 10.44).

10.9 D  evelopmental Deformities of Lower Extremity Caused by Physeal Injury Shaofeng Jiao, Qi Pan, Jiancheng Zang and Sihe Qin Physeal injuries include the lesions around the growth plate and epiphysis, often associated with trauma, infection, or insufficient blood supply. About 15% of fractures in children involve physeal injury, with boys being more common, as physis closes later in boys. Few physeal injuries can cause early closure of the growth plate, leading to skeletal growth disorders and limb deformities. The bacterial infections and other diseases can also cause physeal destruction.

10  Traumatic Sequelae of Lower Limb Fig. 10.44  Treatment of equinovarus deformity secondary to ischemic contracture: (a) Appearance preoperative; (b) X-ray photographs preoperative; (c) Appearance during treatment; (d) Appearance at the end of treatment

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10.9.1 The Mechanism of Lower Limb Deformity After Physeal Injury The physeal plate in the growing and developing children is unique, which is different from the adult mature bone. It is also the weak area of the bone and is prone to damage. Compression injuries damage the proliferating cells in the proximal side of the physis and the cells in the germinal layer, thereby inhibiting the growth of long bones. If the physis is only partially damaged, the development of the injured area stops, and the healthy part continues to grow, and the bone is deformed. The younger the child, the more obvious the deformities are, and even the longitudinal growth discrepancy. The limb is shortened and varus or valgus deformities occur. For example, in the patient whose ankle joint is severely damaged, the medial physis of the distal tibia is injured, and the chondrocytes on medial side stop growing, the lateral part of tibia and fibula continues to grow, finally resulting in a progressive ankle varus deformity. About 25–30% of the lesions in the physis cause growth disorders, and about 5–10% cause deformity. If the cartilage damage is mild, or only the blood supply is insufficient, the cartilage proliferative ability is reduced, and the growth is slowed down. If the damage is severe, cartilage proliferation stops, and the epiphysis closes early. When the local physis fusion is small and located in the center of the physeal plate, the production of the bone bridge

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is obviously small compared with the symmetrical growth potential of the surrounding normal cartilage. Under the strong growth of the surrounding chondrocytes, the trabecular bone of the fusion site of the physis can be thinned, broken, and atrophied finally, so that no deformity occurs. Conversely, if local epiphysis fusion is large and the growth potential of the surrounding chondrocytes cannot overcome its restrictive force, a deformity will occur.

10.9.2 Clinical Examination and Imaging of Limb Deformity Caused by Physeal Injury Patients with physeal injuries need to be followed closely for 2 years. The late physeal closure can occur after 2 years, so follow-up should be continued until the skeletal maturity. If there is a suspected growth arrest in the X-ray examination, further diagnostic examination should be done. On the X-ray film, pay attention to the presence or absence of a bone bridge in the physeal plate, and check whether there is a Park-Harris growth barrier line, which can help to determine whether the asymmetric growth arrest occurred prematurely. 1. Knee joint deformity Distal femoral and/or proximal tibia injuries can cause knee deformities. When the growth disorder is caused by

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Fig. 10.45  Ilizarov technique combined with limited surgery for clubfoot deformity caused by ischemic muscle contracture. (a–c) Clinical appearance, clubfoot deformity right side, front view and back view; (d) Preoperative X-ray; (e) X-ray was made 5  days after surgery; (f) Clinical appearance 5  days after surgery; (g–h) The right clubfoot deformity was corrected on the 19th day after surgery; (i) X-ray on the

27th day after surgery. (j–l) At 40 days after surgery, the correction of right clubfoot deformity was completed. (m) The external fixator was removed 57 days after surgery and orthopedic brace was worn for ankle and foot for after operation. (n–p) At 4 years and 7 months follow-up, she could walk with full weight-bearing. (q) X-ray at 4  years and 7 months postoperatively

10  Traumatic Sequelae of Lower Limb Fig. 10.46  Genu varum deformity caused by medial epiphyseal injury: (a) Medial physeal injury of the distal femur; (b) Medial physeal injury of the proximal tibia

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medial physis damage, varus deformity occurs (Fig. 10.46); when the growth disorder results from lateral physeal injury, the result will be valgus deformity (Fig.  10.47). The anterior part injury can cause knee recurvatum deformity; the posterior injury can cause knee flexion deformity; the complete damage of the growth plate can lead to limb shortening (Fig. 10.48). 2. Ankle joint deformity The distal tibia physeal injury mainly causes deformity of ankle joint. Different injured site shows different deformity. Varus and valgus deformity are the most common (Fig. 10.49).

10.9.3 Surgical Treatment of Physeal Injury, Limb Shortening, and Deformity When the area of the closed physeal plate is larger than half of the whole physeal width, the physeal plate should be fused to prevent further aggravation of the deformity, and the deformity can be corrected by osteotomy simultaneously. If the limb shortening is greater than 2  cm, the limb lengthening will be required for limb length discrepancy. The limb deformity and shortening should only be treated by osteotomy and limb lengthening either after maturity or after growth arrest.

Fig. 10.47  Genu valgum deformity caused by lateral physeal injury of the distal femur

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10.9.4 Typical Cases

Fig. 10.49  Right ankle varus deformity caused by distal tibia physeal injury

1. This patient was a 12-year-old male, who sustained injury in a road traffic accident at the age of 8. The physis of left distal femur was damaged due to which the varus knee deformity gradually appeared and increased with time. On examination, right genu varum and shortening was found. The range of knee flexion and extension was normal; X-ray showed varus deformity of the right distal femur, about four-fifth of the distal femoral physis was closed (Fig. 10.50). (a) Goals of treatment: Correcting the distal varus deformity of the femur, to prevent the recurrence of deformity; femur lengthening to equalize the length of both lower extremities.

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(b) Surgical plan: Osteotomy of the distal femoral, fixation with Ilizarov fixator. (c) Preoperative preparation: Electric drill, osteotome, double barrel drill sleeves, Ilizarov external fixator. (d) Surgical procedure: A small incision of 1 cm length was given on supracondylar area of femur. Then a row of bone holes was drilled with the help of a double barrel drill sleeves. An Ilizarov external fixator was then applied, osteotomy was completed with an osteotome and then the incision was closed in layers. (e) Postoperative management: The patient was encouraged to start walking with crutches on the 5th day after surgery. From the 7th day, the fixator was adjusted to correct the femoral deformities. Once the

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deformity was corrected, the external fixator was fixed until the bone healing occurs and then it was removed. 2. This patient was a 45-year-old male, who sustained injury to proximal tibial physis during childhood. He developed a genu varum deformity on left side which gradually progressed during his growth. Physical examination: severe varus deformity of the left knee, scar on the anterior left leg, normal movement of knee joint; X-ray showed varus deformity of left proximal tibia, and partial defect of medial tibial condylar (Fig. 10.51). (a) Goals of treatment: Correcting genu varum deformity to restore the lower extremity mechanical axis, tibia lengthening to equalize the length of both lower extremities.

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Fig. 10.50  Genu varum deformity caused by distal femoral physeal injury: (a) Preoperative clinical appearance; (b) AP and lateral radiographs show more than three-fourth of physeal closure of the distal femur; (c) Supracondylar osteotomy of femur and Ilizarov fixator appli-

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cation; (d) Postoperative AP and lateral radiographs; (e) At the 50th day after surgery, right knee varus deformity and femur shorting were corrected; (f) 8 months after surgery, external fixator was removed

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(b) Surgical plan: Osteotomy below the tibial tuberosity, osteotomy below the left fibular head, fixation with Ilizarov external fixator. (c) Preoperative preparation: Electric drill, osteotome, Ilizarov external fixator. (d) Surgical procedure: A longitudinal incision was given on lateral side of left fibula. The common peroneal nerve was exposed and protected. Then osteotomy was made at the junction of the head and neck of fibula, and a small wedge of bone was removed, and incision was sutured. Proximal tibia was exposed with anteromedial incision of 1 cm below tibial tuberosity. Drilling was done with an electric drill, and then bone was cut with an osteotome. The deformity was corrected partially by manipulating the osteotomy site. Temporary fixation of the ends was done with crossed-K-wires, and then

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Ilizarov fixator was applied and incision was closed. Finally, the knee was spanned by extending the external fixation frame on distal femur across the knee joint. (e) Tips and tricks: It is more important to protect the common peroneal nerve while doing osteotomy; pay attention to avoid damage to the scar and the skin flap when tibial osteotomy incision is given. (f) Postoperative management: The patient was walking with partial weight-bearing assisted by crutches from 5 days after surgery. At the 7th day after surgery, the external fixator was adjusted to correct knee varus deformity; the femoral part of external fixator was removed after deformity was corrected completely. The number of fixation pins was gradually reduced according to the callus formation; the frame was removed after bone healing on the basis of the regular check X-rays.

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Fig. 10.51  Genu varum deformity caused by proximal tibial physeal injury: (a) Preoperative clinical appearance; (b) Preoperative X-rays; (c) Fibular osteotomy; (d) Tibial osteotomy; (e) Application of Ilizarov external fixator; (f) X-rays after surgery; (g) Postoperative clinical

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appearance; (h) Correction of deformity at the 6th month after surgery; (i) Removal of few wires to simplify the external fixator; (j) After removing the external fixator, a long leg brace for 3 months

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Fig. 10.52  Ankle varus deformity caused by distal tibia physeal injury: (a) Preoperative clinical appearance; (b) Preoperative X-ray; (c) Fibular osteotomy; (d) Drilling in the tibia for osteotomy; (e) Application of Ilizarov External fixator; (f) Postoperative clinical appearance; (g)

Ankle varus deformity has been corrected; (h) External fixator has been removed, ankle foot brace was given; (i) X-ray after removal of external fixator

3. A 26-year-old female patient suffered from medial physeal injury of right distal tibia due to road traffic accident, and gradually developed limb shortening and ankle varus deformity. She had undergone tibial lengthening in a local hospital 5 years ago; Physical examination: Varus deformity of right ankle, skin scars visible over the medial malleolus, normal ankle joint movement. X-ray showed the medial and anterior tilt of right ankle joint (Fig. 10.52). (a) Goals of treatment: Correcting the ankle varus deformity and restoring the normal mechanical axis. The method of supramalleolar osteotomy in combination with Ilizarov technique for ankle deformity is simple, effective, and minimally invasive, which is recommended as the preferred treatment. (b) Surgical plan: Supramalleolar osteotomy and Ilizarov technique. (c) Preoperative preparation: Electric drill, osteotome, double barrel drill sleeve, Ilizarov external fixator, and so on. (d) Surgical procedure: The fibula was exposed with a small incision on the lateral malleolus. Bone was drilled and cut with an osteotome.

(e) Then a small incision was made above the medial malleolus. After the tibia was exposed, a row of holes was drilled in the tibia with the help of double barrel drill sleeve. Then, the Ilizarov external fixator was applied, and the tibia was cut with an osteotome and the incision was sutured. (f) Tips and tricks: Because the CORA is located at the level of ankle joint, the osteotomy plane should be as close as possible to the articular surface, but leaving a space for external fixation. Because the distal part of osteotomy is short, the stability of single plane fixation is not enough, so the calcaneal pins should be fixed across the ankle joint to increase the stability. The joint hinge should be placed at the level of the ankle joint. (g) Postoperative management: The patient was walking with partial weight-bearing assisted by crutches from the 5th day after surgery. At the 7th day after surgery, the external fixator was adjusted to correct ankle varus deformity. When the deformity was corrected satisfactorily, the fixator was fixed until bone healing. The external fixator was then removed and orthopedic brace was given for 3 months.

Lower Limb Deformity Caused by Spina Bifida Sequelae and Tethered Cord Syndrome

11

Jiancheng Zang, Sihe Qin, and Lei Shi

11.1 Introduction Spinal bifida is a posterior spinal canal defect caused by the developmental disorder of the ossification center of the posterior spinal arch during embryonic development. The patient presents with the swelling at the back due to herniation of spinal canal contents. The appearance of the hair or cystic bulge is often seen at the corresponding part (Fig.  11.1), which is called cystic spina bifida (or dominant spina bifida). Those without bulging of contents are called invisible spina bifida. The causes may be due to having fever during pregnancy and deficiency of folic acid in early pregnancy. Some scholars have reported that they may be related to genetic factors. According to Qinsihe orthopedic database, more than 90% of the spina bifida occurred in the lumbosacral region as it is a pivot joint and a weak part during body development which plays an important role in that the four-legged walking animal is evolved into a human being with two legs, walking upright. Dominant (cystic) spina bifida is discovered by family members shortly after the birth, whereas ankle deformities and sensory disorders secondary to recessive spina bifida are often not noticed by children or their families before the appearance of clinical symptoms. After the occurrence of foot deformities, the patients generally go to the orthopedic clinics. Due to the barriers of the specialties, some young orthopedic doctors lack the awareness of the overall diagnosis and treatment of this disease. They cannot know the importance of imaging examination of lumbosacral region which results in a considerable

J. Zang · S. Qin (*) · L. Shi Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China

number of patients being missed diagnosis, being misdiagnosed, and being missed the right orthopedic treatment which can otherwise be implemented in time, resulting in the development of deformities to a serious extent. Due to the possible compression or involvement of the spinal cord and nerve roots in the spinal canal corresponding to the spina bifida (scar, lipoma, etc.), the conus and the terminal filament of the spinal cord are adhered to the surrounding tissues. As a result, the spinal cord and nerve of the adhesion site during the development of the spine cannot synchronously shift, which causes traction injury, and then denervation. Some patients may have undergone meningocele repair. Nerve and dura mater have different degrees of postoperative scar adhesion. Sometimes iatrogenic injury cannot be ruled out. The adhesion or thickening of the spinal cord causes the tethered cord. As the patient grows, the cauda equina is gradually distracted and chronically injured, resulting in different grades of paralysis of the lower limbs, joint contracture, and imbalance of muscle strength, which in turn cause the disorders and deformities of hip, knee, foot, and ankle joints in accordance with the patient’s age (Fig. 11.2). The numbness of the skin in different parts can also cause the formation of ulcers and hemorrhoids, and the neuropathy of the anorectal nerves can cause dysfunction of the recto urinary system. The deformities of lower extremities of spina bifida sequelae are caused by imbalance of muscle strength that results from denervation. If the patient who suffered from this disease can be diagnosed by the doctors in time, his or her function can be improved and recovered only by simple orthopedic surgery. On the contrary, there will be a rapid progress, even causing some deformities in knee or hip joints, limb alignment abnormalities and other serious consequences such as joint contracture and lower limb length discrepancy. Therefore, early diagnosis and treatment are the only effective method to prevent and delay the deformity development of spina bifida sequelae (Fig. 11.3).

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_11

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Fig. 11.1  Clinical appearance. (a) Lumbosacral bulge, (b) Lumbosacral hair, (c) X-ray shows insufficiency of the lumbar laminectomy, (d) Local bulge and hair growth in the thoracolumbar spine

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Fig. 11.2  Diagram for the mechanism of spina bifida sequelae

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Fig. 11.3  The flow chart for deformity development of spina bifida sequelae

Traction injury of lumbosacral nerve

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11.2 T  he Relationship Between Spinal Lamina Defect and Clinical Manifestations

check clinical symptoms by subtle physical examinations and indicators found in imaging examinations.

During the process of spinal growth and evolution, the human spine is divided into segments and exhibits an “S”-shaped physiological curvature. The sensory distribution of the ganglion is strip-like. Different segments of the spinal cord belong to different functional divisions (Fig. 11.4). The clinical symptoms are compatible with the anatomically functional division of the spinal nerves (Fig.  11.5). In the clinics, we can infer the location of spina bifida through clinical symptoms, and also can

11.3 C  haracteristics of Lower Limb Deformities of Spinal Bifida Sequela Due to the different levels and different degrees of damaged spinal nerves, the deformities are complicated and diverse. The main features are as follows: 1. The child has no foot deformity at birth, gradually develops lower limb deformities at the peak of growth, especially the deformity of ankle, which is related to the

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spinal lesion in the lumbosacral region. Their parents usually find gait abnormalities when they are learning to walk. 2. Foot and ankle deformities are accompanied by different degrees of sensory disturbance, such as in the mild situation, only a small hypoesthesia area on the foot, and in the severe situation, the missing sensation of the entire foot depending on the damage of cauda equina. There is a ­certain correlation between dyskinesia and sensory disturbance, which often coexists (Fig. 11.6). 3. Some patients had ulcers on the foot weight area. The patients with good sensory function often showed spasm, localized soft tissue keratinization thickening in the weight-bearing area. Those with poor sensory function are often accompanied by ulcers in the weight-bearing area. The mild ones only have superficial soft tissue ulceration. In severe cases, the ulceration affects the fascia layer and even reaches the bones. The ulcers will not heal for a long time, forming osteomyelitis, bone discharge, and local malodor (Fig. 11.7).

4. Knee and hip deformities can still occur, commonly showing knee flexion deformity and hip dislocation. Therefore, the patients with spina bifida with foot and ankle deformity should be routinely examined for their hip and knee joints, especially hip joints. Taking a pelvic plain film can not only understand the vertebral lamina regurgitation of the spina bifida, but also understand the coverage of the hip joint. 5. The lumbosacral spina bifida often shows peripheral paralysis, and different spinal nerve involvement can weak the corresponding muscle. There are many kinds of deformities in the foot and ankle joints. The talipes equinovarus is caused by the paralysis of some nerve fibers in the superficial peroneal nerve that involved the peroneus longus and peroneus brevis muscles and Achilles tendon contracture. The talipes equine valgus is due to the fact that deep peroneal nerve and partial tibial nerve of L4~S1 are involved. Muscle spasm can be seen in the thoracolumbar spina bifida (Fig. 11.8), and the symptoms are manifested as damage of the upper motor neuron.

11  Lower Limb Deformity Caused by Spina Bifida Sequelae and Tethered Cord Syndrome Fig. 11.5  Different parts of spina bifida or tethered lesions can cause different types of lower extremity deformities. The function of the T10 is to mainly maintain upper body siting up from supination position, and T12 to maintain sitting position, L2 for lower extremity adduction, L3 for knee extension, L4 for ankle joint dorsiflexion and knee flexion, L5 for hip abduction, and S1 mainly for genitourinary system

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11.4 Clinical Manifestations and Classifications Lower limb deformity of spina bifida is closely related to the injured spinal cord plane. Different location and extent of spinal cord injury correspond to different deformities. This session mainly describes different types of foot and ankle deformities. 1. Talipes equinovarus deformity: Achilles tendon, posterior tibial muscle and plantar aponeurosis contracture, the muscle force for dorsal expansion and eversion was weakened or paralyzed (Fig. 11.9). 2. Talipes equine valgus deformity: contracture of Achilles Fig. 11.6  Foot and ankle deformities with sensory disturbance, point-­ tendon, paralysis of anterior and posterior tibia tendons like area suggesting a hyposensitivity zone with the normal strengths of peroneus longus and peroneus brevis muscles (Fig. 11.10).

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Fig. 11.7  The ulcer in the weight-bearing area of the foot

Fig. 11.8  The case of thoracic spina bifida, a cystic uplift on his back, and foot deformity is spastic

Fig. 11.9  Talipes equinovarus deformity

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3. Clubfoot backward deformity: the clubfoot backward deformity was named by Qinsihe. It is the type of extreme flexion of the ankle after the paralysis of the extensor muscles. The Achilles tendon, the flexor toe tendon, the flexor thumb tendon, and the aponeurosis plantaris are extremely contracted. When loading, the tip of the foot is completely folded to the rear (Fig. 11.11). Fig. 11.10  Talipes equine valgus deformity (a). The deformity is not obvious at the weight-bearing position due to the forefoot valgus, extension, and longitudinal arch collapse; (b). The equine deformity appears when the forefoot is placed in the neutral position

Fig. 11.11  The clubfoot backward deformity

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4. Calcaneus foot deformity: calf triceps tendon is paralyzed; the strength of the dorsal extensor muscle is more than grade 3 (Fig. 11.12). 5. Calcaneus valgus foot deformity: calf triceps tendon, anterior and posterior tibia tendon are paralyzed, the muscle forces of dorsal extensor and eversion muscles were grade 3 or above (Fig. 11.13). b

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6. Calcaneus varum foot deformity: calf triceps tendon and peroneus muscles were paralyzed, the forces of foot extension and varus muscles were grade 3 or above (Fig. 11.13). 7. Varus foot deformity: the posterior tibial muscle contracture is predominant, peroneus muscles paralyzed (muscle strength below grade 3), and the foot lateral edge is on the ground when walking (Fig. 11.14). 8. Flat foot valgus deformity: the foot arch is collapsed, the foot inner edge is grounded when walking, subtalar joint was inward and downward, commonly accompanied by hallux valgus deformity, anterior and posterior tibia ­tendon was paralyzed, and peroneus muscles were contracted (Fig. 11.15). 9. Flail foot deformity (Charcot’s joint): the muscles on calf and foot are paralyzed and the ankle joint and triple joints are relaxed, usually accompanied with severe sensory disorder. 10. Claw toe deformity: metatarsophalangeal joint dorsal extension and interphalangeal joint flexion (Fig. 11.16).

11.5 Physical Examination and Radiological Examination

Fig. 11.12  Calcaneus foot deformity Fig. 11.13  Calcaneus valgus foot deformity on the left foot, on the right is calcaneus varum deformity

Fig. 11.14  Foot varus deformity

The systematic physical examination and scientific evaluation are very important for formulating a right individualized plan of surgical treatment.

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Fig. 11.15  Flat foot valgus deformity

Fig. 11.16  Claw toe deformity

11.5.1 Physical Examination 11.5.1.1 Lower Limb Examination The patient’s lower limbs and waist were fully exposed. The patient was first examined in the standing position and was observed from chest through waist to the ankle, at anterior-­ posterior, left and right view respectively. Secondly, the gait was observed by letting the patient walk back and forth. The characteristics of the foot appearance, the foot area for grounding, the strengths of muscles and the limp gait were analyzed. Then the patient was asked to sit or lie on the examination bed in order to observe the foot position, functional status of the lower extremity, and the relationship between the lower limbs.Muscle force test: Muscle strength assessment method of grading from 0 to 5 should be done. As shown in the picture, the strength of the Achilles tendon is grade 0, and the strength of the anterior tibialis muscle is grade 5 (Fig. 11.17). If the strength of the posterior tibia muscle is 4–5, the strength of the peroneus longus and peroneus brevis muscles is grade 0, the patient will be characterized by varus foot deformity (Fig. 11.18). Sensory function examination: Qinsihe mainly examines superficial sensation, pain sensation, and positional

Fig. 11.17  Calcaneus foot deformity

awareness sensation. The cotton swab and the tip of the percussion hammer can be used to test the range of skin dysfunction. Positional awareness is identified by patient’s awareness of having the toes moved (Figs. 11.19 and 11.20).

11.5.1.2 Waist Examination Whether there are hair, scars, bulges, surgical incisions (length and direction) on the back, scoliosis or spine protrusion, tenderness, range of motion, etc. are examined.

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Fig. 11.20  Percussion hammer

lower limb at the standing position. If the spine is deformed, the full-length X-ray of the spine should be taken. 2. CT scan examination is not used as a routine examination. It is only used for complex deformities so as to understand the three-dimensional spatial relationship. 3. MRI: to understand the anatomical structure and pathological anatomy, to identify the level of spinal cord involved, and presence or absence of tethered cord. 4. Gait analysis: The doctor from Qinsihe Orthopedic department observes and evaluates patients only with the naked eye. The pathological photography of appearance or gait of the patient are routinely taken as a control for the functional change after treatment. Fig. 11.18  Varus foot deformity

11.5.3 Checklist for the Lower Limb Deformity of Spina Bifida Sequelae Spina bifida deformity checklist was designed by the Qinsihe orthopedics. This table was mainly designed for preoperative recording of the information of patients and lower extremity deformities, including general information, contact information, medical history, waist and lower limb deformity, muscle strength and sensation situation, motor function, presence or absence of bowel movements, and treatment plan and procedures, etc. (Fig. 11.21).

11.6 P  rinciples of Deformity Correction and Functional Reconstruction Fig. 11.19  Cotton swab

11.5.2 Radiology Examination

11.6.1 Overview

Lower limb deformity and disability with spina bifida are difficult to be classified in the current orthopedic subdisci 1. X-ray examination: The pelvic X-ray film of the anterior-­ pline in China, and the rate of misdiagnosis and mistreatposterior view should include the lower lumbar vertebrae, ment is high. Therefore, for a child with deformed feet, the AP (Anteroposterior position) and lateral radiographs of lumbosacral imaging is routinely performed to determine affected foot and ankle joint, and the full-length X-ray of the whether it is caused by spina bifida or other space-occupying

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Fig. 11.21  Checklist of lower limb deformity in spina bifida sequelae

lesions in the spinal canal. If it is indeed caused by spina bifida, the neurosurgeon should be consulted. It is recommended to perform tethered cord surgery first, which can avoid or reduce the strain on the nerve growth. The earlier the tethered lysis surgery is performed, the better the effect is. However, this surgery must be performed by experienced neurosurgeons with microsurgical techniques. Otherwise, the surgery may cause new injury to the

spinal nerve. Severe patients should consult with the doctors from Urology and Spine surgery. If a severe foot and ankle deformity has occurred, surgical correction should be performed first. In 2 years after the lumbosacral neurolysis, whether the nerve can be repaired or not has been confirmed. It is the right time for correcting the foot and ankle deformities. In a clubfoot case with ankle muscle imbalance, simple dynamic

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balance surgery should be performed early. Otherwise, deformed bone changes are likely to occur. The progress speed of valgus foot and claw foot deformity is relatively slow, so the operation can be suspended or delayed.

11.6.2 Surgical Indication The foot is the final load part when humans stand and walk. In theory, all the deformities that affect the weight-bearing walking should be corrected by surgery. For a specific case, whether the surgeon can successfully complete the operation depends on two basic conditions: 1. Patient’s condition: Whether the ankle deformity has requirements or conditions for correcting deformity and improving function; 2. Doctor’s condition: Whether the doctor has overall awareness and orthopedic surgical skills to correct such deformities, and whether the operation can achieve the purpose of correcting deformity and improving function after surgery. Therefore, the surgical indications for this disease are relative to the patient and the medical practitioner.

11.6.3 Basic Principles of Surgery The types of foot and ankle deformities are diverse. The age and gender of the patient are different. The degree of deformity and sensory disturbance are different. Some patients have spinal, hip, knee deformity, and defecation dysfunction. As there is a variety of clinical manifestations, currently, various high-tech examinations and equipment do not play a decisive role in the treatment of such ankle deformities. The experience, wisdom, dialectical thinking, overall awareness, and systematic evaluation of orthopedic surgeons can be required to develop a reasonable treatment plan individually. The surgical strategy basically follows the principle of treatment of poliomyelitis sequelae, that is, to correct deformity, balance muscle strength, stabilize joints, and restore normal load bearing sole. Patients with skin dysfunction are treated with external fixators after surgery. When a bone surgery is performed to correct a deformity in patients with sensory disorder, it is necessary to retain a certain degree of foot flexibility as the stiff foot is prone to pressure ulcers in the weight-bearing area. 1. Correcting deformities: This is the most basic requirement of patients and their families. For a simple deformity of soft tissue contracture, simple soft tissue release and tendon lengthening can achieve satisfactory orthope-

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dic effect. Osteotomy is performed on the basis of soft tissue release when bone deformity is present. 2. Balancing muscle strength: Dynamic imbalance of ankle joint is an important factor in the occurrence and development of deformities. Dynamic balance of tendon transposition should be performed as soon as possible, so that bone deformity can be avoided. 3. Stabilizing joints. The main function of the foot is a stable weight-bearing walking. The tendon transfer or joint fusion is determined according to the degree and the location of joint relaxation as well as the age of the patient. The patients with particularly severe relaxation can be treated with ankle joint arthrodesis or ankle joint plus subtalar joint arthrodesis by paying attention to retain the elasticity of the foot. The patient wears an orthopedic shoe for some period of time on the basis of stable surgery. 4. Assemble prosthesis after amputation. If there is a long-­ lasting ulcer or chronic osteomyelitis, and the muscle power of hip and knee are better, it is recommended to assemble prosthesis after amputation. Through the power of the hip joint to drive the prosthesis, the function of standing and walking of the lower limb can still be restored. 5. Age. In children under 10 years old, foot and ankle deformities are usually corrected with soft tissue release and muscle balance. In severe cases, soft tissue surgery is combined with Ilizarov technique. For those who are above 12 years or adults with ankle deformity, the surgical method should be determined according to the classification and extent of the deformity.

11.6.4 Qinsihe Orthopedic Experiences and Precautions 1. Patients with defecation dysfunction should have enema and urinary catheter before surgery. 2. Minimize surgical invasiveness and reduce subcutaneous soft tissue dissection. Such patients should not be fixed with plates. 3. Give play to unique advantages of Ilizarov technology. Even the patients with skin ulcers can also be performed bone surgery at the same time. Patients with external fixation device can walk early, which can stimulate the n­ atural healing of ulcer wounds, promote bone healing, and bone reconstruction. 4. Bilateral deformities of lower limb should be operated in stages, which will be beneficial for functional exercise and recovery. Patients with hip and knee deformities should be corrected as much as possible together with their ankle deformity, so that the gravity line of lower limbs can be restored in one stage. Of course, severe hip and knee deformity can be staged.

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11.6.5 How to Optimize the Combination of Different Surgical Methods? Talipes equinus foot deformity: Achilles tendon lengthening, aponeurosis plantaris release, and first metatarsal osteotomy are performed when it is accompanied with cavus foot. Talipes equinovarus deformity: Achilles tendon lengthening (the medial part of Achilles tendon should be cut), posterior tibia tendon lengthening, aponeurosis release, bone osteotomy with bony deformity are all performed. If the ankle joint surface is obviously inclined, the super malleolus osteotomy should be performed. Talipes equines valgus deformity: Achilles tendon lengthening (the lateral part of Achilles tendon should be cut) plus peroneus tendon lengthening or peroneus tendon transfer to anterior tibia muscle are needed. If there is a skeletal deformity, subtalar joint arthrodesis should be done with bone graft. Calcaneus foot deformity: the anterior tibial tendon of ankle joint should be released, and the tendon (medial or/and lateral) is displaced to replace Achilles tendon. Varus foot deformity: the calcaneus valgus osteotomy or subtalar joint arthrodesis can be performed with tendon transposition of anterior or posterior tibial muscle. Flail foot deformity: According to the degree of joint relaxation, the fusion of the subtalar joint or ankle joint is chosen during which attention is paid to move the foot backward. Fig. 11.22  The ulcer always at weight-bearing area of the foot. (a) The fifth metatarsal head, (b) A small ulcer on foot lateral side, (c) A large ulcer on the dorsum

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Claw toe deformity: toe tendon lengthening, interphalangeal joint fusion, or distraction with Ilizarov frame.

11.6.6 The Rational Application of External Fixation (Ilizarov) Technology The Qinsihe orthopedic method of foot and ankle surgery combined with Ilizarov external fixation technique for the treatment of limb deformity of spina bifida sequelae can obtain satisfactory results. A large number of foot and ankle deformities with skin ulcers, who were advised amputation, were saved. The current orthopedic theory is still difficult to explain its peculiar curative effect.

11.7 C  orrection of Foot and Ankle Deformity with Ulceration In the case of foot and ankle deformity with sensory disorder, the stress in the weight-bearing area is concentrated without pain, so the ulcer is difficult to heal. In the case of clubfoot, the ulcer is usually present on the anterior aspect of the plantar or on the lateral side of the foot (Fig.  11.22). In talipes equinovalgus deformities, the ulcer tends to appear in the first metatarsal head which is weight-­ bearing area. These ulcers rarely heal without correcting deformity. In severe cases, osteomyelitis developed, and even spontaneous toe amputation happens.

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If the patient with sensory dysfunction and chronic ulcers are properly handled before surgery, the orthopedic operation still can be performed. The external fixation technique is used to control the orthopedic position required. Because the bone healing ability of such a patient is slower than a normal person, the paralyzed patient walks with an external fixator and a suitable sponge, which is conducive to the healing of residual ulcer and can promote the bone healing and remolding. Ankle foot orthosis should be worn for a period of time after the removal of the external fixator.

weight-bearing area in the left foot has been ulcerated for 22  years. It has been treated with various methods and remains unhealed. No tumor cells have been found by pathological examination (Fig. 11.23). Surgical plan:

Case Illustration This is a typical case of a 26-year-old male with severe talipes equinovarus deformity in left foot for 25  years. The

Surgical steps: The posterior tibia muscle of the left foot was lengthened, ulcer resection and triple joint osteotomy were performed, and Ilizarov external fixation mounted.

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1 . Posterior tibia muscle lengthening 2. Partial ulcer resection 3. Triple joint osteotomies and arthrodesis 4. An Ilizarov external fixator.

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Fig. 11.23  Severe talipes equinovarus deformity with ulcer. (a–c) Clinical appearance; (d, e) X-ray; (f–h) The surgery was done; (i) The varus deformity was corrected at 28 days after surgery; (j–l) Clinical appearance 2 years after surgery; (m) 11 years follow-up

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Fig. 11.23 (continued)

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Dressing was changed at 5 days after the operation, and the external fixation frame was adjusted at 7 days later. The varus deformity was corrected at 28  days after surgery. Residual ulcers naturally healed under push-pull stress stimulation. Tips and tricks: The surgeries include ulcer resection, soft tissue release, and osteotomy and arthrodesis are performed at the same stage. The residual wounds after surgery are only treated with regular gauze replacement. In one stage surgery, the deformity was completely corrected and the ulcer healed naturally. More than 200 patients had been treated in Qinsihe Orthopedics. None of them had postoperative infection, which subvert the classic orthopedic principle that ulcers should heal before bony surgery. This simple and peculiar treatment result deserves to be considered deeply by peers from some countries. External fixation removal: At 110  days after surgery, X-ray showed that the bone of triple arthrodesis had healed, the structure of the foot and ankle joint was basically restored, so the external fixator was removed. The deformity ­correction was satisfactory. The ulcer healed. The patient can walk normally. Ankle foot orthosis was worn for 4 weeks. Follow-up: The patient was followed up for 36 months after surgery, deformity and ulcer did not recur. He could walk freely in soft-soled shoes. At 11  years follow-up, the patient had no ulcers and could walk for more than 5 km.

11.8 C  linical Data of Lower Limb Deformities of Spina Bifida Sequelae 11.8.1 Clinical Data In Qinsihe orthopedic Institute, 842 cases with lower limb deformities of spina bifida sequelae had undergone orthopedic surgery up to December 31st, 2017. According to the case column on the checklist, the statistical information is as follows: (Table 11.1).

11.8.2 Atlas of Typical Cases This part will show some cases of lower extremity deformities of spina bifida sequelae, including preoperative symptom, physical examination, treatment strategy, treatment process, postoperative appearance, and follow-up results. Case 1 The patient was a 25-year-old female with severe clubfoot deformity of bilateral sides due to spina bifida sequelae. The patient has severe deformity and ulceration on ankle, and the

J. Zang et al. Table 11.1  Statistics information about 842 patients with spina bifida sequelae Category Gender Age(years)

The time surgery operated

Fixation method

Sides

Joint deformity∗

Item Male Female 1–14 15–30 31–45 >45 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Internal fixation Others Left Right Bilateral Hip Knee Foot and ankle

Cases (n) 385 457 320 457 62 3 44 136 176 486 317 274 46 205 145 158 539 67 83 806

Percentage (%) 45.72 54.28 38.00 54.28 7.36 0.36 5.23 16.15 20.90 57.72 37.65 32.54 5.46 24.35 17.22 18.76 64.01 7.96 9.86 95.72

Note: some patients had compound deformity

partial deformity is corrected through medial soft tissue release and triple joint osteotomy, then Ilizarov external fixator is installed with wires, and the residual deformity is gradually adjusted after operation. Patients are encouraged to walk out of bed with crutches; they will be treated while walking.   1.  Preoperative weight-bearing area on the lateral side of the foot accompanied by foot sensory disturbance and defecation abnormality.   2.  Preoperative X-ray films: the left calcaneus bone had been partially missing due to ulceration, and the ankle joint gap disappeared.   3.  Dressing was changed at 1 week after operation, the external fixation frame was gradually adjusted, distracted on the medial side, compressed on the lateral side. Attention is paid to prevent squeezing the ankle joint surface. If the soft tissue tightness happened, distraction was properly slowed down or stopped. The right foot orthopedic surgery will be performed when the left foot varus deformity was completely corrected.   4.  The postoperative view, the left foot at 105 days, the right foot at 74 days, bilateral deformities were satisfactorily corrected, the external fixator was removed, and the orthopedic shoes were worn for walking with the sole weight.   5–6.  The postoperative right foot at 74 days, the view after removing the external fixator, the front view (5) and the lateral view (6) were basically normal.

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Fig. 11.24  The patient was a 25-year-old female with severe clubfoot deformity of bilateral sides due to spina bifda sequelae

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Fig. 11.24 (continued)

  7–8.  X-ray AP view of bilateral ankle joint, the varus deformity was completely corrected and the bone of triple joint had healed (Fig. 11.24). Case 2 The patient was a 16-year-old male with spina bifida sequelae. The patient had undergone cauda equina lysis when he was 6 years old, and then the right foot talipes equine cavus deformity occurred gradually. The patient has a compound deformity at the age of 16 years. The operations of releasing the contracture tissue, bony osteotomy, and Ilizarov external fixation installing were performed at the same stage.

  1–2.  The clubfoot backward deformity and weight-­ bearing on metatarsal head are shown.   3.  Pelvis X-ray shows vertebral defect in the lumbosacral region, and normal situation of bilateral hip joint.   4–5.  Achilles tendon was lengthened, plantar fascia was released, and bone osteotomy around the talus was added; Ilizarov external fixation device was installed. The adjustment was started at the seventh day after surgery, and the talipes equine cavus deformity was slowly corrected.   6.  X-ray film showed satisfactory position of the right ankle joint.

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  7–8.  The foot deformity was corrected completely at 3  months after surgery, and the patient can walk with the external fixation.   9.  The ankle joint subluxation was found before the removal of the fixator at 4.5 months after surgery and immediate treatment was given.   10.  At the follow-up of 26 months, the right foot was normal, the deformity did not recur, and the patient was able to walk with normal looking foot with full weight-bearing.   11–12.  X-ray AP view of ankle joint at the 26th month after operation; the ankle joint was congruent with

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mild osteoarthritis and had 20 degrees of dorsal extension and plantar flexion (Fig. 11.25). Case 3 The patient was an 18-year-old male with bilateral foot varus deformities.   1.  The talus was touching the ground and the sole was facing backwards.   2.  The operation included posterior tibia muscle lengthening, the flexor digitorum longus and flexor toe tendon lengthening, the triple joint osteotomy, and fixation with

Fig. 11.25  The patient was a 16-year-old male with severe talipes equine cavus foot deformity of spina bifda sequelae

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26 months postoperatively Fig. 11.25 (continued)

an Ilizarov fixator gradually correcting the deformity to neutral position.   3.  The external fixator was removed 107  days after surgery, and the foot deformity was corrected with full sole weight–bearing (Fig. 11.26). Case 4 The patient was a 19-year-old female with bilateral calcaneus foot deformity of spina bifida sequelae. The patient suffered from bilateral foot deformities and ulceration with spina bifida sequelae. The surgical goals were to correct deformities, improve function, and cure ulcer in one stage. The gauze was changed at 5 days after the operation. If the incision was clean, it would no longer be bandaged. X-ray should be taken at the seventh day. The X-ray showed that the K-wire was too long and then was retreated below the talus articular surface. Foot deformity was basically corrected by adjusting the external fixation frame, and the patient started physical exercise.

  1.  Bilateral calcaneus foot deformity and Achilles tendon were in the state of extreme relaxation.   2.  Small ulcer in the heel, which is prolonged unhealed and sensory disorder around the heel.   3.  X-ray shows the insufficiency of the lumbosacral spine.   4.  X-ray AP view of ankle shows calcaneus foot deformity, the joint is relaxed, and the right side is severe.   5–6.  Physical examination during operation showed that the left foot was dorsally flexed extremely with one finger, which demonstrated that the soft tissue of the foot was very relaxed.   7–11.  Subtalar joint arthrodesis of the left foot was done for the foot stability. Anterior tibial muscle transfer to Achilles tendon was done to increase its strength. Ulcer resection was not performed. Ilizarov external fixator was installed to maintain foot position and to correct residual deformity. The torsional deformity of the right tibia underwent derotation surgery and was fixed with external fixator combined with plaster.

11  Lower Limb Deformity Caused by Spina Bifida Sequelae and Tethered Cord Syndrome Fig. 11.26  The patient was an 18-year-old male with bilateral foot varus deformities of spinal bifida sequelae

67 days postoperatively

109 days postoperatively

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  12–13.  At the eighth week after operation, the X-ray showed that the osteotomy site healed. The structure of ankle joint was restored. The position of ankle joint was maintained. Therefore, the external fixator was removed and orthosis was wearing. AFO was on left foot. Long leg

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orthosis was on the right leg after the tibia torsional osteotomy.   14–15.  The bilateral deformity was satisfactorily corrected. The patient had full weight-bearing, walked normally, and the ulcer on the heel disappeared (Fig. 11.27).

Fig. 11.27  The patient was a 19-year-old female with bilateral calcaneus foot deformity of spina bifda sequelae

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Fig. 11.27 (continued)

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Fig. 11.27 (continued)

11.9 Conclusion Because of the complex deformities, usually accompanied by sensory disturbance and dysfunction of the bowel or bladder, it is a difficult problem in the foot and ankle surgeries.

Based on a large number of clinical practices, rich clinical experiences have been accumulated and effective method for deformity treatment have formed in Qinsihe Orthopedics Institute. The chapter above is specially introduced to peers for evaluation and discussion.

Lower Limb Deformities Caused by Immunological Diseases and Viral Infectious Diseases

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Sihe Qin, Jiancheng Zang, Shaofeng Jiao, Lei Shi, and Xulei Qin

12.1 Introduction Sihe Qin and Shaofeng Jiao

12.1.1 Relationship Between Immunological Diseases and Viral Infectious Diseases There is a close relationship between immunity and viral infectious diseases and sometimes responsible for mutual causation. The normal immunity of the human body in healthy humans is an extremely important self-defense mechanism of the human body. Overwork, mental disorders, mental tension, emotional anxiety, and other high-level nervous regulation system disorders may cause the body’s immune regulation imbalance affecting immune response. Viruses, bacteria, and other microbial infections, poisoning, and other factors in the human body can cause immune function abnormalities. When the body’s immune regulation is in imbalance, it cannot resist the disease to protect the body but can also cause damage to their own tissues resulting in new diseases.

12.1.2 Diagnosis and Treatment The immunological and viral infectious diseases commonly include systemic lupus erythematosus, rheumatoid

S. Qin (*) · J. Zang · S. Jiao · L. Shi · X. Qin Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China

arthritis, scleroderma, dermatomyositis, Guillain-Barre syndrome (GBS), etc. A definite diagnosis can usually be made based on a typical history, clinical symptoms and signs, and laboratory tests. Unfortunately, there is no specific and effective treatment for these diseases. In the early stages of these diseases, it is mainly treated with immunosuppressive agents and hormones to control symptoms. In some severe cases, target organ damage is inevitable. Skin, muscle, tendon and other connective tissue, and nerve damage can lead to bone and joint dysplasia, contracture deformities, and dysfunction gradually. The surgery will be the only effective way once the lower limb deformities and dysfunction occurred.

12.1.3 Characteristics of Surgical Treatment No matter whatever is the cause of limb deformity, as long as the patient’s physical condition is stable, the general condition permits, there is dysfunction caused by the deformity, the patient himself has an understanding of the magnitude of disease, a reasonable prognosis, and actively requests and is ready to cooperate with the correction treatment, and the doctor who is in charge of treatment has the correct concept of orthopedics and rich clinical experience in deformity correction, then that patient is the ideal candidate for orthopedic surgery. Before surgical correction, it is necessary to analyze the etiology and pathogenesis of deformity according to the characteristics of each patient’s condition and the target of deformity correction. Careful and comprehensive physical examination should be carried out, combined with X-ray and other accessory examination, to grasp the characteristics of deformity, dynamic and static balance of the joint around the deformity, and local soft tissue skin condition.

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_12

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A detailed and complete surgical plan and adequate preoperative preparation should be done including the design of external fixator frame for complex deformities. Good preoperative planning and preparation can ensure the smooth implementation of surgery and postoperative management is also an important part of the treatment process. Careful observation, patient guidance, good communication, meticulous and timely adjustment, and the formulation of rehabilitation plans at different stages are the ultimate guarantee for good results. Due to the over-segmentation of clinical disciplines in hospitals, majority of doctors have limited clinical thinking and lack of timely guidance for many limb deformities and dysfunction. The patients who suffered from immunological and viral infectious diseases were struggling for a long-term with limb disability and life problems. Any effective treatment is needed to improve the quality of daily life of patients.

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higher incidence around 40–60  years. It can be associated with weight loss, low grade fever, and fatigue. Morning stiffness is a characteristic feature of the joints. The duration of joint stiffness is directly proportional to the severity of the disease. Joint involvement is mostly symmetrical, with involvement of hand, foot, wrist, ankle, and temporomandibular joints and other small joints. It can lead to carpal tunnel or tarsal tunnel syndrome also. The lower limb should be considered as a whole in clinical examination. The range of hip and knee motion has important reference significance for ankle. When examining the joint deformity, we should judge whether it is rigid or relaxed firstly, and then master the balance of muscle strength around the joint. This section only introduces preservative method for functional reconstruction of lower limb deformity without joint replacement.

12.2.3 Typical Cases

12.2 L  ower Limb Deformity Caused by Rheumatoid Disease Sihe Qin, Shaofeng Jiao, and Jiancheng Zang

12.2.1 Etiopathogenesis and Pathogenesis Rheumatoid arthritis (RA) is a chronic, inflammatory synovitis-­based systemic disease with unknown etiology. It is characterized by symmetrical multiple joints involvement and aggressive arthritis of the small joints of hand and foot, often accompanied by involvement of extraarticular organs and positive rheumatoid factors, which can lead to joint deformities and dysfunction. The pathogenesis of RA may be related to heredity, infection, and sex hormones. Pathological features of RA include proliferation of synovial cells, infiltration of inflammatory cells in the inter stitium, micro angiogenesis, pannus formation, and destruction of cartilage and bone tissue, etc. Contracture and destruction of articular capsule and surrounding soft tissue can lead to severe bone and joint deformities.

12.2.2 Clinical Manifestation and Key Points of Examination The incidence of rheumatoid arthritis in women is two to three times more than men. It can occur at any age with a

Case 1 General condition: A 17-year-old male patient with complicated deformity of both feet due to rheumatoid arthritis for more than 10 years. The general condition was good. Physical examination on admission: dull skin color of both feet, poor skin sliding, deformity included hindfoot varus, forefoot adduction, hallux valgus, and lateral toe metatarsus, etc. The X-ray showed that the subtalar joint, calcaneal cuboid joint, and tarsometatarsal joints were fused and the first to third metatarsophalangeal joints were dislocated laterally (Fig. 12.1). Therapeutic targets: The treatment idea is to correct the bony deformity, restore the lower limb alignment, and correct the dynamic imbalance by releasing the soft tissue contracture. The purpose of treatment is to improve the walking function. Surgical procedures: The patient should be in supine position with general anesthesia. After disinfection with alcohol iodine routinely and covering the part with sterile surgical towels, the surgery was performed under tourniquet as follows: minimally invasive incision for left tibial posterior tendon lengthening, talus calcaneus joint osteotomy, hallux metatarsophalangeal joint release and osteophyte resection, first metatarsal base osteotomy, and fixed with Hybrid fixator with foot in corrected position. Tips and tricks: Because of the long-term inflammation, the soft tissue of the affected foot is fragile. The surgical incision should avoid the skin with poor blood supply and mobility, reduce subcutaneous dissection, minimally invasive incision, and minimally invasive osteotomy should be adopted to reduce the risk of skin necrosis.

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Fig. 12.1  Foot and ankle deformity caused by rheumatoid arthritis. (a–d). Preoperative clinical appearance of left foot; (e, f) Preoperative X-ray of both ankles; (g) Release of metatarsophalangeal joint with

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osteophyte resection; (h, i) Application of Hybrid external fixator; (j–l) Postoperative appearance of left foot with weight-bearing walking; (m, n) X-ray showed bone healing and then the fixator was removed

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Fig. 12.1 (continued)

Bony osteotomy was performed to correct varus of the hind foot and adduction of the first metatarsal, restoring the stability of medial column of the foot. The deformity of multiple toes was corrected and repositioned by minimally invasive wire distraction. Postoperative management: The patient was encouraged to walk with crutches from third to fifth day postoperatively; dressing removal was on fifth to seventh day postoperatively and then X-ray film was taken. The external fixator can be further adjusted to rectify deformities according to the X-ray film and soft tissue conditions; care the pin tract to prevent infection; pay attention to daily walking and active and passive joint function exercises. The fixator should be maintained after reaching the desired position and be removed after bone healing (Fig. 12.1). Case 2 This patient was a 12-year-old female with lower extremity deformities including knee flexion contracture, stiffness, and

equinovarus foot. She suffered from juvenile rheumatoid arthritis 5 years ago. She had been treated by many methods such as traditional Chinese medicine and Western medicine. Rheumatoid disease is stable, but the function of standing, squatting, and walking of lower limbs is completely lost. Preoperative examination revealed that there was no bony fusion on the knee and ankle joint, and it belonged to fibrous contracture rigidity. In the first stage, Ilizarov technique was used to correct the flexion deformity of both knees to reconstruct the flexion and extension function. The second stage surgery was performed for foot deformity with the Achilles tendon subcutaneous release and Ilizarov frame application. Two months after second surgery, the external fixator was removed, and the patient was put on exercises under the protection of orthosis. At 4 years follow-up, the lower limbs were restored with good gravity line, and the joints of knee and ankle were reconstructed in a good motion (Fig. 12.2).

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Fig. 12.2  Ilizarov technique for treatment of lower limb deformities caused by rheumatoid arthritis. (a, b) A 12-year-old female with knee flexion and clubfoot deformity caused by juvenile rheumatoid arthritis, (c, d) Preoperative X-ray examination showed reduction of joint space; (e) first stage surgery: Ilizarov frame was used to correct flexion deformity of both knees. (f, g) X-ray film at 12th day postoperatively; (h)

External fixator was removed at second month postoperatively and orthosis was applied for lower extremities; (i) Second-stage surgery for rigid clubfoot deformity correction; (j) At 4 years follow-up, lower limb deformity was corrected, knee joint flexion was more than 40°, and the patient can walk independently; (k, l) At 4 years follow-up, knee joint X-ray examination

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12.2.4 The Data of Lower Limb Deformity Caused by Rheumatoid Arthritis (Table 12.1)

12.3 L  ower Limb Deformity Caused by Scleroderma Sihe Qin and Jiancheng Zang

Table 12.1  Statistics of lower limb deformity caused by rheumatoid arthritis in Qinsihe orthopedics Category Gender Age(year)

Time

Fixation

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Deformity∗

Item Male Female 1–14 15–44 45–59 >60 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Plaster Internal fixator Left Right Bilateral Hip Knee Foot and ankle

Cases (n) 15 19 5 27 2 0 3 8 13 10 13 7 11 3 4 2 28 16 25 13

Percentage(%) 44.12 55.88 14.71 79.41 5.88 0.00 8.82 23.53 38.24 29.41 38.24 20.59 32.35 8.82 11.77 5.88 82.35 47.06 73.53 38.24

*Note: Some patients with compound deformities are included

12.3.1 Etiopathogenesis and Pathogenesis Scleroderma is a connective tissue disease characterized by inflammation, degeneration, thickening and fibrosis of the skin, followed by sclerosis and atrophy, which can cause multiple system damage. Systemic sclerosis may involve the digestive tract, lung, heart, and kidney as well as the skin, synovium, and digital (toe) arteries. The etiology of scleroderma is still unclear. Fibroblasts synthesize and secrete collagen, which may be affected by genetic, environmental factors, estrogen, cellular, and hormonal immune abnormalities, leading to fibrosis of the skin and viscera. Chemical or viral infections and environmental factors can affect susceptibility to diseases. Skin sclerosis and atrophy will lead to dynamic imbalance around the joint, affecting the development of lower limb and aggravating the development of deformity. The most common deformities were ankle and knee joints, and in some cases, upper limbs were also involved.

12  Lower Limb Deformities Caused by Immunological Diseases and Viral Infectious Diseases

12.3.2 Clinical Manifestations and Key Points of Examination According to the degree of skin involvement, scleroderma can be divided into two subtypes: 1. Localized type. In patients with localized scleroderma, only the distal limb skin is thickened and the trunk is not involved. Typical manifestations are generalized as CREST syndrome (Calcinosis, Reynolds phenomenon, Esophageal dysfunction, Fingertip sclerosis, and Telangiectasia). 2. Diffuse type. Diffuse scleroderma is characterized by thickening of the distal part of the extremities and proximal with involvement of trunk skin. The key points of examination are the location of limb deformity, the degree of stiffness, the extent of skin scar or sclerosis, the presence or absence of bony deformity, etc.

12.3.3 Principles of Surgical Treatment At present, there is no good method to cure the primary disease of scleroderma, let alone the limb deformity caused by. Nine cases who suffered scleroderma deformities were treated with external fixation in our department. The overall evaluation of the curative effect was satisfactory and some clinical experience was obtained. The principles of surgical treatment as follows: 1. If the deformity is only soft tissue contracture in the affected limb, Ilizarov external fixator can be applied.

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Fig. 12.3  Ilizarov technique for treating scleroderma valgus foot deformity in adult: (a) Preoperative clinical appearance: the left foot was valgus; the lateral dorsum of the foot and the lower part of the calf were sclerotic; (b) Left foot and ankle X-ray; (c) Ilizarov external fixator was applied; (d) External fixator was adjusted to correct valgus foot deformity from seventh day postoperatively; (e). 65 days postoperatively, the valgus foot deformity was corrected satisfactorily and the

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Postoperatively, the deformity can be slowly corrected by stable, slow, and continuous stretching and sticking to the bone scar contracture deformity. 2. For those complicated with obvious skeletal deformity, partial correction by osteotomy, and then Ilizarov technique the residual deformity correction. 3. The skin of scleroderma has a slow response for distraction, and so when the deformity is corrected by external fixator, it is needed to continue fixation for more than 2  months. When the scar relaxes, the fixator can be removed. A brace should be worn in another 2 months to prevent deformity recurrence.

12.3.4 Typical Cases Case 1: Left Foot and Toe Valgus Deformity Caused by Scleroderma The patient is a 19-year-old female with left foot and toe valgus deformity caused by severe scleroderma (Fig. 12.3). Surgical treatment: With medial foot incision for subtalar joint osteotomy and fusion, partial correction of talipes valgus deformity was done. Then, Ilizarov technique was applied to correct the residual deformity. Five months later, ulceration occurred in the area of scleroderma, the fifth metatarsal bone was osteotomized and the wound was repaired with steel wire pushing and pulling. The core of postoperative management is slowness, which makes the stiff scar skin extend and soften slowly. When expected position was reached, the frame will still remain fixed (Fig. 12.3).

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external fixator was maintained; (f) The skin on the lateral dorsum of the foot formed a strip ulcer; (g) The wires were applied to repair the wound; (h) the wound became smaller at 11th day after second surgery; (i) At 32 months follow-up, the foot valgus recurred slightly, the wound healed well, the scar softened, and the skin thickening area decreased. (j) X-ray film were taken at 32 months follow-up

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Case 2: Lower Limb Deformity Due to Juvenile Scleroderma (Fig. 12.4) Case 3 (Fig. 12.5)

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Fig. 12.4  Orthopedic surgery combined with Ilizarov technique for the treatment of lower limb deformities caused by juvenile scleroderma: (a) The patient is a 10-year-old female with lower limb shortening and valgus foot deformity; (b) Preoperative foot and ankle X-ray; (c) Calcaneal osteotomy and application of Ilizarov fixation; (d) Foot deformity was corrected at 17th day postoperatively; (e) X-ray at 17th day postoperatively; (f) 3  months postoperatively,

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Ilizarov external fixator was removed and foot and ankle orthosis were given; (g) 3 months after operation, X-ray showed the deformity was corrected satisfactorily and the osteotomy was healed; (h) At 3 years follow-up, the right foot valgus deformity reoccurred slightly, and the right lower limb was shortened by 5 cm. Because the patient was in the growth and development stage, second surgery will be carried out in future

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Fig. 12.5  Orthopedic surgery combined with Ilizarov technique for the treatment of right upper limb deformity caused by scleroderma: (a) The patient was a 26-year-old female with right elbow flexion and wrist extension deformity caused by Scleroderma: front view and lateral view; (b) Application of Ilizarov fixation. The distraction was started at

seventh day postoperatively, wrist deformities were mostly corrected, the finger extension and flexion activities were normal 3 weeks later; (c) At 3 months postoperatively, wrist deformities were corrected satisfactorily. (d) At 13  months follow-up, satisfactory deformity correction and no recurrence, and good right-hand function

12.3.5 The Surgical Data of Limb Deformity Caused by Scleroderma (Table 12.2)

Table 12.2  Surgical data of limb deformity caused by scleroderma Category Gender

12.3.6 Conclusion

Age(year)

Ilizarov technique combined with Qinsihe experience in lower limb orthopedics is an effective, minimally invasive, and risk-free treatment for the functional reconstruction of lower limb and upper limb deformities due to scleroderma. Clinical observation has proved that through slow, sustained, and stable distraction, the thick tough skin can be softened and extended to fit for deformity correction. It is still effective even when two patients with partial recurrence were treated with Ilizarov technique several years later.

Time Fixation∗ Side Deformity∗

Item Male Female 1–14 15–20 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Left Right Hip Knee Foot and ankle

Cases (n) 4 5 3 6 1 8 8 3 3 6 0 5 9

*Note: Three cases with compound deformities in this group were treated with combination of Ilizarov fixators and Hybrid fixator simultaneously

12  Lower Limb Deformities Caused by Immunological Diseases and Viral Infectious Diseases

12.4 L  ower Limb Deformity Caused by Dermatomyositis Sihe Qin and Jiancheng Zang

12.4.1 Etiopathogenesis and Pathogenesis Dermatomyositis is a non-suppurative inflammatory disease mainly involving striated muscle with lymphocytic infiltration. It can be accompanied with or without multiple skin lesions. Clinically, patients present with symmetrical gridle muscle, neck muscle, and pharyngeal muscle weakness, often involving a variety of organs, but also can accompany with tumors and other connective tissue diseases. The exact etiology of this disease is unknown. It is generally believed to be related to genetic and viral infections. Dermatomyositis has obvious racial distribution. The incidence in African Americans is high, and the incidence of dermatomyositis of children in Asia and Africa is higher than that in Europe and America.

12.4.2 Clinical Manifestations and Key Points of Examination The disease in most of the cases is characterized by the acute onset of attack and slowly progressing within weeks, months, and years. Very few patients with acute onset, within a few days, develop severe myasthenia or even rhabdomyolysis, myosin urine, and renal failure. Patients may have morning stiffness, fatigue, loss of appetite, weight loss, fever ­(moderate to low fever or rarely high fever), and joint pain while a few patients present with Reynolds phenomenon. The main pathological changes of dermatomyositis are damage, necrosis, and inflammation of muscle cells, subsequent atrophy, regeneration, and hypertrophy of muscle cells. Muscle tissue is replaced by fibrotic tissue and fat. Abnormal muscle biopsy can be found in 90% of the patients, showing muscle fiber damage or even necrosis, regeneration in different degrees, and different muscle fiber thickness. The patients who come to Qinsihe Orthopedic department present with bone and joint contracture deformities and dysfunction due to muscular lesions. The patients and their families’ demand for treatment to correct limb deformities and improve motor function, not to treat dermatomyositis itself.

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The main points of examination are the history of the disease, the history of previous treatment and the special examination related to surgical correction, such as the location and degree of limb deformity, the nature of deformity, joint mobility and stability, local skin, and soft tissue conditions. Surgical indications: whether the patients have desire for correction of deformities and improve function; whether the goal of improving function can be achieved postoperatively; and whether the surgical complications can be avoided.

12.4.3 Typical Case 1. The patient was a 22-year-old male with bilateral cavus foot deformity due to dermatomyositis for 5  years (Fig. 12.6). 2. Strategies and targets of treatment: Deformity correction and improvement of the lower limb function. The muscles, tendons, capsules, skin, and soft tissues of the lesions can be regenerated gradually with the application of Ilizarov technique, and the deformity was gradually corrected to normal position. 3. Surgical methods and procedures: The patient in supine position, both feet will be operated simultaneous. Percutaneous release of Achilles tendon and plantar aponeurosis, small incision for the peroneal longus tendon lengthening, calcaneocuboid and talonavicular joint osteotomy, and then applied with Ilizarov external fixator. 4. Tips and tricks Small incision, minimally invasive osteotomy and minimal soft tissue dissection, above all is conducive to the healing of the original pathological soft tissue. As for the cavus deformity, bony osteotomy should be performed at the apex of mid tarsal joint. When mounting the Ilizarov external fixator, the hinge should be matched with the rotation center of the ankle, which is useful for the tibial talus joint distraction and reduction, and one wire or pin should be inserted on talus and cuboid during the operation, which is beneficial to adjustment of external fixation postoperatively. 5. Postoperative management and quality control The patient was instructed to walk with the help of crutches from the third to fifth day postoperatively. Removal of the dressing and evaluating the X-ray at the fifth day, the residual deformity was corrected from gradually adjusting the external fixator; Because of severe equinocavus foot, plantar flexion ankle should be retained at about 15° at the end of deformity correction to prevent anterior ankle impingement, which is conducive to walking.

506 Fig. 12.6 Bilateral equinocavus foot deformity caused by dermatomyositis: (a) Preoperative standing photograph showing bilateral severe equinocavus foot deformity; (b) X-ray preoperatively; (c) X-ray at 3 months postoperatively; (d) At 1-year follow-up, foot deformity has been corrected, and walking function significantly improved

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12.5 Lower Limb Deformity Caused by GBS Sihe Qin, Shaofeng Jiao, and Jiancheng Zang

12.5.1 Etiopathogenesis and Pathogenesis GBS is a common demyelinating disease of the spinal and peripheral nerves. It is also known as acute idiopathic neuritis or symmetric multiple radicular inflammation. The clinical manifestations are progressive ascending symmetrical paralysis, limb flaccid paralysis, and varying degrees of sensory disturbance. The patient presents with acute or subacute clinical course, most of which could be completely recovered, a few of which could cause fatal respiratory paralysis and bilateral facial paralysis, and the survivors were often left with limb paralysis and dysfunction. The etiology of GBS has not been fully elucidated. It may be related to infection of virus or mycoplasma and immune damage. Immunoglobulin found in the nerve tissue of patients suggests that it should be related to humoral immunity. The

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limb paralysis after GBS mainly involves the distal extremity. If the lower extremity is involved in infancy, with the growth and development of child, it can lead to serious deformities. If it affects after puberty, it is mainly muscle paralysis, joint relaxation and instability, affecting standing and walking function. The most common parts of the deformity were foot and ankle. There were 81 cases included in this group with foot and ankle deformity in 79 cases, accounting for 97.5%.

12.5.2 Clinical Manifestations and Key Points of Examination Limb paralysis is the most common symptom of this disease. Generally, it begins from the lower extremities and gradually affects the trunk, both upper extremities, and cranial nerves. It is characterized by low muscle tone, and the proximal end is often heavier than the distal end. Usually within few days to 2 weeks, the disease develops to a peak and patients become critically ill within 1–2 days with com-

12  Lower Limb Deformities Caused by Immunological Diseases and Viral Infectious Diseases

plete limb paralysis, respiratory and swallowing muscle paralysis, dyspnea, dysphagia which is life-threatening. The tendon reflex of the extremities was mostly symmetrical weakening or disappearing, the abdominal wall testis reflex was normal, and a few patients had pathological reflex sign because of pyramidal tract involvement. It can also be seen that limb sensory disturbance, such as numbness, tingling, and burning, can occur before paralysis or simultaneously. Half of the patients had cranial nerve damage, most of them were having peripheral paralysis of glossopharyngeal vagus nerve and one or both sides of facial nerve. Electrophysiological examinations, such as electromyography, suggest that motor and sensory nerve conduction velocities (NCV) are slower, providing evidence for denervation or axonal degeneration. Two years after the acute phase, the dysfunctional muscles are no longer restored, which is the so-called sequelae. The clinical manifestations are similar with poliomyelitis sequelae. Till December 2017, 81 cases of lower limb deformity caused by GBS were admitted. The patients who came to Qinshe Orthopaedic department were all the patients with lower limb flaccid paralysis and walking dysfunction left from the acute stage or after rescue. The physical examination focuses on walking gait, joint stability, joint mobility, body center of gravity, coordination and balance, bone and joint deformities, and muscle strength around the joint.

12.5.3 Typical Cases Case 1 1. General information. This patient was a 26-year-old male with lower limb deformity caused by GBS. He got a fever before paralysis Fig. 12.7  Right foot deformity caused by Guillain-Barre Syndrome: (a). Preoperative clinical appearance; (b) Preoperative X-ray; (c) Postoperative X-ray; (d) X-ray when the fixator has been removed; (e) Postoperative clinical appearance at 1-year follow-up

24 years ago. No family history. Limbs deformity occurred with body growth and development, and having a cold can aggravate the disease but no progress of which has been made after the age of 13 years. Physical examination on admission: limping gait with hand on knee, calcaneus foot, muscle atrophy of both upper and lower limbs, low muscular tension right limb is heavier than left; both hands deformity, right hip relaxation with increased passive mobility and limited active extension and right knee flexion deformity at 10°, slight varus foot on right side, and normal sensation (Fig. 12.7). 2. The goals and ideas of treatment. The patient mainly complained of walking difficulty. The main causes of dysfunction are extensive paralysis of the right lower extremity muscles, including gluteus maximus and med-gluteus paralysis leading to hip instability and swing gait, quadriceps partial paralysis leading to knee flexion and mild hand on knee gait, Achilles tendon paralysis leading to calcaneus deformity, and so on. The treatment goal is to correct the deformity, stabilize the joint of lower extremity, restore the alignments of lower limbs, and improve the walking function. Two stage operations were planned to achieve the target: In the first stage, ankle arthrodesis on right side. The ankle arthrodesis should be performed with foot as far back as possible and the plantar flexion angle should be about 15 °preserved. After the osteotomy, the ankle joint is fixed by Hybrid external fixator. 3. Tips and tricks. Under anesthesia, the ankle joint was fixed by crossing wires and then the activity of subtalar joint should be checked. If the talus joint was relaxed, the subtalar arthrodesis was performed simultaneously. Attention should

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Fig. 12.8  Orthopedic surgery combined with Ilizarov technique for treatment of clubfoot deformity due to Guillain-Barre Syndrome: (a, b) Right talipes equinovarus deformity caused by Guillain-Barre syndrome; (c) Ilizarov external fixator was mounted after triple joint osteotomy on right foot, and the talipes equinovarus deformity was corrected by slow distraction postoperatively, and the deformity was

corrected completely at 21st day postoperatively; (d) X-ray film of the foot and ankle at 21 day postoperatively; (e) 3 months postoperatively, the fixator was removed, and X-ray showed deformity was corrected; (f) Wearing foot and ankle orthosis for another 3  months; (g, h) At 7 months follow-up, clubfoot deformity was corrected completely and walking with full weight bearing

be paid to protect the anterior tibial vessels and nerves to avoid injury when exposing the ankle joints in the anterior incision. When resecting articular cartilage with osteotome, we should try our best to cut the articular cartilage as completely as possible according to the joint radian and make the subchondral bone like fish scale to ensure the fusion quality. 4. Postoperative management and quality control. Following the principle of lower extremity deformity correction, the fixation for osteotomy should be done with the wire or pin gradually to reduce the fixation rigidity, and the fixator can be removed after firm bone healing.

12.5.4 The Clinical Data of Lower Limb Deformity Caused by GBS (Table 12.3)

Case 2 The patient was a 17-year-old male with right talipes equinovarus deformity due to GBS.  Treatment using orthopedic surgery combined with Ilizarov technique was performed; the patient achieved satisfactory results at 7 months follow-­up (Fig. 12.8).

Table 12.3  81 cases of lower limb deformity caused by Guillain-Barre Syndrome in Qinsihe Orthopedics Institute Category Gender Age(year)

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Deformity∗

Item Male Female 1–14 15–44 45–59 >60 1980–1989 1990–1999 2000–2009 2010–2017 Ilizarov fixator Hybrid fixator Internal fixation+orthosis Left Right Bilateral Hip Knee Foot and ankle

Case (n) 54 27 22 58 1 0 13 27 15 26 10 18 4 9 7 65 6 12 79

Percentage (%) 66.67 33.33 27.16 71.61 1.23 0.00 16.05 33.33 18.52 32.10 12.35 22.22 4.94 11.11 8.64 80.25 7.41 14.81 97.53

*Note: Some patients with compound deformities are included in this group

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12.6 L  ower Limb Deformity Caused by Hand-Foot and Mouth Disease Lei Shi, Shaofeng Jiao, Xulei Qin, Jiancheng Zang, and Sihe Qin

12.6.1 Etiopathogenesis and Pathogenesis Hand-foot and mouth disease (HFMD) is mainly caused by enterovirus EV71 infection. It is mainly an infectious disease in children. Severe cases often involve the nervous system, causing disturbance of consciousness and limb paralysis similar to poliomyelitis. Since the outbreak of the disease in Southeast Asia in 1997, millions of children have been ill. The sequelae of severe patients are the limb paralysis in varying degrees, accompanied by bone and joint deformities, affecting walking function. The onset of the disease is consistent with the characteristics of lower limb bone and joint deformities caused by neurogenic diseases. At the beginning of the disease, the virus invaded multiple segments of the spinal cord, causing varying degrees of damage to ventral column, the corresponding areas of muscle paralysis and atrophy; incomplete paralysis of lower limb muscles lead to dynamic imbalance, finally a fixed deformity gradually develops under abnormal stress in walking.

12.6.2 Clinical Manifestations and Key Points of Examination HFMD can be caused by more than 20 viral infections. It is a common infectious disease that has been epidemic in different parts of the world. The main clinical symptoms are fever, herpetic form of rash on the hands, feet, mouth, and buttocks. Severe cases are caused by Enterovirus 71 (EV71) and lead to meningoencephalitis and other central nervous system complications. Flaccid paralysis may occur after inflammation, similar to poliomyelitis-like manifestations. If muscle abnormalities do not disappear after one and a half years, permanent limb dysfunction will remain, generally, without affecting skin sensation. The patients of HFMD who come to our department for treatment are those who survive the acute period, resulting in flaccid paralysis in lower limb and walking dysfunction. The preoperative physical examination and imaging examination are as same as the sequelae of poliomyelitis. The key examination and evaluation are the range, degree, nature of muscle paralysis and joint deformity, walking gait, joint stability, scoliosis, pelvic tilt, body center of gravity, coordination, and balance ability.

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As the paralysis and deformity of the lower limbs are caused by HFMD, the preoperative evaluation and the formulation of surgical plan are equivalent to the poliomyelitis sequelae. The specific ideas and principles of surgical treatment can be referred to the Chap. 5, “Surgical treatment of poliomyelitis sequelae.”

12.6.3 Typical Cases Case 1 1. General information. A 10-year-old female was diagnosed with HFMD after infection at the age of 4. Consciousness disorder appeared at that time, and her condition improved after half a month of treatment in intensive care unit of local hospital but right foot paralysis was found. With the growth and development, equinus valgus deformity appeared gradually on right foot with obvious limping gait. The patient is more rebellious, and physical examination is not cooperative. Physical examination showed that her pelvis was tilted to right, the right lower extremity muscles atrophy, right knee recurvatum, tibia varus and external rotated, flat, and valgus foot deformity with hallux valgus, subtalar joint stiffness, and limited ankle joint dorsal extension. The muscle strength of the anterior and posterior tibial muscles was 0. The right lower limb is shorter than left by 2 cm. The full-length standing position X-ray showed that the right lower limb was shortened, and the compound deformities of varus knee and equinovalgus foot are found. 2. Goal and idea of treatment. The surgery should be done following the principle of correcting deformity, stabilizing joint, and balancing muscle strength of lower extremity; walking exercise assisted by walker and reviewed regularly postoperatively. The preoperative procedure is as follows: (a) Subtalar joint arthrodesis and cutting off the insertion of the fibular brevis tendon through this incision. (b) The fibular brevis tendon was transferred to posterior tibial muscle through the lateral malleolus incision. (c) Achilles tendon lengthening. (d) Fibular neck osteotomy. (e) Tibial valgus osteotomy. (f) The Hybrid external fixator was applied. These surgical procedures can be completed in a single stage, and four objectives of deformity correction, lower

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limb gravity recovery, joint stability, and dynamic balance can be achieved. The entire process of lower extremity surgery is carried out under tourniquet. Despite so many complicated procedures, the amount of bleeding is usually only 10 milliliters. 3. Tips and tricks. The common peroneal nerve should be released and then the fibula osteotomy should be performed in same incision. When tibia osteotomy, a row of bone holes is drilled by electric drill, then cortical osteotomy is performed with a sharp thin osteotome. The blood supply of periosteum and soft tissue is preserved during the surgery. Because this patient has a severe valgus foot deformity, the medial incision for osteotomy is better than lateral. After valgus deformity correction, the tarsal sinus will form a larger space, which needs to be filled with autogenous or allogeneic bone. The tendon transfer

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of the fibular brevis tendon to the posterior tibial muscle can reconstruct the dynamic balance of foot and ankle joint and prevent the recurrence of deformities. 4 . Postoperative management. The patient can walk with walker from the third to fifth day postoperatively. X-ray radiographs were taken at the fifth day postoperatively. Attention to be paid to the correct way of walking exercise, and isometric contraction of transferred muscles should be done to prevent adhesion. Physical exercise with external fixator was carried out for 3  months and then fixator was changed to orthosis for protection (Fig. 12.9). Case 2 The patient was a 6-year-old male with left foot valgus deformity caused by HFMD. Peroneal muscle transposition was done in Qin’s way (Fig. 12.10).

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Fig. 12.9  Complex deformity of the right lower extremities due to hand-foot-and-mouth disease: (a) Preoperative clinical appearance showing varus knee on right side and flat foot valgus. (b) Local appearance of right foot; (c) Preoperative full-length X-ray of both lower limbs; (d) X-ray of right foot; (e) Osteotomy at the junction of the head and neck of right fibula; (f). free the peroneal brevis muscle; (g) The peroneal brevis muscle was transferred to tibial posterior muscle stop through posterior side of tibiofibular; (h) Calcantalar joint fusion; (i)

Tibial valgus Osteotomy; peroneal brevis muscle was sutured with tibialis posterior muscle; (j) Peroneal brevis muscle was sutured with endpoint of tibialis posterior muscle; (k) 3  months postoperative, the deformities of varus knee and flat foot were corrected; (l) X-ray postoperative, bone healing of tibial osteotomy; (m) X-ray postoperative, bone healing of subtalar joint fusion; (n) external fixator was removed and fixed with orthosis for consolidation

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Fig. 12.10  Modified fibula longus transfer to anterior tibial muscle. (a–c). The long peroneal tendon was exposed through the first incision on the left lateral malleolus, and was cut at the end point subcutaneously, and then diverted to the proximal incision across the subcutaneous tunnel. (d, e) The distal endpoint of the anterior tibial tendon was exposed, the long peroneal muscle was introduced into the anterior

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tibial muscle incision through anterior tibial tendon sheath. (f, g). External fixator was mounted to control foot and ankle joint in neutral position, long peroneal muscle, and tibial anterior tendon were sutured together under appropriate tension. (h, i). At the anterior incision, the long peroneal tendon was sutured with the third peroneal tendon to balance the muscle strength of ankle joint

12  Lower Limb Deformities Caused by Immunological Diseases and Viral Infectious Diseases

12.6.4 Clinical Data of Limb Deformities Caused by HFMD in Qinsihe Orthopedics (Table 12.4) Table 12.4  Clinical data of Limb deformities caused by hand-foot and mouth disease Catalog Gender Age (year) Time Fixation

Side

Deformity∗

Item Male Female 1–14 2010–2017 Ilizarov fixator Hybrid fixator Others Left Right Bilateral Hip Knee Foot and ankle

Case (n) 3 3 6 6 0 4 2 4 1 1 2 4 5

Note: Some patients with compound deformities are included in this group

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Nonunion, Bone Defects and Osteomyelitis Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Yilan Wang, Yilian Han, Qi Pan, Xuejian Zheng, Wei Wang, Yueju Liu, and Quan Wang

Table 13.3  Number of surgery

13.1 Clinical Data Sihe Qin, Yilan Wang, and Jiancheng Zang A total of 69 cases of lower extremity nonunion and bone defect have undergone surgery in Qinsihe Orthopedics Institute; the clinical data is as follows (Tables 13.1, 13.2, 13.3, 13.4, 13.5, 13.6, and 13.7):

Cases (n) 48 21

Percentage (%) 69.57 30.43

Table 13.2  Age at surgery Age (years) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 61–65 66–70 Maximum age Minimum age Average age

Cases (n) 3 2 3 7 25 29

Table 13.4  Side distribution

Table 13.1  Gender distribution Gender Male Female

Period 1988–1992 1993–1997 1998–2002 2003–2007 2008–2012 2013–2017

Cases (n) 2 4 5 5 11 3 7 11 5 6 3 5 1 1 70 3 32.90

Percentage (%) 2.90 5.80 7.25 7.25 15.93 4.35 10.14 15.93 7.25 8.70 4.35 7.25 1.45 1.45

S. Qin (*) · S. Jiao · J. Zang · Y. Wang · Q. Pan X. Zheng · Q. Wang Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China

Side Left Right

Cases (n) 41 28

Percentage (%) 59.42 40.58

Table 13.5  Location of deformity Location Femur Tibia and fibula Calcaneus

Cases (n) 10 58 1

Percentage (%) 14.49 84.06 1.45

Table 13.6  The type of external fixation FSihe Qinixator type Hybrid fixator Ilizarov fixator Unilateral fixator Others

Cases (n) 11 53 1 4

Percentage (%) 15.94 76.82 1.45 5.79

Table 13.7  Surgical procedures Name of procedures Bone transport Debridement and fixation

Cases (n) 23 46

Percentage (%) 33.33 66.67

Y. Han Beijing Tongan Orthopedics Hospital, Beijing, China W. Wang Shengji Orthopaedics Hospital, Beijing, China Y. Liu Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China

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13.2 B  reaks Through the restrict Bottleneck treatment of Nonunion and Bone Defect Sihe Qin Bone healing is a ubiquitous natural life phenomenon that can be stably inherited. Cells are the carrier and performer of genetic information. Biological processes of bone healing are very similar to those of embryonic bone development. There are precise genetic procedures to regulate bone formation, apoptosis, and bone remodeling. The signal transmission and mysterious system regulation mechanism are awesome. Therefore, for the treatment of nonunion and bone defects, the doctor’s job is to create conditions to help initiate diseased tissue that has been damaged, dormant, and lacking vitality, so that it can re-energize the vitality of regeneration and complete the reconstruction of limb defects. Leaving the original nature of life’s natural restoration ability, no high technology can do anything. Understanding the cause and exploring the best treatment for the disease remain the ultimate goal pursued by clinical orthopedic surgeons.

13.2.1 Nonunion, Bone Defect, and “Fracture Disease” In the 1960s and 1970s, Chinese orthopedic surgeons had three major measures for the treatment of fractures: traction (including bone traction and skin traction), plaster, and surgical reduction. The major complications that are easy to appear with the above treatment methods are nonunion, bone defect, and joint stiffness, called “fracture disease.” In order to effectively solve the problem of fracture disease, Prof. He Meng who have Chinese traditional medicine background successfully developed the “fracture reduction external fixator,” promoted it nationwide, and achieved satisfactory results. With the introduction and application of AO internal fixation technology in China, modern “fracture disease” should probably include some complications such as osteoporosis, re-fracture, chronic osteomyelitis, and so on. Some cases of nonunion and bone defect were caused by a simple femoral or tibial closed fracture. The standard AO internal fixation technique was used. The doctor who presided over the operation thought that the operation was successful. The X-ray film postoperative also showed anatomic reduction of the fracture, but the plate break and bone nonunion, the patient had to perform more complicated internal fixation and bone graft surgery again, and some even have the tragedy of infectious bone defects. This suggests that the “fracture disease” under the modern scientific and technological civilization is not only a

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medical technology problem but also closely related to the social background and the market-driven medical model (Fig. 13.1).

13.2.2 Bone Metabolism Is Regulated by Stress All life tissues have a common phenomenon in the ability of wound repair. Any biological tissues such as mucosal tissues and connective tissues that appear early and differentiated in evolutionary history have stronger regeneration ability. Tracing back to the biological origin, bone is one of the strongest regenerative tissues. The evolution from low-level organisms to advanced organisms is first manifested in the occurrence and evolution of bones. The animal endoskeleton with calcium phosphate structure appeared about 400 million years ago, and until 300 million years later, the synovial joint with flexible motor function evolved. It is not difficult to understand why mammalian bones have such a simple, beautiful, and practical skeletal structure. The bone healing and fracture repairment can be seamless, while the muscles, skin, nerves, and other tissues do not have such a strong ability to regenerate and repair. Bone is a structure that adapts quickly to environmental changes and has a strong self-regulation ability. Bone cells are constantly changing in dynamic and optimized remodeling, that is, after the cells’ perceptual mechanical load in the bone, the density and structure of the bone undergo adaptive changes. The biological process of bone tissue regeneration follows Wolff’s law. As well known, exercise increases bone mass, and long-term reduction of exercise can lead to osteoporosis. A large number of experiments and clinical phenomena have confirmed that under the premise of micro-injury (such as bone elongation), bone repair has a magnified osteogenesis, that is, the amount of repair is greater than the amount of damage, otherwise the fracture will not be repaired by macro perspective. After the treatment of lower limb fractures, proper weight-bearing walking exercise in the early stage of the affected limb is the best stress-conducting stimulation to promote bone healing. The premise is that the fixation method cannot have obvious stress shielding effect. There are three main reasons that affect bone healing: Patients’ own factors or fracture local factors, improper medical methods or surgical procedures, and inappropriate postoperative management. Bone is the most regenerative tissue in the body. Modern medical technology should be able to complete the process of fracture reducing and bone remodeling. Understanding the origin and regenerative potential of bone, changing the thinking method and medical concept, the occurrence of “fracture disease” can be reduced or avoided; the bottleneck of treatment of bone nonunion and bone defect can be broken.

13  Nonunion, Bone Defects and Osteomyelitis Fig. 13.1  Nonunion of the lower extremities: (a) Nonunion of the proximal femur; (b) Nonunion of the distal femur; (c) Nonunion of the middle femur; (d) Nonunion and plate breakage of the middle femur; (e) Nonunion of proximal tibia; (f) Nonunion of the middle and lower part of the tibia; (g) Bone defect of the middle part of the tibia; (h) Nonunion of distal tibia

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13.2.3 Distraction Osteogenesis (DO) Is Gold Standard for the Treatment of Nonunion and Bone Defects “Bone Transport” has become the preferred method internationally for the treatment of bone defects. The principle of this procedure is supporting limbs of the injured or bone defect with external fixator by distraction or compression. The movable bone segment is moved along the predetermined direction, with appropriate speed and frequency that is given by movable external fixation device. Thus, the tail of the moving bone segment maintains continuity with the osteotomy by distraction osteogenesis; the cephalad side of the moving bone segment is fused with the targeted bone by bone transformation. Bone transport surgery can complete bone defect repair, bone healing, and limb deformity correction in one stage. “Bone transport” for the treatment of bone defects and related orthopedic diseases is the original creation by Prof. G.A.  Ilizarov. In September 1991, Prof. G.A.  Ilizarov made a 4-hour academic lecture in Beijing; he mentioned the rate of bone healing is close to 100%, when Ilizarov method is applied for the treatment of fractures, nonunion, and bone defects except bone tumors or other unexpected factors in Ilizarov Center of Russia. Chinese doctors did not believe this conclusion at that time. However, according to the data of two teams of Dr. Hetao Xia and Dr. Sihe Qin, more than 100 patients were included, and the cure rate of nonunion and bone defects reached 92% in one stage surgery. Why does the distraction osteogenesis technique have such a peculiar effect on nonunion and bone defects? It is rooted in the combination of tension-stress law and modern technology. Its theoretical basis and medical model follow the nature principle and Wolff laws, that is, under the stimulation of stress and strain, human tissues can reproduce the potential of regeneration, and then the shape and function of limb can be reconstructed. The regeneration of microvascular network is precursor in the process of osteogenesis, and the occurrence or extinction of other tissues must be carried out on the basis of blood circulation reconstruction. This therapeutic mechanism is in line with the concept of “activating blood circulation to dissipate blood stasis,” “eliminating necrotic tissues and promoting granulation” from traditional Chinese medicine. Although there are deep understanding of the concept of limb natural reconstruction and skilled usage of Ilizarov technology, combined with autogenous bone grafting and internal fixation if necessary, nonunion curing and bone defect restoring are not impossible in one-stage treatment.

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How to use mechanical stress to induce two different biomechanical processes which is distraction osteogenesis and transformational osteogenesis should be understood when bone nonunion and defects were treated using Ilizarov technology. The distraction osteogenesis produces new bone between the osteotomy surfaces that are subjected to continuous traction. Histologically, this process is very similar to intraosseous ossification; transformation osteogenesis is pathological bone interfaces (such as nonunion) restores normal bone connections through mechanical stimulation. The nonunion without shortening can heal without bone transport and bone grafting but only by sclerotic bone exfoliating and breaking with a sharp osteotome. The alignment can be corrected acutely during the operation, and the Ilizarov external fixator is applied through the wires. An axial elastic compression continuous stimulus is formed after the patient walks with weight-bearing. This method is simple and effective (Fig. 13.2). In order to reduce the period of external fixation, it is an optimized combination of external and internal fixation which is supported by intramedullary nail or titanium alloy rod. Dr. Qin Sihe particularly emphasized that a patient is the first assistant of doctors. Walking is the best treatment, and affected limb must be used for walking with weight-bearing.

13.2.4 Summary Reliable, simple, economical, minimally invasive, avoiding, or reducing damage to the donor area is the basic criterion for measuring the pros and cons of medical methods. The history of scientific development shows that technology is often ahead of basic research as a precursor to theoretical breakthroughs. The research of nonunion and bone defect has reached crossroads. If we continue to carry out “refinement research and micro-theoretical explanation” and follow the traditional orthopedic concept and medical model, it may be difficult to make a progress. If you return to nature, all forms are dominated by the laws of nature. The human body is also under the control of natural laws. Imitating nature, understanding and practicing the natural reconstruction concept can realize applying simple, mature, reliable, and practical techniques correctly. It is not difficult to cure all kinds of nonunion and bone defects. The curative effect is the unique standard for testing of medical methods and doctors’ comprehensive ability.

13  Nonunion, Bone Defects and Osteomyelitis Fig. 13.2  This patient is a 70-year-old female with distal tibial nonunion and ankle varus deformity, she suffered left tibial fracture 3 years ago and underwent six surgeries. (a) Preoperative clinical appearance; (b) Preoperative X-ray film; (c) The site of tibial nonunion was debrided intraoperatively; (d) Fibula plate was removed and fibula osteotomy; (e) The Ilizarov external fixator was applied; (f) Postoperative walking with crutches; (g) In 14 months follow-up, the ankle varus deformity was corrected; (h) X-ray film showed bone healing in 14th month after surgery

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13.3 F  emoral Nonunion, Bone Defect, and Osteomyelitis Shaofeng Jiao, Jiancheng Zang, and Sihe Qin

13.3.1 Etiology, Pathogenesis, and Classification 13.3.1.1  Etiology and Pathogenesis The process of bone healing requires a good environment around the fracture site. The following conditions should be met: a stable biomechanical environment, a favorable biological environment (excellent soft tissue coverage providing good vascularity and growth factors), and contact of the bony ends; it is the “diamond concept.” The absence of any of the above conditions may result in a nonunion. 1. Mechanical instability can cause excessive movement at the fracture site. 2. The most important factor affecting bone healing is the local blood supply. Any factor affecting the blood supply will impair bone healing. 3. Contact between fracture ends is an important prerequisite for bone healing. 4. Infection will worsen the internal environment required for bone healing, reduce the blood flow of the nourishing artery, lead to occlusion of the nutrient vessels, and thus destroy the normal process of osteogenesis and promote the formation of dead bone. 5. There are many systemic factors that can affect the healing of fractures, including aging, malnutrition, alcoholism, diabetes, atherosclerosis, neurological diseases, radiation therapy, and drugs (such as hormones, anticoagulants, and cytotoxic drugs). 6. Improper use of internal or external fixation may result in a nonunion due to a poor local biomechanical environment around the fracture site. (a) Classification of femoral nonunion The classification of femoral nonunion is as follows: hypertrophic nonunion, dystrophic nonunion, atrophic nonunion, pseudoarticular nonunion, infectious nonunion, and bone defect nonunion.

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there is abnormal movement at the fracture site 2. Thigh pain during weight-bearing. (b) Limbs that have a nonunion often have some associated angular, shortening, or rotational deformities. (c) Obvious muscular atrophy and disuse of the affected limb. 2 . Imaging examination (a) Plain radiographs of a typical nonunion generally include the following characteristics (Fig. 13.3): (1) a gap between the fracture ends; (2) bone sclerosis and increased focal density; (3) marrow cavity closure, with the ends of the bones being thin and tapered; (4) osteoporosis; (5) trabecular discontinuity between the fracture ends; (6) pseudoarthrosis formation. (b) CT scans play a significant role in early diagnosis and accurate prediction of femoral nonunions.

13.3.1.3  Surgical Treatment Goals The treatment goals generally include (1) eradication of the nonunion; (2) deformity correction; (3) joints contracture release; and (4) functional rehabilitation. Most of the above can be resolved in one surgery; however, some patients need to have a staged approach, to achieve the desired result.

13.3.1.2  Clinical Manifestations and Imaging The diagnosis of femoral nonunion depends on the clinical examination and X-ray findings, and sometimes CT scan plays an important role in the confirmation of the diagnosis. Blood tests (hemoglobin count, erythrocyte sedimentation rate, and CRP) are also important diagnostic criteria for an infective femoral nonunion. To determine the extent of the infection in the affected bone, MRI scan is a useful imaging tool. 1. Clinical manifestations (a) Femoral fractures taking more than 8 months to heal can be diagnosed as a femoral nonunion, as long as

Fig. 13.3  X-ray of femur nonunion; the internal fixation has failed due to stress shielding

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13.3.1.4  Surgical Procedures, External Fixation Configuration, Operating Procedures, and Surgical Risk Avoidance Using an external fixator has become the accepted method of treatment of nonunion, especially for infective, boney defect and deformity associated with the nonunion. 1. Monorail external fixator: The monorail external fixator is relatively simple in configuration, consisting of a long-slotted rail with several clamps fixed to the rail which can slide independent of each other, distraction/compression device, and half-­pins (Fig. 13.4). This apparatus is relatively convenient for the patient because the fixator is applied on the lateral side of the femur and is significantly cumbersome than circular fixators. Three half-pins are fixed to each clamp for the stability of fixation and preventing bone displacement during the distraction process. In the presence of osteoporosis, it is best to place screws with hydroxyapatite coating to increase the holding power. The specific surgical procedures are as follows: (a) Place the external fixator: Draw a line between the tip of the greater trochanter and another point on the mid-point of lateral femoral condyle; the half-pins should be inserted along this line. First, place one pin in the distal of femoral along the rail; three clamps can slide smoothly. Insert a trocar through the outer sleeve on the distal clamp to the lateral femoral cortex find the midpoint of the femur, and push the trocar to the cortex. Take out the trocar and insert the 4.8  mm drill guide in the outer sleeve. Use the 4.8 mm drill making sure the drill is perpendicular to the longitudinal axis of the femur and is placed 15° above the coronal plane, to penetrate the lateral and medial cortex of the femur. An assistant keeps the rail parallel to the longitudinal axis of the femur. A half-pin is screwed into bone with a “T” handle after the drill guide is removed, and make sure that the pin tip is 2  mm across the contralateral cortex. The second pin is fixed in the proximal part of the femur and generally located at the upper edge of the lesser trochanter as described in the previous method. The operator adjusts the position of the intermediate clamp under fluoroscopy, to ensure the pin is located at the center of femur on a lateral view. The assistant maintains the position of the monolateral rail and tightens the three clamp templates to the rail when the operator determines the other pin holes at satisfactory point by the above method. Pins fixation remained using the standard method described above. For increased stability, the cortical pins with hydroxyapatite coating can be used. Loosen and remove the clamp templates, rail links, and outer sleeve guide together from the pins.

Fig. 13.4  Monorail external fixator for femur lengthening

Fix the definitive three clamps and rail frame according to the position of pins, ensuring the distance between rail and skin is at least 2 cm and then tighten the clamp locking screw to the rail. ( b) Osteotomy, debridement: A compression-distraction device that has been adjusted to an appropriate length is placed over the clamps,

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which is put on tension between the intended osteotomy and the moving bone segment. A longitudinal incision on the anterior surface of the femur is made, and the periosteum is cut longitudinally, the anterolateral 1/4 of the femoral circumference is carefully exposed. Drill holes are made at the level of the intended osteotomy with the help of a perforator. The debridement of the nonunion is performed with regular shape, and then the cortical osteotomy is performed with a sharp osteotome. Due to the tension applied by the compression-­distraction device at the osteotomy site, the ends of the osteotomy will separate automatically when cut with the osteotome. Rotate the bolt in the compression-distraction device in a clockwise direction to compress the gap between the osteotomy ends and then tighten the clamp on the rail to secure this position. 2. Ilizarov external fixator: The Ilizarov external fixator has the most stable mechanical properties, which can apply a uniform stress to the bone segment. The device is not a fixed final configuration, but can be adjusted by doctors and/or patients gradually during the treatment. The Ilizarov external fixator is a complete system that is mechanically stable, minimally invasive, and functionally well adapted, which can meet clinical practice as much as possible, and to enable the affected limb to load and to retain the ability of adjacent joint activities. (a) Application of Ilizarov external fixator A standing full-length X-ray film of both lower limbs should be taken before surgery. The doctor needs to determine the extent of the diseased bone to be excised and the location of the normal bone and template the external fixator with the bone. An external fixator is constructed depending on the thickness and deformity of the affected limb. The size of the ring should be at least 2–3 cm greater than the thigh. The ring at the ends of the femur is called “basic ring,” and the middle ring is called “reset ring.” A reset ring and a basic ring form a fixed module for a bone segment, and the two modules are connected by threaded rods and hinges. In order not to affect the joint function, a half ring or two-­thirds of a ring is required. If the femoral nonunion or bone defect is close to the knee joint and the distal bone block is a sufficient room to accommodate a fixed module, it is necessary to go across knee joint with hinges. External fixator preassembly is a very convenient way for preforming surgery when we treat nonunion and bone defect using the Ilizarov technique. It is very important to mount the fixator on the limb before the diseased bone is removed and osteotomy performed. Otherwise, there will be significant deviations and separations between proximal and distal parts of bone segment.

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Fig. 13.5  Safe zone for wire insertion in the thigh

(b) Wire technique of external fixator There are certain rules and techniques for wire insertion in the thigh, because the thigh is rich in muscles, blood vessels, and nerves. • It is not suitable to pass wires in the proximal thigh. Reasonable use of pins can avoid crossing too much soft tissues, reduce the chance of neurovascular injury and infection rate of pin tract, which can detrimentally affect the patient’s activities of daily living. • The number of pins is determined according to the size of the affected limb and the age or weight of the patient. Generally, one 2–3  mm diameter wire is passed parallel to knee joint in the distal segment, two or three 4–6 mm diameter half-pins around this reference wire, three or four 4–6 mm diameter halfpins in the proximal segment (Fig. 13.5). • The distance from the parallel wire to joint surface is about 5 cm. The location of pin insertion is slightly ahead of the midpoint of distal femur and 2–3  cm from the articular surface. The direction

13  Nonunion, Bone Defects and Osteomyelitis Fig. 13.6  Optimal angle of pin insertion on the distal femur: (a) front view; (b) lateral view

Fig. 13.7  Optimal angle of pin insertion on the proximal femur: (a) front view; (b) lateral view

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of half-pins is from posterior-­lateral to anteromedial or posteromedial antero-lateral at 30–40° to the parallel wire (Fig. 13.6). • Three half-pins in the proximal femur side are inserted in a triangle. The distance between these pins is 2–3 cm. The two half-pins at the bottom of the triangle are on the coronal plane of the femur. One pin is 1 cm from the apex of great trochanter, and another pin at the bottom of triangle is placed at the level of lesser trochanter. The pin on the top of the triangle is at an angle of 30° to the coronal plane of the femur (Fig. 13.7). • The correct pin implantation technique. • Predrill with a new, sharp drill bit at low speed, and then manually insert the half-pin. Do not put the steel pin too tight, because this may cause microfractures around the pin and reduce the torsional resistance of the pin. After external fixator application, the subsequent surgery is debridement of the affected area of bone. (c) Bone debridement and bone resection In atrophic nonunion or a bony defect, sclerotic bone around the lesion should be resect. In infective nonunion, infected bone resection should be performed with debridement simultaneously. The criteria for the bone resection are no dead bone and inflamma-

tory erosion, no secretions, obvious point-like hemorrhage on the surface of the cortical bone, reddish color on the bone shaft, medullary cavity smooth without granulation tissue, and active bleeding. When the extent of debridement is determined, the surgery can be performed. A sharp drill bit and osteotome are recommended instead of oscillating or jigsaw. The diseased bone is removed with a periosteal stripper as completely as possible, and then one observes the blood supply of soft tissue and the two bone ends; the bone ends may need to be cut again if necessary. ( d) Osteotomy: Osteotomy is the last step in this procedure. Osteotomy site should be determined first, and a small longitudinal 1–2 cm incision is made; the periosteum using blunt dissection push to both sides, and then osteotomy performed using a 2.5  mm drill bit and double barrel drill sleeves. The cortical bone is cut with a small thin osteotome to ensure the periosteum remains intact.

13.3.1.5  Postoperative Management 1. Postoperative management procedures The knee is moved through passive flexion and extension on completion of surgery, to ensure the muscles around

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the knee are not tethered, which will help in postoperative rehabilitation of the patient. After returning to the ward, a small pillow is placed in the popliteal fossa to maintain the knee joint in a semi-­ flexion position, and the affected limb is raised 20–30° to promote the venous and lymphatic drainage and to prevent or reduce the swelling of the affected limb. On the second day post operation, the patient is instructed to perform isometric contraction of the thigh muscles. Some older patients are treated with anticoagulant drugs to prevent deep vein thrombosis. The patient’s family members or therapists give the patient a passive flexion and extension of the hip and knee joint to prevent a contracture, and relieve Fig. 13.8  Gauze wrapping the pain caused by the external fixation. The pin tracts are wrapped and moderately pressed with sterile gauze, which can keep the pin sites clean. It is not necessary to change the dressing frequently to prevent pin tract infection. Bone lengthening is started on the seventh day after surgery, 1/4 mm turn, four times per day, with a total distraction rate of 1  mm per day. A postoperative X-ray should be taken to confirm the osteotomy is complete. X-ray films are taken every 2 weeks during lengthening period and monthly during the consolidation period to observe the bone formation and the limb alignment. If the bone formation is poor, it is necessary to slow down the bone lengthening or a compression-distraction regime started to promote osteogenesis. If there is an axis offset, Fig. 13.9  Hard palate around the pin the appropriate measures can be performed in time. thicker soft tissue (Fig. 13.8). The hard scab originatIn the lengthening phase, the patient is encouraged to ing from continuous exudation around the pin is a partial weight-bearing with crutches and is encouraged protective reaction to avoid pin infection, because full weight-bearing when the bone formation has comthis hard palate (Fig. 13.9) like a gauze can avoid slidpletely mineralized. ing between soft tissue and pins. 2. Complication (c) Stiffness and dislocation of knee joint. With the wide range of indications, the applications of In the case of nonunion of distal femur and instability Ilizarov technique have become more and more accepted of single-ring fixation, cross-knee fixation should be by the academic communities. The complications of carried out, and hinges applied at the CORA for knee application of external fixation can be avoided as long as movement, and movement can be alternated in the the clinical practice is in accordance with the standard process of treatment. procedure, careful design before surgery, timely examinaWhen femur lengthening is more than 4  cm, the tion, and adjustment in follow-up period. quadriceps femoris and the hamstring muscles are not (a) Thermal injury and neurovascular injury. lengthened synchronously, resulting in imbalance of Sharp K-wire is inserted; a small incision is made the anterior and posterior muscles of the knee, and the before pin or wire insertion; control the speed of the posterior dislocation of the knee joint will gradually electric drill at low speed and high torque and insert appear (Fig.  13.10). When the femur lengthening is the wire intermittently; and cool the wire with alcomore than 6 cm, a ring should be added in the proxiholic gauze. When penetrating near the blood vessels mal tibia across the knee joint (Fig.  13.11). This and nerves, the skin should be incised with a sharp application can prevent dislocation of the knee joint knife, and the soft tissue separated to the bone surface and reduce stiffness of the knee joint. If a dislocation with vascular forceps, if necessary, with a cannula. of the knee has occurred, the configuration of (b) The pin tract infection. Ilizarov fixator can be changed, and the joint can be Wrap the pin tract with gauze to ensure adequate ­repositioned by gradual distraction. Then the external pressure between the gauze and pin, especially for

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fixator joint hinge can be fixed at the CORA of the normal joint for 2–3 months. (d) Osteoporosis. The patient should be encouraged to walk with full weight-bearing to prevent or reduce osteoporosis. (e) The erythra. The erythra is less common, and the cause is unknown. In the early stage, anti-allergy treatment was considered for metal allergy, but in some cases it was ineffective. In severe cases (Fig.  13.12), glucocorticoids can be used externally or the pins and fixator be removed directly.

13.3.1.6  Removal of External Fixation When X-ray shows the density of callus is similar to normal bone, the pin of external fixator can be loosened, and the patient continues to exercise with full weight-bearing. Another X-ray film is reexamined 1 or 2 months later. If the bone healed well and is solid, the external fixator can be removed without anesthesia. The removal of external fixator postoperative should be based on both imaging findings and functional healing of the bone. If the external fixator is removed too early, there may be compression collapse or angular deformity. Soft tissue has not been fully regenerated and reconstructed under Fig. 13.10  Knee joint dislocation during femoral lengthening

Fig. 13.11  Cross-knee fixation

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s­ ustained tension, so deformity recurrence may occur after removal of the external fixator. Notes for removal of external fixator: (1) Removal of pin or wire by stages, gradually reducing the fixed stiffness; (2) The principle of “Better late than early” should be followed.

13.3.1.7  Typical Cases The patient was a 30-year-old male with infective nonunion on the right femur due to an open fracture 2  years ago (Fig. 13.13). 1. Two years ago, the patient sustained an open comminuted fracture of the right femur and treated in a local hospital.

Fig. 13.12  Severe rash case during the application of external fixator

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The initial operation was debridement, fracture reduction, and plate fixation. Unfortunately, infection and nonunion occurred postoperatively. On admission, there was a sinus in the middle and lower part of the right thigh and a small amount of purulent discharge, and the range of motion of knee was 0–30°; X-ray showed that the lower third of the right femur was fixed with plate, with reactive calluses and a nonunion. 2. Surgical treatment plan: Removal of the plate and infected bone segment; monolateral fixator application with a proximal femoral osteotomy. 3. Preoperative preparation: Tools for plate and screw removal, electric saw, monolateral fixator with bone transport function and the relevant instrumentation. 4. Surgical procedure: After disinfection of the skin, the sinus should be covered with sterile surgical patch to prevent contamination. First, a monolateral external fixator was applied parallel to the thigh. Under the guidance of module template, a 6  mm diameter half-pin was inserted in the lateral side of the femoral condyle, and then a 6 mm diameter half-pin was inserted into the greater trochanter to adjust the alignment. Next, another 6 mm diameter half-pin was inserted into the femoral condyle, and two 6  mm diameter half-­ pins were inserted into the great trochanter; the other two 6 mm diameter half-pins were inserted through the middle femoral module. Second, a subtrochanteric cortical osteotomy was preformed through a 1 cm incision. The infected bone segment was resected through a middle and lower thigh lateral incision, and the internal

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Fig. 13.13  The treatment of right femur infective nonunion. (a). Preoperative X-ray; (b). Postoperative X-ray; (c). Postoperative X-ray, bone transport completed, and bone healed

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fixation can expose and be removed. The incision was irrigated with 1000 mL saline. After debridement, a drainage tube was placed. The last 6 mm half-pin was inserted into the femoral condyle. 5. Tips and tricks: The sinus tract should be protected when external fixation mounting and subtrochanteric osteotomy performed, and then the infected bone segments can be removed to prevent cross-infection. “Fixator first and then osteotomy” can maintain the femoral axis and prevent displacement of the boney segments. 6. Postoperative management: The patient started weight-bearing with crutches from fifth day after surgery, X-ray was taken on seventh day after surgery, and then the fixator was adjusted. The speed of bone transport was 1 mm/day (divided into six times). The X-ray film was reviewed once every 2 weeks. When the bone segment was docked with the distal end, it had to be further compressed by 5 mm to ensure adequate compression. The fixator remained in site until bone healing. A 32-year-old female with 16  cm femoral defect sustained an open femoral fracture in a road accident 1 month previously, with bone loss occurring at the scene of the accident (Fig. 13.14). 1. Initial debridement and simple fixator were performed at the local hospital. One month after the injury, the thigh wound healed, and she went to our hospital for further treatment. X-ray film shows the left femur defect of 18 cm. 2. Surgical plan: The left femur simple external fixator was removed, the Ilizarov external fixator was applied, and the femoral trochanter was removed to repair the bone defect. 3. Preoperative preparation: Ilizarov external fixator, electric drill, double barrel drill sleeves, narrow osteotome. 4. Surgical procedure: An assistant maintains axis of the lower limbs with distraction. Ilizarov external fixator was applied to the thigh. The distal ring was fixed with a 2 mm K-wire in the femoral condyle level, and the proximal ring was fixed with a 5 mm half-pin at the great trochanter level, so the basic framework was established. A 3  mm K-wire and two 5 mm half-pins were inserted in the middle part of the femur and connected with the movable ring. The anterolateral incision was about 1 cm below the lesser trochanter. The cortical ­osteotomy was completed by electric drill, double-barrel drill sleeves, and narrow osteotome. 5. Tips and tricks: During the application of external fixation, pay attention to maintain the axis of femur. Because the distal

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residual bone segment was too short, it was necessary to cross the knee joint to improve the fixation stability. 6. Postoperative management: The patient started weight-­ bearing with crutches from the fifth day after surgery, and X-ray was taken at seventh day after surgery. The speed of bone transport was 1 mm/day (divided into six times), and then the fixator was adjusted until the bone defect is restored. The patient should keep the fixator in situ until the bone formation is completely ossified. The iliac bone graft was performed in the second stage of surgery because of a triangular defect at the docking site.

13.3.1.8  Summary The application of Ilizarov external fixator greatly improves the success rate of treatment of femoral nonunion and bone defect and shortens the treatment period of infective femoral nonunion. Although this technique has the drawbacks of long treatment cycles and inconvenient equipment to carry, these drawbacks are perfectly accepted by the patients compared to the effectiveness they achieve. The complications occurred in clinical practice are mostly related to doctors who cannot understand the Ilizarov technique principle, nonstandard application, improper indication selection, and neglected management postoperatively. In the standard process, through careful and strict peri-post-operative management and regular follow-up, generally, the occurrence of complications can be avoided.

13.4 Tibial Nonunion and Defect Sihe Qin, Shaofeng Jiao, Quan Wang, Jiancheng Zang, and Yilian Han Tibial nonunion is usually caused by fracture, osteotomy, and other factors that destroy the blood supply. The broken ends of the tibia are filled with fibrous tissue or cartilage to form pseudo-joints, resulting in pain, abnormal motion, and a variety of deformities (Fig. 13.15). Tibial defect is often caused by congenital anomalies, trauma, infections after internal fixation, and other factors, resulting in a local tibial defect of more than 1 cm. The two broken ends do not come in contact, resulting in a gap filled with fibrous tissue (Fig. 13.16). Ilizarov technique is the most suitable method for the treatment of tibial nonunion and bone defect. It has the advantage of simplicity and safety and is minimally invasive and effective. Correct use of Ilizarov technique can achieve 100% satisfactory clinical results.

528 Fig. 13.14  A 32-year-old female with 16 cm femoral defect, she suffered open fracture in a road accident 4 weeks ago. (a) External fixator was temporarily applied to maintain limb stability and length in emergency. (b) Ilizarov technique was applied to restore the bone defect. (c) X-ray 10 months after surgery; (d). Clinical appearance 13 months after surgery; (e) Sliding bone segment has been touched with distal end at 22 months follow-up. (f) Clinical appearance when the external fixator was removed; (g) X-ray showed a triangular bone defect on the docking site; (h) Clinical appearance at 2 weeks after the surgery of iliac bone graft and fixation; (i) The X-ray took at 2 weeks after the surgery of iliac bone graft; (j) Clinical appearance at 42 months follow-up; (k) X-ray of 42 months follow-up

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13.4.1 Tibial Nonunion 13.4.1.1  Indications 1. Tibial nonunion without soft tissue infection. 2. The patient must be cooperative for treatment and willing to tolerate long-term external fixation. 3. Nonunion with tibial shortening. 4. Absence of other systemic diseases affecting surgery. 13.4.1.2  Preoperative Evaluation 1. X-ray: X-ray of tibia and fibula can show local anatomy and type of nonunion. Full-length X-ray view helps in understanding the deformity and limb length discrepancy.

2. Laboratory tests: Routine laboratory tests help to diagnose and exclude any concomitant systemic disease. 3. Local examination of the affected limb: Presence of infective foci or adherent scar can be checked from the local soft tissue examination. 4. Gait analysis.

13.4.1.3  Preoperative Preparation 1. The surgical plan: The operative plan should be designed according to the local condition and result of the X-ray assessment. It includes the location of osteotomy, configuration of external fixator, need for debridement, and whether bone graft is needed. 2. The preparation of external fixator and instruments: The configuration of external fixator can be assembled in advance and autoclaved according to the preoperative surgical plan.

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13.4.1.4  Surgical Procedure 1. An epidural or general anesthesia is used for surgery. 2. The patient lies in supine position. Iliac crest is prepared if bone grafting is required. When tibial nonunion is combined with deformity, both can be corrected simultaneously.

13.4.1.5  Postoperative Management The patient can start walking with partial weight-bearing with walker from 5 to 7 days after surgery. X-rays are done 1 week after surgery, and adjustment of external fixator is started for lengthening and correction of residual deformity. Proper care of external fixator should be taken to prevent infection of the skin around the pin. If the bone ends at ­nonunion site are flat and well aligned, they can be compressed. If the bone ends are not flat, they can be distracted, or “Accordion” technique can be used.

Fig. 13.15  Tibial nonunion Fig. 13.16  Tibial defect. (a) Tibial defect after debridement; (b) X-ray shows tibial defect

Fibular osteotomy is performed first through a small incision. A series of holes are drilled with a drill bit, and fibula is broken completely by applying pressure with thumb. Then the tibial nonunion is exposed, and fracture ends are freshened by removing sclerotic cortical bone. The defect at nonunion site is filled with cancellous bone from iliac crest. A series of holes are drilled at the lengthening site of tibia as determined before surgery, Ilizarov fixator is then applied, and finally, tibia is cut with an osteotome along the drilled holes. 3. Tips and tricks: (a) Care should be taken to avoid injury to common peroneal nerve while performing proximal fibular osteotomy and inserting proximal wire. (b) Avoid neurovascular injury while removing necrotic and sclerotic tissue. (c) Do not make an incision over soft tissue scar to avoid postoperative skin necrosis. (d) If the anticipated tibial lengthening is more than 3 cm, the Achilles tendon device should be installed across the ankle joint.

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1. Surgical plan: The external fixator is installed to correct the deformity at nonunion after freshening the fracture ends; Osteotomy (corticotomy) for lengthening was performed in the distal tibia. 2. Preoperative preparation: Ilizarov external fixator, double-­ barrel drill sleeves, electric drill, sharp osteotome, etc. 3. Surgical procedure: A small incision was made in the middle of the fibula. Using the drill sleeve, a row of holes were made by electric drill, and fibula was broken completely with osteotome. An appropriate incision was made at the nonunion site in the proximal tibia to expose the nonunion, and cortical bone

The fixation should be maintained once the predetermined length and anatomical axis are restored. The stiffness of fixation is reduced gradually, and fixator is removed once healing is complete as per the principle of application of external fixation.

13.4.1.6  Typical Cases Case 1 A 32-year-old female with right tibial nonunion secondary to an open comminuted fracture sustained in a car accident 15 years ago (Fig. 13.17).

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Fig. 13.17  A 32-year-old female with tibial nonunion secondary to open fracture of tibia 15 years ago. (a) Clinical appearance on admission, right tibial varus, and shortening; (b) X-ray on admission; (c) The surgery was performed to freshen the fracture ends, and the osteotomy was performed at distal tibia; (d) X-ray at 35 days after surgery; (e) Front view 35 days after surgery; (f) Back view 35 days after surgery; (g) 62 days after surgery; the proximal tibial deformity was corrected, the leg was lengthened about

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5 cm, and the lower limbs were of equal length; (h) X-rays 62 days after surgery; (i) 9 months after surgery; X-ray showed that the callus grew well, so the Ilizarov external fixator was removed, and the two pins were connected with unilateral external fixator; (j) X-ray 11 months after surgery; external fixator has been removed; (k) 1 year after surgery; the limb length and mechanical axis restored to normal; (l) Knee joint function was normal; (m) The healing of nonunion and lengthened callus was good

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exfoliation with sharp osteotome was performed to expose the broken end. When all of the sclerotic cortical bone was removed, the wound was sutured and supramalleolar osteotomy was done using double-barrel drill sleeve. ­ Finally, Ilizarov external fixator was mounted. 4. Tips and tricks: When the nonunion is exposed, special attention should be paid to protect the flap due to adherent scar. The common peroneal nerve should be protected to avoid injury during surgery. 5. Postoperative management: The patient is allowed to walk with partial weight-bearing with walker on the fifth day after surgery, X-rays were taken 1 week after surgery, and the external fixator was adjusted to correct proximal tibial varus. Bone lengthening in distal tibia was started with a speed of 1 mm/day, divided into six times. When the proximal tibial varus deformity was corrected, tibial lengthening was continued till equalization of the lower limb. External fixator was not removed unless the bone has healed firmly.

13.4.2 Tibial Bone Defect 13.4.2.1  Surgical Indications 1. Tibial bone defect without infection in soft tissue. 2. Normal intelligence, compliance to treatment, and willing to carry external fixator for a long time.

3. For the patients with limb shortening, lengthening surgery can be performed simultaneously. 4. There should not be any other systemic diseases affecting the operation.

13.4.2.2  Preoperative Examination and Preoperative Preparation For preoperative examination and preoperative preparation, refer to the section about nonunion of tibia. 13.4.2.3  Surgical Plan 1. The tibial bone defect caused by trauma can be restored by bone transport (Fig. 13.18). For patients with bone defects in the middle tibia, sufficient length of bone proximally and distally, bone transport can be performed with bifocal osteotomy. If tibial defect is close to the joint, and the length of the other segment is enough for bone transport, biplane osteotomy can be performed in which the two segments move in the same direction. The two methods can effectively shorten the period of bone defect reconstruction. 2. Bone defects as a sequel of osteomyelitis in childhood is often accompanied with varus deformity and shorting of the tibia when it becomes mature. It presents compensatory hypertrophy of fibula and dystrophy at both ends of tibia (Fig. 13.19). The patients can be treated by resection of tibial pseudarthrosis and tibialization of fibula.

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Fig. 13.18  Bone transport. (a) Monofocal bone transport; (b) Bifocal bone transport; (c) Bifocal unidirectional bone transport

Fig. 13.19 Transverse transport. (a) Tibial defect; (b) Tibialization of fibula

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13.4.2.4  Surgical Procedure 1. Spinal or general anesthesia. 2. The patient is in supine position, affected limb is painted and draped sterile. (a) Bone transport: Tibial osteotomy can be done with small incision. Ilizarov external fixator is mounted

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neck region can be made for fibular osteotomy. Common peroneal nerve is exposed and protected. Fibular osteotomy is performed below the fibular neck. Another osteotomy is performed with a mini incision above the lateral malleolus. Ilizarov external fixator is mounted with wires and pins, and the incisions are sutured. 3. Tips and tricks. (a) When fibular osteotomy is performed, the common peroneal nerve should be handled carefully. (b) When bone ends are resected, care should be taken to avoid neurovascular injury. (c) Surgical incision should be kept away from the scar to avoid skin or flap necrosis after surgery. (d) For the patients with severe limb shortening, a special device for simultaneous Achilles tendon lengthening should be used to prevent complications. 4. Postoperative management. (a) The patient can walk with weight-bearing with crutches, 5–7 days after surgery. (b) X-ray should be taken 7 days after surgery; the adjustment of external fixator can be started for fibular centralization (medialization). (c) Pin tract care. (d) The configuration of the external fixator can be adjusted for limb lengthening when the fibular segment was pulled to correct position. (e) When the length and anatomical axis are restored, the fixator should be maintained until good bone formation and rigidity of fixation is gradually reduced until removal.

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ator was then mounted, and the bone was cut along the holes using a narrow osteotome. 4. Tips and tricks. During installment of the Ilizarov external fixator, normal axis of the tibia should be maintained. If this was not done during surgery, readjustment of the configuration of external fixator was needed later. 5. Postoperative management. The patient was allowed to walk with crutches 5  days after surgery. Lengthening was started at the rate of 1 mm/ day divided into six times from the seventh day after surgery, after taking X-ray. The two bone segments were gradually brought together to close the bone defect. When this was achieved, further compression of 5 mm was given. The fixator was then maintained until bone healing and then removed. Case 2 A 26-year-old male presented with severe bone defects of the left tibia secondary to osteomyelitis in infancy. He had developed gradual shortening of leg, varus, and internal rotation deformity. X-ray films showed a shortening of left tibia of about 18 cm and defect in the middle of tibia. It also showed shortening, thickening, and bending of fibula to the tibial side in a C shape (Fig. 13.21).

1. Surgical plan: Fibular osteotomy, tibialization of fibula, and then fibular lengthening. 2. Preoperative preparation: Ilizarov external fixator and tools, electric drill, sharp osteotome, etc. 3. Surgical procedure: A small incision over the lateral aspect of fibular head and neck was made, the common peroneal nerve was exposed, and osteotomy of fibula 13.4.2.5  Typical Cases was done. Case 1 A small incision was made below the tibial tubercle A 38-year-old female patient presented with tibial bone defect over the medial aspect, and osteotomy of tibia was persecondary to debridement of open and infected comminuted formed with drill and osteotome. A distal fibular osteotfracture of left tibia, sustained in a road accident 23 months omy was done just above the lateral malleolus, and fibular ago. At admission, the infected wound had healed for segment was moved medially. The two ends of the fibula 6 months. X-ray film showed left tibial bone defect of 74 mm were opposed to the ends of the tibia and then fixed with (Fig. 13.20). a 2 mm K-wire. The incision was sutured, and the Ilizarov external fixator was installed. 1. Surgical plan. 4. Tips and tricks: Common peroneal nerve should be proOsteotomies were planned below the tibial tubercle and tected from injury while performing fibular osteotomy. in supramalleolar region, and bone transport was planned The axis of tibia should be restored while installing the to be carried out with Ilizarov technique. Ilizarov external fixator. The bone formation at docking 2. Preoperative preparation. site of tibia should be monitored carefully after surgery, Ilizarov external fixator and installation tools, double-­ barrel drill sleeves, electric drill, sharp osteotome, etc. and the speed of bone transport is adjusted accordingly. 3. Surgical procedure. 5. Postoperative management: The patient was made to A 1 cm incision was given below the tibial tubercle, tibia walk 5 days after surgery with crutches. On the seventh was exposed, and a row of holes were drilled under the day after surgery, X-ray was done and bone transport was guidance of double-barrel drill sleeves. started at the speed of 1  mm/day for six times. During Another row of holes were drilled 15  cm above the this period, the patient could walk bearing weight on the ankle joint using same method. The Ilizarov external fixaffected limb. The final length of bone transport was

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16 cm. Even then, it was still 2 cm shorter. However, the patient was satisfied because the duration of external ­fixation was too long. The external fixator was removed after 28 months postoperatively, and the length and function of the affected limb was satisfactory.

13.5 Fibular Bone Defect Shaofeng Jiao and Jiancheng Zang Fibular defect usually occurs with tibial defect. It is always overlooked during clinical practice because the fibula only bears about one sixth of the weight. We must pay attention

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Fig. 13.20  A 38-year-old patient presented with left tibial bone defect secondary to an open comminuted fracture and bone infection post-­surgery. (a) Appearance on admission; (b) X-ray films on admission; (c) Surgical osteotomy below tibial tubercle and distal part of tibia, Ilizarov external fixator was mounted for bone transport; (d) The postoperative appearance; (e) 54  days after surgery;

to the distal fibula defect, which can influence the stability of ankle joint.

13.5.1 Overview The length of the lateral malleolus plays a very important role in restoring the stability of ankle joint. If the lateral malleolus is short and the ankle integrity can be destroyed, the weight of the talus also can be affected. Distal fibula defect will result in lateral malleolus shortening, which can affect the pressure balance of the joint surface. It is reported that 75% of the ankle fractures with tilting of the talus may be secondary to osteoarthritis.

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bone segments in contact, but the axis of the tibia deviated; (f) the configuration of external fixator was changed for further adjustment; (g) Axis restored; (h) The bone formation in lengthening area and docking site was good; (i) Simplifying the fixator; (j) 24  months after surgery; good bone healing, external fixator removed; (k) 24 months after surgery

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It is generally believed that a simple fibular defect does not require special treatment, but distal fibular defect that located in the area less than 6–10 cm above ankle requires attention. It is usually reconstructed by bone graft and internal fixation or external fixation.

13.5.2 The Reconstruction of Distal Fibular Defect There are many literatures about the reconstruction of bone defect on tibia and femur, but few about fibular reconstruction.

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Qin Sihe et  al. reconstructed a case of distal fibular bone defect with Ilizarov fixator successfully and achieved good clinical results of the continuity of fibula and the balance of ankle mortise.

13.5.3 Typical Case The patient was a 19-year-old male with tibiofibular nonunion. He suffered from distal tibiofibular fracture due to road accident 5 years ago. A surgery of open reduction and internal fixation with plate was performed in local hospital.

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Fig. 13.21  Transverse transport of fibula for large segmental defect of tibia: (a) A 26-year-old male with tibial bone defect secondary to osteomyelitis, presented with shortening, varus, and internal rotation deformity of the left leg. (b) The bilateral popliteal fossa reached the same level when 16 cm block was kept under the left foot. (c) X-ray showed the tibial bone defect, and a thickened and bent fibula. (d) The fulllength X-ray of lower extremities showed 18 cm shortening in left tibia. (e) Bifocal fibular osteotomy was performed, and then the middle part was transferred to the tibial side in first stage of operation. X-ray taken 7

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days after surgery showed well alignment of tibia and fibula. (f) 10 days after surgery, lengthening was started at the proximal site. The fixation was extended over foot to correct the deformity of foot. 2 cm of bone formation could be seen 45 days after surgery; (g) 5 months after surgery; the patient insisted on walking weight-bearing with crutches; (h) The range of motion of knee joint was good; (i) 28 months after surgery; the length of lower limbs was equal and alignment was restored; (j) The function of knee and ankle joint was good; (k) Bone healing could be seen on the X-ray film; (l) Appearance after removal of external fixator

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The plate was removed 2 years ago (Fig. 13.22). Refracture occurred on distal tibia and fibula at the tenth month after the plate removal just by microtrauma, and then was fixed with plaster in a local hospital. Three months later, X-ray showed the fracture did not heal and the end became atrophy (Fig. 13.23). 1. Surgical plan: Fibula bone transport; application of Ilizarov external fixator. 2. Preoperative preparation: Ilizarov external fixator and instrument, electric drill, double-barrel drill sleeves, sharp osteotome, etc.

3. Surgical procedures: An incision about 1 cm on the middle and lateral side of fibula was made, and then, insert a double-barrel drill sleeves, drill holes with an electric drill, mounted with Ilizarov fixator, cut the fibula with an osteotome, and finally, suture the incision (Fig. 13.24). 4. Tips and tricks: The hinges of Ilizarov fixator should be placed on fracture plane for the adjustment of tibial mechanical axis. The wires on lateral malleolus should fix the lower tibiofibular joint. 5. Postoperative management: The patient was encouraged to walk with crutches from the fifth day after surgery. The external fixator for tibia compression began to adjust from the seventh day, and the fibular bone transport was started

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Fig. 13.23 Refracture Fig. 13.22  X-ray that just removed of plate

Fig. 13.24  Application of Ilizarov external fixation

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Fig. 13.26  The continuity of tibia and fibula has been restored

13.6.1 Calcaneal Defect 13.6.1.1  Etiology Calcaneal defects include congenital deformity and sequela of trauma and infection.

Fig. 13.25  Fibula bone transport

simultaneously at the speed of 1  mm per day which be divided into six times. The tibial ends were compressed for 10  mm and the fibular bone transport for 20 mm (Fig. 13.25). The external fixator on tibia was removed on the 202th day after surgery (Fig. 13.26). On the 265th day after surgery, the restoration of tibia and fibula was still poor (Fig.  13.27); K-wire internal fixation combined with bone graft (Fig. 13.28) was performed at the second stage; the tibia and fibula healed well, and the external fixator was removed 1 year after surgery (Fig. 13.29).

13.6 Bone Nonunion and Defect on Foot Jiancheng Zang and Sihe Qin

13.6.1.2  Clinical Manifestation and Key Points of Examination In clinic appearance, the heel is short, and the lateral view of heel shows an “L” shape. X-ray shows that the calcaneus is short or the posterior part of the calcaneus defect. When taking X-ray films, both sides of the calcaneus should be taken simultaneously, as a reference, to determine the length and degree of calcaneal defect. 13.6.1.3  Indications and Contraindications for Calcaneus Reconstruction with Distraction Osteogenesis 1. Indication. Short calcaneus and posterior calcaneal defect that did not exceed the subtalar joint; the patient has calcaneal defect, but his or her skin and soft tissue on heel is intact, no infection or infection on heel has been cured. 2. Contraindication. Complete absence of calcaneus, anterior defect of calcaneus, residue calcaneus less than 1/2, and incurable infection in calcaneus.

13  Nonunion, Bone Defects and Osteomyelitis Fig. 13.27  The bone structure of distal tibia and fibula was still in poor situation on the 265th day after surgery. (a) X-ray; (b) Front view; (c) Lateral view; (d) Back view

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13.6.1.4  Treatment Goals and Ideas 1. Treatment goal: To repair calcaneus length and shape and to restore the arch of foot. 2. Surgical plan: The location of osteotomy and the direction of distraction should be designed according to the shape of residual calcaneus. The configuration of Ilizarov fixator should be designed in advance and tested before surgery. External fixator was mounted according to the design of osteotomy, and the calcaneus was reconstructed based on Ilizarov method after surgery.

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13.6.1.5  Surgical Procedures 1. Surgical method: Calcaneal osteotomy, distraction osteogenesis with Ilizarov fixator. 2. Surgical steps: To determine the location of calcaneal osteotomy under X-ray fluoroscopy, calcaneus is exposed with lateral incision and osteotomy with a sharp osteotome, Ilizarov fixator is applied.

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Fig. 13.28  The second stage of surgery was performed with bone graft, cross-wire, and intramedullary nail

13.6.1.6  Tips and Tricks The calcaneus osteotomy should be accurate to prevent calcaneus bone too small to pin. The external fixator fixes the tibia and forefoot as a supporting structure to provide support for distraction osteogenesis of calcaneus; the right direction be adjusted by hinges; osteotomy with a sharp osteotome to minimize bone loss; control the direction of osteotome well to avoid the medial neurovascular injury. 13.6.1.7  Postoperative Management The patient is encouraged to walk partially weight-bearing with crutches from the fifth day after surgery. It is started to distract and lengthen the calcaneus at a rate of 1  mm/day divided into 4–6 times from the seventh day after surgery. Pain may occur during the lengthening process, and appropriate analgesic treatment can be given. If the pain is severe and unbearable, suspend lengthening and then the pain can be relieved. The opposite calcaneus is used as the control during lengthening; the weight-bearing walking should be done during the lengthening process. The external fixator should be fixed while lengthening is completed and be removed until bone healing. 13.6.1.8  Possible Complications 1. Neurovascular injury. Control the right direction of osteotome to avoid the medial neurovascular injury. 2. Pin tract infection. The pin tract should be wrapped with sterile gauze.

In mild infection, taking oral medicine, reducing exercise; in severe infection, the wire should be removed or replaced. 3. Pain. The pain means the speed of lengthening is too fast; we should suspend or reduce the speed.

13.6.1.9  Typical Cases 1. This patient was a 20-year-old male with severe clubfoot deformity and calcaneal defect. His left leg and hind foot were crushed in a road accident, resulting in a large area of soft tissue defect in the hind leg and heel and partial defect of calcaneus. The wound was healed after debridement and skin grafting, but the equinovarus foot deformity and short calcaneal deformity occurred gradually and aggravated with the growth and development (Fig. 13.30). Physical examination: Severe equinovarus deformity on the left side, walking and weight-bearing with five heads of metatarsal bone and toes, extensive skin scars on the posteromedial side of the leg and heel, foot, and ankle in flexion 110° stiffness, normal range of flexion and extension of each toe, ankle joint activity was 0°, no calcaneal tubercle protrusion, normal dorsalis pedis artery pulsation. The X-ray showed a defect in the posterior part of the calcaneus, a gap between the tibia and talus, and a joint between the lower tibia and the posterior part of the talus (Fig. 13.30). 2. Treatment process: Three phases for treatment. (a) First-stage surgery: Scar resection of the left leg and application of free flap of anterolateral thigh.

13  Nonunion, Bone Defects and Osteomyelitis Fig. 13.29  The continuity of tibia and fibula was restored and the walking function returned to normal at 365 days of follow-up. (a) Front view; (b) Lateral view; (c) Back view; (d) X-ray

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Fig. 13.30  Severe equinovarus deformity with calcaneal defect. (a). Preoperative clinical appearance; (b) Preoperative X-ray film; (c–f) Second surgery: severe equinovarus deformity correction by Ilizarov fixator. An ankle foot orthosis was assembled after removal of external fixator; (g) X-ray film showed that calcaneal defect; (h) Calcaneus oste-

otomy and Ilizarov frame application; (i, j) The adjustment of Ilizarov fixator; (k) Calcaneus lengthening was monitored by radiography; (l, m) The heel shape was restored; (n) X-ray showed that both sides of calcaneus were equal in length and the arch of left foot was well restored

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(b) Second-stage surgery: Three and a half months after first surgery, the second-stage surgery was performed. Subcutaneous release of Achilles tendon, osteotomy of calcaneocuboid and talus-navicular joint, and with Ilizarov orthodontic application included. Equinovarus deformity was corrected partially during operation, residual deformity was adjusted to correct by Ilizarov external fixator. After 84 days, the deformity was corrected satisfactorily. After another 39 days of fixation, the external fixator was removed and the ankle foot orthosis (AFO) was worn to practice walking. (c) Third-stage surgery: The patient was re-hospitalized and underwent the third surgery 1  year later. Left calcaneal osteotomy and Ilizarov fixator application were done. One week after surgery, the calcaneus was lengthened at a set angle, and the right lengthening rate was 1 mm/day. During the lengthening process, the lengthening rate was adjusted between 0.4 and 1  mm/day according to the patient’s pain tolerance. At the 35th day of lengthening, bilateral lateral radiographs were taken to measure the length of the calcaneus, and the lengthening was stopped. During the lengthening period, the limbs could be lightly supported with two crutches. After 110 days of fixation, the lengthened segment healed, the external fixator was removed, and X-ray films showed that the lengthened segment healed well, and the shape of calcaneus and arch of foot returned to normal range.

13.6.2 Metatarsal Defect and Nonunion 13.6.2.1  Etiology The cause of metatarsal defect and nonunion is mainly trauma or infection. 13.6.2.2  Clinical Manifestation and Key Points of Examination The forefoot is short or deformed, usually with scar. X-ray shows metatarsal defect or nonunion in different extent. 13.6.2.3  Indications and Contraindications 1. Indications. Metatarsal defect or nonunion, but the corresponding toes are normal, the skin and soft tissue are intact, no infection or the infection has been cured, the walking function has been affected. 2. Contraindication. Metatarsal defect accompanied by the corresponding toe defect; the third or fourth metatarsal defect, standing and walking function is well; the foot with infection focus.

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13.6.2.4  The Goal and Idea of Treatment 1. Treatment goal: Metatarsal lengthening, to restore the metatarsal length and shape, and to cure nonunion. 2. Treatment idea: The patients who suffered single metatarsal nonunion or bone defect without forefoot deformity can be treated with bone graft and internal fixation. The patients who suffered multiple metatarsal defect or nonunion with forefoot deformity can be applied with Ilizarov distraction osteogenesis. 13.6.2.5  Typical Case 1. A 17-year-old patient with thoracolumbar myeloma who underwent surgery in a local hospital developed loss of sensation in the medial forefoot right side, dysfunction, and progressive deformity (Fig. 13.31). Neurotrophic ulcer of the right forefoot occurred in 19  years of age, secondary to metatarsal osteomyelitis, resulting in varying degrees of metatarsal necrosis and defect. Severe shortening of the medial right forefoot was found after osteomyelitis was cured. Physical examination: Moderate limping gait, valgus foot deformity, and medial forefoot shortening deformity on right side, combined the first, second, third, and fourth toe floating deformity. The flexion and extension function each toe exists, muscle strength is about grade 3. Sensory deprivation in the forefoot. X-ray showed that bone defect area includes 80% of first metatarsal, 60% of second metatarsal, the head of the third metatarsal, and the ankle joint degenerated. 2. Treatment process: (a) Osteotomy on tarsal bone and lengthening with Ilizarov external fixation. The dorsal longitudinal incision on medial cuneiform bone was taken to expose the medial and middle cuneiform bone, the dorsal longitudinal incision of lateral cuneiform bone was made to expose the lateral bone, and osteotomy between forefoot and hind foot was done completely with osteotome, and then the fixator was mounted for distraction osteogenesis. The lengthening started on the fifth day after surgery, at the speed of 0.6 mm/day, four times. The X-ray showed the osteotomy end was distracted at the tenth day after surgery 3 cm on the midfoot was lengthened, and then stopped and fixed at the eighth month after surgery, the osteotomy healed well, the external fixator was removed, the lateral length of the right foot was restored, and the medial side was still deformed. (b) Medial tarsal osteotomy lengthening was performed at the third month after fixator removal. With a longitudinal incision at the base of the second metatarsal, the first, second, and third ­

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metatarsal bones were exposed. Osteotomy was performed with an osteotome, and then the Ilizarov frame was mounted. The lengthening started on the fifth day after surgery, at the speed of 0.6 mm/day, four times. During the lengthening process, the first toe appeared drooping deformity, and the second, third, and fourth toe appeared claw deformity. (c) Four months after the second surgery, wire distraction surgery has been done. a

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The first toe was penetrated from the distal end of toe to the proximal dorsal end of the distal phalanx joint with a 2 mm K-wire, a hook was formed after bending, and the same method was repeated for second, third, and fourth toes with 1.5 mm K-wire. Distraction was applied to correct the toe deformities. The osteotomy end was lengthened, and the four toes were distracted longitudinally. The osteotomy healed well and the external fixator was removed at 7 months after surgery. The appearance and length of the right foot were restored satisfactorily (Fig. 13.31).

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Fig. 13.31  The reconstruction of forefoot defect: (a–c) This patient was a 34-year-old female with medial tarsal and metatarsal bone defect and sensory disturbance of plantar; (d). X-ray showed the first metatarsal defect, the second, the third, and the fourth metatarsal defect partially; (e). The lengthening started on the fifth day after surgery; (f–h). The patient adjusted the fixator herself; (i). The X-ray at 8.5 months after surgery showed that the bone healed and the external fixator was removed; (j) 11 months after surgery, the lengthened bone mineralization was good; (k–m) One year after the first surgery, the

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patient was re-hospitalized and planned to perform medial tarsal lengthening; (n, o) The length of medial foot had been restored at the fourth month after surgery, but toe contracture deformity occurred; (p) X-ray showed that the callus grew well in the lengthened segment; (q) The toe contracture was corrected by wire distraction in the second surgery; (r) 200 days follow-up, the deformity of toes was corrected; (s–u) The external fixator was removed; (v) X-ray showed good bone restoration of the foot; (w) Brace wearing for another 3–6 months

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13.7 T  reatment of Tibial Defects Combined with Talipes Deformity

and is not convenient to early weight-bearing exercise. In our study, Ilizarov distraction osteogenesis technique was used to restore large bone defect and to correct foot deformity simultaneously; satisfactory results were obtained.

Sihe Qin, Xuejian Zheng, and Jiancheng Zang Tibial defect is often associated with varying degrees or types of foot and ankle deformities. Previous literatures have reported that the defects can be cured in the first stage, and the foot and ankle deformities were corrected by the second stage of surgery. This method prolongs the treatment period

13.7.1 The Configuration of External Fixator This configuration is a combination of the configuration for tibial bone transport and configuration for foot and ankle deformity correction (Fig. 13.32).

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13.7.4 Typical Cases

Fig. 13.32  The configuration for tibial defects combined with talipes deformity

13.7.2 Surgical Plan The external fixator should be preassembled individually before surgery. For patients without bone infection, electric drilling is used for osteotomy of the both ends of the defect; For those with bone infection, debridement is necessary to prepare for bone transport. For those equinus foot, Achilles tendon should be subcutaneously released in different planes. If foot has varus deformity, tibial posterior tendon should be lengthened or talus calcaneus joint arthodesis should be performed. The Ilizarov external fixator can be mounted with wires and pins.

13.7.3 Postoperative Management Patients with osteomyelitis were treated with sensitive antibiotics 7–10 days after operation, and the drainage tube was kept unobstructed. On the third day after operation, the patients were encouraged to perform active flexion and extension exercises on knee and ankle joints. One week after the operation, the bone segment was removed and the external fixator of ankle and foot was adjusted to correct the deformity of foot. The patients could walk with a proper weight-bearing crutch. Ankle joint should be in 0° position or 10° overextension. The foot external fixator should be removed after 3 weeks of foot deformity correction, and foot orthopedic support should be made and connected with the leg external fixator to avoid recurrence of deformity.

1. A 60-year-old female patient with left tibial defect and severe stiff foot deformity due to open fracture 3  years ago. X-ray showed that tibial defect was about 1/3 of the total length (Fig. 13.33). (a) Surgical plan: Osteotomy below tibial tubercle, application of Ilizarov fixation for tibia bone transport and foot ankle deformity correction simultaneously. (b) Preoperative preparation: Ilizarov external fixator and tools, double-barrel drill sleeves, sharp osteotome, etc. (c) Surgical procedure: 1 cm incision below tibial tubercle was made, a row of holes were drilled under the protection of double-barrel drill sleeves, and then Ilizarov external fixator was mounted. Finally, tibia osteotomy was performed with osteotome. (d) Tips and tricks: When drilling and osteotomy on tibia, attention should be paid to avoid neurovascular injuring posteriorly; when mounting external fixators, attention should be paid to maintaining the axis of the tibia to prevent deviation. (e) Postoperative management: The patient was encouraged to walk with double crutches from the fifth day after surgery. Tibia bone transport started from the seventh day after surgery at a rate of 1 mm/day in six times; At the same time, foot and ankle deformities were corrected by external fixator. The external fixation maintains the ankle at the functional position for 2 months and then is removed. The fixator should be fixed until the bone is healed completely. 2. A 19-year-old male patient with chronic tibial osteomyelitis and secondary clubfoot deformity following open comminuted fracture of the left leg. The left tibial ­infection was debrided and resected, the length of the resected bone segment was about 14 cm, two-level osteotomy was performed and bone transport technique was used to repair the bone defect, and clubfoot deformity was corrected simultaneously. Bone defects were restored at the thirteenth month after surgery, and bone healing and fixator removal at the nineteenth month after surgery (Fig. 13.34).

13.8 Prevention and Treatment of the Secondary Problems Jiancheng Zang and Sihe Qin Ilizarov technology has a wide range of indications. In clinical application, problem or complication can be avoided by following the standard procedure, careful preoperative design, timely inspection, and adjustment in the application

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Fig. 13.33  This patient was a 60-year-old female with left tibial defect and severe stiff foot equnivarous deformity due to open fracture 3 years ago. (a, b) Preoperative clinical appearance; (c) Preoperative X-ray showed that the length of tibial defect was about 12 cm; (d, e) Application of external fixation; (f) X-ray at 3.5 months after surgery;

f

(g) X-ray 8 months after surgery; (h) 16 months after surgery, the bone at docking site healed well, and the external fixator was removed; (i) Full-length X-ray film of both lower limbs 18 months after surgery; (j, k) Clinical appearance at 18 months follow-up

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process, strictly based on the principles of slow, stable, continuously, and timely follow-up. The common problems or complications are as follows:

pin tract, the dressing and sensitive antibiotics need to be given; for severe infection, the pin or wire should to be removed or replaced.

13.8.1 Pin Tract Infection

13.8.2 Axial Deviation of Moving Bone Segment (Fig. 13.35)

Prevention is the most important. Pin tract infection is easy to occur in thicker soft tissues and can be wrapped with gauze to prevent infection. For mild or moderate infection of

a

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The bone defect is too large, the distance of bone transport is too far, and the instability of the external fixator will

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Fig. 13.34  Left tibial osteomyelitis with equinovarus deformity. (a) A 19-year-old male patient with chronic tibial osteomyelitis and secondary clubfoot deformity following open comminuted fracture of the left leg, walking with two crutches preoperatively; (b) Infection defect and filled with bone cement in the middle part of tibia; (c) Preoperative X-ray; (d) Surgical removal of infected bone segment, osteotomy below tibial tubercle and supramalleolar, applied with Ilizarov fixator; (e)

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Eighteenth day after surgery, the wound was clean; (f) The wound closed gradually; (g) Eighth month after surgery, the bone segments were touching each other and the foot deformity was corrected; (h) X-ray 8 months after surgery; (i) 19 months after surgery, the foot deformities were completely corrected, and the fixator was removed; (j) X-ray showed the bone healed well

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Fig. 13.34 (continued)

cause the axial deviation of the bone segment. Therefore, the osteotomy and wire setting should be designed before surgery, the angle direction should be predicted, and the fixator should be adjusted promptly postoperatively.

13.8.3 Skin Depression The skin and soft tissue on the surface of the bone will move and grow with bone transport. At the area of bone

defect, where a depression is formed by bone defect, the skin and subcutaneous tissue in the depression are sandwiched at the opposite end with the bone transport (Fig. 13.36). Surgical treatment is needed to remove the folded skin and the soft tissue between the ends of the bones and going on; or to free the soft tissue between the bone ends and then lift the skin with a K-wire for preventing re-entry between the ends of the bones (Fig. 13.37).

13  Nonunion, Bone Defects and Osteomyelitis Fig. 13.35  Axial deviation of bone segment

Fig. 13.36  Skin depression

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13.9 Chronic Osteomyelitis of Lower Limbs Sihe Qin, Shaofeng Jiao, Jiancheng Zang, and Qi Pan

13.9.1 Introduction The treatment method of chronic osteomyelitis includes Ilizarov technology, Masquelet technology, microsurgical techniques, etc. This section mainly introduces the clinical experience of two teams, Dr. Xia Hetao and Dr. Qin Sihe, treated with Ilizarov technology.

13.9.1.1  Shortening and Lengthening After Bone Segments Resection (Fig. 13.38) The infected bone segment should be resected, the wound was debrided thoroughly, and all the infectious granulation tissue visible with naked eye was removed. The end of bone was shortened and fixed with external fixator. After the infection control was determined, the metaphysis far

from the infection area was lengthened by osteotomy to restore the limb length. The method is suitable for patients with infection and resection of bone segment less than 5  cm, shortening and osteotomy without affecting the blood supply of the limbs.

13.9.1.2  Bone Transport for Restoration of Bone Defects (Fig. 13.39) After bone segmental resection, external fixator was used to fix the bone to keep the limbs in same length. At the same time, epiphyseal osteotomy was performed for bone transport. This method has been widely used in the treatment of chronic osteomyelitis of the long bone of the lower limbs. 13.9.1.3  The Choice of External Fixator The choice of external fixation depends on the specific location of osteomyelitis and the proficiency of the doctor. Usually, mono fixator is better for femur and Ilizarov fixator for tibia. 13.9.1.4  The Method for Pin Inserting The pin and wire inserting according to the safe zone of the femur and tibia. The K-wire and half pin should be vertically drilled into the center of bone under the monitor of “C” arm. 13.9.1.5  The Location for Osteotomy The osteotomy should be performed in the normal bone away from the infected lesion, and the osteotomy line should be 1 cm above the level for wire inserting. Cortical osteotomy should be performed with drill or jigsaw after installing the external fixator, which is to facilitate the axial maintenance and to reduce the bleeding during osteotomy. 13.9.1.6  The Time for Osteotomy After infected bone segment resection, whether shortening or lengthening is performed simultaneously depends on what is seen during the operation. If the infection is completely controlled, the lesion is limited, and the lesion is far

Fig. 13.37  K-wire was used to stir the skin up Fig. 13.38  Application of debridement and Ilizarov technique for infectious bone defect: (a) Focal mass resection; (b) Shortening and fixed by fixator in first stage; (c) Osteotomy in the normal part; (d) Skeletal lengthening at a rate of 0.5–1.0 mm/day, waiting for cortical ossification and both lower limbs equalization

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Extensive focal resection

Continue lengthening

Shortening as much as possible docking site

Fig. 13.39  Treatment of infectious bone defects: (a) Extensive focal resection; (b) Shortening and fixation as much as possible; (c) Osteotomy in the normal part for bone transport; (d) Lengthening for equalization

away from the osteotomy level, one-stage osteotomy is feasible; if the infection is not controlled at the resection site or is serious, especially the intramedullary infection, the infection should be managed first, and then osteotomy in the second stage.

13.9.1.7  Lengthening Method The bone lengthening should be started from the seventh day after surgery at a rate of 0.5–1  mm/day in 4–6 times. The continuity of new bone should be paid attention during lengthening. Even if there are fewer new bones, it should continue to lengthen as long as there is partial continuity. The new bone formation of femur and the possibility of early healing should be paid attention. The Ilizarov frame is applied by 5–10 mm longer than the target to wait for the growth of new bone. If a new bone is formed, the bone segment can be powered dynamic to wait for bone formation. 13.9.1.8  Bone Formation Attention should be paid to atrophic osteogenesis. Atrophic osteogenesis refers to the poor quality of bone formation on X-ray film, which is related to poor blood supply of bone and soft tissue caused by trauma or operation. Excessive lengthening can also lead to ischemic hourglass-­ like and transverse image transmission zones in the area of new bone formation. The maturity of new bone, to a great

extent, depends on the blood supply and load-bearing stress stimulation at the osteotomy site. If the load-bearing stress of the affected limb is insufficient, the bone formation will be delayed by 30–50%. Bone marrow inflammation caused by vascular occlusion in infected bone defects is very likely to cause cortical ischemia. At the beginning of lengthening, the situation of new bone formation should be observed closely, and the lengthening rate should be determined according to the quality of new bone formation. The rate of bone lengthening in the patient who has poor blood supply on bone marrow and periosteum is generally less 1/2 than that normal bone lengthening.

13.9.1.9  Treatment of Atrophic Osteogenesis The lengthening speed of atrophic osteogenesis should be reduced to less than 0.25–0.5 mm/day. If the formation of new bone is still poor, the following measures should be given: 1 . Further slowing down the speed. 2. Temporarily stop lengthening. 3. “Accordion” procedure that is lengthening-shortening repeat. 4. Re-osteotomy and slow lengthening from the beginning. 5. Autologous iliac bone was implanted into the defect area, or 10–15  mL bone marrow from ilium was injected, or 5  mL mesenchymal stem cells was condensed from 60 mL bone marrow blood for injection.

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13.9.1.10  Fixator Removal The external fixator can be removed after complete cortical osteogenesis of new bone, at least three cortical osteogeneses in the anterior and lateral position is judged by X-ray or CT three-dimensional reconstruction. In order to test the strength of bone healing, the nut on the threaded rod can be relaxed, and the affected limb can walk under full load for 1 month. If no pain and edema on the affected limb, suggesting that the quality of bone formation is good, the external fixator can be completely removed. After removing the frame, a brace should be applied for protection 2–3 months to prevent breakage of new bone.

13.9.2 Femoral Osteomyelitis 13.9.2.1  Indications 1. Infection was localized in the area of bone nonunion and defect. 2. Systemic nutrition is in good condition, which accords with the basic requirements of general orthopedics surgery. 3. The patients could cooperate with the treatment seriously. 13.9.2.2  Preoperative Examination 1. Medical history. Ask for medical history to know the cause and treatment process. 2. Physical examination. Basic physical examination, gait, deformity, skin, and sinus examination. 3. Imaging examination. (a) Routine X-ray examination and X-ray films of full-­ length standing view of bilateral limbs. (b) CT examination: For patients whose nonunion adjacent to joint, CT examination should be performed to assess the joint structure and articular cartilage. (c) CT examination (three-dimensional reconstruction) should be performed in serious complex deformities. (d) Sinus radiography. For those who are difficult to determine the scope of infection, sinus radiography should be performed. (e) MRI. To determine the range of infectious bone. 4. Bacteriological examination. Bacteriological examina tions and drug sensitivity tests are performed on wound or sinus endocrine materials to select effective antibiotics for treatment. 13.9.2.3  Apparatus Configuration According to the total length of bone, the diameter of limbs, the location of bone defect and the size of wound, the type and configuration of external fixator for femoral lengthening or compression fixation was prepared, and its length and diameter were determined. To facilitate the dressing, the diameter of the device should be slightly larger than the limbs (Fig. 13.40).

Fig. 13.40 This compression

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13.9.2.4  Surgical Steps 1. Under successful anesthesia, focal debridement was performed. 2. The lacuna of the bone defect was filled with sterile gauze after removal of the lesion. 3. Skin disinfection again, towel spreading, and changing gloves and surgical instruments. 4. Application of external fixation. (a) Put the fixator on the thigh and fix it with wires and pins at distal and proximal segments, respectively. Pay attention to the distance between the ring and the skin. (b) After removal of the femoral infectious lesion, the bone defect can be moderately shortened, but not more than 5  cm, in view of the blood supply and drainage.

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Fig. 13.41  Wire distribution for femur bone transport

13.9.2.5  Wire Distribution 1. The distal of femur is usually pierced by one 2 mm wire and two 5 mm pins, three 5 mm pins for proximal femur, one 2 mm full wire, and one or two 5 mm pins on the sliding bone segment. 2. For the layout of wires for sliding bone segments, skin-­ lengthening wire should be added as needed (Fig. 13.41). 13.9.2.6  Important Matters 1. The basic operating procedures for external fixator. 2. Avoids neurovascular injury, avoids affecting the movement of hip and knee joint. 3. The wire should be avoided putting on the infected area as far as possible. 4. Avoid skin compression. 13.9.2.7  Postoperative Management 1. Strictly follow the basic requirements of external fixation. 2. Restore the anatomical axis of the femur and the mechanical axis of the lower limbs. 3. Pay attention to functional exercise of the knee joint.

13.9.2.8  Typical Case The patient is a 52-year-old female with femoral nonunion due to closed fracture of the middle and distal part of right femur. She suffered bone infection after internal fixation surgery with a plate in a hospital 10 months ago. During 6 years, she had undergone seven surgeries including plate removal, intramedullary nail fixation, and cement replaced again, the bone infection was still not cured. There were multiple sinuses on lateral thigh on admission (Fig. 13.42). Germ culture was MRSA. 1. Surgical plan: Femoral infected segmental resection, debridement, shortening with Ilizarov external fixation; femoral osteotomy to restore bone defects. 2. Preoperative preparation: Ilizarov external fixators and instrument, electric drill, etc. 3. Surgical procedures: With lateral thigh incision, the femur was exposed, removed the bone cement and infectious granulation tissue in the medullary cavity, irritated thoroughly with saline, sutured intermittently with drainage tube, and then Ilizarov external fixator was mounted, and appropriate shortened by 3 cm for reducing the length of bone defect.

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a

c

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Fig. 13.42  A 52-year-old female with chronic osteomyelitis of the right femur. (a) Multiple sinuses on the lateral right thigh, drainage of pus; (b) Bone cement was removed during operation; (c) Femur lateral groove was debrided thoroughly; (d) Postoperative X-ray, the femur

was gradually shortened to close the bone defect; (e) Subtrochanteric osteotomy was done for bone transport. As a result, osteomyelitis cured, femur length restored, the external fixator was removed

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4. Tips and tricks: Debridement of inflammatory granulation with longitudinal groove of the lateral femur should be done thoroughly. The axis of the femur should be maintained when Ilizarov external fixator mounted. Incision suture should not be too close to facilitate drainage. 5. Postoperative management. The patient could walk with weight-bearing from the fifth day after surgery; X-ray was taken on the seventh day, and then, femur shortening started to reduce the length of bone defect with fixator adjusting at the speed of 6 mm/day in three times. One month after surgery, the infection was controlled, and the second subtrochanteric osteotomy was performed. The bone segment was lengthened at a rate of 1 mm/day in six times until the length of the femur was restored. The external fixator was removed after bone healing.

13.9.3 Tibial Osteomyelitis 13.9.3.1  The Configuration of External Fixation 1. The configuration of external fixator for tibial lengthening was prepared preoperatively according to the factors such as the total length of tibia, the diameter of limbs, the location of bone defect, and the size of wound. 2. The external fixator configuration was prepared according to the function of fixator. Type A: for bone defect. Tibial horizontal distraction or compression configuration (Fig. 13.43). Type B: for bone defect and large skin defect. This configuration with the function of bone segment lengthening and skin stretching (Fig. 13.44). 13.9.3.2  Surgical Steps 1. Under successful anesthesia, focal debridement was performed. 2. The lacuna of the bone defect was filled with sterile gauze after removal of the lesion. 3. Skin disinfection again, towel spreading, and changing gloves and surgical instruments. 4. Distribution of wire and pin. (a) 1–2 groups of 2.5 mm cross K-wires were placed on the distal and proximal tibia respectively. (b) 1 wire and 1 or 2 pins were placed on the bone segment for transportation (Fig. 13.45). 5. Location of osteotomy

Fig. 13.43  Type A

Choose the location of osteotomy near the metaphysis where the skin is intact, the diameter of the bone is thicker, and the bone segment which is easy to wire insertion. 6 . Overall adjustment After the overall adjustment is completed, the following problems should be verified, if any, should be dealt with promptly:

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(c) Whether there was tension between the wire and the skin. (d) Whether the bolts or nuts are locked. 7. Replace the dressing with sterile gauze.

13.9.3.3  Matters Need Attention 1. The wire or pin on the moving bone segment should avoid touching the anterior tibial artery and anterior tibial muscle, so as to avoid pain relative to movement of ankle joint. 2. Skin compression of wire or pin should be avoided.

Fig. 13.44  Type B

(a) Check the static stability and dynamic stability of the fixation system (passive joint motion). (b) Check the position and relationship of limbs, joints, and external fixators.

13.9.3.4  Postoperative Management 1. Routine treatment and nursing of external fixation. 2. Application of antibiotics. Ilizarov technique for the treatment of infectious nonunion, the key factors to cure infection as follows: lesion debridement, regular surgical dressing, and bone transport, thereby improving the patients’ immune function. The use of “sensitive” antibiotics is only for preventing new infection. 3. Improving systemic nutrition. It is also of great significance to shorten the period of bone healing and cure infection by treating primary diseases, improving systemic nutrition, and eliminating internal and external disturbances (nutrition, physiology, psychology, etc.) which are unfavorable to healing and encouraging patients to build up confidence and cheerful mood to conquer diseases. 4. Bone lengthening index Bone lengthening should be individualized according to the patient’s age, osteotomy location, pathological characteristics, new bone growth, different lengthening stages, and distraction reflection. The preparation time for lengthening is 7–12 days, and the rate of basic standard is 0.5–1 mm/day with an average of 0.7 mm/day, which is completed in 4–6 times adjusted according to different osteotomy methods, treatment stages and specific conditions, so as to achieve the best balance between mechanical distraction and tissue regeneration. 5. Infected wound. The principle of treatment of infected wound is surgical dressing and adequate drainage. 6. If the gliding bone segment occurs axis deviation during bone transport, the infection should be completely controlled first and then adjust the alignment. The wound healing should not be affected by seeking anatomical contraposition.

13  Nonunion, Bone Defects and Osteomyelitis Fig. 13.45  The distribution of wire and pin 1; (a) Type A2 and (b) type B

a

7. Docking site. For the patient with poor contact at docking site, small incision can be made to repair and align the bone, increase the area of contact interface and stability of the bone end. Simultaneously, wound margin restoration technique can be carried out to promote skin healing. 8. Ensure that tibial anatomical axis is restored, and the angular or rotational deformity is greater than 5° should be avoided. 9. Fixator removal. The external fixator be removed according to the standard process, and then a brace should be worn 2  months for protection.

13.9.3.5  Typical Cases Case 1 This patient was a 34-year-old male with tibia osteomyelitis due to open comminuted fracture in firearm injury. He was treated with interlocking intramedullary nail in local hospital 1 month ago. Unfortunately, the wound was infected, and the intramedullary nail was exposed. There were 20  cm tibial defects and 6  ×  12  cm skin defects after debridement (Fig. 13.46). The X-ray showed the comminuted fracture of middle tibia.

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1. Surgical plan: Debridement, remove the intramedullary nail, infected bone segment resection, tibial tuberosity osteotomy, and bone transport with Ilizarov frame. 2. Preoperative preparation: Ilizarov external fixator and instrument, double-barrel drill sleeves, sharp osteotome, electric drill, etc. 3. Surgical procedures: First, the intramedullary nail could be removed, then wound debridement removed all the infected and necrotic bone segment in the middle of tibia, tibia wound was protected with bandage, disinfect again on the affected limb, and covered with sterile surgical towel. A row of bone holes was drilled under the guidance of double barrel drill sleeves, and then the preassembled Ilizarov external fixator was mounted with wires and pins. Finally, the tibia was cut off with an osteotome along the bone holes and the small incision was sutured. 4. Tips and tricks. During the operation, intramedullary nails were taken out first, pay attention to protect the incision and nail path from contamination. The infected bone segment should be removed thoroughly. The skin and soft tissue defect areas should be covered with gauze bandage.

562 Fig. 13.46  The patient was a 34-year-old male with right tibial osteomyelitis: (a) X-ray film; (b) Clinical appearance at 1 month after debridement and open reduction with intramedullary nail fixation; (c) X-ray film showed intramedullary nail and wire fixation, no callus growth; (d) After surgical resection of infected bone segment, X-ray film postoperatively showed bone defect in the middle of tibia; (e) Bone transport with Ilizarov fixator; X-ray films showed that the callus grew well in the lengthened area; (f) The wound was gradually reduced without infection; (g) The wound was closed gradually by soft tissue distraction; (h) The wound healed; (i) The process of bone transport was smooth, and the callus grew well in the lengthened area; (j) The patient could walk with weightbearing during the treatment; (k) Bone defect restored, and bone formation was good; (l) X-ray showed bone healing after removal of external fixator; (m) When the treatment completed, the morphology and function of right leg returned to normal

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Preventing contamination when osteotomy was performed under tibial tubercle with disinfection again and covered by sterile surgical towel. Pay attention to avoid common peroneal nerve injury. 5 . Postoperative management. Wound dressing was changed on the third day after surgery, soft tissue defect was covered with common gauze.

The patient can walk with crutches from the fifth day after surgery. On the seventh day after surgery, X-ray film should be taken. The bone segment started to move and lengthen at a speed of 1 mm/day completed in six times. With the bone transport, the skin and soft tissue defect gradually decreased. All the defects can be restored simultaneously, and external fixator was maintained until bone healing.

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Case 2 This was a 36-year-old male with tibia nonunion and infection due to open fracture of right tibia and fibula. He was treated by open reduction and internal fixation with AO plate, infection, and nonunion occurred postoperatively. Eight months after surgery, the anterior sinus of the leg was puruFig. 13.47  This patient was a 36-year-old male with right tibia osteomyelitis: (a) X-ray film after traumatic fracture; (b) Osteomyelitis appearance at eighth month after surgery; (c) X-ray showed that tibia and fibula nonunion; (d) Surgical resection of infected bone segment, incision with open drainage, bone transport started with Ilizarov frame; (e) The incision of wound gradually reduced with the tibial bone transport; (f) When bone transport was complete, the wound was closed; (g, h) During the treatment, the operative limb could walk with weight-­bearing; (i) The callus grew well and the docking site had healed; (j) The external fixator was removed when the bone healed firmly; (k) The morphology and function of the right leg were restored

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2 . Preoperative preparation: Same to typical case 1. 3. Surgical procedures: With anterior incision of right leg, the plate and screws were taken out, and infected and necrotic bone and soft tissue were debrided and resected, irritated with saline, and then the wound was wrapped for protection. Disinfect the affected limbs again, spread

aseptic surgical towels, a row of holes were drilled under the guidance of double-sleeves below the tibial tubercle, Ilizarov external fixator was mounted, then tibia was broken with an osteotome along the drilled holes. Finally, the osteotomy incision was sutured; tibial debridement incision was intermittent sutured with a drainage tube.

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4. Tips and tricks: Debridement of infected bone segments should be thorough. The operative limb is disinfected and aseptic surgical towel is prepared again, and then, drilling and osteotomy are performed below the tibial tubercle to prevent ­contamination. When the wire is placed on proximal tibia, attention should be paid to protect the common peroneal nerve. Drainage tube is placed in the incision of tibial debridement, and a gap is provided in the suture to facilitate drainage. 5. Postoperative management: On the third day after surgery, the incision dressing was changed and drainage tube was removed, but gauze was used to fill the gap when the incision was sutured to prevent closure and to facilitate drainage. On the fifth day after surgery, the patient can walk with partial weight bearing under crutches. On the seventh day after surgery, the X-ray film was taken, and the bone segment started to move at a rate of 1 mm/day, which divided into six times. In the process of bone transport, the wounds reduced gradually. Bone defect, skin and soft tissue defect restored gradually with bone growth, the external fixator should be maintained until bone healing. Case 3 This patient was a 39-year-old male with infected nonunion. He suffered comminuted fracture of the middle and distal part of the left tibia in a heavy injury and underwent intramedullary nailing surgery in a local hospital 2  years ago. Bone infection with exposure occurred for 1 year. On admission, the anteromedial skin of the lower left leg was black

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about 15 × 10 cm2, the tibia was exposed about 1.5 × 2 cm2 with purulent exudation. X-ray showed that tibial fracture was fixed with intramedullary nail and not healed (Fig. 13.48).

13.9.4 Tibia Osteomyelitis in Children The treatment of osteomyelitis in children has its inherent characteristics. If the weight-bearing walking condition is not created for children as soon as possible, the osteoporosis will come quickly, which is a complicated and confused situation. A patient with tibia osteomyelitis will be introduced in this section, hoping to give readers some inspiration. The boy was 7 years old with left tibia osteomyelitis; he suffered fever and swelling of the left lower extremity caused by tibial infection 6 months before admission. He was treated in a local hospital for several months and was transferred to our hospital because of the aggravating tendency of bone infection. General examination: Intelligence of the patient was normal, physical development was normal, the nutrition condition was poor and weight was 20 kg. Special examination: The left knee cannot be straight completely, knee active flexion at 60°, extension −50°, and the range of motion of left ankle was normal. The whole calf presents inflammation like performance such as red, swelling, hot, and painful. There was a sinus with pus on each side of calf. X-ray showed wormlike alteration of the whole length of the left tibia with sclerotic bone strips, destruction of the epiphyseal plate and extensive osteoporosis. The process of treatment was as follows (Fig. 13.49).

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Fig. 13.48  This patient was a 39-year-old male with infected nonunion. He suffered comminuted fracture of the middle and distal part of the left tibia in a heavy injury and underwent intramedullary nailing surgery 2 years ago, bone infection occurred 1 year ago. (a) Preoperative clinical appearance; (b) X-ray film; (c) Planned osteotomy plane and debridement scope; (d) Preassembled Ilizarov fixator; (e) Remove the infected bone segment; (f) Postoperative clinical appearance; (g) The wound after infected bone segment removal; (h) X-ray film on the fifth

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Genu Varum, Genu Valgum, and Osteoarthritis of Knee Sihe Qin, Xuejian Zheng, Shaofeng Jiao, Yilan Wang, Jiancheng Zang, Qi Pan, Xulei Qin, and Li Zhang

Table 14.2  Age analysis (year)

14.1 S  tatistical Analysis of 753 Cases of Genu Varum, Genu Valgum, and Osteoarthritis of Knee Sihe Qin, Yilan Wang, and Jiancheng Zang The clinical data of genu varum, genu valgum, and osteoarthritis of knee in Qinsihe Orthopedics Institute is as follows: (Tables 14.1, 14.2, 14.3, 14.4, and 14.5).

Table 14.1  Gender analysis (n) Gender Male Female Total

Genu varum 69 402 471

Genu valgum 43 198 241

OA∗ 8 31 39

Note: osteoarthritis is shortened to OA

Age period 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–50 51–60 61–70 >70 Maximum age Minimum age Average age

Genu varum 8 17 58 132 122 68 25 21 9 9 2 0 67 1 25.0

Genu valgum 7 14 34 80 56 23 10 11 5 0 1 0 65 2 17.6

OA 0 0 0 2 0 2 2 1 7 14 8 3 82 17 52.1

Table 14.3  The side of deformity (n) Side Left Right Bilateral

Genu varum 64 63 344

Genu valgum 59 57 125

OA 5 12 22

Table 14.4  Application of external fixation (n) Period 1990~1999 2000~2009 2010~2017

Ilizarov fixator 16 50 97

Hybrid fixator 9 33 52

Unilateral fixator 2 0 0

Taylor SF 0 0 5

Table 14.5  Surgical method (n)

S. Qin (*) · X. Zheng · S. Jiao · Y. Wang · J. Zang · Q. Pan X. Qin · L. Zhang Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China

Type Femoral osteotomy Tibia and fibula osteotomy Lengthening

Name of surgery Middle femoral osteotomy Supracondylar osteotomy Proximal tibial osteotomy Middle tibial osteotomy Supramalleolar osteotomy Femoral lengthening Tibia lengthening

Genu varum 37 36 316 22 51 1 20

Genu valgum OA 5 0 108 11 23 31 6 0 3 1 2 0 2 0

Qinsihe Orthopeadics Institute, Beijing, China © Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_14

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14.2 Clinical Manifestations and Preoperative Examination Shaofeng Jiao, Jiancheng Zang, and Qi Pan

14.2.1 Clinical Manifestations and Classifications 14.2.1.1 Genu Varum Mild type: The patient at the standing position, whose feet close together, the condylar space between the knee joints is smaller than the knee joint diameter (Fig. 14.1).

Severe type: The distance between the knees is greater than the transverse diameter of the knee. The patient in the standing position with feet close together (Fig. 14.2).

14.2.1.2 Genu Valgum Mild type: In the standing position, knees close together, the distance between the both medial malleolus is smaller than the transverse diameter of the knee joint (Fig. 14.3). Severe type: In the standing position, knees close together, the distance between the both medial malleolus is greater than the transverse diameter of the knee joint (Fig. 14.3). Genu varum deformity with osteoarthritis (Figs.  14.4, 14.5 and 14.6).

Fig. 14.1  Mild genu varum: (a). Front view in standing position; (b). Back view

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Fig. 14.2  Severe genu varum: (a). Front view; (b). Back view; (c). Full-length standing AP view radiograph Fig. 14.3  Mild genu Valgum: (a). Front view; (b). Back view

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Fig. 14.4  Severe genu valgus: (a). Front view; (b). Back view

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Fig. 14.5  Genu varum deformity with pain

Fig. 14.6  Genu valgum deformity with osteoarthritis

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14.2.2 Preoperative Checklists 14.2.2.1 Physical Examinations 1. When the patient has genu varum deformity, the knee spacing should be checked at the standing position with the feet close together. The patient with genu valgum should be checked for the spacing distance of the ankles when they are standing with the knees close together. 2. Check the ROM of the knee joint. 3. Check the knee joint relaxation (lateral collateral ligament, cruciate ligament). 4. Check the knee for signs of swelling, tenderness, and pain. 5. Check the presence or absence of the combined rotational deformity (Fig. 14.7). 14.2.2.2 X-Ray 1. X-rays of the knee joint. Take a standard AP and lateral view radiographs with the knee joint as the center. The films should include as much femur and tibia as possible (Fig. 14.8). 2. Full-length X-ray standing AP view radiographs. The range of standard full-length standing AP view radiographs should include the upper edge of the pelvis until the sole of the foot. The lateral angle of the distal femur and the medial angle of the proximal tibia should be measured the site of deformity and to determine the osteotomy level and site (Fig. 14.9).

Fig. 14.7  Genu varum combined with internal rotational deformity

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Fig. 14.8  Standard AP and lateral view radiographs of knee joint: (a). AP view; (b). Lateral view; (b). Full-length standing AP view radiographs

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Fig. 14.9  The range of standard full-length standing AP view radiographs should include the upper edge of the pelvis until the sole of the foot. (a). Mild genu varum in full-length photograph; (b). Severe genu

varum in full-length photograph; (c). Severe genu valgum in full-length photograph

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Fig. 14.10  Genu valgum deformity mainly from distal femur

14.3 Q  in’s Classification and Surgical Indications Sihe Qin

14.3.1 Qinsihe’s Classification for Genu Varum and Genu Valgum 14.3.1.1 Genu Varum 1. Femoral varum (Type I): Genu varum caused by varus deformity of the distal femur (Fig. 14.10)

Fig. 14.11  Genu varum deformity mainly from proximal tibia

2. Tibial varum (Type II): Genu varum caused by varus deformity in the proximal tibia (Fig. 14.11) 3. Femoral and tibia varum (Type III): Genu varum caused by distal femoral varus and proximal tibia varus deformities (Fig. 14.12) 4. Ligament laxity type (Type IV): Genu varum caused by collateral ligament laxity of the knee joint (Fig. 14.13)

14.3.1.2 Genu Valgum 1. Femoral valgum (Type I): Genu valgum caused by valgus deformity of the distal femur (Fig. 14.14)

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Fig. 14.14  Genu valgum deformity mainly from distal femur

Fig. 14.12  Genu varum deformity mainly from proximal tibia

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Fig. 14.15  Genu valgum deformity mainly from proximal tibia Fig. 14.13  Genu valgum deformity mainly from medial ligament

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Fig. 14.16  Genu valgum deformity from proximal tibia and distal femur

Fig. 14.17  Genu valgum deformity mainly from ligament

2. Tibia valgum (Type II): Genu valgum caused by valgus deformity of the proximal tibia (Fig. 14.15) 3. Femoral and tibia valgum (Type III): Genu valgum caused by distal femoral valgus and proximal tibial valgus ­deformity (Fig. 14.16) 4. Ligament laxity (Type IV): Genu valgum caused by laxity of the collateral ligament of the knee joint (Fig. 14.17)

2. The patient whose genu varum or genu valgum is not obvious, AP view of knee at standing position shows the inclined joint line and abnormal LDFA or abnormal MPTA.

14.4 Mild Genu Varum Shaofeng Jiao, Jiancheng Zang, and Qi Pan

14.3.2 Surgical Indications 1. The patient whose genu varum or genu valgum is obvious, AP view of knee on standing position shows abnormal LDFA (lateral distal femoral angle) or abnormal MPTA (medial proximal tibial angle) or knee collateral ligament laxity.

14.4.1 Diagnostic Criteria In the full-length standing AP view radiographs of the lower limbs, the mechanical axis of the lower limbs is offset horizontally inward by no more than the medial edge of the knee joint (Fig. 14.18).

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Fig. 14.19  Distal femoral varus

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Fig. 14.18  Full-length standing AP view radiographs of the lower limbs shows genu varum

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Fig. 14.20  Proximal tibia varus

14.4.2 Classifications 1. Femoral type (Type 1): which caused by distal femoral varus (Fig. 14.19) 2. Tibial type (Type 2): which caused by proximal tibia varus (Fig. 14.20) 3. Mixed type (Type 3): which is caused by both the femur and tibia (Fig. 14.21)

14.4.3 Treatment 14.4.3.1 Femoral Type: Valgus Osteotomy on the Femoral Condyle A 29-year-old female patient with genu varum deformity in left lower limb secondary to osteomyelitis of left femur when

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use an external fixator for fixing the proximal and the distal fragments. 2. Surgical plan: femoral condyle valgus osteotomy, fixed with external fixator. 3. Preoperative preparation: electric drill, hybrid external fixator, sharp osteotome, etc. 4. Surgical procedure: A lateral incision is made over the thigh, exposing the distal femur, using a sharp osteotome, a lateral based wedge part on the femoral condyle is removed and the medial cortex is cut for translation of the distal fragment; once the deformity is corrected it is fixed with a hybrid external fixator using wires and pins, and the incision sutured in layers. 5. Tips and tricks: The osteotomy plane should be located in CORA as much as possible, and can be positioned by C-arm X-ray. When performing osteotomy, the blood ­vessels and nerves on the posterior side of knee should be taken care. The mechanical axis of the lower limbs needs to be made sure corrected and brought to the center of the knee by fluoroscopy during surgery. 6. Postoperative management: On the second day after surgery, bedside exercise of leg and foot should be started. On the fifth days, the patient starts to walk weightbearing with crutches. Knee joint exercise starts after loosening the fixed rod 4 weeks later and involves knee flexion and extension exercises; the flexion degrees should be increased gradually. The knee joint is fixed while walking; the external fixator was removed after the bone healing. Fig. 14.21  Mixed genu varum (Type 3): which is caused by both femur and tibia

the patient was 8 years old, X-ray films shows varus deformity and shortening of the distal femur (Fig. 14.22). 1. Goals and aims of treatment: The treatment goal is to restore the normal mechanical axis and knee joint line of the left lower limb. The treatment idea: firstly, the mechanical axis of the left lower limb was drawn, we can find that the mechanical axis is passing medial to the knee, and then the femoral anatomical axis, the knee joint line, and the anatomical axis of tibia were drawn. It was found that LDFA is increased and the MPTA was normal. It was judged that the genu varum deformity was caused by the distal femoral varus, and the femoral condyle osteotomy should be performed. According to the Paley orthopedic principle to draw the CORA of the distal femoral deformity, it was found that the CORA was close to distal femoral articular surface. After the osteotomy at the CORA point, the space in the distal fragment of the osteotomy was not enough to be fixed by the plate. So it is planned to

14.4.3.2 T  ibia Type: Valgus Osteotomy Below Tibial Tuberosity A 26-year-old female had mild genu varum deformity in both knees. She had mild pain in the medial side of her knees while walking. The X-ray photograph showed that the mechanical axes of the lower limbs were deviated horizontally in the knee joint (Fig. 14.23). 1. Goals and ideas of treatment: The goal of treatment is to relieve pain in both knees and restore the beautiful appearance of lower limbs. Treatment idea: The X-ray photograph measurement shows that the MPTA of the bilateral tibia is less than normal, and the extent is mild. The knee joint pain and indecent shape of the lower limbs are caused by knee varus deformity, which can be corrected by the proximal tibia osteotomy. 2. Surgical plan: Bilateral tibial valgus osteotomy below tibial tuberosity fixed by Ilizarov fixation. 3. Preoperative preparation: Osteotome, electric drill, Ilizarov external fixator, double-sleeve drilling osteotomy device, etc.

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4. Surgical procedure: First fibula and then tibia.The lateral incision is made over the head and neck of the fibula, expose and protect the common peroneal nerve, and then expose the junction of head and neck of the fibula. Cut the bone with the osteotome and suture the incision. The anterior medial incision was made below the tibial tuberosity, and the tibia was revealed. A row of a

bone holes was drilled below the tibial tuberosity with the double-­ sleeve drilling osteotomy device. Then, the Ilizarov external fixator was mounted with wires and pins. Finally, the bone was cut with osteotome along with the bone holes and incision sutured in layers. The surgical procedure on both sides is same.

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Fig. 14.22  Femoral valgus osteotomy for correction of genu varum deformity: (a). Front view; (b). Dorsal view; (c). Full-length standing AP view radiograph; (d). Femoral valgus osteotomy fixed with K-wire; (e). Hybrid external fixator to fix distal fragment after osteotomy and

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Fig. 14.23  Bilateral genu varum deformity correction with osteotomy below the tibial tuberosity and combined Ilizarov technique: (a). Preoperative appearance; (b). Full-length standing AP view radio-

graphs; (c). The patient with Ilizarov external fixator; (d). Appearance at the end of treatment; (e). Full-length standing AP view radiographs

5. Tips and tricks: Pay attention to the protection of the common peroneal nerve during the fibula osteotomy; avoid to touch the nerve vessels on the posterior side in the process of tibia osteotomy. 6. Postoperative management: Joint movement exercise of the lower limbs should be started in the bed on second day after surgery. Crutch walking will start at the fifth day post operation; on the seventh day, the distraction of the tibial external fixator will be started on the medial side to correct the genu varum deformity; when the deformity is corrected completely the frame is fixed until the bone healing occurs, and then the fixator will be removed.

A 17-year-old female with mild genu varum deformity on right side. X-ray photographs show varus deformity in the middle femur and proximal tibia (Fig. 14.24).

14.4.3.3 Mixed Type Femoral valgus osteotomy + tibia and fibula osteotomy, fixed with Ilizarov external fixation.

1. Goals and ideas of treatment: The goal of treatment is to correct genu varum deformity in the right lower limb and restore the normal mechanical axis of the lower extremities. Treatment idea: X-ray photographs measurement shows that there are genu varum deformities in the middle part of the femur and the proximal part of the tibia. The treatment target can be achieved by the mid-femoral osteotomy and the proximal tibia valgus osteotomy. 2. Surgical plan: Valgus osteotomy in the middle of femur fixed with hybrid external fixation + osteotomy below tibial tuberosity and Ilizarov technique.

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3. Preoperative preparation: all the bone knife should be instead of “Osteotome”, electric drill, Ilizarov external fixator, hybrid fixator, double-sleeve drilling osteotomy device, etc. 4. Surgical procedure: First fibula osteotomy is done, then femoral osteotomy and then osteotomy of proximal tibia is performed. The lateral incision is made over the head and neck of the fibula, expose and protect the common peroneal nerve, and then expose the junction of head and neck of the a

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Fig. 14.24  Genu varum deformity was corrected with femoral valgus osteotomy, tibia and fibula osteotomy, and Ilizarov technique. (a). Preoperative clinical appearance; (b). Full-length standing AP view

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fibula. Cut the bone with the osteotome and suture the incision. A row of bone holes was drilled in the femoral CORA plane with the aid of the double-sleeve drilling osteotomy device. One pin was placed at each end of the bone hole. The femur was cut along the holes. When the femoral deformity was corrected, the two parts were fixed with a hybrid external fixator, and three pins should be used at both ends of the femoral osteotomy plane. And then, the incision was sutured. b

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radiographs; (c). Patient was walking with external fixator; (d). Full-­ length standing AP and lateral view radiographs after operation

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Procedures for tibia osteotomy: The anterior medial incision was made below the tibial tuberosity and the tibia was exposed. A row of bone holes was drilled below the tibial tuberosity with the double-sleeve drilling osteotomy device. Then, the Ilizarov external fixator is mounted with wires and pins. Finally, the bone was cut with osteotome along with the bone holes and incision sutured in layers. 5. Tips and tricks: Before the operation, the angle of the femoral deformity should be determined. When the pin is inserted on both sides of the femoral deformity, the angle of pins is the angle needed to be corrected; when the femoral deformity was corrected ­ completely, two pins should be parallel; care should be taken to protect the common peroneal nerve during fibula osteotomy; care should be taken to avoid damage to the posterior tibial nerve and vessels during tibia osteotomy; care should be taken while inserting distal femoral pins, so as not to affect the knee motion. 6. Postoperative management: Joint movement exercise of the lower limbs in bed should be started on the second day after surgery; the walking with crutches will start at the fifth day after the operation; on the seventh day, the distraction of the tibial external fixator started on the medial side to correct the genu varum deformity; when the deformity is corrected completely the frame was fixed until the bone healing, and then the fixator is removed.

14.5 Severe Genu Varum Sihe Qin and Jiancheng Zang

14.5.1 Diagnostic Criteria On the full-length standing AP view radiograph of the lower extremities, the mechanical axis of lower extremity is deviated medially beyond the medial skeletal edge of the knee joint (Fig. 14.25).

14.5.2 Etiology and Clinical Manifestations

Fig. 14.25  Severe genu varum

14.5.3 Auxiliary Examination The standard full-length standing AP view radiographs were taken, and the axis and angles were drawn on X-ray films according to Paley’s orthopedic principles to determine the CORA of deformity (Fig. 14.26).

14.5.4 Treatment Strategy

According to the full length of the lower limbs in the standing position, the deformed bone segments were determined, Severe genu varum deformities are common in low-­ and the CORA and deformity angle were measured to deterphosphorus rickets, osteogenesis imperfecta, Blount disease, mine the osteotomy site. The femoral osteotomy was fixed Juvenile epiphyseal cartilage damage, and so on. Bilateral with plate internal fixation combined with the hybrid exterdeformities of both legs look similar to the letter O, also nal fixator. The Ilizarov ring fixator was used for tibia correcknown as O-shaped leg deformity. Single sided deformity of tion after osteotomy. The genu varum deformity of the tibia one leg looks similar to the letter D, also known as D-shaped was corrected by gradually distracting the threaded rod. leg deformity. Severe knee varus deformity mostly is accom- Ilizarov external fixator should be designed and preassempanied with internal rotation deformity. bled preoperatively (Fig. 14.27).

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14.5.5 Typical Cases Case 1 An 18-year-old female, with severe genu varum deformity (O-shaped leg) caused by low-phosphorus rickets. X-ray films showed severe varus deformities of the bilateral femur and tibia (Fig. 14.28).

Fig. 14.26  Deformity analysis of severe genu varum on the X-ray photograph

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1. Goals and ideas of treatment: The goal of treatment is to correct the genu varum deformity of both lower extremities and to restore the mechanical axis and knee joint line of both lower extremities. Treatment idea: The femoral deformity was corrected by the middle femoral valgus osteotomy, fixed with short plate which can reduce the extent of incision, and ­combined with external frame to increase the strength of fixation. The application of internal fixation could reduce the external fixator time. The tibia deformity can be corrected by the osteotomy below the tibial tuberosity, and Ilizarov external fixator can be used for gradual deformity correction, which could increase the length of the bone and increase the height. Bilateral surgeries at one stage were not convenient for early functional exercise; therefore, the bilateral deformities of the lower extremities should be corrected in stages. One side of the femoral osteotomy and the tibial osteotomy should be performed in each sitting. 2. Surgical plan: middle femoral valgus osteotomy, fixed with plate and external fixation + tibial osteotomy under the tuberosity with Ilizarov technique.

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Fig. 14.27  Ilizarov external fixator for severe genu varum deformity correction. (a). Before deformity correction; (b). After deformity correction

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3. Preoperative preparation: Osteotome, electric drill, Ilizarov external fixator, hybrid external fixator, plate and screws, double-sleeve drilling osteotomy device, etc. 4. Surgical procedures: First fibula osteotomy is done, then femoral deformity is corrected and lastly tibial valgus osteotomy is performed. The lateral incision is made over the head and neck of the fibula, the common peroneal nerve is exposed and

protected, and then osteotomy of the fibula is done at the junction of head and neck of the fibula, incision was sutured. The CORA of the femoral deformity and the osteotomy site was located under fluoroscopy. With the lateral incision of the thigh of about 10  cm long with center being the osteotomy plane, the lateral femoral muscle was pulled forward, and the femur was exposed.

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Fig. 14.28  Correction of severe genu varum: Female, 18 years old, severe genu varum. (a). Preoperative appearance; (b). X-ray film showed the varus deformity from the middle and lower parts of the bilateral femurs and the proximal part of both tibiae. (c). Curved osteotomy on the right middle part of femur; (d). Fixed with plate and hybrid external fixator; (e). Tibial osteotomy with Ilizarov external fixation; (f). Distraction of the osteotomy site by Ilizarov external fixator started on the seventh days after surgery; (g). X-ray film showed femo-

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ral varus deformity had been corrected and good alignment of tibia restored. (h). Most of the right lower limb deformity had been corrected 22 days after surgery; (i). Alignment of right lower limb was restored at five and half months after operation; (j). The second stage operation was performed to correct another limb deformity, and the lower limb looked normal; (k). Back view of the patient in the second stage of treatment

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A row of bone holes was drilled in the femoral CORA plane with the aid of the double-sleeve drilling osteotomy device. One pin was placed at each end of the bone hole. The femur was cut at the hole line. When the femoral deformity was corrected, the two parts were fixed with a hybrid external fixator and a 6-hole plate. Two more pins should be used at both ends of the femoral osteotomy site, and then the incision was sutured. The anterior medial incision below the tibial tuberosity revealed the tibia. A row of bone holes was drilled below the tibial tuberosity with the double barrel drill sleeves. Then, the Ilizarov external fixator was mounted

with wires and pins. Finally, the bone was cut with osteotome along with the bone holes and the incision was sutured. 5. Tips and tricks: Before the operation, the angle of the femoral deformity should be determined. When the pin is inserted on both sides of the femoral osteotomy site, the angle of pins is the angle needed to be corrected; when the femoral deformity was corrected completely, two pins should be parallel. Care should be taken to protect the common peroneal nerve during the fibula osteotomy.

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Care should be taken to avoid nerve and vessels at posterior tibia during tibial osteotomy. Pin insertion procedure on the distal femoral should be followed so as not to affect the knee motion. The upper and lower tibiofibular joints should be fixed respectively. After the end of the operation, the knee joint was flexed and extended to reduce the influence of external fixator on the joint movements. 6. Postoperative management: Joint movement exercise of the lower limbs started in bed on the second day after surgery. The crutch walking started on the fifth day after the operation. On the seventh day, the distraction of the tibial external fixator started on the medial side to correct the genu varum deformity. The external fixator on femoral side can be removed on sixth week. After deformity is corrected completely, the frame was fixed until the bone healed, and then the fixator is removed. Case 2 The patient female, 22 years old, low-phosphorus rickets caused severe knee varus deformity (O-shaped legs). Internal rotations of bilateral tibia were more severe. X-ray film showed severe varus deformities in both femurs and tibiae (Fig. 14.29). 1. Goals and ideas of treatment: The goal of treatment is to correct the genu varum deformity of both lower extremities and to restore the mechanical axis and knee joint line of both lower extremities. Treatment idea: The femoral deformity is corrected by the middle femoral valgus osteotomy, fixed with short plate which can reduce the extent of incision, and combined with external frame for increasing fixation strength. The application of internal fixation can reduce the external fixator time. The tibia deformity can be corrected by two-level osteotomies at proximal and distal tibiae, respectively. The internal rotation deformity of tibia must be taken care. Taylor spatial frame has obvious advantages over the Ilizarov frame in correcting the angle and rotational deformities. So, it was prepared. The osteotomies at the two planes of tibia, according to the conventional situation, require two sets of six-axis systems to be used in series. However, because the tibia is short and the space is small, it is difficult to mount two sets of six-axis systems in series. Moreover, the cost is expensive, so it is planned to adopt one six-axis system. After the operation, the fixed position of the middle bone segment is changed to correct the two deformities in turn. The bone healing on the distal part is slower than the proximal part, so the distal part will be treated first. The segment is fixed on the proximal reference ring to c­ orrect the distal deformity; when the distal deformity corrected, the middle segment and the distal moving rings should be

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fixed to correct the proximal deformity, so that all deformities can be corrected. Bilateral surgeries in one stage are not convenient for early functional exercise, therefore, the deformity correction of bilateral lower extremities should be staged, that is one side of the femoral osteotomy and the tibial osteotomy should be performed in each stage. 2. Surgical plan: middle femoral valgus osteotomy, fixed with plate and external fixation + tibial two-level osteotomy fixed with TSF. 3. Preoperative preparation: Osteotome, electric drill, Taylor spatial frame, hybrid external fixator, plate and screws, jigsaw, etc. 4. Surgical procedures: First fibula, femur, and then tibia. The lateral incision was made over the fibula above the lateral malleolus and a 0.5 cm bone segment of fibula was removed and then the incision was sutured. The CORA of the femoral deformity was located under fluoroscopy as the osteotomy plane. The lateral incision of the thigh of about 12 cm long at the center of the osteotomy site was made. The lateral femoral muscle was pulled forward and the femur was exposed. A row of bone holes was drilled in the femoral CORA plane with the aid of the double-sleeve drilling osteotomy device. One pin was placed at each end of the bone hole. The femur was cut at the hole line. When the femoral deformity was corrected, the two parts were fixed with a hybrid external fixator and a 6-hole plate. Two more pins should be used at both ends of the femoral osteotomy plane. And then, the incision was sutured. Insert the wire under the fluoroscopy to install the reference ring of TSF, then mount the moving ring at the distal tibia, and finally install the six-axis rods. Three pins in the middle segment were set and first connected with reference ring; finally, the two-level osteotomy of tibia was performed with a jigsaw, and the incision was sutured. 5. Tips and tricks: Before the operation, the angle of the femoral deformity should be determined. When the pin is inserted on both sides of the femoral osteotomy site, the angle of pins is the angle needed to be corrected. When the femoral deformity be corrected completely, two pins should be parallel. Care should be taken to protect the common peroneal nerve during fibula osteotomy. Care should be taken to avoid damage to the nerve and vessels at the posterior tibia during the jigsaw through the tibial bone. Pin insertion procedure on the distal femoral should be followed, so as not to affect the knee motion. The upper and lower tibiofibular joint should be fixed respectively. In the end of surgery, the knee joint should be moved flexion and extention in turn, the influence of external fixator as joint movement can be reduced to the minimum.

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Fig. 14.29  Severe O-leg deformity correction with Taylor spatial frame: (a). Appearance preoperative; (b). X-ray film preoperative; (c). Right-side lower extremity with fixator; (d). AP and lateral view X-ray film for right tibia with TSF; (e). AP and lateral view X-ray film for

right femur with plate; (f). Appearance after deformity correction; (g). Full-length standing AP view radiographs; (h). Appearance postoperative

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6. Postoperative management: Joint movement exercise of the lower limbs in bed should be started on the second day after surgery; the crutch walking should be start at the fifth day after the operation. On the seventh day, the prescription for deformity correction was calculated by computer to correct the genu varum and internal rotation deformity of the distal tibia, then fix the middle bone segment on the proximal reference ring, recalculate the prescription to correct the proximal tibia deformity. The external fixator on femoral side can be removed on the sixth week. When the deformity ­corrected completely, the frame can be fixed until the bone healing, and then the fixator will be removed.

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deformity of the knee on the X-ray AP view looks like the letter K or mirrored K, also known as the K-shape leg (Fig. 14.31).

14.6.1 Definition On the full-length standing AP view radiographs, the mechanical axis of the lower limb is deviated outside from the center of the knee, which is called knee valgus deformity.

14.6 Genu Valgum Sihe Qin, Shaofeng Jiao, Jiancheng Zang, and Qi Pan Genu valgum deformity is one of the common deformities of the knee joint. The bilateral knee valgus deformity looks like the English letter X on the anteroposterior X-ray, so it is also called the X-shape leg (Fig.  14.30). Unilateral genu valgus

Fig. 14.30  X-shape leg

Fig. 14.31  K-shape leg

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third section of this chapter to analyses the knee valgus, to determine the deformity level and accurate osteotomy plane.

14.6.5 Goals and Ideas of Treatment The treatment goal of genu valgus is to correct knee deformity and restore normal lower limb mechanical axes and articular lines. According to the positioning classification of the genu valgus deformity, genu valgus type I is implemented varus osteotomy of the femoral supercondyle. Genu valgus type II is implemented varus osteotomy below tibial tuberosity. Genu valgus type III is implemented femoral supercondylar varus osteotomy and tibial varus osteotomy at same time; the knee valgus type IV is implemented reconstructions of cruciate ligament and medial collateral ligament.

14.6.6 Typical Cases

Fig. 14.32  Tibial plateau partition

14.6.2 Analysis of Common Cause The main causes of knee valgus deformity include rickets, epiphyseal injury of the distal femoral or proximal tibia, and disorders of epiphyseal development around the knee joint. Knee valgus deformity not only affects the beauty of the body, but also damages the normal stress distribution of the knee, which increases the lateral stress of the joint and decreases the stress of the inner side relatively. At the same time, due to the change of lower limb force line, the friction between the tibia and the femur increases, and the presence of long-term deformity can cause pain in the knee joint, which can easily lead to knee osteoarthritis. So, it should be corrected as soon as possible to improve the stress imbalance of the knee joint.

14.6.3 Surgical Indications 1. Mild genu valgum. When the mechanical axis of the lower extremity passes from the center of the tibial plateau to 70% of the lateral side (Fig.  14.32), the surgery is not recommended. 2. Severe genu valgum. Surgical correction should be performed when the mechanical axis of the lower extremity passes through 70% of the lateral aspect of the tibial plateau.

14.6.4 Analysis of Genu Valgum Before the surgery of genu valgus, the patient’s lower extremity X-ray film should be analyzed. In reference to the

Case 1 One patient, 16 years old, female, the femoral distal valgus deformity was caused by epiphyseal injury and aggravated gradually. The patient was examined at the time of admission. The right knee showed valgus deformity and a shortening of about 7 cm. The range of knee motion was normal. On the basis of the X-ray photographs, the genu valgus belongs to type I (Fig. 14.33). 1. Surgical plan: varus osteotomy of the right femoral supercondylar fixed with Ilizarov external fixator. 2. Preoperative preparation: Ilizarov external fixator, electric drill, sharp osteotome, etc. 3. Surgical procedure: the medial and lateral incisions of the lower thigh exposed the lower part of the femur. After drilling with the electric drill on the femoral condyle, the surgeon make the medial wedge osteotomy with osteotome, cut the lateral cortical bone by the lateral incision. When the valgus deformity was corrected, the Ilizarov external fixator was placed through wires and pins, finally the incision was sutured. 4. Tips and tricks: The nerves and vessels on the posterior side of the femur should be protected during osteotomy. As the CORA of femoral deformity is lower, the distal part of the osteotomy needed to be properly displaced outward. Since the distal segment of the osteotomy is shorter, the connection crosses the knee with hinge usually can be used to increase the stability of the osteotomy end. 5. Postoperative management: Joint movement exercise of the lower limbs in bed should be started on the second day after surgery. The walking on the ground with crutches start at the fifth day after the operation. On the seventh day after surgery, the X-ray film was reviewed and the FDLA of femur distal part was checked. If the deformity was not

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completely corrected, the external fixator can be used for further correction. After the deformity was corrected satisfactorily, the fixator was fixed until the bone healed. Case 2 The patient, 33 years old, male, bilateral tibial valgus deformity due to overcorrection of bilateral genu varum after the bilateral tibial valgus osteotomy in the local hospital. When the patient was admitted in hospital, the incision scar

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was seen on the bilateral tibia with mild genu valgum deformity (K-shape leg). X-ray film showed that the mechanical axis of both lower limbs was deviated to the lateral side. The MPTA was greater, and it was genu valgus type II (Fig. 14.34). 1. Surgical plan: bilateral tibia osteotomy and fibula osteotomy below the fibula head, fixed with Ilizarov external fixation. 2. Preoperative preparation: electric drill, osteotome, Ilizarov external fixator, etc.

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Fig. 14.33  Genu valgum deformity type I: (a). Preoperative appearance; (b). Preoperative X-ray film; (c). Femoral supercondylar osteotomy, installation of Ilizarov external fixation; (d). Postoperative X-ray film, the right lower extremity mechanical axis, and articular line returned

to the normal. (e). The deformity of the right lower extremity was corrected at the 21st day after surgery; (f). The appearance when the external fixator was removed; (g). The knee joint X-ray film AP and lateral view showed that right femoral valgus deformity had been corrected

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Fig. 14.33 (continued)

3. Surgical procedure: The lateral incision of the head and neck of the fibula revealed and protect the common peroneal nerve, and then expose the junction of head and neck of the fibula. Bone was cut with the osteotome and the incision was sutured.

The anterior medial incision under the tibial tuberosity was made to expose the tibia. A row of bone holes were drilled under the tibial tuberosity with the double-sleeve drilling osteotomy device. Then, the Ilizarov external fixator was installed with wires and pins. Finally, the bone

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was cut with osteotome along the bone holes, and the incision was sutured. 4. Tips and tricks: When the fibula osteotomy was made, damage for the common peroneal nerve should be avoided. The tibia osteotomy should try to be made in the original osteotomy site. 5. Postoperative management: Exercise in bed should be begun on the second day after surgery. The joint movement of the lower limbs should be done at the fifth day after the operation. The patient can walk with crutches on the ground. a

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On the tenth day after the operation, the X-ray photograph was reviewed and the mechanical axis and articular line had returned to the normal. The fixation was maintained until the bone healed. Case 3 The female patient, 26 years old, with bilateral genu valgum deformity who underwent bilateral osteotomy in the local hospital 5 years ago. Surgical incision scar was seen on the femoral medial side, and X-ray film showed that the b

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Fig. 14.34  Genu valgum type II: (a). Preoperative appearance; (b). Preoperative X-ray film; (c). Postoperative appearance; (d). Postoperative X-ray film; (e). Appearance at the end of treatment

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mechanical axis of the lower limbs was deviated to the outside of the knee joint. The right side was more severe than left. The bilateral FDLA was reduced, and the MPTA was enlarged. It was genu valgum type III (Fig. 14.35).

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1. Surgical plan: right femoral supercondylar varus ­osteotomy fixed with hybrid external fixation. Correction osteotomy of tibia deformity below tibial tuberosity using Ilizarov external fixation.

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Fig. 14.35  Genu valgus deformity type III: (a). Preoperative appearance; (b). X-ray film preoperative; (c). K-wire at both ends of the femoral osteotomy intraoperative, measuring the angle between the wires by the protractor; (d). Lateral cortical osteotomy; (e). Two K-wires should be parallel when femoral deformity was corrected; (f). Two cross K-wires for fixing the osteotomy; (g). The deformity is obviously improved; (h). The tibia was drilled for osteotomy; (i). Appearance

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postoperative when the fixator was mounted; (j). X-ray film showed that the mechanical axis and the knee joint line of right lower extremity were returned to the normal; (k). Satisfactory correction of right-side lower limb deformity postoperative; (l). The motion range of knee joint was normal when the fixator was removed; (m). When the external fixator was removed, the X-ray film showed that the mechanical axis and knee joint line right lower limb was returned to the normal

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2. Preoperative preparation: Ilizarov external fixator, hybrid external fixation, electric drill, sharp osteotome, etc. 3. Surgical procedures: The lateral incision of the head and neck of the fibula revealed and protect the common peroneal nerve, and then expose the junction of head and neck of the fibula. The bone was cut with the osteotome and the incision was sutured. The medial and lateral incisions of the lower thigh expose the lower part of the femur. After drilling with the electric drill on the femoral condyle, the surgeon put a pin on the middle and distal thigh, respectively. The angle between the pins is the angle of the femur deformity. Then the medial wedge osteotomy was made with an osteotome. Femoral lateral cortical bone was cut with lateral incision. Two pins were paralleled when the deformity was corrected. More pins were added and the osteotomy was fixed by a hybrid external fixator. The incision was sutured. The anterior medial incision of 1 cm length under the tibial tuberosity was cut and the tibia was exposed. A row of bone holes was drilled under the tibial tuberosity with the double-sleeve drilling osteotomy device. Then, the Ilizarov external fixator was installed with wires and pins. Finally, the bone was cut with osteotome along with the bone holes, and the incision was sutured. 4. Tips and tricks: Avoid damaging the common peroneal nerve when the fibula is osteotomized. The medial and lateral double incision is used for the femoral condylar osteotomy, so that osteotomy is easier. One K-wire is inserted at each end of the femoral osteotomy, and the angle is measured by the protractor, the angle between the two wires should be equal to the angle of the distal femur deformity. The two wires should be parallel while the femoral deformity was corrected. This wire method can make deformity correction more accurate. 5. Postoperative management: Joint movement exercise of the lower limbs in bed should be started on the second day after surgery; the walking on the ground with crutches will start at the fifth day after the operation. On the seventh day after surgery, the X-ray film was reviewed, the external fixator was started to adjust for further correction. After the deformity correction was satisfied, the fixator can be fixed until the bone healed.

14.7 Windswept Deformity in Lower Limb

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Fig. 14.36  Windswept deformity

strong wind blowing across both legs, which is called a windswept deformity (Fig. 14.36).

14.7.2 Characteristics of Deformities 1. There are deformities occurs in bilateral femur and tibia at the same time. 2. The deformities in the ipsilateral limb are in the same direction, such as the varus femur, tibia, and fibula in the same side, meanwhile valgus femur, tibia, and fibula on the other side (Fig. 14.37).

Sihe Qin, Xuejian Zheng, Jiancheng Zang, and Xulei Qin

The frontal deformity in the femur is often accompanied by a sagittal deformity of anterior bowing (Fig. 14.38).

14.7.1 Definition

14.7.3 Treatment

There is a genu varum deformity on one side of the knee, and a genu valgum deformity on another side. It is just like a

Femoral deformities should be corrected in both coronal and sagittal planes; the common peroneal nerve should be taken

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Fig. 14.37  Windswept deformity

care to avoid distractive injury during surgery for valgus deformity; the management is focused on (1). correction of deformities and (2). Restoring the limb length. It is recommended that the operation should be completed in two stages, in each stage osteotomy of both femur and tibia should be done in the ipsilateral limb. The attention should be paid to restoring the limb length subsequently.

14.7.4 Typical Case A 25-year-female patient with severe windswept deformity caused by rickets. X-ray photograph shows varus deformity in the middle part of the left femur and varus deformities in the left tibia and fibula. In the right side, there were a valgus deformity in the distal femur and valgus deformity in the proximal tibia and varus deformity in the distal tibia (Fig. 14.39). 1. Goals and ideas of treatment: The treatment goal is to correct the deformities of bilateral lower limbs and restore the normal mechanical axis and knee joint line.

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Fig. 14.38  Sagittal deformity of anterior arch

The femoral deformity on the right side was corrected by supracondylar varus osteotomy. In order to reduce the size of incision, the femur was fixed with mini plate combined with external fixator to ensure the strength of fixation. The use of the plate could make the fixator to be removed early. The valgus deformities in the tibiae were corrected by the osteotomy under tuberosity and an osteotomy in the junction of middle and lower part of tibia. In order to achieve the treatment goal, the osteotomy site should be slowly distracted with an Ilizarov external fixator, so that bone length can be increased. The left femoral deformity was in the middle segment and should be osteotomized in the middle segment. It was also fixed with a plate combined with an external fixator. The tibia is osteotomized under the tibial tuberosity and in the middle part respectively; with Ilizarov technique, deformity is slowly corrected. Considering the surgical trauma and early functional rehabilitation, the lower extremity surgeries should be staged. At each stage, the surgery including ipsilateral femoral and tibial osteotomies would be performed in only one side of the limb.

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Fig. 14.39  Patient female, 25 years old, windswept deformities of double lower extremities caused by rickets (a). Preoperative clinical appearance; (b). Full-length X-ray film of both lower extremities showed multiple deformities of bilateral femurs and tibiae; (c). The first stage, correction of the right leg deformities, revealing the common peroneal nerve, osteotomy at the junction of head and neck of fibula; (d). Osteotomy using a drill under the tibial tuberosity; (e). Varus osteotomy of the femoral condyle to correct femoral valgus deformity after fixing with a mini plate; (f). The Ilizarov external fixation was mounted on the tibia. The femur was fixed with a hybrid external fixator. The Ilizarov fixator was adjusted to correct the valgus deformity on the seventh day after the operation. The picture at the 38th postoperative day showed that the right lower extremity mechani-

cal axis was restored; (g). At the 40th day post operation, the deformities of the right lower extremity were corrected and lengthened by about 10 cm longer than the left lower extremity, and the femoral external fixator was removed at the time of discharge; (h). Follow-up of 4 months after surgery; (i). X-ray photograph at 4 months after surgery showed the bone on osteotomy site had healed, the Ilizarov external fixator was removed; (j). The second stage surgery, left femoral osteotomy fixed with an external fixation and a plate; (k). Tibial biplane osteotomy fixed with Ilizarov external fixation; (l). The left lower extremity deformity had been corrected at 38 days after the second surgery; (m). Follow-up at 23rd month after the second stage surgery; (n). X-ray film at 23rd month after the second stage surgery

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2. Preoperative preparation: osteotome, electric drill, Ilizarov external fixator, hybrid external fixator, plate and screws, double-sleeve drilling osteotomy device, etc. 3. Surgical procedure: (a) Right side. A lateral incision on the head and neck of fibula revealed the common peroneal nerve to be retracted and protected, and then the junction of head and neck of fibula was exposed, and then osteotomized with osteotome. The incision was sutured. Using a distal lateral incision of the lower leg, the fibula was revealed, and the osteotomy was done after drilling holes with an electric drill. With a medial incision over femoral supracondylar region, the vastus medialis muscle was pulled forward, the femur was exposed, and a close wedged osteotomy was performed with osteotome. One 4 mm K-wire was inserted parallel to the knee joint, one 5 mm pin was set on the lateral side of middle femur, and the angle between the pin and the K-wire was same as the distal femoral deformity. The osteotomy was completed to correct the femoral valgus deformity, making the pin and the K-wire parallel. Then the hybrid external fixator was installed and tightened. A 6-hole plate was

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used for internal fixation, and then the incision was sutured. Under the tibial tuberosity the tibia was exposed with 1 cm anteromedial incision. A row of bone holes were drilled assisted by special osteotomy device. The lower middle segment of the tibia on the CORA plane is exposed with a small incision and is drilled continuously with a mini device. An Ilizarov external fixator is mounted, and finally tibia was cut along the bone holes, and then the incision was sutured. (b) Left side. A lateral incision on the head and neck of fibula revealed the common peroneal nerve to be retracted and protected, and then the junction of head and neck of fibula was exposed, and then osteotomized with an osteotome. The incision was sutured. Using distal lateral incision of the lower leg, the fibula was exposed, and the osteotomy was done after drilling holes with an electric drill. With a 10 cm lateral incision over the femur, the vastus lateralis muscle was pulled forward, the femur was exposed, and a close wedged osteotomy with a bone knife was done. A pin was set on the proximal and distal parts of femur, respectively. The angle between the two pins was in the same as that of femoral deformity. The osteotomy was completed to correct the femoral varus deformity, making the pins parallel. Other two pins were used for mounting the hybrid external fixator and tightened. A 6-hole plate was used for internal fixation, and then the incisions were sutured. Under the tibial tuberosity, the tibia was exposed with a 1 cm anterior medial incision. A row of bone holes was drilled assisted by a special osteotomy device; the lower middle segment of the tibia on the CORA plane was exposed with a small incision and drilled continuously with a mini device. An Ilizarov external fixator was mounted, and finally the tibia bone was cut along the bone holes, and then the incision was sutured. 4. Tips and tricks: The angle of the femoral deformity was determined before surgery. The angle between two pins on the both sides of the femoral osteotomy plane should be equal to the angle of femoral deformity needing to be corrected. After the osteotomy, the two pins should be parallel. The anterior arch deformity in the sagittal plane should be corrected simultaneously during femoral frontal deformity correction. The surgeon should pay attention to the protection of the common peroneal nerve during fibula osteotomy. During the tibial osteotomy procedure, the surgeon should avoid injury to the posterior tibial nerve and vessels. When the external fixator was mounted, upper and lower tibiofibular joints needed to be fixed respectively;

14  Genu Varum, Genu Valgum, and Osteoarthritis of Knee

care is taken while inserting the pins and wires, so that movement of knee joint is not restricted. 5 . Postoperative management: Joint movement exercise of the lower limbs in bed should be started on the second day after surgery; walking on the ground with crutches would start at the fifth day after the operation. On the seventh day, the Ilizarov external fixator would start to distract the medial side and to correct the genu varum deformity. The external fixator on the femoral part could be removed on the sixth week. When the deformity is corrected completely, the frame is fixed until the bone healing, and then the fixator would be removed. After the treatment in one side of the lower limb, the other side can be started as the second stage.

14.8 K  nee Osteoarthritis with Tibia Varus Deformity Sihe Qin, Shaofeng Jiao, and Jiancheng Zang Osteoarthritis of the knee occurs easily when elderly patients with genu varus deformity. The medial space of the knee joints becomes narrower with aging, which aggravates the genu varum, forming a vicious circle and speeding up the process of joint degeneration. Lower limbs can achieve good alignment through deformity correction with high tibial osteotomy, which can prevent the deterioration of the joint degeneration, improve the joint function, delay or even avoid joint replacement. The advantages of high tibial osteotomy with Ilizarov technique are as follows: (1). Minimally invasive osteotomy with small incision; (2). Dynamic adjustment can be applied according to the recovery of force line and the sensation from patient; (3). Joint distraction can be carried out simultaneously to create an environment for reconstruction of articular cartilage; (4). In the processing of treatment, the patient can walk weight-bearing in early stage to avoid complications; (5). No need of second surgery for internal fixation removal. Typical case (Fig. 14.40)

14.9 Tibia Vara Sihe Qin, Shaofeng Jiao, Jiancheng Zang, and Xuejian Zheng The tibia vara, also known as Blount disease, is a rare dysplasia of the proximal tibia, mainly involving the medial and

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posterior part of tibial epiphysis and metaphysis. It is of two types which are as follows: 1. Infantile tibia vara: This is more common, usually occurs under 3 years of age and is mostly bilateral. Deformity progresses rapidly and is usually more severe. 2. Adolescent tibia vara: This is less common, usually occurs in 8–15 years of age group and is mostly unilateral. Deformity is mild, and involves female more than male.

14.9.1 Etiology Dr.Blount described this disease in detail in 1937. The cause is still unknown and may be related to obesity, trauma, and ischemic necrosis of the medial epiphysis of the tibia.

14.9.2 Pathology The main site of this disease is the epiphyseal cartilage and the epiphyseal plate on the medial side of the proximal tibia. The cartilage formation in the medial epiphysis is disturbed. The ossification center only appears on the lateral side, while the medial epiphysis remains cartilaginous. Due to this asymmetry of growth in proximal tibia, the knee develops varus deformity. The upper 1/3 of the tibia is in varus and internally rotated. The medial condyle inclined medially, posteriorly, and inferiorly, and the tibial physeal plate closes prematurely.

14.9.3 Symptoms and Signs In standing position, the affected limb shows varus deformity. The knee is bent outwards and the fibular head is prominent. There is limping gait in unilateral deformity, whereas in bilateral deformity waddling gait (duck step) is seen. Infantile type has mild symptom and deformity is usually unilateral. In adolescent type, there is usually no pain.

14.9.4 X-Ray Findings X-ray findings of tibia vara depend on the degree of skeletal maturity and involvement of proximal tibia. The posterior medial aspect of the epiphysis, epiphyseal plate, and metaphysis are involved. The course of Blount disease can

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Fig. 14.40  Treatment of knee osteoarthritis with tibia varus deformity. (a). Preoperative clinical appearance; (b). X-ray showed that the proximal tibia varus deformity right side, the medial space of the knee joint narrowed, and osteophytes formed in medial tibial condyle; (c). Full-length X-ray of both lower extremities showed that the mechanical axis of the right lower extremity deviated from the medial knee joint; (d). Fibula osteotomy; (e). Tibia osteotomy was done with double barrel drill sleeves; (f). The proximal tibial varus deformity was corrected 2 weeks after surgery; (g). Force line of the right lower extremity was restored on the 19th day

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after surgery; (h). X-ray showed that the mechanical axis of the right lower extremity was restored; (i). Sixteen months after surgery, there was no recurrence of right lower extremity deformity and the pain disappeared; (j). The range of motion of right knee was normal; (k). X-ray showed that the medial space of the right knee joint was widened; (l). The force line of the right lower limb was normal at 39 months after surgery; (m). The range of motion of right knee was normal; (n). X-ray showed knee degeneration did not aggravated; (o). The full-length X-ray showed that the mechanical axis of the right lower extremity was normal

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be divided into six stages based on the X-ray findings as suggested by Dr.Langenskiold. The sixth stage is a deformity with an epiphyseal fusion and medial tibial condyle facing 90°.

14.9.5 Treatment The children over 3 years of age with deformity less than 20°, tibial osteotomy should be performed at an early age. Tibia dome osteotomy and medial condylar elevation can be performed. Other option is to do an epiphysiodesis on lateral tibia and fibula. In older children, a close wedge osteotomy of the proximal tibia can be done and the wedge removed from the lateral side can be transferred to the medial side. The osteotomy can be fixed with an external fixator. If the patient is of short stature, deformity correction and lengthening can be performed simultaneously. If the patient has joint laxity, the lateral collateral ligament should be tightened. In 1981, Dr. Qin Sihe performed his first surgery for tibia vara deformity on a 23-year-old female. The proximal tibia osteotomy was done and fixed with long-legged cast. A satisfactory correction was obtained after operation (Fig. 14.41). For the past 10 years, the authors have been applying external fixator (Ilizarov technique) and adjusting it slowly in postoperative period to correct the deformity. With this technique, not only the surgical incision is small, but it is less

invasive and all the deformities can be corrected completely. The knee joint line can be restored and limb lengthening can be done simultaneously.

14.9.6 Typical Case 1. A 21-year-old female patient with right knee varus deformity due to Blount disease; the preoperative X-ray showed a bilateral proximal tibia vara deformity. MPTA is 35° on the right side and 78° on left side. On the right side, proximal tibial valgus osteotomy below tuberosity and Ilizarov external fixation was performed. Most of deformity was corrected during the operation, and the residual deformity was corrected slowly by adjusting the external fixator (Fig. 14.42). 2. A 23-year-old female patient with right genu varum deformity caused by Blount disease; preoperative X-ray showed proximal tibia vara deformity and distal femoral compensatory valgus deformity. LDFA: 69°, MPTA: 50°, tibial torsion angle: 15°, and tibial shortening of 2  cm. Distal femur supracondylar osteotomy was done to correct valgus deformity and was fixed with a plate. Proximal tibial osteotomy was done below the tuberosity and was fixed with Taylor spatial frame. Femoral valgus deformity was corrected acutely and intraoperatively, whereas tibial deformity was corrected gradually by external fixator (Fig. 14.43).

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Fig. 14.41  First case of tibia vara deformity (23-year-old female) was performed by Dr. Qin Sihe

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Fig. 14.42  The right tibia vara deformity due to Blount disease. (a). Preoperative clinical appearance; (b). Preoperative full-length standing AP radiographs; (c). Fibula osteotomy, the fibula was cut 1 cm and used as a graft; (d). Fibula osteotomy at 10 cm above the lateral malleolus with a small osteotome; (e). Osteotomy of the tibia with osteotome along the CORA; (f). Deformity was corrected partially intraoperative, and then temporarily fixed by two 2.5 mm K-wires; (g). The fibular graft was implanted into the defect on the medial side of tibial osteotomy; (h). Application of

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Ilizarov external fixator; (i). The external fixator was gradually adjusted to correct residual deformity from sixth day after surgery. Deformity was totally corrected on 47th day after surgery; (j). 47 days later, lower extremity full-length AP photograph showed the lower extremity axis restored to normal; (k–o). 5 months follow-­up, the osteotomy has healed well, the external fixator was removed and a brace was given for 3 months; (p–r). 8 months follow-up, the deformity was corrected very well, knee range of motion was normal, the osteotomy has healed well

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adjust Taylor spatial frame gradually to correct the varus deformity from fourth day after surgery; (j, k). X-ray at fourth day after surgery; (l). 31 days after surgery, Taylor spatial frame was adjusted smoothly, and continued to correct residual varus deformity and partial internal rotation deformity; (m). X-ray at 52nd day after surgery showed the correction of deformity; (n). The tibial deformity was corrected at tenth week after surgery; (o). 8 months after surgery. (p). X-ray shows tibia osteotomy has healed well; (q). X-ray shows bone healing at 11th month after operation, and the mechanical axis of the lower limb restored to normal; (r). Clinical appearance just after external fixator was removed

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Lower Limb Deformities Caused by Hemangiomas and Vascular Disorders

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Sihe Qin, Dingwei Zhang, Jiancheng Zang, Shaofeng Jiao, Qi Pan, Baofeng Guo, and Yilan Wang

15.1 Introduction Sihe Qin

15.1.1 Lower Limb Deformities Caused by Hemangioma Hemangiomas and vascular deformities are hamartomas caused by congenital vascular dysplasia. In 1982, Muliken classified hemangioma into either true hemangiomas or vascular deformities at molecular level. The principles of treatment are to control the development of the hamartoma, to promote their regression, to reduce the impact of any associated complications, and to preserve the function of involved or affected organs. Sclerosing agent injection therapy has a long history but repeated injection often causes extensive local necrosis and atrophy of cells and tissues. Hemangiomas that occur in the lower extremities and cause deformities of the motor system are mainly found in skeletal muscle hemangiomas or are the result of congenital venous deformities related to bone hypertrophy syndrome. Skeletal muscle hemangiomas are a form of benign tumor originating from the skeletal muscle. They are characterized by abnormal proliferation of blood vessels in the muscle tissue. These can infiltrate the muscle locally, and can also involve several adjacent muscles. Deformities of bone and joint therefore sometimes result in contractures. In skeletal muscle, the invading area of hemangioma is often confined to S. Qin (*) · Y. Wang · J. Zang · S. Jiao · Q. Pan Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China B. Guo Tsinghua University Chuiyangliu Hospital, Beijing, China D. Zhang Mianyang Center Hospital, Mianyang, China

the intramuscular and intermuscular spaces. There are no abnormal blood vessels in the skin, subcutaneous tissue, or deep fascia, and there is usually obvious tenderness in the local musculature. Calcification of deep soft tissue and adjacent osteoporosis are characteristic radiographic features, while an MRI can define the extent of muscle invasion. Limb intramuscular hemangioma (IMH) typically produces more clinical complaints during childhood. The main symptoms include swelling, pain, and aggravation after exercise. Hemangioma invades muscle and fascial tissue, which can cause contracture and secondary deformities of adjacent to bones and joints. The treatment of limb IMH is difficult, and surgical resection is a common method. However, if the invasion of involved tumor tissue is wide, it is difficult to remove the pathology completely and improper resection can easily damage a large number of vascular tissues and lead to iatrogenic limb dysfunction (Fig. 15.1).

15.1.2 Ilizarov Reconstruction of Ischemic Disorders Thromboangiitis obliterans is one of the main causes of ischemic disease of the lower extremity. Destruction of the arterioles reduces circulation to the extremities, resulting in mild cooling of the limbs, intermittent pain, and severe terminal necrosis leading to dry gangrene or possibly more severe wet gangrene associated with infection. Conservative treatment can be effective for mild and moderate ischemic disease of the lower extremity, but once the disease progresses to gangrene nonoperative care is often unsuccessful, and amputation becomes the inevitable final method for many of these patients. Diabetic foot is another common disease of lower extremity reflecting a disease affecting the microvasculature. The pathogenesis of diabetic foot is based on the pathological changes of peripheral blood vessels and the coincident neuropathy of the lower extremities resulting from chronic inadequate control of blood glucose in diabetic patients. The incidence of arteriosclerosis in

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Fig. 15.1  Lower limb deformities caused by hemangioma

diabetic foot patients is reportedly four times higher than that in normal subjects, and the resulting ischemia is one of the main causes of soft tissue injury and pain. Since the discovery of the tension-stress effect by Prof.G.A.Ilizarov, vascular regeneration has realized a new era in the treatment of lower extremity ischemic diseases by regenerating blood vessels, thereby rejuvenating the abnormal microcirculation. This “Ilizarov microcirculatory reconstruction” is fundamentally different from established procedures such as endarterectomy to improve circulation because it interrupts the

vicious circle of pathophysiology formed by ischemia, and its excellent therapeutic results have been encouraging.

15.2 C  linical Data of Hemangioma with Lower Extremity Deformity (Tables 15.1, 15.2, 15.3, and 15.4) Sihe Qin, Yilan Wang, and Jiancheng Zang

15  Lower Limb Deformities Caused by Hemangiomas and Vascular Disorders Table 15.1 Gender ratio of hemangioma patients in Qinsihe Orthopedics Institute Gender Male Female

Cases (n) 24 31

Percentage (%) 43.64 56.36

Type Ilizarov technique Others

Table 15.2 Age at surgery of hemangioma patients in Qinsihe Orthopedics Institute Age (year) 1–5 6–10 11–15 16–20 21–25 26–30 30–40 >40 Maximum age Minimum age Average age

Cases (n) 1 4 15 13 14 4 3 1 48 5 18.9

Percentage (%) 1.82 7.27 27.27 23.64 25.46 7.27 5.45 1.82

Dynamic balance

Bone osteotomy

Name Posterior tibial tendon lengthening surgery Achilles tendon lengthening surgery Knee flexion release surgery Hip flexion release surgery Hamstring muscle tendon lengthening Plantar aponeurosis release surgery Iliotibial band lengthening surgery Gastrocnemius aponeurosis lengthening surgery Biceps femoris tendon lengthening surgery Digitorum longus and flexor pollicis lengthening surgery Semitendinosus and semimembranous tendon lengthening Posterior tibialis moves laterally Tendon transfers for paralysis of Achilles tendon Chopart arthrodesis Tibia osteotomy Supracondylar osteotomy Peritalar osteotomy Triple arthrodesis Metatarsal basal osteotomy Tarsal bone osteotomy Calcaneal osteotomy

Name Hip joint distraction surgery Knee joint distraction surgery Ankle joint distraction surgery Common peroneal nerve release surgery Quadricepsplasty

Surgeries (n) 1 18 11 1

Frequency (%) 1.82 32.73 20.00 1.82

1

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Table 15.4  External fixation (EF) for deformity correction of hemangioma patients in Qinsihe Orthopedics Institute Type Ilizarov fixator Hybrid fixator Others

Cases (n) 44 2 9

Frequency (%) 80.0 3.6 16.4

15.3 L  ower Limb Deformity Caused by Hemangioma

Table 15.3  Operation method of hemangioma patients in Qinsihe Orthopedics Institute Type Soft tissue release

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Sihe Qin, Shaofeng Jiao, Qi Pan, , Baofeng Guo, and Jiancheng Zang

15.3.1 Common Reasons for Lower Limb Deformity Caused by Hemangioma Intramuscular hemangioma of skeletal muscle is characterized by the abnormal proliferation of blood vessels in muscle tissue, which can then infiltrate within intramuscular compartments and involve adjacent muscle tissue, resulting in contractures and associated deformities of bone and joint. The intramuscular hemangioma which occurs in the popliteal part of the calf muscle is liable to cause knee pain and secondary knee flexion deformity, and in combination with equinus deformity can result in secondary effects such as gait abnormalities, pelvic tilt, and scoliosis.

15.3.2 Clinical Manifestations Most cases involving the lower extremity have been diagnosed with hemangioma previously. Some patients give a history of hemangioma resection or local injection with a sclerosing agent (Fig. 15.2), and the knee or ankle deformities then developed gradually. Hemangiomas of the lower extremities often appear in children and adolescents at the developmental stage. In some severe patients, cutaneous and subcutaneous hemangiomas are visible in the affected limbs (Fig.  15.3). Intramuscular hemangiomas in the popliteal muscles of the calf are prone to knee pain and secondary knee flexion and even equinovarus deformity (Fig.  15.4). Knee and

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Fig. 15.2  The deformity occurred. After resection of hemangioma and injection of sclerosing agent in the right lower extremity

Fig. 15.3  On the right lower limb, skin and subcutaneous venous aneurysms can be seen in the posterior popliteal, anterior tibia, heel, and back of the foot

Fig. 15.4  Knee flexion and equinovarus deformity of the left lower limb caused by hemangioma

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ankle deformities are the most common bone and joint deformities secondary to hemangioma of the lower extremity.

15.3.3 Imaging Characteristics Due to the abnormal blood flow in hemangioma, thrombus, phlebolithiasis, and neovascularization often occur. Rupture of the hemangioma can lead to recurrent hemorrhage and secondary hematoma formation, fibrous tissue proliferation, and the associated calcification of muscle can often be seen on X-ray examination (Fig. 15.5). MRI examination of the lower extremities can better reflect the location, extent, and depth of the hemangioma (Fig. 15.6).

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15.3.4 Classification 1 . Knee flexion deformity caused by hemangioma 2. Ankle deformity caused by hemangioma 3. Combined knee and ankle deformity caused by hemangioma

15.3.5 Surgical Principles for Lower Extremity Deformity Caused by Hemangioma Hemangiomas often invade soft tissues, and contractures subsequently develop gradually. It is not only easy to damage the fragile hemangioma but also difficult to thoroughly correct severe contractures using traditional methods.

Fig. 15.5  Equinovarus deformity caused by hemangioma on the calf; X-ray shows large area of calcification of soft tissue posteriorly

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Fig. 15.6  MRI shows that the triceps of left leg is invaded by hemangioma

Severe knee flexion deformity, ankle equinus deformity, dense scar formation and fibrous contracture of adjacent soft tissue, associated deformities of bone, extensive vascular variation, and a high chance of remaining hemangioma are often found following hemangioma sclerotherapy. All of these problems are particularly difficult to address using traditional surgery in a single stage.

15.3.5.1 Basic Principles of Surgical Treatment Surgery mainly deals with the knee and ankle deformities caused by hemangioma based on the principles of deformity correction, to restore the normal morphology of limbs and weight-bearing line. For knee flexion deformities where there is a hemangioma in the popliteal region, it is often unsuitable for open soft tissue

15  Lower Limb Deformities Caused by Hemangiomas and Vascular Disorders

release procedures. However, the Ilizarov method can be applied for gradual correction without open exposures, and foot and ankle deformities can be treated with percutaneous soft tissue releases simultaneously. Subtalar joint minimally invasive releases or peri-talar osteotomies can be performed in moderate and severe cases. Combined with the Ilizarov technique, recurrence of the deformity can be effectively prevented. Following removal of the external fixator, an orthosis should be worn continually to maintain the correction achieved. Due to the presence of the hemangioma, there is a tendency for the deformity to recur quickly if an orthosis is not provided. The wearing time for the orthosis should be controlled flexibly according to the severity of an individual deformity.

15.3.5.2 Surgical Method 1. Knee flexion deformity: when hemangiomas occur in the posterior part of the lower thigh and popliteal fossa, the tight fascia and hamstring tendons are first released percutaneously with a scalpel (Fig.  15.7), then an Ilizarov

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fixator is applied with gauze wrapping of the pin tracts to prevent infection. If there are no hemangiomas posteriorly in the thigh, hamstring tendon releases can be simply performed to reduce the distraction resistance postoperatively and shorten the time of treatment. 2. Foot and ankle deformity: equinovarus is the most common deformity of the foot and ankle. The surgical procedure should be performed as follows: a 3 cm longitudinal incision is made on the posterior aspect of the medial malleolus area. The skin, subcutaneous tissue, and tendon sheath of the posterior tibial muscles are exposed. The posterior tibial tendon is exposed, and then lengthened in a “Z” shape. If the flexor digitorum longus is also contracted, then the common flexor digitorum tendon can be lengthened in a Z shape through the same incision. As an assistant dorsiflexes the ankle joint, the Achilles tendon can be released with three different partial cuts with a sharp knife percutaneously. Taut plantar fascia can be cut percutaneously with a scalpel (Fig. 15.8), and if there are varus deformities in the midfoot, a subtalar joint fusion can be completed through a lateral incision; a triple arthrodesis may need to be performed in the most severe equinovarus deformities. Finally, the Ilizarov external fixation frame is mounted with wires and pins. If both knee and ankle deformities are present, all of them should be corrected in a single stage to restore the weight-­ bearing line of the lower extremities or the deformities will recur quickly otherwise.

Fig. 15.7  Hamstring tendon is released percutaneously

Fig. 15.8 Percutaneous release of Achilles tendon and plantar aponeurosis. (a). Achilles tendon release; (b) Plantar aponeurosis release

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15.3.5.3 H  ow to Avoid Bleeding During and After Surgery? If the hemangioma is large or widespread, a small K-wire as thin as possible should be chosen to reduce the amount of blood loss. After the operation, the wire can be wrapped with gauze to achieve compression and prevent bleeding.

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When the hamstrings, Achilles tendon, and plantar aponeurosis are released with a scalpel, the surgeon should master the local anatomy. Holding the knife stable will avoid damage to the popliteal vessels and adjacent nerve. Percutaneous releases should be performed after mastering the open procedure. Wires for mounting the external fixation should be inserted in safe zones to avoid neurovascular injury.

15.3.6 Typical Cases (Fig. 15.10)

15.3.5.4 Application of a Plaster Cast A plaster cast can be used to stabilize the involved limb instead of external fixation when the deformity is able to be corrected completely. It can facilitate weight-bearing functional exercises in plaster immediately, but also can also be used to maintain the effect of gradual deformity correction obtained using external fixation (Fig. 15.9).

15.4.1 Overview

15.3.5.5 Application of Orthosis In order to maintain the surgical correction and facilitate early weight-bearing, an orthosis should be applied for a period after removal of the external fixator.

Fig. 15.9  Right knee flexion deformities caused by hemangioma: long leg plaster fixation after external fixator removal, doctor’s order was written on the plaster

15.4 Lower Limb Ischemic Diseases Dingwei Zhang, Sihe Qin, and Jiancheng Zang

The Ilizarov method and the principles of distraction histogenesis are used for tissue regeneration and functional limb reconstruction, initially described and fully developed by Prof G. A. Ilizarov in Russia. The principle is that the tension generated in biological tissues when it is gradually distracted can stimulate tissue regeneration and active growth. New tissue grows in the same way as fetal tissue, with active cell division and proliferation. Human bones, like human epithelium and connective tissue, have great regenerative potential and plasticity. Under the appropriate conditions of “tension-­stress,” bone and

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Fig. 15.10  Ilizarov technique for correction of severe knee flexion deformity caused by hemangioma. (a) A 14-year-old male with hemangioma, who suffered from left knee flexion deformity for 7 years and equinovarus deformity for 2 years. Preoperative appearance showed the left knee flexion at 110 °and equinovarus deformity. (b) Preoperative angiography showed extensive hemangioma of the left lower extremity.

(c) Knee and ankle Ilizarov external fixation was mounted for simultaneous correction. (d) 3  months after operation, left knee flexion and equinovarus deformity had been completely corrected. (e) After the removal of the external fixator, an orthosis was applied. (f) At 2 years follow-up after surgery; photograph demonstrating satisfactory correction of the left knee flexion contracture and clubfoot deformity

the attached muscles, fascia, blood vessels, and nerves grow simultaneously, generating new tissue. Prof. Ilizarov observed osteogenesis occurring in the distraction gap from both ends of a closed osteotomy that was slowly pulled apart, and actively studied distraction osteogenesis in the legs of dogs. The active regeneration of the microvascular network was first observed, and this neoangiogenesis confirmed the reconstructive potential of the “neovascularization and microcirculation” in the distraction area of the extremities (Fig. 15.11(1)), and documented the increased local tissue perfusion (Fig. 15.11(2)).

Although Prof. Ilizarov discovered the phenomenon of neovascularization associated with the process of distraction osteogenesis, he did not applied this technique for microcirculation reconstruction. In recent years, with the further development of technological innovation and extensive clinical applications of distraction osteogenesis, great progress has been made in this concept. Neovascularization has now entered the stage of distraction tissue regeneration, and this technique has been applied to plastic surgery, vascular surgery, and other fields. It is now possible to suc-

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Fig. 15.11  Angiography demonstrating reconstruction and expansion of the “neovascularization and microcirculation,” confirming the tremendous vascular proliferation observed following transverse tibial bone transport. (This photo from Ilizarov center)

cessfully treat and correct many deformities that would have otherwise been unreconstructedly and previously considered candidates for amputation. A large number of animal experiments have proved that mechanical stimulation using controlled gradual distraction can promote neoangiogenesis and tissue regeneration, and the techniques of distraction histogenesis can stimulate the formation of a “vascular network.” At the same time, it has been demonstrated that the technique of transverse tibial transport can significantly improve the microcirculation locally, and this capacity to improve and expand the microvascular network can be used in the treatment of ischemic diseases of lower extremity. After surgery, angiography has demonstrated that there is a resulting rich network of neoangiogenesis and vascular proliferation around the bone transported, and the microcirculation of ischemic tissue is able to be reconstructed effectively. This technique began to be used clinically and now provides new opportunities for the treatment of ischemic diseases of lower extremity.

15.4.2 Treatment of Diabetic Foot Conditions and Pathology 15.4.2.1 Introduction The foot is a complex target organ for diabetes. Diabetic foot is a multisystemic disease, and in concept refers to the foot infections, ulcers, and/or deep tissue destruction caused by diabetic lower extremity arterial lesions and local nerve

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abnormalities. Diabetic foot is a very serious complication of diabetes mellitus, and is both highly disabling and potentially fatal. According to WHO, there are about 200 million diabetic patients worldwide. As the most common disease, diabetes is often associated with lower limb amputation in western countries, and the incidence is increasing at a rate of 2.5% per year. For those aged 65–74, the current risk of amputation associated with diabetes has increased to 20%, with 33% of these patients facing amputation due to lower limb ischemia. The clinical presentation of diabetic patients is further complicated by the excessive mechanical pressure resulting from peripheral neuropathy and peripheral vascular diseases. This can lead to destruction and deformity of the foot and ankle, thus causing a series of foot problems, ranging from mild neurological symptoms to severe ulcers, infection, vascular diseases, Charcot arthropathy, and neuropathic fractures. If active treatment does not adequately address the symptoms and complications of the lower extremities, the consequences can be catastrophic. The ulcers of a diabetic foot can cause pain, changes in sleep patterns, and loss of activity, thus resulting in depression, dissatisfaction, and other negative emotions, which seriously affect their quality of life. Although the current treatment of diabetic foot disorders is increasing and improving, each treatment method and experience is different. Diabetic foot is still a refractory chronic disease, with many difficult problems still to be recognized.

15.4.2.2 The Pathogenesis of Diabetic Foot The etiology and pathological basis of diabetic foot is the result of abnormalities in the microcirculation caused by the combination of microvascular disease, increased blood viscosity, and related disturbances in the blood flow in diabetic patients. These aspects are also the determining factors for the prognosis of diabetic foot conditions. Its pathophysiological basis is fundamentally a metabolic disorder, and hyperglycemia, hyperlipidemia, high glycoprotein, and other pathogenic factors lead to peripheral nerve injury, atherosclerosis, stenosis, or obstruction of local blood vessels. This inevitably results in further injury with the proliferation of capillary endothelial cells in diabetic patients. Diabetic patients have more severe lower limb ischemia, and the foot neuropathy and ischemic lesion can aggravate the foot condition. The pathogenesis of diabetic foot is mainly caused by peripheral vascular disease, peripheral neuropathy, repetitive trauma, and local infection, which complement each other, promoting the occurrence of diabetes mellitus and restricting the treatment of diabetic foot at the same time. Peripheral vascular lesions cause skin ulceration, gangrene, and infection, which in turn further exacerbates tissue damage and leads to additional pathology. Neuropathy has long affected blood supply and caused foot structural abnormalities, with trophic skin changes (dry, chapped) leading to foot infection.

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These three aspects, peripheral vascular lesions, neuropathy, and infection, are intimately related and influence each other.

15.4.2.3 Clinical Manifestation and Classification The clinical manifestations of diabetic foot can be divided into two types. Type one is characterized by acute infection, and by small skin breakage, which develops rapidly along tendon sheaths, superficial fascia, myofascial space, metatarsal fascia, and often involves Gram positive bacteria with anaerobe infections, and the disease develops rapidly. The associated widespread septicemia then endangers life and may result in amputation. The second type is characterized by chronic foot ischemia and skin ulceration, with long lasting wound characteristics, or the sudden incidence of toe gangrene resulting from the poor blood supply, with ischemia and necrosis as the main manifestations. There are many grading methods for diabetic foot, the most commonly used is the Wagner grading system: • Wagner 0: There is no foot ulceration, but there are high risk factors for ischemic disease of the lower extremity including decreased skin temperature, diminished sensation, and weak dorsalis pedis arterial pulses. • Wagner 1: Superficial ulceration, accompanied by callus, loss of continuity and integrity, and blisters all limited to the epidermis. • Wagner 2: Infection invades subcutaneous tissue with cellulitis, abscess cavity formation, and creation of a sinus, but without involving or destroying deep tissue. • Wagner 3: Deep tissue destruction with abscess cavity expansion, additional tissue necrosis, and extension to bone resulting in osteomyelitis. • Wagner 4: Ischemic necrosis, local gangrene. • Wagner 5: Most or all of the foot is actively infected, and is associated with foot gangrene, even affecting the ankle and leg.

15.4.2.4 Traditional Surgical Treatment The traditional surgical treatment options for diabetic foot are often selected based on the Wagner criteria. Patients with Wagner 1 were treated with skin grafts after superficial ulcer debridement, and the wound was repaired over time based on thorough drainage of the abscess. Wagner 2 lesions require removal of all of the deep abscess tissue distributed between the fascia and the muscle. If the resulting wound is small, it can be closed primarily; if the wound is large with a complex infection, flap transfer or skin grafting should be carried out and drainage should be completed during surgery. Only after the purulent cavity has been thoroughly cleared, the defect can be closed. With Wagner 3 diabetic foot lesions have sinus tracts that are unable to heal completely. The sinus itself can be excised or enlarged to facilitate removal of necrotic bone and ­damaged

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joints thoroughly, and then filled with adjacent fascio-­cutaneous flaps to completely eliminate the resulting dead space. Wagner 4 lesions can be covered using local island flaps. For Wagner 5 diabetic foot lesions, after excision of gangrenous tissue and necrotic toe stumps, if the artery of the lower extremity is stenotic, the combined therapy of interventional therapy and vascular surgery can be done, and lower limb amputation can be undertaken after the blood supply of the extremity has been improved. However, even strictly adhering to the above management protocols, there can be little optimism when treating the diabetic foot. Diabetic foot remains difficult to treat because in these patients’ peripheral vascular lesions do not have sufficient blood supply to the foot. Effective reconstruction of the involved limb microcirculation is often urgently needed to achieve a successful outcome.

15.4.2.5 S  urgical Methods and Postoperative Management of Ilizarov Technique 1. Basic treatment: Dietary control and subcutaneous insulin injections are used as necessary to control blood sugar, maintaining fasting blood glucose levels less than 8.3 mmol/l. Based on the bacterial culture results of the wound and antibiotic sensitivities, the most effective antibiotics are selected and adjusted as indicated. During hospitalization, all patients are treated with medications that promote improved circulation and eliminate hemostasis to improve the microcirculation, and nourish and improve nerve metabolism. 2. Transverse tibia transport technique: The surgery is performed under epidural anesthesia or general anesthesia, without a tourniquet. The planned osteotomy is defined on the medial anterior tibia, the length of which was about 1/4 of the tibia (Fig. 15.12), with a width of 20 mm and a typical length of 120 mm. Three 15 mm longitudinal incisions are performed at predetermined osteotomy positions. A tibial bone window of 20 mm × 120 mm in square is then elevated on the medial aspect of the tibia. Finally, a device for transverse bone transport is mounted (Fig. 15.13a).

Fig. 15.12  Skin marked identifying planned borders for the tibial osteotomy

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3. Debridement: the necrotic tissue of the diabetic foot can be debrided, the wound can be expanded, and the granulomatous tissue in the wound can be removed completely. The wound is irrigated and disinfected with hydrogen peroxide, 1/1000 iodophor solution, and normal saline. 4. Postoperative management: radiographs of the tibia and fibula are obtained 5–7 days postoperatively (Fig. 15.13b), and based on the local condition of the wound, the tibial bone piece was gradually transported horizontally, at the rate of 1 mm every day in 6 increments, and stopped after 21  days (Fig.  15.13c). The tibial bone window is then replaced by reversing back in the opposite direction at the same speed. Following another one month, after radiographs confirm early healing, the device can be removed. During treatment, the fasting blood glucose must be controlled strictly below 8.3  mmol/l, appropriate pathogen specific antibiotics are used intravenously, and the wound is dressed regularly. If the wound is particularly large and deep, the negative pressure wound therapy can be applied to accelerate wound healing.

15.4.2.6 Typical Cases Case 1 An 82-year-old female with arteriosclerotic occlusion of the left lower extremity and ischemic necrosis of her left foot due to diabetes. The patient had severe ischemic pain (VAS pain score 8), the preoperative fasting blood glucose was 9.6 mmol/l, blood glucose postprandial 2 h was 16.4  mmol/l, and glycosylated hemoglobin of 11.8 was associated with diabetic retinopathy. The foot pain was relieved quickly after surgery. Within 4 weeks of the operation, arteriography and recanalization of the artery were performed, resulting in successful limb salvage (Fig. 15.14). Case 2 A 78-year-old female with diabetic foot, Wagner 4, with severe right foot pain (VAS pain score 7) preoperatively, fasting blood glucose was 8.9  mmol/l, blood glucose postprandial 2  h was 15.2  mmol/l, and the glycosylated was hemoglobin 9.9  mm/l. Preoperative angiography

15  Lower Limb Deformities Caused by Hemangiomas and Vascular Disorders Fig. 15.14  An 82-year-old female with diabetic foot. (a) Left foot cyanosis and toe necrosis preoperatively. (b) Angiography revealed anterior and posterior arterial occlusion. (c) At 4 weeks after surgery, the cyanosis has resolved, and the toe necrosis is obviously improved. (d) Angiography demonstrated recanalization of the anterior and posterior tibial arteries

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Case 3 A 40-year-old male with right diabetic foot, Wagner level 4–5. Preoperatively, right foot pain (VAS pain score 5), f­asting blood glucose 7.6  mmol/L, postprandial blood glucose 11.6  mmol/l, and glycosylated hemoglobin 7.3  mmol/l. Preoperative radiography revealed destruction of the first

638 Fig. 15.15  A 78-year-old female with diabetic foot. (a) Right foot infection with toe gangrene. (b) Preoperative angiography showed extensive sclerosis and occlusion of the popliteal artery of the right lower extremity. (c) At 3 months after surgery, the infection of the right foot was cured. (d) Abundant neovascularization was observed on angiography 4 weeks after surgery

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metatarsophalangeal joint on the right foot, and arteriography confirmed sclerosing occlusion of the posterior tibial artery. At 60 days after surgery, the wound of the foot healed spontaneously, and the arteriography of the affected limb demonstrated extensive regeneration of microvascular networks (Fig. 15.16).

15.4.2.7 Clinical Data of Diabetic Foot From September 2015 to December 2017, 108 patients with diabetic foot were treated at our center using the Ilizarov tibial transverse transport technique. There were 72 males and 36 females, aged 45–82 years (mean 64.8 ± 8.9 years). The follow-up period ranged from 3 months to 24 months. a

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The ischemia symptoms in 105 patients were obviously improved, the foot temperature increased, and the wounds gradually healed. In three patients, limb salvage was complicated by painful diabetic neuropathy. Although the wound condition was improved after surgery, these patients’ pain symptoms were not alleviated, resulting in amputation. At 2  years follow-up, 15 patients had died from cardio-­ cerebrovascular diseases, a mortality rate of 13.9%. This is consistent with the current international authoritative organization statistics that have documented the mortality rate at 2 years in patients undergoing amputation of diabetic foot ranges from 13 to 20%. Although the microcirculation regeneration technique can effectively improve the success b

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rate of limb salvage, it cannot reduce the mortality rate in diabetic patients. Correcting associated metabolic disorders is the fundamental measure to prevent the occurrence and development of diabetic macrovascular disease. Education regarding diabetic management and preventing infection and trauma to the feet plays a particularly important role in avoiding and reducing the occurrence of clinical events in these patients.

15.4.2.8 Future Trends Traumatic healing disorder is a common phenomenon with diabetic feet. As early as 2500 years ago, Hippocrates stated, “The ability of the human body to heal itself is the best cure for disease. The doctor’s duty is to use, help, motivate, and mobilize the body’s natural healing, not to replace it.” Following long-term clinical observation, many diabetic patients cannot support the normal reparative function of damaged tissue under their own physiological conditions, and often minor injuries result in the spread of foot infection and necrosis. But in patients with bilateral diabetic foot treated by the Ilizarov technique, we were surprised to find that, while the wound on the surgical side improved, the contralateral side often also rapidly improved simultaneously (Figs. 15.17 and 15.18), as the wound healing ability of diabetic feet improved significantly.

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Fig. 15.17  The wound on the surgical side improved and contralateral side also rapidly improved. (a) (red arrow)Bilateral toe infection. (b)

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At present, research regarding the pathogenesis of diabetic foot at the molecular level is making progress. Knowledge is increasing at the molecular level, such as the role of platelet-derived growth factor (PDGF), transforming growth factor (TGF), and other important molecules in diabetic foot. This also plays an important role in vascular diseases and provides a theoretical basis for finding more effective methods in the future. This knowledge can potentially provide new solutions for tissue restoration in diabetic patients.

15.4.3 Treatment of Thromboangiitis Obliterans 15.4.3.1 Introduction Thromboangiitis obliterans, also known as Buerger’s disease, is a chronic pathological condition characterized by segmental arteriole and non-suppurative inflammation and intra-arterial thrombosis. Pathological changes are seen mainly in young men, with manifestations exacerbated by smoking. Alternatively, arteriosclerotic obliteration is a chronic arterial occlusive disease caused by atherosclerosis. The age of onset is generally after 45 years. With improved standards of living, the age of onset of arteriosclerosis is gradually decreasing, and it tends to occur in the abdominal aorta, iliac artery, fem-

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Fig. 15.18  In another case, the wound on the surgical side improved and contralateral side also rapidly improved. (a) Bilateral diabetic foot with toe gangrene (red arrow). (b) 4 weeks after surgery, the infection

and necrosis on the operated side improved, and the contralateral toe healed simultaneously (red arrow)

oral artery, and popliteal artery. Both diseases can cause distal limb ischemia, cold limbs, pain, foot ulcers, and even gangrene. Non-surgical treatment has proved to be ineffective and these patients are at risk of amputation. Traditional surgical treatment is based on various vascular bypass procedures, but in patients with chronic perivascular occlusive disease there is typically no suitable outflow tract at the distal end of the lesion. Because it is difficult to identify a suitable target vessel, the long-term patency rate is therefore unsatisfactory. Developing a method that can improve the blood supply, increase the rate of limb salvage, reduce the risk of amputation, promote ulcer healing, and have satisfactory long-term effects is the ultimate goal of many scholars. In recent years, the development of transverse distraction osteogenesis technology has provided a novel concept for the treatment of peripheral ischemic disease. From September 2015 to December 2017, 21 patients with chronic ischemic disease of the lower extremities were treated with the Ilizarov transverse distraction osteogenesis technique. Within this series of patients, 10 cases were thromboangiitis

obliterans and 11 cases were arteriosclerosis obliterans. All 21 patients had different degrees of foot gangrene and 3 cases had amputations after operation. Those patients with foot pain and wounds were clearly improved following treatment. The clinical effect was significantly better than that with traditional treatments, and the rate of successful limb salvage was 85%.

15.4.3.2 S  urgical Methods and Postoperative Management 1. Preoperative examination: CTA and noninvasive vascular examination were used to determine the vascular supply of patients, including the ankle-brachial index (ABI) preoperatively. Popliteal artery outflow tract infarction is a relative contraindication. 2. The surgical procedure with tibial transverse transport: Same method as described above. 3. Postoperative management: Same protocol discussed above. Prophylactic antibiotics were used for 3  days (if necessary 7 days), an intravenous drip of low-molecular-­ weight dextran 500 ml plus salvia miltiorrhiza (40 ml) for

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15 days, alprostadil 20 μ with intravenous or arterial drip, low molecular weight heparin sodium 5000 μ/day, followed by oral warfarin 2.5 mg/day for 15 days and more than 6 months. Assisting oral dilatators can be taken and patients were educated to refrain from smoking. The foot wounds were dressed regularly. 4 . Typical case. Case 1 A 65-year-old male with ischemic necrosis of the left foot and severe pain in the left lower extremity caused by

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Fig. 15.19  A 65-year-old male with ischemic necrosis of the left foot and severe pain in the left lower extremity caused by thromboangiitis obliterans. (a). left foot ischemic necrosis, (b) 1 month after surgery,

t­hromboangiitis obliterans (VAS pain score 9). The left foot was on the verge of necrotic toe ischemia, but and limb salvage was ultimately successful (Fig. 15.19). Case 2 A 27-year-old male with right foot pain and chronic wounds (VAS pain score 9) due to thromboembolic vasculitis. The pain was clearly improved and the wounds healed completely following surgery. There was no recurrence of necrosis in the right foot one year after surgery (Fig. 15.20).

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15  Lower Limb Deformities Caused by Hemangiomas and Vascular Disorders Fig. 15.20  A 27-year-old male with right foot wounds and pain due to thromboembolic vasculitis. (a, b) Clinical appearance of right foot preoperatively. (c, d) One month after surgery, the pain in the right foot was relieved and scabs formed on the necrotic site; no recurrence of necrosis on right foot 1 year after surgery

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Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Xuejian Zheng, Qi Pan, and Baofeng Guo

16.1 L  ower Limb Deformity Caused by Osteofibrous Dysplasia Sihe Qin and Shaofeng Jiao Osteofibrous dysplasia is a proliferative lesion of intraosseous fibrosis tissue, with massive fibrous tissue instead of normal bone tissue in the lesion. It is also called fibrous dysplasia of bone and can be divided into two types: the single and multiple lesions. This disease is characterized by deformity, claudication, pain, and pathological fracture, which seriously impair the limb function and cause disability.

16.1.1 Etiology and Pathogenesis Osteofibrous dysplasia is a self-limiting benign fibrous tissue disease of unknown origin with slow progression. It might be related to abnormal development of embryonic primitive mesenchymal tissue, infection, trauma, endocrine dysfunction, and microcirculation disorders, but none has been confirmed. In the lesion area, the fibrous tissue initiates branching erosion and destruction, eventually penetrates the medullary membrane and cortical bone from multiple sites. Consequently, the cortical bone becomes thinner, vulnerable, and even broken, while the trabecular

S. Qin (*) · S. Jiao · J. Zang · Q. Pan Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China

bone is gradually replaced by fibrous tissue and loses its strength. Therefore, pathological microfractures induced by weight-bearing and bone remodeling lead to the bone deformity (Fig. 16.1).

16.1.2 Clinical Manifestation and Key Points of Physical Examination Osteofibrous dysplasia can occur at any bone of the body but frequently involves femur, tibia, and humerus. A single lesion mostly locates in the femur, tibia, and rib, while multiple lesions are usually concentrated in one limb, especially in the lower limbs. The initial symptoms are mild and the disease course lasts for 1 year, several years, or even decades. As most of the long bones are affected, the femur becomes curved and convex, which is caused by adductor muscle tension and continuous gravity, and often results in shortening or angular deformity of the limbs (Fig. 16.2). The radiographic presentations vary according to pathological structure changes. If the lesion is fibrous proliferation accompanied with bone hyperostosis, X-ray film shows frosted glass shadow, while it shows a transparent image if the lesion is fibrous proliferation and cyst formation, and it is high-density imaging if the lesion has a high degree of ossification. In the lesion site, the cortical bone is bloated and thinner with the inner wall formed by bone crest. The film shows porous cyst-like shadow. As lesions involve long bones, various limb deformities appear (Fig. 16.3).

16.1.3 Typical Case (Fig. 16.4)

Qinsihe Orthopeadics Institute, Beijing, China X. Zheng Sihe TCM Hospital, Beijing, China B. Guo Tsinghua University Chuiyangliu Hospital, Beijing, China

16.1.3.1 General Information A 28-year-old woman with osteofibrous dysplasia of the right lower extremity had previously been treated with external fixation for 8 years. Her right lower limb revealed

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16  Lower Limb Deformity Caused by Tumor and Tumor-Like Disease Fig. 16.3 Osteofibrous dysplasia in X-ray. (a) Bilateral proximal femur deformity, frosted glass shadow, and a porous cyst-like shadow in proximal femur; (b) Severe angular deformity of tibia and fibulas, frosted glass shadow, and middle cortical bone swelling and thinning, while the inner wall indicates bone crest formation. The shadow mainly appears porous cyst shape

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showed tibia valgus and proximal femur rotation and varus on the right side (Fig. 16.3).

removed. The mechanical axis returned to normal with satisfactory joint range of motion of the right lower limb.

16.1.3.2 Treatment Protocols To correct the deformity of right femur and tibia, restore the normal mechanical axis, and reconstruct the appearance and function of lower limb by osteotomy and external fixation.

16.1.3.4 Tips and Tricks 1. Make sure of the location of the femur and tibia deformity that is the osteotomy site. 2. Use a sharp osteotome or special mini-instrument to do osteotomy. Try to minimize the thermal injury at the osteotomy site. 3. Release the deep fascia and place drainage when doing tibiafubular osteotomy to avoid compartment syndrome. 4. Avoid neurovascular injuries.

16.1.3.3 Surgical Technique 1. Firstly, osteotomy was conducted on the right proximal femur to correct the femoral deformity immediately and fixed with hybrid external fixators. The varus deformity was corrected in one stage of operation. 2. 36 days later, another osteotomy on the right tibia and fibula was performed, combined with Ilizarov technique to correct valgus and shortening deformity, which aimed to restore the normal mechanical axis of the right lower limb. 3. 20 months postoperatively, the X-ray illustrated that the right tibiofibular osteotomy site healed well, so the right leg external fixator was removed. Thirty-one months postoperatively, the right thigh external fixator was

16.1.3.5 Postoperative Management 1. 3–5  days after surgery, the patient is encouraged to weight-bearing walk with crutches. This is beneficial to callus growth and joint function. 2. 5–7 days after surgery, the wound dressing is changed and X-ray is taken. The external fixator is adjusted for deformity correction and lengthening. 3. Pin sites are cared to avoid infection. 4. When the mechanical axis and length is restored, the fixation must be maintained. The pin numbers should be

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Fig. 16.4  Osteofibrous dysplasia of the right lower extremity. (a) Frontal view, the right lower limb is shortening, valgus and external rotated; (b) Posterior view; (c) Full-length X-ray film; (d–f) Appearances of the lower limb after removed of external fixator; (g) Full-length X-ray film of both lower limbs; (h) 3-D CT reconstruction of right proximal femur; (i, j) X-ray film of right foot and ankle; (k) After subtrochanteric valgus osteotomy, medial translation osteotomy and fixation by hybrid external fixators; (l) Postoperative X-ray film; (m–o)

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36 days later, right tibiofibular osteotomy with Ilizarov external fixation; (p) The tibial valgus deformity was gradually corrected after surgery. The right lower extremity mechanical axis became restored; (q–s) After the bone healed, the external fixator was removed. The normal appearance of the lower limb has been restored; (t) The range of motion of knee; (u, v) X-ray film; (w–y) Appearances of the lower limb; (z) Full-length X-ray film of both lower limbs

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gradually reduced to reduce fixed stiffness. The external fixator is removed after the bone is firmly healed. The rule of fixator removal is “rather later than earlier.”

16.2 L  ower Limb Deformity Caused by Spinal Cord Tumor Jiancheng Zang, Xuejian Zheng, and Sihe Qin Spinal cord tumors are tumors in the spinal canal and adjacent spinal cords. With an incidence rate of 2.5:100,000, it is one of the important causes for compression of spinal cord and cauda equine. The incidence rate is no different between genders. Meningeal tumors are more common in females, while ependymoma in males.

16.2.1 Etiology and Pathogenesis The etiology of spinal cord tumor remains unclear. It could be due to multiple causes which may be closely related to heredity, trauma, and environment.

16.2.2 Clinical Manifestation and Key Points of the Physical Examination 16.2.2.1 Pain and Sensory Disturbance Extramedullary tumors constricting nerve roots can cause pain and paresthesia in the corresponding dominating areas, further leading to loss of sensation. 16.2.2.2 Dyskinesia The compression results in progressive hypertonic or hypotonic paralysis of the limbs, based on the level involved by the lesions, accompanied with superficial epidermal sensation and proprioception disorders below the level. The loss of the sphincter control function results in the urinary retention or incontinence. 16.2.2.3 Limb Deformity In the denervation area, muscular imbalance can lead to limb deformity. As the typical case shown in this chapter, the tumor causes the deformed foot and toes.

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16.2.3 Typical Case 16.2.3.1 General Information A 34-year-old woman who had undergone surgery previously for thoracolumbar spinal cord tumor. The medial side of the right forefoot was paresthesia, and then the right forefoot gradually formed a neurotrophic ulcer. Finally, the right foot developed metatarsal osteomyelitis, which resulted in some extent of metatarsal necrosis and defect. After osteomyelitis has been cured, the medial right forefoot appeared severely shortened and deformed. The physical examination at admission revealed that mild valgus deformity of right foot, accompanied with medial shortening of forefoot, floating of 1, 2, 3, and 4 toes, and loss of skin sensation in about one-fourth the area of medial forefoot. The X-ray showed that the first metatarsal bone of the right foot lacked about 80%, while the second metatarsal bone was defective about 60%, the third metatarsal head was missing, and degenerative changes of the ankle joint (Fig. 16.5). a

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16.2.3.2 Treatment Protocols The medial tarsal osteotomy combined with Ilizarov technique was used to lengthen the short bone. The operative incision located in the base of the second metatarsal of the foot. The longitudinal incision is about 3 cm to reveal the 1, 2, and 3 basal parts of metatarsal bones. The osteotomy was performed with an osteotome on these three metatarsals. In addition, the anterior osteotomy was added on the lateral third basal part of metatarsal bone to dissociate the medial osteotomy block. Finally, an Ilizarov distracting frame was installed, which was divided into two parts: proximal fixed half-ring and distal distracting half-ring with three threaded extension rods. A 2.5-mmdiameter K-wire was used to penetrate the distal osteotomy segment and secured with the distal distracting half-ring, additionally two 3-mm-diameter threaded pins were applied to pierce the bone segment and fixed with the half-ring. The proximal half-ring was attached by two 2.5-mm-diameter K-wires and two thread half-pins c

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Fig. 16.5  Ilizarov technique for treatment of secondary deformity and bone defect of foot and ankle after surgical treatment of thoracolumbar spinal cord tumor. (a) Preoperative appearance; (b) Preoperative X-ray showed that 1–4 distal metatarsal had different degrees of defect, nonunion; (c) Osteotomy on the medial basal part of metatarsals; (d) 4 months after surgery, X-ray showed that metatarsal had been lengthened properly; (e) 4 months later, the gross appearance revealed that the medial foot length had been restored; (f) Due to soft tissue traction, the toes occurred contracture deformity; (g) The

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which penetrated through or seized the cuneiforms and navicular. Furthermore, a reinforced ring located at the calcaneus was placed with a 2.5-mm K-wire traversed the calcaneus and two 2.5-mm half-pins obliquely inserted the calcaneus. As soon as the frame set was adjusted and secured, the operation was completed. At 5  days after surgery, bone lengthening began with distracting speed of 0.6  mm/day by 4 times per day. At beginning of the lengthening process, the first toe of right foot appeared varus and drooping deformity, while the 2, 3 and 4 toes presented claw toe deformity. Especially, a hook-shaped pullback as bending on the first metatarsal was apparent due to the bone defect, which was rectified with a 2-mm K-wire penetrated from the distal end of the phalange to the proximal dorsal side. Additionally, the 2, 3, and 4 toes were traversed with a 1.5-mm K-wire attached to threaded rods that was fixed on the main frame to form a longitudinal traction for correction of the toe deformity. Then, on the first to fourth toes of the right foot of the patient, longitudinal traction was applied to correct deformity. As the osteotomy on the metatarsals continued to be distracted, and the four toes were simultaneously stretched longitudinally, the complex deformities were gradually corrected over time. At 7  months after operation, the lengthened metatarsals achieved bone healing, and the external fixator was removed. The appearance and length of the right foot got a satisfactory recovery.

16.2.3.3 Tips and Tricks 1. There are plenty of blood vessels and nerves around the tarsals. As osteotomy and pin insertion are performed, be careful to avoid damage to nerves and blood vessels. 2. Osteotomy should be complete and sufficient. Otherwise, it will hinder postoperative lengthening and even require reoperation. 3. Attention should be paid that no pins place through the osteotomy space, which will hinder the postoperative lengthening adjustment. 16.2.3.4 Postoperative Management 1. At 3–5 days after operation, it is recommended that the patient should walk with crutches and carry a proper weight-bearing to do exercise of the limb. 2. At 5–7 days after operation, X-ray is taken and then bone lengthening is started by adjusting the frame at a distracting speed of about 1 mm/day according to the patient’s tolerance. 3. Be careful to treat the pin paths for prevention of pin tract infection. 4. After reaching the predetermined lengthening length and anatomical axis, the fixation should be maintained, and then gradually reduced by removing pins and declining the stiffness of the fixation sequentially. The external fixator should be removed after the bone is firmly healed, following the principle of “rather later than earlier.”

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16.3 L  ower Limb Deformity Caused by Lymphangioma

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coexist in one patient. Lymphangioma often presents swelling, hypertrophic, and deformed limbs. A typical deformity is flexion contracture and stiffness of the knee.

Sihe Qin and Qi Pan Lymphangioma is a benign hyperplasia of the lymphoid tube. It can be divided into three types: simple lymphangioma, cavernous lymphangioma, and cystic lymphangioma.

16.3.1 Etiology and Pathogenesis The etiology remains unclear; however, the factors of genetics, geography, environment, endocrine, virus, and immunity defect might be contributing to the pathogenesis.

16.3.2 Clinical Manifestation This disease may occur at birth, 1 year old, and even older (Fig.  16.6). Clinically, three types of lymphangioma may

16.3.3 Typical Case 16.3.3.1 General Information The patient was a 22-year-old female; she had got flexion contracture of the left knee after 4 times of lymphangioma resection when she was only 9 months old. The left knee stiffened at 45° of flexion whereas the ankle joint ankylosed at 20° of planter flexion. The X-ray films showed flexion and eversion deformities of the left knee (Fig. 16.7). 16.3.3.2 Treatment Protocols The main objective is to correct the deformities and restore the mechanical axis and function of the left knee. According to Qin’s principles of correction surgery, including correction of deformity, muscle strength rebalancing, joint stabilization, and leg-length equalization, Ilizarov techniques can be used to achieve two purposes simultaneously, the correction of deformity and leglength equalization. In this case, the Ilizarov technique was applied to rectify the flexion contracture of the knee and maintain the joint space for rehabilitation of the joint movability. 16.3.3.3 Surgical Technique The surgical techniques used for knee flexion deformity secondary to lymphangioma are the same for the correction of the deformity induced by other reasons. 16.3.3.4 Tips and Tricks 1. To avoid damaging vessels and nerves when wires and pins are inserted. 2. The hinges of the frame must be placed on the same axis of flexion-extension of the knee. 3. To distract joint space of the knee for about 5–10 mm for rehabilitation of knee movability. 16.3.3.5 Postoperative Management Postoperative management is the same as other knee surgeries for deformity correction.

Fig. 16.6 A patient with lower limb deformity caused by lymphangioma

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Fig. 16.7  Left knee joint flexion stiffness secondary to lymphangioma resection. (a) Left knee contracture at 40° of flexion, accompanied with clubfoot deformity of left foot; (b) Maximum flexion of left knee was about 100° preoperative; (c) Preoperative radiographs revealed knee

flexion combined with proximal tibial valgus; (d) The appearance at 7 days after surgery; (e) 2 months after surgery, the knee flexion deformity was corrected; (f) 1-year follow-up, left knee flexion deformity was completely corrected

16.4 L  ower Limb Deformity Caused by Enchondroma

16.4.1 Etiology and Pathogenesis

Sihe Qin and Jiancheng Zang If an enchondroma occurs within the bone, it is called a central type. If it occurs on the surface of the bone, it is called the marginal type, the periosteal chondroma. This disease may have a single lesion, or multiple lesions called enchoudromatosis, or accompanied by soft tissue hemangioma called Maffucci syndrome. The single type enchondroma is characteristic of slow growth, small volume and asymptomatic for a long time, whereas the type of multiple lesions has symptoms and signs in early childhood, which can lead to limb shortening and bending deformity.

Enchondroma is a tumor caused by the embryonic ectopic tissue.

16.4.2 Clinical Manifestations and Keys of Physical Examination Enchondroma in the hand and foot often leads to the deformities of the fingers or toes. The bloating growth of this tumor stimulates the short bone and local soft tissue, presents swelling and pain, even pathological fractures. But in the long bones of the limbs, most of the enchondroma are asymptomatic, usually found in the X-ray films because of other diseases or pathological fractures. By contrast, the type

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of multiple lesions shows symptoms and signs in early childhood, which leads to limb shortening and bending deformity. Within the metaphysis of long bone, enchondroma may have a slight swelling. However, along with the growth of the enchondroma, the bone will be shortened deformity.

16.4.3 Typical Case (Fig. 16.8) 16.4.3.1 General Information The patient was 12-year-old female, and suffered from deformity in right lower limb caused by multiple enchondroma. As she began to walk when she was 1 year old, it had been found that the right lower limb was shortened, associated with valgus, and posterior arch deformities. Physical

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examination showed that the right lower limb shortened by 17.78  cm, accompanied with valgus and recurvation of the knee. Radiographs revealed that multiple enchondroma lesions were noticed in the right distal femur, right proximal tibia, and right proximal fibula. The femur shortened by 6.23 cm, while the right tibia shortened by 11.33 cm, combined with right tibia valgus and posterior arch deformity.

16.4.3.2 Treatment Protocols The goal of surgical treatment is to correct the right lower limb deformity. According to Qin’s principles of correction surgery, including deformity correction, muscle strength rebalancing, joint stabilization, and limb length equalization, a surgical plan and operation protocol were formed. The first stage surgery is to correct the right tibia and fibula shortened,

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Fig. 16.8  The patient was a 12-year-old female with right lower limb deformity caused by multiple enchondroma. (a–d) X-ray films showed multiple enchondroma lesions in the right distal femur, right proximal tibia, and right proximal fibula. The right femur was shortened by 6 cm, right tibia shortened by 11 cm, and right tibia was valgus and had posterior arch deformities; (e–m) Preoperative clinical appearance; (n) Osteotomy of the right ankle during operation; (o) Right fibular head osteotomy, right middle tibial closed minimally invasive osteotomy; (p) Ilizarov external fixator was applied; (q) The anteroposterior and lateral

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X-ray films of the right tibia and fibula 6  days after surgery; (r–u) 117 days after surgery, the X-ray films revealed that bone lengthening was complete with well growing bone callus; (v–x) 212 days after surgery, the alignment of the right lower limb was well restored; (y) 212  days after surgery, X-ray films showed that the bone callus was growing well in the area lengthened, whereas the proximal tibia remained with the varus deformity. The configuration of the external fixator was adjusted to correct the remaining deformity

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valgus, and recurvation deformities, while the second stage operation aims to correct the right femoral deformity. Amid treatment period, the immediate correction by osteotomy is combined with gradual correction by distraction using Ilizarov external fixator, and active rehabilitative exercises.

16.5 L  ower Limb Deformity Caused by Adenomatous Hyperparathyroidism Syndrome (Parathyroid Adenoma)

16.4.3.3 Surgical Technique The surgical procedure is as follows: supramalleolar osteotomy, fibular head osteotomy, tibial osteotomy, and application of Ilizarov techniques.

Primary hyperparathyroidism is a metabolic disorder of calcium and phosphorus caused by over-secretion of PTH from parathyroid glands. The main manifestations are bone changes, such as limb deformity, urinary calculi, hypercalcemia, and hypophosphatemia. In the developmental period, the children with hyperparathyroidism will have limbs and joints deformity due to the abnormal metabolism of calcium and phosphorus as well as skeletal dysplasia.

16.4.3.4 Tips and Tricks 1. The blood vessels and nerves around the tibia and fibula are abundant. Be careful to avoid the neovascular injury as wires and pins are inserted to prevent the compartment syndrome. 2. Be sure that the osteotomy is complete; otherwise, it will interfere with the lengthening of the bone after surgery and might even need reoperation. 3. It is necessary for the frame to be across the ankle joint because of the large lengthening of tibia and fibula (about 11 cm). 4. Postoperative management is as same as Ilizarov techniques for lower limb lengthening.

Sihe Qin and Jiancheng Zang

16.5.1 Clinical Symptoms and Physical Examination Limb deformities caused by hyperparathyroidism are not easy to be differentiated from other developmental ­osteochondral deformities. The growing patients tend to show progressive bone and joint deformities only due to immature closure of

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the epiphysis. Laboratory tests, including serum calcium, phosphorus, and alkaline phosphatase levels, may be needed to assist in the diagnosis. The serum calcium in typical hyperparathyroidism patients significantly increase, whereas the blood phosphorus decrease and alkaline phosphatase increase (Fig. 16.9). For limb deformities, necessary physical examination and X-ray examination (Fig. 16.10) are performed to determine the location and extent of bone and joint deformities.

16.5.2 Treatment After a definite diagnosis is made, the primary disease, the hyperparathyroidism should be treated firstly by head and neck surgeons, and then the limb deformity by orthopedic surgeons.

Fig. 16.10  X-ray films of knee valgus deformity caused by hyperparathyroidism

16.5.3 Typical Cases (Fig. 16.11) 16.5.3.1 General Information The patient was a 14-year-old boy. At the age of 2, he was found with valgus deformities of both the knees, which gradually aggravated. He was misdiagnosed with rickets in a local hospital and treated with calcium supplementation, which was ineffective. Physical examination at admission showed bilateral knee valgus deformities with normal range of motion of the knee and muscle strength. X-ray films of both lower extremities revealed bilateral knee valgus. The serum calcium was 3.18 mmol/L, while the serum phosphorus was 1.25 mmol/L.

Fig. 16.9  Knee valgus deformity caused by hyperparathyroidism

16.5.3.2 Treatment Protocols Bilateral femoral supracondylar varus osteotomies were conducted to correct partial deformities immediately, and fixed with hybrid external fixators, subsequently, to correct

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Fig. 16.11  Valgus deformities of both knees caused by hyperparathyroidism. (a) Preoperative bilateral knee valgus; (b) Preoperative bilateral full-length X-ray film of lower limbs; (c) Postoperative correction of valgus of both knees with external fixation, front view and back

view; (d) Postoperative bilateral full-length X-ray film of lower limbs, valgus deformity was corrected; (e) At 2  years follow-up, front view and back view; (f) X-ray film at 2 years follow-up

the residue deformities progressively by distraction with the frame. The preoperative instruments preparation involved hybrid external fixator, which should be previously configured based on surgical plan.

Postoperative management: the knee joint exercises started at the second day after operation. Ambulation was allowed using walking aids from 5 days after operation. Two and a half months later, as the bone healed, the external fixator was removed.

16.5.3.3 Surgical Techniques An incision was made on the medial femoral condyle to expose vastus medialis muscle, distract it from the posterior to the anterior, and expose the distal femur. Drill the femur on the intended osteotomy line with separation distance of 1 cm with electric bone drill and then cut the remaining bone along the predetermined osteotomy line with osteotomes to finish osteotomy of the distal femur. The distal limb was bended medially to correct valgus deformity grossly. The osteotomy ends were fixed with a hybrid external fixator, and the wounds were closed.

16.6 L  ower Extremity Deformity Caused by Hard Fibroma Sihe Qin, Shaofeng Jiao, Baofeng Guo, and Jiancheng Zang Hard fibroma, also known as ligament-like tumor, is a rare benign hypertrophic tendon hyperplasia with an incidence of about 3.7%. It occurs at the muscles, aponeurosis, and deep

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16.6.3 Treatment Objective

fascia, and is very hard. The fibroma is invasive, and prone to relapse, with the recurrence rate as high as 25–40%. Therefore, the disease is generally considered to be a low-­grade malignant tumor, and the treatment is mainly surgical resection.

To correct joint deformities, increase joint mobility, and restore mechanical axis of the lower limbs for improvement of the standing and walking function.

16.6.1 Etiology

16.6.4 Treatment Strategy

Due to invasive growth of hard fibroma, and the boundary of the tumor is unclear. As hard fibroma occurs in the lower limbs, it is prone to invading normal muscle tissue and causing muscle fibrosis, hardening, contracture and finally limb deformity. This deformity and stiffness is difficult to correct, and conventional surgical release rarely works. In patients who have already undergone resections, traumatic stimulation such as surgical release may cause tumor recurrence, which is also a factor affecting deformity correction.

After the resection, the tumor is prone to recurrence due to the stimulus from another operation. Therefore, the tissue release should be avoided at the tumor site. If the deformity is severe, the Ilizarov technique should be used to correct deformity gradually with minimal incision.

16.6.5 Typical Cases Case 1 The patient was a 10-year-old female. She received a resection of hard fibroma in her right popliteal fossa 14 months ago. Gradually she got a flexed knee and clubfoot deformity in her right lower limb. The deformity worsened and affected ambulation seriously. Physical examination at admission showed right knee flexion contracture had reached 25°, accompanied with right clubfoot deformity, and ankle joint flexion of 60° (Fig. 16.12).

16.6.2 Clinical Manifestations and Physical Examinations The lower limb malformation caused by hard fibroma is characterized by joint deformity and activity limitation. Especially after the resection of the tumor near the joint, hard scar tissue is formed. The contracture of the scar tissue causes stiff joint deformity and joint activity is limited.

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Fig. 16.12  Flexed knee and clubfoot caused by hard fibroma. (a) Preoperative appearance; (b) Maximum flexion of the right knee; (c) Preoperative knee X-ray films; (d) Preoperative X-ray films of the foot and ankle; (e) 2 weeks after surgery, knee flexion and clubfoot deformity

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were corrected; (f) 5  weeks postoperatively the external fixator was removed and a long splint was used for another month; (g) Postoperative follow-up of 6.5 months showed no recurrence of the deformities; (h) 1.5 years follow-up showed no recurrence of the deformities

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Surgical plan Percutaneous Achilles tendon release on the right side, and distraction of knee and ankle joint with Ilizarov fixators for correction of deformities. Preoperative preparation Ilizarov external fixator, electric drill, etc. Surgical techniques The different parts of Achilles tendon fibers in different planes were percutaneously cut by a sharp lancet to correct the clubfoot deformity partially, and then Ilizarov external frame was installed for the correction of residual deformities by gradual distraction. However, the deformity of knee flexion was corrected by distraction only using an Ilizarov frame assembled without soft tissue release. Tips and tricks Percutaneous release of the Achilles tendon should involve no more than half of the tendon to avoid rupture during distraction. K-wires drilling of external fixator should avoid damage to the nerves and blood vessels. The hinges of the fixator should correspond to the center of rotation of the knee and ankle joints. Postoperative Management Five days after operation, a walker was used to aid the ambulation. Seven days after operation, the external fixator was adjusted to distract the flexed knee and clubfoot; Proper pin site care was given to prevent infection. The distraction rate was 3–5 mm per day. This rate could be adjusted according to patients’ tolerance. After deformity correction, the fixation remained for another 3 weeks, and then was removed. A plaster was used for 4 weeks, followed by a long leg splint for 3–6 months. Case 2 The patient was a 6-year-old female. When she was 2 years old, she was found with a hard fibroma in the left hip. Since then, she received 4 times of surgical resection, and the fibroma recurred each time after the resections. After the fourth resection, she received chemotherapy. The left hip joint activity was limited as the scar contracted gradually; the hip was in a fixed deformity at abduction and external rotation combined with a flexed knee and clubfoot. These deformities seriously impaired the patient’s ambulation. At admission, physical examination showed a severe limp, a 20-cm-long incision scar, and an obvious depression on the buttock. The scar and surrounding tissue was stiff. The hip was fixed at abduction and external rotation. The left knee was in a flexion deformity of 70° and the clubfoot was third degree. X-ray films showed a narrowing of the left hip joint space (Fig. 16.13). Surgical plan After K-wires were placed on bilateral iliac and left femur and attached to a hybrid frame, Ilizarov distraction tech-

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niques were applied for correction of knee and foot deformity. With a slow distraction in the pelvis and lower limb, the hip abduction and external rotation should be corrected gradually. Preoperative preparation Hybrid external fixator, Ilizarov external fixator, electric drill, etc. Surgical techniques Manual release of the hip joint was conducted first. As the assistants stabilized the bilateral ilium, the surgeon slowly performed the manual release of the hip joint. During the manipulation, the surgeon could feel that the hip motion gradually increased, whereas the hip deformity was also significantly improved. When the surgeon felt a strong resistance, the manual release should be stopped, and started to install the external frame. Three K-wires were inserted firstly on bilateral ilium penetrating both the inner and external cortical bones. At this time, a caution should be taken to avoid the penetration of K-wires into scar tissue to prevent the recurrence of fibroma. Subsequently, insert the K-wires and pins into the femur, tibia, and foot, and install the Ilizarov device on the knee and ankle joint. Tips and tricks No need to do skin incision and surgical release, only manual release and distraction by external fixator were conducted for deformity correction. During insertion of K-wires on the ilium, K-wires should run between the inner and outer plates to avoid penetration into pelvis. When K-wires are placed on the thigh and leg, be careful to avoid damage to the nerves and blood vessels. Hinges of the knee and ankle should correspond to the center of rotation of the two joints. Only thin K-wires are used to minimize the trauma. Postoperative management Five days postoperatively, a walker was used for ambulation. Seven days postoperatively, the external fixator was adjusted to correct the knee and foot deformity. The distraction rate was 3–5 mm per day, so long as the patient tolerated to it. At 10 days postoperatively, the external fixator of the fixed hip joint was released to force manually; hip joint internally rotated and adducted properly. If the patient tolerated no more, the external fixation was locked again to fix the hip. At 15 days postoperatively, the same treatment for hip joint was repeated. On the third time of external fixator adjustment, the abduction and external rotation deformity of the hip was corrected. After that, the fixation was maintained for 3 weeks and then removed. A plaster splint was used instead for 4 weeks, and then a long splint was used for 3–6 months.

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Fig. 16.13  Lower extremity deformity after repeated resection of hip hard fibroma. (a) Preoperative appearance, left hip abduction external rotation, left knee flexion, left clubfoot; (b) Preoperatively the left hip joint space is narrowed; (c) The deformity was improved 6 days after surgery; (d) The knee 6 days after surgery; (e) 12 days postoperatively, a walker was used, the hip, knee and foot deformity were improved; (f)

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The hip external fixator was removed 41  days after surgery, and the knee flexion and clubfoot were corrected; (g) 58 days postoperatively, the external fixator was removed and replaced with plaster immobilization; (h) At 9 months of follow-up, the left hip, knee and ankle deformities were all corrected and patients’ gait was significantly improved

Lower Limb Deformities Caused by Iatrogenic Factors and Social Reasons

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Lei Shi, Sihe Qin, Yilan Wang, Jiancheng Zang, Shaofeng Jiao, Li Zhang, Xulei Qin, Qi Pan, Quan Wang, and Baofeng Guo

With the advances in social development and medical technology, people now have increased opportunity to receive medical treatment, thereby increasing the risk of deformities due to iatrogenic factors, such as obstetric brachial plexus palsy (OBPP) during childbirth, sciatic nerve injection palsy, gluteal muscle contracture (GMC) due to injections in gluteal region, and osteofascial contracture and deformity caused by gas poisoning. Injection contracture of gluteal muscle has become rare since the twenty-first century. The aim of these cases is to help us understand the etiology and prevent or reduce the incidence of new cases. It can remind doctors to be careful while giving treatment and solve the problem in time, which can avoid or reduce the occurrence of sequelae.

17.1 Clinical Data Sihe Qin, Yilan Wang, and Jiancheng Zang There are 319 cases of lower limb deformities caused by iatrogenic factors and social reasons in Qinsihe Orthopedics Institute; the data analysis is as follows:

17.1.1 Etiology Analysis

17.1.2 Gender Analysis See Table 17.2.

17.1.3 Age Analysis See Table 17.3.

17.2 Gluteal Muscle Contracture Sihe Qin, Shaofeng Jiao, Xulei Qin, and Jiancheng Zang Gluteal muscle contracture (GMC) syndrome is characterized by special gait and signs caused by degeneration and contracture of gluteal muscle fibers and its fascia leading to limited function of hip joint. It is an important iatrogenic disease caused by repeated injection of drugs in the gluteal muscle, resulting in its fibrous contracture and dysfunction. The patient has a definite history of hip injections during infancy. The symptoms begin to appear around the age of 4  years and most of them are bilateral. Males are affected more than females, the ratio being 2:1.

17.2.1 Clinical Manifestation

See Table 17.1. L. Shi · S. Qin (*) · Y. Wang · J. Zang · S. Jiao · Q. Pan · Q. Wang L. Zhang · X. Qin Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China B. Guo Tsinghua University Chuiyangliu Hospital, Beijing, China

The clinical features are as follows: 1. There is skin dimpling in upper and outer quadrant of buttock and the contracture can be felt in the direction as the gluteus maximus muscle fiber. The contracture is more obvious when the hip passively adducted, internally rotated, and flexed (Fig. 17.1). 2. Posture and gait abnormalities: There is slight external rotation of the lower limb while standing. Squatting is limited when the knees are parallel, showing a typical breaststroke position, as squatting needs abduction and

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_17

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Table 17.1  Etiological analysis (n) of lower limb deformities caused by Iatrogenic factors and social reasons Etiology Injection contracture of gluteal muscle Tibial lengthening Poor limb stumps TOCP/Gossypol poisoning Intramuscular injection Gas poisoning Organophosphorus pesticide poisoning Genu valgum correction Other procedure Dichlorvos poisoning Bear scratch injury TKA (Total knee arthroplasty) Spinal canal surgery Other treatment Resection of lipoma of thigh Lead poisoning

Cases 229 28 7 5 5 4 4 4 4 2 2 2 2 2 2 1

Etiology Venomous snakebite Cervical spinal cord tumor operation Intervertebral disc surgery Acute renal failure due to vaccination Lower extremity catheter operation Knee surgery Decompression of lumbar vertebrae Intravenous injection Genu varum correction Scalp acupuncture infusion Arthroscopic surgery of the knee Ligament reconstruction Curettage of distal femoral tumor Transfer of tendon to replace quadriceps muscles Resection of giant teratoma of the retroperitoneum Reduction of lumbar spondylolisthesis Table 17.3  Age at the time of surgery (year)

Table 17.2  Gender ratio (n) Gender Male Female Total

Injection contracture of gluteal muscle 146 83 229

Cases 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Sequela of limb lengthening 9 19 28

Others 24 38 62

Total 179 140 319

rotation at the hip joint. There is jumping gait when child attempts to walk fast (Fig. 17.2). 3. Snapping hip: With the child in lateral position, flexion of the hip produce snapping sound due to gliding of the fibrotic band of gluteus maximus muscle over the great trochanter. 4. Cross sign: It is difficult to cross the lower limbs due to contracture of gluteus maximus muscle. 5. The flexion of hip and knee is limited when both hips extended together. 6. X-ray shows no significant changes in the early stage. However, in later stage, pelvic deformation secondary to the traction effect of the contracture can be seen. Other signs are increase in femoral neck shaft angle and proximal femoral rotation deformity (Figs.  17.3, 17.4, and 17.5). In the past 40  years, 229 cases of injective GMC have undergone surgery in Qinsihe orthopedics department including 146 males and 83 females. Most of them aged from 6 to 20 years. These cases mainly occurred in the 1980s and 1990s. Severe cases usually had secondary bone deformity or hip dislocation.

Age 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–50 51–60 >60 Total

Injection contracture of gluteal muscle 9 64 60 59 19 12 4 1 1 0 0 229

Sequela of limb lengthening 0 1 3 0 15 5 3 1 0 0 0 28

Others 3 3 8 11 14 9 4 5 1 3 1 62

Total 12 68 71 70 48 26 11 7 2 3 1 319

17.2.2 Typical Case Case 1 (Fig. 17.6) 1. General information: The patient was a 20-year-old female, who presented with a GMC. She had a clear history of injection in her gluteal region in childhood. Physical examination revealed bilateral gluteal muscle atrophy, mild lower limb external rotation, and difficulty in squatting and crossing legs. She had no obvious pain in her buttock. 2. Surgical plan: Release of GMC, superolateral hip capsulotomy, and fixation with external fixator. 3. Preoperative preparation: Hybrid external fixator and instrument, suction, sharp osteotome, etc.

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was fixed with Hybrid external fixator in adduction and flexion. 5. Tips and tricks: The range and extent of soft tissue release, and pay attention to prevent sciatic nerve injury. 6. Postoperative management: In addition to routine treatment, it is important to maintain the limb in adduction and internal rotation position.

Case 2 (Fig. 17.7)

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Fig. 17.1  Injection contracture of gluteal muscle present skin dimpling on the buttock. (a) Back view; (b) local view

4. Surgical procedure: The incision was made from posterior superior iliac spine to the lateral greater trochanter for bilateral gluteal fascia and iliotibial band release. The sciatic nerve should be carefully protected. The left hip

1. General information: The patient was a 26-year-old male, who presented with a GMC.  He had a clear history of injection in his gluteal region in childhood. Physical examination revealed bilateral gluteal muscle atrophy, mild lower limb external rotation, and difficulty in squatting and crossing legs as in frog-like position. He had no obvious pain in his buttock. 2. Surgical plan: Release of GMC, superolateral hip capsulotomy, proximal femoral osteotomy, and fixation with external fixator. 3. Preoperative preparation: Hybrid external fixator and instrument, electric drill, electric cautery, suction, sharp osteotome, etc. 4. Surgical procedure: First stage: The incision was made from posterior superior iliac spine to the lateral greater trochanter for bilateral gluteal fascia and iliotibial band release. The sciatic nerve should be carefully protected. The left hip was fixed with Hybrid external fixator in adduction and flexion. Second stage (6 months later): Adduction and flexion osteotomy of left femur below greater trochanter was performed and fixed with plate and screws. This position was maintained with an external fixator. Third stage: Right femoral osteotomy below great trochanter was done and fixed with plate and screws. Right hip capsule was released and Hybrid external fixator was applied to maintain hip in adduction and flexion. 5. Tips and tricks: The range and extent of soft tissue release, the angle of proximal femoral osteotomy, and prevention of sciatic nerve injury. 6. Postoperative management: In addition to routine treatment, it is important to maintain the limb in adduction and internal rotation position.

17.3 Other Iatrogenic Deformities Shaofeng Jiao, Xulei Qin, and Jiancheng Zang

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Fig. 17.2  Injection contracture of gluteal muscle patient in breaststroke position. (a) Squat; (b) Semisquatting Fig. 17.3  The left gluteus contracture, pelvic tilt, limb length discrepancy: (a) Clinical appearance; (b) X-ray

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Fig. 17.4  Contracture of bilateral gluteal muscles, pelvic tilt: (a) Clinical appearance; (b) X-ray

17.3.1 Statistics of 67 Cases of Iatrogenic Deformities Iatrogenic deformity of the lower extremity, other than injection contracture of gluteal muscle includes those due to limb lengthening (most common, 28 cases). Others are deformities caused by genu varum correction, cervical and lumbar spine surgery, knee arthroscopy, lower extremity tumor resection, etc. (Fig. 17.8).

17.3.2 Clinical Manifestation

Fig. 17.5  Contracture of bilateral gluteal muscles, pelvic deformity, abnormal femoral neck and shaft angle and anteversion angle

Equinovarus and knee flexion deformity caused due to neurovascular injury, muscle injury, infection, and their sequela.

17.3.3 Surgical Strategy Correct the deformity, balance the muscle strength, and stabilize the joint.

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Fig. 17.6  Injection contracture of gluteal muscle. (a, b) Clinical appearance; (c) The leg was maintained in internal rotation position by fixator on 14th day after surgery; (d, e) 12 months follow-up; (f) Full-length X-ray of lower extremity

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Fig. 17.7  Injection contracture of gluteal muscle. First stage surgery: (a) Clinical appearance; (b) Preoperative planning incision; (c) Pelvic X-ray; (d) Patient with external fixator on 14th day after surgery; (d X-ray; e Clinical appearance). Second stage surgery: (e–g) Right side surgery; the right hip was fixed in adduction internal rotation position; (h) The patient could walk 20 days after second surgery, front view; lateral view; back

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view; (i) X-ray films 20 days after second surgery; (j) The photos 20 days after surgery of left femur osteotomy; (k) full-length X-ray 30 days after surgery of left femur osteotomy; (l, m) 4 months follow-up after surgery of left femur osteotomy; Appearance improved, but he is still unable to squat completely

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6 months postamputation

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Fig. 17.8  Iatrogenic deformity of the lower extremity. (a) This patient was a 28-years-old male with right lower limb amputation. Clinical appearance: Shortening and flexion deformity on the stump. (b) This patient was an 11-year-old male with knee flexion deformity after total knee arthroplasty. AP and lateral view of X-ray showed knee joint dis-

location. (c) This patient was a 26-year-old male with knee flexion deformity after femur lengthening. (d) This patient was a 19-year-old male with knee joint stiffness after surgery for patella fracture. (e) Clubfoot deformity due to ischemic muscle contracture of lower leg caused by popliteal artery injury during knee arthroscopic surgery

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17.3.4 Typical Cases Case 1 (Fig. 17.9) 1. General information: This patient was a 40-year-old female with equinovarus deformity. She underwent

Fig. 17.9  Lower extremity deformity due to popliteal artery injury during arthroscopic surgery. (a) Clinical appearance of right lower limb preoperatively (a Anterior; b posterior view). (2) Clinical picture of the patient with fixator at fifth day after surgery; (c) The foot deformity was corrected 40 days after surgery; (d) Ilizarov external fixator was removed at 57th day after surgery. The patient was wearing with a brace of foot and ankle 5 months after surgery

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arthroscopic resection of popliteal cyst 10  months ago. Unfortunately, the popliteal artery and tibial nerve was damaged during surgery. She developed equinovarus deformity gradually due to ischemic muscle contracture. 2. Surgical plan: Tibialis posterior tendon, flexor pollicis longus tendon, Achilles tendon, and flexor digitorum

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longus tendon should be lengthened, posterior tibial nerve should be exposed and released, and Ilizarov fixator should be applied. 3. Preoperative preparation: Preoperative planning for muscle imbalance caused by lower limb ischemic muscle contracture and tibial and common peroneal nerve injury.

4. Surgical procedures: Through a posteromedial incision, Z lengthening of tibialis posterior, flexor hallucis longus, flexor digitorum longus, and Achilles tendon was done; and Ilizarov external fixator was applied. 5. Postoperative management: adjust external fixator gradually to correct residual deformity, and pay attention to peripheral sensation and blood supply.

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Case 2 (Fig. 17.10) A 30-year-old female with left clubfoot deformity secondary to limb lengthening. The patients at the age of 20 underwent bilateral leg cosmetic lengthening by 8 cm, but left clubfoot deformity occurred during the lengthening process. Left

talus osteotomy, posterior tibial muscle externalization, and Ilizarov technique were performed during surgery. When the equinovarus deformity was corrected, ankle pain disappeared, and gait restored to normal.

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Fig. 17.10  Foot deformity caused by leg lengthening. (a) Preoperative clinical appearance, equinovarus deformity of left foot; (b) X-ray film preoperatively; (c) Foot and ankle deformity was corrected at tenth day

postoperatively; (d) The fixator was removed 3 months after surgery, and the deformity was corrected completely

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was still in flexion deformity, the interphalangeal joint arthrodesis was performed and fixed with wire in second stage.

Jiancheng Zang and Sihe Qin Osteofascial compartment syndrome often occurs in the lower leg. Once diagnosed, the compartment should be decompressed immediately. Early complete decompression is the only effective way to prevent ischemic necrosis of muscles and nerves. Ischemic muscle contracture is one of the serious consequences of compartment syndrome.

17.4.1 Typical Cases Case 1 Foot and ankle deformity caused by ischemic muscle contracture (Fig. 17.11) 1. General information: The patient was a 34-year-old female with foot and toe deformity and sensory disorder below the ankle; she suffered from compartment syndrome 18 months ago. 2. Surgical plan: Percutaneous Achilles tendon lengthening, transfer of peroneus longus to extensor digitorum longus, lengthening of tibialis posterior, flexor hallucis longus and flexor digitorum longus, and application of Ilizarov external fixator. 3. Preoperative preparation: Ilizarov external fixator, installation tools, sharp osteotome, etc. 4. Surgical procedure: The longitudinal incision on the left lower leg was used to expose the peroneus longus tendon. It was cut off at its insertion. The extensor digitorum longus was then exposed and peroneus longus was sutured to it in proper tension. Finally, the Ilizarov external fixator was applied. Two months later, the external fixator was removed and the interphalangeal joints were fused by using crossed K-wire. 5. Tips and tricks: Achilles tendon should be lengthened. The long extensor muscle of toe is displaced posteriorly and the peroneus longus is displaced towards the long extensor muscle of the toe. Take care to avoid damage to the superficial peroneal nerve. 6. Postoperative management: residual deformity was corrected by external fixator; the external fixator was removed 2 months after surgery. Because the patient’s toe

17.5 L  ower Limb Deformity Caused by Carbon Monoxide Poisoning Sihe Qin, Shaofeng Jiao, Jiancheng Zang, Qi Pan, and Quan Wang Carbon monoxide poisoning is a type of gas poisoning. The inhaled carbon monoxide enters the blood through alveolar gas exchange to form carboxyhemoglobin which results in poisoning. Lower extremity deformity caused by gas poisoning is similar to ischemic muscle contracture and mainly leads to ankle stiffness and equinovarus deformity.

17.5.1 Typical Case 1. General information: The patient was a 13-year-old female with equinovarus deformity of right foot caused by carbon monoxide poisoning 6 months ago. 2. Operation plan: Achilles tendon lengthening, digital aponeurotomy, tibialis posterior muscle lengthening, osteotomy around talus, Ilizarov fixator application. 3. Preoperative preparation: Ilizarov external fixator and its instrument, sharp osteotome, etc. 4. Operative procedures: A longitudinal incision in distal one-third of right leg was made to expose the tibialis posterior muscle and Achilles tendon, and Z lengthening of both tendons was performed. Then plantar fascia was released percutaneously. The subtalar and talonavicular joints were exposed and fused through an arc-shaped incision on the dorsum of foot. Ilizarov external fixator was mounted after temporary K-wire fixation of the fused joints. 5. Tips and tricks: Osteotomy around talus, Achilles tendon, and tibialis posterior tendon lengthening should be taken care to prevent superficial peroneal nerve injury. 6. Postoperative management: The residual deformity was corrected gradually by external fixator. The external fixator was removed at 80th day after surgery and then, an ankle foot orthosis was given (Fig. 17.12).

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Fig. 17.11  Foot and ankle deformity caused by ischemic muscle contracture. (a–h) Preoperative clinical appearance and X-ray film; (i, j) Clinical appearance of the patient with Ilizarov external fixator at 11th

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17.6 L  ower Limb Deformity Caused by Sugarcane Poisoning Jiancheng Zang and Sihe Qin The injured site of sugarcane poisoning mainly in brain and lumbar spinal cord, the limb deformity mainly is limb spastic paralysis and deformities.

17.6.1 Typical Case (Fig. 17.13) 1. General information: The patient was a 29-year-old female with left lower limb spastic deformity, including left foot valgus deformity, hallux valgus deformity, and toe flexion deformity. She slipped in a coma after eating moldy sugarcane at 3 years old; the deformity above is sequela. 2. Surgical plan: Flexor digitorum tendon release, peroneus brevis muscle lengthening, bone grafting and calcaneal-­ talus joint arthrodesis, Ilizarov external fixator application. 3. Preoperative preparation: Ilizarov external fixator and installation tools, sharp osteotome, and so on. 4. Surgical procedures: Along the posterior tibial crest incision in the middle part of the left leg, the flexor digitorum tendon was dissected and released at the starting point. The peroneal brevis muscle was exposed through a longitudinal incision at the posterolateral malleolus and lengthened by Z-shaped lengthening; and then the hallux adductor was released percutaneously. Subtalar joint

osteotomy was performed, and Ilizarov external fixator was installed. Finally, the toe was fixed to the external fixator through the wires. 5. Tips and tricks: Calcaneus-talus joint osteotomy and flexor digitorum tendon release. Attention should be paid to prevent injury of superficial peroneal nerve. 6. Postoperative management: The residual deformity was corrected by external fixator gradually, and the external fixator can be removed after 3 months fixation and a brace to be worn for another 3 months.

17.7 L  ower Limb Deformity Caused by Animal Bite Sihe Qin, and Baofeng Guo

17.7.1 Lower Limb Deformity Caused by Snake Bite 17.7.1.1 Typical Case (Fig. 17.14) 1. General information: This patient was a 6-year-old male with rigid talipes equinovarus deformity of right foot. He was accidentally bitten by a venomous snake 2 years ago. Foot deformity developed as a sequela of extensive necrosis of the calf muscles. 2. Surgical plan: Achilles tendon lengthening, tibialis posterior tendon lengthening, and Ilizarov fixator application. 3. Preoperative preparation: Ilizarov external fixator.

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4. Operative procedures: The tibialis posterior and Achilles tendon were exposed through a longitudinal incision on the medial part of the lower leg and Z lengthening was done. Ilizarov external fixator was then applied.

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Fig. 17.12  Lower extremity deformity caused by Carbon Monoxide poisoning, and then secondary to ischemic muscle contracture. (a–c) Clinical appearance from front, back, and side preoperatively; (d) AP and lateral X-rays preoperatively; (e) X-ray at seventh day after sur-

gery; (f, g) Clinical appearance at 22nd day after surgery, front view and lateral view; (h) X-ray films at 80th day after surgery; (i, j) Application of orthosis after fixator removal, front view, and lateral view

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Fig. 17.13  Lower limb deformity caused by sugarcane poisoning. (a–d) Preoperative appearance of lower extremities; (e, f) Preoperative X-ray films of ankle and foot; (g, h) The exposure during operation, flexor digitorum tendon and peroneal brevis muscle; (i) X-ray films at

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sixth day postoperatively; (j) Clinical appearance at 30 days postoperatively; (k, l) Clinical appearance at 3  months postoperatively; (m) Plaster fixation when the fixator was removed; (n–p), 4 months follow-up, (n) front view, (o) plantar view, (p) lateral view

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Fig. 17.14  Lower limb deformity caused by snake bite. (a, b) The appearance of the lower limb deformity caused by snake bite; (c) Intraoperative examination; (d) The tibialis posterior tendon was exposed; (e) Percutaneous Achilles tendon lengthening; (f) Application

of Ilizarov external fixator; (g, h) Clinical appearance of front view and lateral view at 26th day after surgery; the deformity has been corrected

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17.7.2 Lower Limb Deformity Caused by Bear Scratch 17.7.2.1 Typical Case (Fig. 17.15) 1. General information: The patient was a 22-year-old female with short right lower limb and varus foot deformity. She suffered from sciatic nerve injury due to a bear scratching her right buttock when she was 4  years old. She underwent debridement in a local hospital. Sciatic nerve was removed partially resulting in the lower limb deformity and hypoesthesia. 2. Surgical plan: Foot and ankle deformity correction combined with tibial derotation osteotomy in first stage. Tibial lengthening in second stage, 2 years later.

3. Preoperative preparation: Hybrid external fixator, Ilizarov external fixator and relevant tools, sharp osteotome, etc. 4. Surgical procedure: In first stage, the subtalar joint was exposed through an arc-shaped incision and was fused and fixed temporarily with wire. Then osteotomy was done below the tibial tuberosity through a minimally invasive incision, and tibial deformity was corrected. In second stage, tibial lengthening was performed with Ilizarov external fixator by doing Z-type osteotomy. 5. Tips and tricks: Posterior tibial vessel and nerve injuries. 6. Postoperative management: Residual deformity should be corrected gradually in first stage. Attention should be given for development of neurological symptoms and bone formation.

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Fig. 17.15  Right lower limb deformity caused by bear scratch. (a) Preoperative clinical appearance; (b) Front view in standing position; (c) Appearance of heel in standing position; (d) Plantar view; (e, f) X-ray of AP view and lateral view; (g, h) Clinical appearance of front view and

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Limb Length Discrepancy Sihe Qin, Jiancheng Zang, Yilan Wang, Shaofeng Jiao, Xulei Qin, Xuejian Zheng, Hetao Xia, Aimin Peng, Qi Pan, and Baofeng Guo

18.1 D  ata Analysis of 2549 Cases of Lower Limb Lengthening Surgery Sihe Qin, Jiancheng Zang, and Yilan Wang Some of the patients were performed lengthening surgery on both legs, such as femur and tibia lengthening, so the sum of the following data exceeds the total number of actual patients. There were 1330 cases (52.18%) which underwent surgery with iliac bone lengthening, rotation osteotomy, and lengthening of iliac bone to improve the coverage of femoral head, which included majority of polio patients treated in Qinsihe Orthopedics department. 1 . Lengthening area statistics (Table 18.1) 2. Gender statistics of lower limb lengthening surgery (Table 18.2) 3. Age statistics of lower limb lengthening surgery (Table 18.3) S. Qin (*) · J. Zang · Y. Wang · S. Jiao · Q. Pan · X. Qin Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China

Table 18.1  Lengthening area statistics of lower limb lengthening surgery Lengthening area Ilium Femur Tibia and fibula Calcaneus Tarsal bone Metatarsal bones

Cases (n) 1330 193 1018 18 5 10

Percentage (%) 52.18 7.58 39.94 0.71 0.20 0.39

Table 18.2  Gender statistics of lower limb lengthening surgery (n) Tibia and fibula Iliac bone Femur Gender lengthening lengthening lengthening Male 787 118 640 Female 543 75 378

Calcaneous, tarsal bone, and metatarsal bone lengthening 11 22

4 . Annual operating volume (Table 18.4) 5. Side analysis of lower limb lengthening surgery (Table 18.5) 6. Types of diseases resulting to leg length discrepancy (Table 18.6) 7. See Table 18.7.

Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China X. Zheng Orthopeadics Department, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil Affairs, Beijing, China Qinsihe Orthopeadics Institute, Beijing, China Sihe TCM Hospital, Beijing, China H. Xia Beijing Institute of Skeletal External Fixation, Beijing, China A. Peng Sihe TCM Hospital, Beijing, China B. Guo Tsinghua University Chuiyangliu Hospital, Beijing, China

18.2 S  urgical Indication and Strategy of Leg Length Discrepancy Sihe Qin and Jiancheng Zang Adults with leg length discrepancy less than 2  cm may wear high insoles on one side, which is natural and comfortable to stand and strongly. Patients with leg length discrepancy over 2 cm are recommended to undergo a surgery. The surgical procedure for leg length equalization includes epiphyseal growth block, short limb lengthening, long limb shortening, and so on. Epiphyseal growth block and long limb shortening can restore the limb length but can make human body become shorter, destroy limb ratio, and affect

© Springer Nature Singapore Pte Ltd. 2020 S. Qin et al. (eds.), Lower Limb Deformities, https://doi.org/10.1007/978-981-13-9604-5_18

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Table 18.3  Age statistics for the case of lower limb lengthening surgery (n) Age (year) 1–5 6–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–60 61–70 71–80 >80 Maximum age Minimum age Average age

Iliac bone lengthening 1 9 111 383 455 234 104 22 9 1 1 0 0 0 58 1 21.93

Femur lengthening 2 13 36 52 47 28 10 2 1 0 2 0 0 0

Tibia and fibula lengthening 12 59 189 242 268 132 56 35 14 9 1 1 0 0

Calcaneous, tarsal bone, and metatarsal bone lengthening 0 1 12 5 6 4 3 1 0 0 1 0 0 0

Table 18.4  Annual operating volume of lower limb lengthening surgery in Qinsihe Orthopedics (n) Year of operation 1978–1982 1983–1987 1988–1992 1993–1997 1998–2002 2003–2007 2008–2012 2013–2017

Iliac bone lengthening 0 285 598 235 90 50 56 16

Femur lengthening 0 4 8 27 14 31 64 45

Tibia and fibula lengthening 0 123 97 134 129 173 218 144

Calcaneous, tarsal bone, and metatarsal bone lengthening 0 3 5 1 1 3 11 9

Table 18.5  Side analysis of lower limb lengthening surgery in Qinsihe Orthopedics (n) Lengthening side Left Right Bilateral

Iliac bone lengthening 651 677 2

Femur lengthening 101 91 1

Tibia and fibula lengthening 498 504 16

the appearance of beauty. This is willingly accepted with limb lengthening, which can maintain the height, especially since the application of Ilizarov technology in the clinical practice of limb lengthening. The modern principle for the treatment of LLD is to maximize and restore the limb function to achieve the gait balance and harmonious body proportion by carrying out osteotomy and limb lengthening, as well as the correction of joint deformities, and the treatment of related diseases. In the process of treatment, it is most important to evaluate the potential effects and therapeutic value of LLD on

Calcaneous, tarsal bone, and metatarsal bone lengthening 19 12 2

limb function, as well as the growth potential, treatment requirements, psychological needs, and cooperation ability of the patients. Secondly, it is needed to determine whether the specific lesion of LLD is in femur or tibia, and then carry out accurately.

18.3 Ilium Lengthening Sihe Qin, Shaofeng Jiao, Xulei Qin, and Jiancheng Zang

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Table 18.6  Diseases species resulting to leg length discrepancy in Qinsihe Orthopedics Disease species Poliomyelitis sequelae Traumatic sequelae Fibular hemimelia Osteomyelitis Congenital pseudarthrosis of tibia Developmental dislocation of hip Congenital lower limb shortening Genu varum Rickets Bone defect Spina bifida sequelae Deformity of lower extremity due to epiphyseal injury Bone nonunion Sequelae of suppurative arthritis Congenital talipes equinovarus Congenital deformity of toe Blount disease Genu valgum Congenital coxa vara Diaphyseal aclasis Scoliosis Incomplete healing of amputation stump Tibial hemimelia Cerebral palsy Dwarfism Hematosepsis Dysplasia epiphysalis multiplex Epithelial dysplasia Nerve injury caused by spinal cord tumor Familial neurofibromatosis Subcutaneous fat atrophy Congenital dislocation of patella Congenital arthrogryposis Congenital band syndrome Congenital toe shortening Latrogenic lower extremity deformity Hereditary sensorimotor neuron disease Nonossifying fibroma Guillain—Barré syndrome Osteogenic fibroma Bone tuberculosis Enchondroma Brain trauma Unilateral limb dysplasia Charcot’s arthritis Congenital femoral pseudarthrosis Congenital tibial dysplasia Congenital tibial curvature Ectrodactylia Bear scratch Hemangioma Ischemic necrosis of femoral head Other congenital deformities of lower limbs Other infectious lower extremity deformities Etiology unknown

Cases (n) 2134 63 44 34 26 22 22 18 16 16 15 13 11 7 5 5 4 4 4 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11 7 14

Table 18.7  Gait index analysis of lower limb lengthening surgery Gait Mild limp Severe limp Heel walking Hand on knee gait Single crutch Double crutches Wheelchair Normal Not clear

Cases (n) 1387 523 38 180 175 114 10 14 108

Percentage (%) 54.41 20.52 1.49 7.06 6.87 4.47 0.39 0.55 4.24

18.3.1  Indication Adult patients with lower limb discrepancy accompanied by pelvic shortening in the side of the short limb and acetabular dysplasia or hip subluxation (Fig. 18.1).

18.3.2  Surgical Procedures With the anterior approach (Smith-Peterson approach) of the hip joint, the iliosciatic notch and the iliac crest were exposed. A segment of the iliac crest was removed for later use. A jigsaw was led through the great iliosciatic notch, and the ilium osteotomy was performed from iliosciatic notch to the plane between the anterior superior and anterior inferior iliac spine. The osteotomy end was opened with retractor and distracted by the medical assistant at the hip and knee joints in flexion positions. The osteotomy end was fixed with plate, and the iliac bone was implanted in the osteotomy space. If the bone mass was not enough, the allograft or contralateral iliac bone could be used to fill the space. The iliac plates and incision were sutured.

18.3.3  Postoperative Management After 2 weeks of rest in bed, X-ray was taken. The patient could walk with light weight-bearing under walker, and gradually walk with a full weight-bearing in 3–5  months (Fig. 18.2).

18.3.4  Typical Case Case 1 Twenty-eight-year-old male with left lower limb shortening deformity, gluteal paralysis, and mild flexion knee due to poliomyelitis sequelae. X-ray showed short ilium and acetabular dysplasia on left side (Fig. 18.3).

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Fig. 18.1  Pelvic shortening in the side of the short limb

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18.3.4.3 The Surgical Procedures The Smith-Peterson incision of the hip joint was made; the aponeurosis of the external oblique ventral muscle was exposed. The aponeurosis of the width of 3 cm was cut along the distal of visible fiber to the pubic bone. The pubic periosteum was exposed and cut with an osteotome. The iliac periosteum was stripped, and the internal and external plates of ilium were fully exposed. The great notch of the ischium was exposed, and a jigsaw was led through the great notch of the ischium to the proximal end of the iliac obliquus muscle. A 1.5 ∗ 4 cm bone mass was removed from the iliac spine. The osteotomy of ilium between the anterior and inferior iliac spines was performed by a jigsaw. The medical assistant pulled the hip joint; at the same time, the iliac osteotomy space was opened with a retractor and the ilium was fixed with plate. The iliac bone mass was implanted into the interspace and fixed with screws. Great trochanter of the femur was exposed through lateral proximal longitudinal incision of the thigh and a hole of about 0.8  mm in diameter was drilled in the anterior part of the great trochanter. The oblique muscle was led through the subcutaneous adipose layer from the abdominal incision to the greater trochanter. With the hip in a position of 30° abduction, the aponeurosis of the external oblique abdominal muscle was reflexed through the bone hole and sutured with the proximal part and the periosteum of the great trochanter. The hip joint was kept in a position of 30° abduction with a hip abduction brace. 18.3.4.4 Tips and Tricks Attention should be paid to protect lateral femoral cutaneous nerve from injury during incision making. Nutrient vessels and innervation of muscle should be protected when external abdominal oblique muscle is dissected. Osteotomy ends of iliac bone are distracted slowly; meanwhile, the operation assistant should keep iliac spine in position to prevent the sacroiliac joint dislocation.

Fig. 18.2  X-ray postoperatively

18.3.4.1 Surgical Plan Left iliac and pubic osteotomies and lengthening, external oblique abdominal muscle transposition for medial gluteal muscle, and subtuberculum tibial osteotomy. 18.3.4.2 Preoperative Preparation Electric knife, retractor, plate and screw, sharp osteotome, hip abduction brace, etc.

18.3.4.5 Postoperative Management On the second day after surgery, hip abduction exercise was begun. The affected hip joint was maintained in abduction position for 8  weeks. At 3  weeks after surgery, double crutches and abduction brace were used for standing and walking on the ground. The practice of walking without crutches was carried out 3 months after surgery, and the bone healing was monitored by X-ray. Case 2 Twenty-year-old female with muscular paralysis of the right lower limb, mild knee flexion deformity, lower limb shortening, and pelvic tilt secondary to poliomyelitis sequelae. Internal rotation deformity of the right lower extremity was

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Fig. 18.3  Ilium lengthening. (a) Preoperative X-ray showed the left ilium was small with acetabular dysplasia. (b) Operation position and incision line. (c) Injection of epinephrine into the incision area could reduce intraoperative bleeding. (d) The aponeurosis of the external oblique muscle of abdomen was dissected. (e) The external abdominal oblique muscle was dissected. (f) The external abdominal oblique ventral muscle was excised. (g) Iliac periosteum was dissected. (h) The iliac bone mass was cut for later uses. (i) The ilium was cut from the great notch of the ischium to the lower margin of the anterior superior

iliac spine with a jigsaw. (j) The iliac osteotomy ends were opened by about 4 cm. (k) The osteotomy ends were fixed with a plate and the iliac bone was implanted. (l) The great trochanter of the femur was exposed and the oblique ventral muscle was transferred through the subcutaneous adipose layer to the trochanter. (m) With the abduction of the left hip joint, abdominal oblique tendon was pulled through greater trochanter and sutured. (n) The hip joint was kept in abduction position postoperatively. (o) X-ray was taken

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18.4 Femur Lengthening Sihe Qin and Shaofeng Jiao

18.4.1  Common Instruments The modified Ilizarov fixator commonly used for femoral lengthening in Qinsihe Orthopedic department. The reasonable mechanical environment can be given from the stable structure including proximal triangle and distal ring (Fig.  18.5), which is convenient for postoperative control. Unilateral femoral lengthener (Fig.  18.6) is suitable for the patient with mild lower limb discrepancy without deformities. The advantage is that it does not penetrate the contralateral soft tissue of the thigh and has less interference with the knee joint motion. The disadvantage is that the frame does not have three-dimensional control and is not suitable for the femoral lengthening with deformity. o

18.4.2  Preoperative Preparation 1. Full length X-ray film of bilateral lower limbs is taken to determine the amount of shortening and the length that needs to be lengthened. 2. An appropriate device for femoral lengthening should be selected. In general, a unilateral device can be used for simple femoral lengthening. If the patient has combined shortening with angulation deformity, the Ilizarov femoral lengthening device should be given. 3. Osteotomy plane

Fig. 18.3 (continued)

presented for stabilization. X-ray showed right hip joint subluxation and right ilium was small. Ilium lengthening surgery was performed. At a follow-up of 2 years, the loading and walking functions of the right lower limb were significantly improved (Fig. 18.4).

Osteotomy plane for simple femoral lengthening should be subtrochanter or distal one third femur, which not only preserves enough length of bone segment at both ends of osteotomy for fixation, but also has abundant blood supply, which is beneficial to bone healing. If deformity correction is required with lengthening, osteotomy plane should be near or at the Center of Rotation Angular (CORA).

18.4.3  Surgical Procedures Under epidural anesthesia or general anesthesia, the disinfectant is applied and aseptic towel is spread. Disinfection scope should be beyond hip joint for fully exposing iliac anterior superior spine and femur greater trochanter.

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5 months follow-up postoperatively

Fig. 18.4  The right ilium lengthening. (a) Preoperative appearance; the patient presented right lower extremity shortening and mild knee flexion deformity. (b) In order to stabilize the hip and knee joint, the right lower extremity should be rotated internally while weight-bearing. (c) Preoperative X-ray film showed right lower extremity shortening, small iliac bone and hip subluxation. (d) Right ilium osteotomy and lengthening were performed; the patient could walk with brace at

35  days after surgery. (e) 5  months after surgery, X-ray film showed bone union of the ilium lengthening; the hip joint is normal. (f) After 2  years follow-up, the function of right lower extremity was significantly improved. (g) X-ray at 2  years after surgery. (h) 3  years after surgery, the iliac bone healed well and the relationship of the acetabulum and femoral head was good

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follow-up 5 years postoperation

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Fig. 18.4 (continued)

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18.4.3.1 F  emur Lengthening with Ilizarov External Fixator

Steel screw fixing clip

The Osteotomy Plane (Fig. 18.7)

Universal joint apparatus

a T-shaped plate

Hole c ring Locking joint device

Drafting connecting rod

Fine steel wire fixing clip

Fig. 18.5  Modified Ilizarov fixator for femoral lengthening

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Fig. 18.6  Unilateral fixator for femoral lengthening

Fig. 18.7  Determine the osteotomy plane. (a) The length of external fixator was tested. (b) A 3-mm K-wire was inserted into the supracondylar. (c) The osteotomy plane was determined under fluoroscopy

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1 . Test the length of Ilizarov fixator. 2. A 3-mm K-wire was inserted into the supracondylar region. 3. The fixator was removed. 4. Determine the osteotomy plane under X-ray C arm. Predrill (Fig. 18.8) 1. When osteotomy plane was marked, a 0.6-cm incision was given with a sharp knife. 2. The soft tissue was separated to reach the bone surface with hemostatic forceps. Many holes were drilled by the electric drill with double barrel drill sleeves. 3. The guide pin was inserted.

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4. Drilling. Application of Femoral Lengthener (Fig. 18.9) 1. The external fixator was put on the femur, the appropriate spacing was adjusted and fixed with the K-wire inserted previously. 2. A 4.5-mm pin was inserted to the proximal femur connected with the ring. 3. The knee joint movement was tested, and then 5-mm pins were added to connect and strengthen the fixator. 4. Totally four pins were inserted into the proximal end of the osteotomy.

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Fig. 18.8  Predrill on femur. (a) Incision; (b) Double barrel drill sleeves; (c) Drilling; (d) Fluoroscopic monitoring; (e) Finished predrill; (f) X-ray fluoroscopy

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Fig. 18.9  Installation of the frame for femoral lengthening. (a) Fix the distal ring with wire; (b) A 2.5-mm K-wire was used to detect femoral orientation; (c) Wire passage was opened up with straight forceps; (d) A 5-mm pin was drilled by electric drill; (e) Insert the pin to penetrate contralateral

cortex with a wrench; (f) Fix the pin with clamp; (g) Knee joint was bent to the maximum range; (h, i) More pins were inserted to connect the ring; (j) A 4.5-mm pin was connected with the proximal ring; (k) Two more pins were inserted to connect the proximal ring; (l) The lengthener was installed

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Fig. 18.9 (continued)

Femoral Osteotomy (Fig. 18.10) 1. The threaded rods between the proximal and distal rings were loose; cortical osteotomy can be done with a narrow osteotome. 2. The osteotomy end was twisted to confirm osteotomy completely. 3. Fixator was connected again.

18.4.3.2 F  emur Lengthening with Unilateral External Fixator Make Sure the Osteotomy Plane When a unilateral external fixator was applied, the osteotomy plane was generally selected below the lesser trochanter with the distance between three and four pins, which can be made sure by C-arm X-ray during the operation. Pin Fixation Under the C-arm fluoroscopy, the fixed pin point was selected below the lesser trochanter of the femur. The skin, the subcutaneous tissue, and the fascia were cut with a sharp knife, and then the muscles were separated with the hemostatic forceps to form a pin entry channel. The external fix-

ator was attached to the lateral of the thigh and the first pin was screwed into the first pin hole after drilling along the pin slot. The φ 6-mm pin was generally selected for the unilateral external fixator. The pin was inserted at the middle of the distal femur with guidance from C-arm. A 3-mm K-wire was fixed in the slot of the clamp, another 2.5-mm K-wire can be used to detect whether the wire could pass the center of the femur through each pin slot on the fixator. If all the positions are right, the 3-mm K-wire was removed and a hole was drilled with drill bit, and 6-mm pin can be inserted. If not, the position was changed. The remaining pins were inserted in turn when two pins were determined. The fixator was removed temporarily when all the pins were in positions. Minimally Invasive Osteotomy In the osteotomy plane, a 1-cm incision was made in the anterior lateral side of the thigh by a sharp osteotome. The muscles were separated using hemostatic forceps to expose the femur. The holes were drilled in turn with double barrel drill sleeves and chiseled with narrow osteotome. The pins were fixed according to the position before osteotomy and the incision was sutured.

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Fig. 18.10  Femoral osteotomy. (a) Cortical osteotomy can be done with a narrow osteotome; (b) The operator and the medical assistant clenched the proximal and distal rings; (c) The threaded rods were repositioned and

f

fixed with hinges; (d) The flexion and extension of the knee joint was done; (e–g) Observation of the wire and osteotomy ends by X-ray fluoroscopy; (h) Incision was sutured with a drainage tube; (i) Aseptic dressing

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Fig. 18.10 (continued)

18.4.4  Postoperative Management 1. Supine position was adopted after surgery. The lower leg was elevated in knee function position. Long-term hip flexion and semi-lying position were avoided. 2. Conventional therapy and nursing care after external fixation. The drainage tube was removed within 48 h. 3. Extension and flexion movement of the knee was started on the second day after surgery. 4. The lengthening began at seventh day after surgery, and the exercise of the knee carried out during the lengthening process. 5. Management of lengthening period. (a) Lengthening Index: a delay period of 7 days, femur lengthening should be at a rate of 1  mm/day, 4–6 times. After 1 cm lengthening, it was slowed down to 0.5–0.7 mm/day. The growth of callus was checked regularly with X-ray to adjust the speed of lengthening. (b) Secondary deformity: Angulation deformity may occur during the femoral lengthening by a unilateral lengthening device. It should be corrected immediately to avoid malunion. (c) Function exercise: At third day after surgery, quadriceps contraction exercise was started. Walking with

weight-bearing partially was carried out at 1  week after surgery. The range of motion of the knee should be kept in 60°–90° to prevent knee stiffness.

18.4.5  Typical Case Case 1 Twenty-four-year-old female with right lower extremity shortening secondary to poliomyelitis sequelae (Fig. 18.11). Case 2 Twenty-five-year-old female with femoral shortening of 9 cm due to epiphyseal injury. The left femoral lengthening was performed with a unilateral apparatus (Fig. 18.12).

18.4.6  Femur Immediate Lengthening For the patient with femur shorting within 3 cm, one stage femur lengthening can be performed with iliac bone graft in order to reduce the time of postoperative recovery. The femur can be distracted to appropriate length by external fixator, which can be retained for a period of time to increase the early fixation strength and removed timely according to the callus growth.

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Fig. 18.11  Ilizarov femoral lengthening. (a) The patient with femur shortening due to poliomyelitis sequelae; (b) Femoral lengthening 6 days after surgery; (c) 16 days after surgery; (d) 18 days after surgery;

Matters needing attention: 1. When the femur lengthening in one stage, it should be slowly distracted so that the soft tissue could adapt gradually. 2. Hip flexion position was maintained in femoral nerve relaxation and knee flexion position was maintained for sciatic nerve relaxation.

(e) 33 days after surgery; (f) 35 days after surgery; (g) 142 days after surgery; (h) 9  months and 17  days after surgery; (i) 11  months and 15 days after surgery

3. The iliac bone grafts with three cortices were taken for enough supporting strength. 4. Deep fascia and iliotibial tract were released to reduce soft tissue tension.

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Fig. 18.11 (continued)

18.4.6.1 Typical Case Nineteen-year-old male with 6-cm shortening of right lower extremity and 3 cm in thigh suffered from the poliomyelitis sequelae. He underwent immediate femoral lengthening with iliac bone graft and plate fixation (Fig. 18.13). With the lateral incision of the thigh, deep fascia, iliotibial tract, and lateral femoral septum were released. Femoral immediate lengthening with 3  cm was performed with Ilizarov external fixator.

18.5 Tibia Lengthening Sihe Qin, Hetao Xia, Xuejian Zheng, Aimin Peng, and Jiancheng Zang

18.5.1  Preoperative Design The tibial osteotomy plane is marked according to the position of fibula head, and the distance from fibula head to osteotomy plane is generally about 3.5 cm, and the osteotomy plane of fibula is usually 15 cm above the lateral malleolus (Fig. 18.14).

18.5.2  Surgical Procedure The patient was in the supine position under spinal-epidural anesthesia or general anesthesia. Disinfection was done and sterile towel was spread after anesthesia. Intraoperative measurement and osteotomy plane marking were carried out (Fig. 18.15).

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Fig. 18.12  A 25-year-old female with left femoral shortening of 9 cm caused by epiphyseal injury. (a) Clinical appearance presents femur shortening; (b) Preoperative X-ray; (c) X-ray 5 days after surgery; (d)

Clinical appearance 42 days after surgery; (e) X-ray 55 days after surgery; (f) X-ray 90 days after surgery; (g) Clinical appearance 90 days after surgery

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Fig. 18.12 (continued)

18.5.2.1 Fibula Osteotomy (Fig. 18.16) 1. An incision of 0.5 cm at one-third of distal fibula was performed and the fibula was reached by hemostatic forceps. 2. Double barrel drill sleeves were inserted. 3. Continuous drilling of 3–4 holes in the fibula was done. 4. The fibula could be broken by pressing both ends, and the sound of crisp fracture could be heard. 5. The fibula was pressed in different directions to make sure it was completely disconnected. 18.5.2.2 Tibial Osteotomy (Fig. 18.17) 1. The plane of tibial osteotomy was marked again, generally below the tibial tubercle; 2. The length of tibial anterior medial skin incision was about 0.5 cm; 3. Tibia osteotome was performed with double barrel drill sleeves. 18.5.2.3 A  pparatus Installation for Tibial Lengthening (Fig. 18.18) 1. The first wire was inserted at the lateral side of the fibula head; 2. A 2-mm K-wire was penetrated from the posteral lateral side of the fibula head toward the anteral medial side of the tibia; 3. The wire was connected to the proximal ring; 4. The distal wire was penetrated at 3  cm above lateral malleolus; 5. The second K-wire was inserted from the posterior side toward the anterior-medial side of the distal tibia and fibula;

6. The wire was fixed to the distal ring with clamp; 7. Close to the upper ring, the third wire was inserted from the anteral lateral side toward the posteral medial side of the tibia in an angle of about 45° with the first wire; 8. The fourth 2-mm K-wire was inserted from the anterior lateral side toward the posterior medial side of the distal tibia; 9. The frame was established; 10. The wires were locked under tension; 11. A 2-mm K-wire was penetrated through the tubercle of the calcaneus from lateral to medial and attached to the semicircle of the calcaneus; 12. Two 2.5-mm half-pin was applied on calcaneal tubercle; 13. 3.5-mm pins were inserted in the proximal tibia to strengthen the fixation; 14. A 3.5-mm pin was inserted in the distal part; 15. A 3.5-mm half pin was fixed in the middle part of the tibia.

18.5.2.4 Tibial Breaking (Fig. 18.19) 1. The fixed bolt of lengthening rod and distal ring was loosened. 2. The rings at both ends were held tightly to carry out torsional osteotomy. 3. The tibia was broken by rotation. 4. The incision was sutured. 5. The pins were wrapped with alcohol gauze at the end of the surgery.

18.5.3  Postoperative Management 18.5.3.1 Postoperative Treatment and Nursing As the routine treatment and care for external fixation, affected limb of the patient was elevated and the patient stayed on bed for 5 days. Intravenous administration of antibiotics for 1  day and dehydrating drugs for 3–5  days was done. Drainage was pulled out within 72 h. The degree of limb swelling, blood circulation, and movement were observed. In the case of any abnormal situation, it should be dealt with in time. 18.5.3.2 Management in Lengthening Period X-ray examination was taken at 5–7  days after surgery, and can be taken every month to assess the growth of new bone. Lengthening Index With a delay of 8–12  days, lengthening speed was maintained at a rate of 1 mm/day for 4–6 times. According to the growth of new bone, the lengthening speed should be adjusted to ensure the bone formation.

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Fig. 18.13  Femoral immediate lengthening. (a) Preoperative clinical appearance; (b) Full length X-ray of lower limb at standing position; (c) Iliotibial tract release, lateral femoral septum release; (d) Femoral osteotomy was performed by a Jigsaw; (e, f) Femoral immediate lengthening of 3 cm was performed by Ilizarov fixator; (g, h) The iliac bone of about 3 cm was taken and implanted into the lengthened gap; (i) The lengthened femoral segment was fixed with plate; (j) X-ray taken

5 days after surgery; (k, l) 12 days after surgery, the knee joint was fixed at straight position. The patient was encouraged to walk weight-­bearing with crutches; (m) 77  days after surgery; (n) 166  days after surgery; (o, p) 6 months after surgery, the bone of lengthening area healed well. The Ilizarov fixator was simplified; (q) Clinical appearance 24 months after surgery; the fixator had been removed

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Fig. 18.13 (continued)

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Fig. 18.13 (continued)

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Fig. 18.15  The osteotomy plane was determinate during surgery

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Fig. 18.14  Preassembly for tibia lengthening. (a) The point of wire insertion and the site of osteotomy were marked preoperatively; (b) An individualized apparatus for tibia lengthening was assembled; (c) preassembly on the limb

18.5.3.3 Prevention of Foot Deformity Different degrees of foot drop will occur during tibia lengthening. Functional position of the ankle joint, of which dorsum extension not less than 90°, could be maintained by exercise. Prevention of Knee Flexion Deformity The patient who underwent tibia lengthening could be encouraged to exercise every day to prevent the deformities of knee and foot joints.

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Fig. 18.16  Fibula osteotomy in tibial lengthening. (a) 0.5-cm incision was made and the soft tissue was separated to expose the fibula with hemostatic forceps; (b) Fibula osteotomy with double barrel drill

sleeves; (c) Four holes were drilled on the fibula; (d) The fibula was broken; (e) The fibula was pressed in different directions; (f) The incision was sutured with a stitch

18.5.3.4 Management of Delay Period The lower extremity axis is adjusted to a normal range. Active functional exercise, nearly normal weight-bearing on the ground are carried out in order to optimize the new bone function and avoid the occurrence of refracture. According to the condition of new bone mineralization, the principle of Adaptive Fixation Stiffness is put into prac-

tice. AP and lateral X-ray films show continuity, uniformity, regularity, and high density of new bone. Knee and ankle joints are maintained nearly in functional position. Knee flexion and foot drop deformities should be avoided. Less than 10% of the normal movement and mild stiffness are allowed, which can recover naturally after fixator removal.

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Fig. 18.17  Tibial osteotomy. (a) The tibial osteotomy plane was determined again, generally below the tibial tubercle; (b) Anterior medial tibia skin incision; (c) The incision length was about 0.5 cm; (d) Bone holes was made by double barrel drill sleeves

If the standard of bone formation is reached, the external fixator can be removed.

18.5.4  Typical Case Twenty-six-year-old female with limb shortening by 9  cm suffered from osteomyelitis in infancy. The left tibia lengthening was performed, and the leg length and limb function were restored to the normal again (Fig. 18.20).

18.6 Cosmetic Lengthening Sihe Qin, Hetao Xia, Aimin Peng, Jiancheng Zang, Shaofeng Jiao, and Qi Pan Bilateral lower limb lengthening is the only effective method for the treatment of short stature. The indications of short stature involve not only pathological, physiological, and functional problems, but also values and psychological factors. The absolute length of lower extremity, severity of

deformity, the ratio of basic height to upper and lower bodies, the value of operation, and the expectation of height were comprehensively evaluated. Priority should be given to severe deformity, height of dwarf, imbalance of proportion, and calf lengthening.

18.6.1  Indication 1. Absolute indications: Short stature caused by dwarf, rickets, achondroplasia, and other severe lower extremities shortening and deformities. 2. Relative indications: Although short stature does not have functional disability like dwarfism, rickets, and achondroplasia, the height does not reach the range of average height because of different degrees of bone and joint deformities. Therefore, we should treat with caution for them. Their height should be increased properly by regenerative potential without medical trauma. There is more practical meaning to change the beauty of short stature and overcome the feeling of the inferiority.

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Fig. 18.18  The steps of wire insertion for tibia lengthening. (a) The first wire was inserted at the lateral side of the fibula head; (b) A 2-mm K-wire was penetrated from the posterior lateral side of the fibula head toward the lateral medial side of the tibia; (c) The wire was connected to the proximal ring; (d) The distal wire was penetrated at 3 cm above lateral malleolus; (e) The second K-wire was inserted from posterior toward anterior-­medial side of the distal tibia and fibula; (f) The wire was fixed to the distal ring with clamp; (g) Close to the upper ring, the third wire was inserted from the anterior lateral toward posterior medial of the tibia in an angle of about 45°

with the first wire; (h) The fourth 2-mm K-wire was inserted from the anterior lateral side toward the posterior medial side of the distal tibia; (i) The frame of the external fixator was established; (j) The wires were locked under tension; (k) A 2-mm K-wire was penetrated through the tubercle of the calcaneus from lateral to medial and attached to the semicircle of the calcaneus; (l) Two 2.5-mm half-pin was applied on calcaneal tubercle; (m) 3.5-mm pins were inserted in the proximal tibia to strengthen the fixation; (n) A 3.5-mm pin was inserted in the distal part; (o) A 3.5-mm half-pin was fixed in the middle part of the tibia

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Fig. 18.18 (continued)

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Fig. 18.19  Torsional force for tibial osteotomy. (a) The fixed bolt of lengthening rod and distal ring was loosened; (b) The rings at both ends were held tightly to carry out torsional osteotomy; (c) Torsional oste-

otomy was carried out to other direction; (d) The incision was sutured; (e) Photo during surgery; (f) The pins were wrapped with alcohol gauze at the end of the surgery

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Fig. 18.20  Tibia lengthening. Twenty-six-year-old female with limb shortening by 9  cm suffered from osteomyelitis in infancy. (a) Preoperative clinical appearance; (b) The external fixator was applied for tibia lengthening; (c) The calf and Achilles tendon were lengthened by 9  cm simultaneously. Lower limbs got equal length and the bone

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healed well at 13th month after surgery; (d) X-ray during tibia lengthening; (e) X-ray at 13th month after surgery; (f) Clinical appearance after fixator removal; (g) X-ray after fixator removal; (h) Clinical appearance at 10 years follow-up; (i) X-ray at 10 years follow-up

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e

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Fig. 18.20 (continued)

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Fig. 18.20 (continued)

3. Available indications: For relatively short stature, although there is mild genu varum deformity, the height is close to the average standard. This kind of patient’s expectation to the operation is urgent and the attitude is firm. The main reasons for surgery are often related to education, employment, marriage, and other factors. Therefore, decisions must be carefully made for such patients. In addition to strict diagnostic criteria, the psychological evaluation, if necessary, psychological counseling are needed.

18.6.2  Contraindication 1 . Primary disease in unstable stage 2. Diabetes 3. Chronic infectious disease 4. Scar body constitution 5. Psychological disorders 6. Irrational decision-makers such as children and emotional patients.

18.6.3  Operative Option 1. Bilateral thigh lengthening is not the first option. It is generally used for patients who had undergone bilateral calf lengthening but still not satisfied with their heights. 2. Bilateral calf lengthening is the first option and also the most commonly used operation.

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18.6.4  Preoperative Preparation 1. The necessity and practical value of the operation are determined according to as many factors as possible, such as comprehensive understanding of the psychological state of the patient, the patient’s educational level, work situation, economic conditions, mental and psychological aspects, coordination ability and perseverance, attitude of relatives, the purpose of the patient’s operation, and the objective expectation or not, understanding of the pain and risk of the treatment process, and so on. Surgery should not be performed for irrational, emotional, and blind volunteers to avoid unnecessary “dispute” and trouble. 2. The standing full-length radiograph is taken to study the whole skeletal structure of lower limbs. 3. Equipped with Ilizarov ring external fixator and mounting tools, sharp osteotome, double barrel drill sleeves, etc. 4. Sign informed consent: patients and their families should be informed of the risks, procedures, and efficacy criteria in a comprehensive and authentic manner. The informed consent of the operation is not only the notification and cooperation of the patient, but also the responsibility of the doctor, as well as the basis or legal document for handling the problem in the trouble event.

18.6.5  Surgical Procedures 18.6.5.1 T  ibial Lengthening with External Fixation 1. Fibula osteotomy: a 0.8-cm longitudinal skin incision was made at the distal third of the fibula in the lateral side. A double barrel drill sleeves was inserted to drill the holes, and then the fibula was broken by hands. 2. Proximal tibial osteotomy: the level 5–6 cm below tibial plateau was select as osteotomy plane, a 1-cm longitudinal skin incision was made at the medial margin of the tibial spine without cutting the periosteum, and a double barrel drill sleeves was inserted to drill holes, but the bone was not broken. 3. Application of Ilizarov external fixator. 4. Tibia osteotomy was performed with osteotome and incision was sutured. 18.6.5.2 T  ibial Lengthening with Fixator over Intramedullary Nail 1. Fibula osteotomy. 2. At the proximal tibia osteotomy plane, a row of holes was drilled with double barrel drill sleeves, then i­ ntramedullary nail was placed through longitudinal incision of the patella tendon. The proximal locking nail was locked, and the distal end was left.

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3. The Ilizarov device was applied with wires and pins, then all the connection rods were loosened, and the anterior medial bone cortex of tibia was cut along the holes with an osteotome; finally, connection rods of the lengthening frame were relocked after incision sutured.

18.6.5.3 F  emoral Lengthening with External Fixation 1. Femoral drilling: Generally, femur subtrochanteric osteotomy was performed with a 0.8–1 cm incision at the lateral thigh. A row of holes was drilled by double barrel drill sleeves. 2. Application of Ilizarov external fixator. 3. The connecting rods of the external fixator were loosened and the femur osteotomy was performed along the holes with an osteotome. The osteotomy ends were fixed by tightening the connection rods of the external fixator. 18.6.5.4 F  emoral Lengthening with External Fixator over Nail 1. Drilling of the femur: the same as mentioned above. 2. Intramedullary nail: a lateral incision was made at the apex of the great trochanter of the femur. The apex of the great trochanter was exposed, open and ream, the femoral intramedullary nail was inserted, and the proximal screw was locked. 3. External fixator was applied with wires and pins, which were inserted to avoid the intramedullary nail. 4. The connecting rods of the external fixator were loosened. The anterior, lateral, and posterior cortexes of the femur were cut with osteotome, and then the medial cortex was twisted and broken. The ends of osteotomy were fixed by tightening the connection rods of the external fixator, and the incision was sutured.

18.6.6  Postoperative Management 1. At 5 days after surgery, the patient walked on the ground with crutches. X-ray was taken on the seventh day and then lengthening was started. 2. Lengthening was carried out at a speed of 1 mm/day for 6 times. The patient could practice walking with crutches. 3. X-ray films were taken for every 1.5  cm of lengthened length. The lengthening rate was adjusted dynamically according to the callus growth. 4. The external fixator was removed and the intramedullary nail was locked according to the callus growth. 5. The patient should exercise for knee joint extension and flexion during femur lengthening.

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18.6.7  Typical Case Case 1 Sixteen-year-old female with bilateral mild genu varum in short stature. She had a strong desire for cosmetic lengthening. X-ray films showed slight varus deformity at the proximal tibia (Fig. 18.21). Tibia lengthening was performed with external fixator over intramedullary nail. Calf was lengthened by 8  cm. Bilateral tibia anatomical axis and lower extremity mechanical axis were restored. Case 2 Twenty-two-year-old male with bilateral genu varum secondary to dwarfism, with a preoperative height of 120 cm. Bilateral tibia lengthening was performed by 18 cm and genu varum was corrected in the first stage surgery. In the second stage, bilateral thigh lengthening was performed by 8  cm. When the external fixation was removed, the patient asked bilateral thigh lengthening in third stage with strong request, and then he got another 8  cm (bilateral thighs was lengthened 16 cm in total). Finally, the patient was satisfied with the treatment process and the final outcome (Fig. 18.22).

18.7 L  ower Limb Lengthening with Fixator and Intramedullary Nail Sihe Qin, Xuejian Zheng, Hetao Xia, Baofeng Guo, and Jiancheng Zang The purpose of lower limb lengthening using both interlocking intramedullary nail and external fixator is as follows: 1 . to shorten the period of wearing external fixator 2. to increase the stability of the ends of osteotomy 3. to reduce the number of wires The intramedullary nail can be used with external fixator at same time, or second stage in which the external fixator was removed when limb lengthening completed or callus partial formatted in the lengthening area.

18.7.1  Femoral Lengthening Using Ilizarov Fixator over Intramedullary Nail Limb shortening is a common problem in orthopedic surgery. It is difficult to lengthen the femur due to rich thigh muscles and anatomical factors, which related to a high rate of wire tract infection in a long term of external frame application can affect the life and work of patients. When the

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Fig. 18.21  Bilateral tibia lengthening. (a) Preoperative bilateral mild genu varum deformity; (b, c) X-ray of bilateral tibial and fibula preoperatively; (d) Bilateral valgus tibial osteotomies and lengthening with internal and external fixation were performed; (e, f) X-ray films during tibia lengthening; (g, h) X-ray after fixator removal; (i, j) The intramed-

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ullary nail was removed; (k–m) When the treatment completely, the height was increased, the mechanical line of the lower extremity was restored, and the range of motion of knee and ankle joints were normal

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Fig. 18.21 (continued)

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Fig. 18.21 (continued)

18.7.1.5 Surgical Procedures 1. Intramedullary nail reaming: The position of piriform fossa is marked with a K-wire at the top of the great trochanter of femur. 18.7.1.1 Indication 2. At the proximal of thigh, below lesser trochanter, the inciFemur in adults shortened by above 2 cm. sion is made about 1 cm long, soft tissues are separated to The medullary cavity conforms to the selected intramedreach the femur. The femur osteotomy is performed genullary nail. tly with a minimal invasive osteotomy device. If the CORA is at the proximal femur, only one level osteotomy 18.7.1.2 Configuration of Ilizarov External at the proximal end is needed for deformity correction Fixator for Femoral Lengthening and limb lengthening. If CORA is at middle and distal (Fig. 18.23) parts, two level osteotomies should be performed respectively for lengthening in the proximal end and deformity 18.7.1.3 Wire Layout correction in the middle and distal segment. Three 5-mm pins are inserted at the proximal side, one 2.5-­ 3. Intramedullary nail insertion: Intramedullary nail is mm K-wire and two 4-mm pins are put at the distal end. inserted according to the operational program, and the proximal screws are locked and the distal one unlocked. 18.7.1.4 Preparation Preoperatively 4. Installation of external fixator: An Ilizarov external fixThe full-length X-ray standing view of bilateral lower limbs ator is mounted and two 5-mm pins are inserted transis prepared preoperatively, and X-ray plain film of AP and versely between the greater trochanter and the lesser lateral view of the affected femur are taken to determine the trochanter of the femur from the posterior side of intracause and length of the limb shortening. Whether or not the medullary nail. A 5-mm pin is inserted from the anterolatfemoral shortening accompanied by deformities of varus, eral side of intramedullary nail. The three pins are fixed valgus, anterior arch, and retroflexion, the length of the interon the proximal ring. A 2.5-mm K-wire is inserted into locking intramedullary nail should be the length from the the distal femoral supracondylar and then fixed under tenpyriform fossa to the 10 cm supracondylar of femur, and the sion. Two 4-mm pins are inserted into the medial and latdiameter should be 1  mm less than that of the narrowest eral condyles at the motion center of the knee joint and at medullary cavity of the femur. 45° with the sagittal plane. All the pins are fixed on the intramedullary nail combined with external fixator in femoral lengthening, the fixation period of external fixator can be reduced by at least a half.

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Fig. 18.22 Limb lengthening for Dwarfism. (a–c) Preoperative appearance, bilateral genu varum deformity, his height was 120 cm; (d–g) The first stage, tibia lengthening by an intramedullary nail and external fixator, X-ray films during the lengthening process; (h, i) During bilateral tibia lengthening, the patient sitting on the bed and standing weight-bearing on the ground; (j) X-ray films at the end of tibia lengthening, the external fixator was removal; (k) The intramedullary nail was removed when the X-ray firm showed bone union of the lengthened segment; (l) The X-ray films of the bilateral thigh

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lengthening; (m) The clinical appearance during bilateral thigh lengthening; (n) In the third stage operation, femur lengthening with intramedullary nail and external fixator; (o) X-ray films during the second femoral lengthening; (p) The clinical appearance during the second femoral lengthening; (q) X-ray was taken when second femur lengthening completed; (r) X-ray films after fixator removal; (s) X-ray films after intramedullary nail removal; (t–v) Clinical appearance when limb lengthening completed, the height was increased by 34 cm, and the joint function of the lower limbs was normal

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Fig. 18.22 (continued)

distal ring. If there are two osteotomies in the femur, another half-pin is needed to be added in the middle bone segment and then connected to the ring. 1/3 ring

2/3 ring

Full ring

: Direction of the force

Fig. 18.23  The configuration of femoral lengthening with Ilizarov fixator and intramedullary nail. (a) There is a one-third ring in the proximal femur. (b) Two-third ring with medial or posterior opening is prepared in the middle of thigh. (c) Thicker and full ring in the distal femur

18.7.1.6 Postoperative Management 1. Early treatment: The knee of the affected limb should be kept in flexion posture postoperatively in early stage, and muscle contraction exercise should be carried out as early as possible. Intravenous injection of antibiotics is given for 3 days. The blood flow and movement of the operative limb should be closely observed. The incision drainage should be removed in 48–72 h. At 5 days after surgery, the patient can get out of bed to walk and function exercise of knee flexion and extension can be started. 2. Lengthening period: Femur lengthening usually starts at 8–10 days after surgery at a speed of 0.6 mm/day in four intervals of every 3 h. The bone formation is observed by X-ray every month, in which the lengthening rate can be adjusted. The patient had better walk with crutches 4–6 times a day 20 min each time, so as to avoid limb swelling due to limb drooping in a long time. Knee joint function exercise is carried out to keep knee joint motion range at least 0–90°. Knee joint was put in a flexion position of 20° at rest. 3. Fixator removal: 20 days later after achievement of predetermined length, thigh muscle tension is relieved a lot. The distal locking screw should be locked and the exter-

18  Limb Length Discrepancy

nal fixator can be removed under intravenous intensive anesthesia. 4. Rehabilitation training: Walking exercise should be carried out with partial weight-bearing with brace until full weight-bearing. Function exercise load free is given and strenuous activities are avoided on hip and knee joints. 5. Intramedullary nail removal: X-ray should be taken to observe bone mineralization, 1.5–2 years after femur lengthening. Intramedullary nail can be removed and continuous functional rehabilitation should be done. If there are two level osteotomies, the middle bone segment should be fixed with a 2.5-mm K-wire and a 4-mm pin. When femur lengthening is completed, the external fixator can be taken continually to strengthen walking and to start function exercise of the hip and knee joints. The average bone mineralization rate is 1.5–2 months/cm. The stiffness of external fixation can be reduced by losing four nuts, in this way, the external fixator and bone become a new whole in balance. After 2–3  weeks, the bone in X-ray do not change obviously and the external fixator can be removed (Fig. 18.24).

18.7.2  Tibial Lengthening Using Ilizarov Fixator over Intramedullary Nail 18.7.2.1 Overview Tibial lengthening single with Ilizarov fixator has some technical defects, such as angular deformities of the lengthened limbs, requirement of secondary adjustment and longer duration of external fixator wearing on the limbs. Therefore, for patients with shrunk leg deformity or large bone defect, the combination of intramedullary nail and external fixator for limb lengthening can shorten the period of using external fixator, facilitate early exercise of weight-bearing, promote the regional tissue regeneration, and effectively prevent complications such as secondary shortening deformity, malunion of deformity, or large bone defect. This technique with high safety, feasibility, and maturity, which was developed by Xia composed of tibial interlocking intramedullary nail, external fixator or synchronous elastic lengthener, and wire positioner (Fig. 18.25). 18.7.2.2 Indication Tibia medullary cavity is conforming the installation condition of intramedullary nail and no infection lesion in operation area.

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18.7.2.3 Surgical Procedure The Ilizarov fixator for tibial lengthening is composed of two groups of rings and four thread rods. The external fixator with three-dimensional structure firmly fixed and can eliminate the shear force and rotation stress. At the same time, it can also realize the periodic axial movement while the patient walks with load, which can promote tissue regeneration in the lengthening area while ensuring the reliability of fixation. It is the most commonly used lengthening instrument in clinics at present. Taking Ilizarov ring external ­fixator combined with intramedullary nail as an example in this section, the procedure and risk aversion of tibia lengthening are introduced as follows. Anesthesia General, spinal, or epidural anesthesia are selected according to the patient’s condition. Posture Supine position. Surgical Procedures 1. Tibial reaming: Through the median incision of the anterior patellar ligament, the tibial plateau is exposed layer by layer. An entry point in the slope at 0.5 cm below the tibial plateau was drilled and reamed. 2. Partial osteotomy: depend on the patient condition, the proper position of osteotomy is selected, and the skin and subcutaneous fascia is cut to expose the tibia. Partial osteotomy is performed with a jigsaw or a mini-­osteotomy device to preserve the continuity of the anterior part of the tibial bone cortex. 3. An intramedullary nail is placed without distal locking. 4. Installation of an external fixator and osteotomy. According to the specific conditions of bone transportation or tibial lengthening, the number of whole or semi-rings as well as the whole wires and half-pins determined. For tibia lengthening, four rings plus one foot and ankle orthosis and five rings for single focus bone transportation are used. Generally, a 2.5-mm K-wire is used, and the tensioner is used to tighten K-wire to make sure tight fixation of an external fixator. And then the tibia osteotomy can be performed completely. A tourniquet is loosened and a drainage tube is placed in the wound and then incision is sutured layer by layer. Surgical Risk Avoidance 1. When K-wires are placed, we should avoid the neovascular injury, especially the injuries to common peroneal nerve and posterior tibial artery and vein. Attention should be paid to the position of locking hole of intramedullary nail and avoiding inserting K-wire into the locking hole of intramedullary nail.

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Fig. 18.24  The patient was a 20-year-old male with 15  cm femoral shortening on right side. (a) Preoperative clinical appearance; (b) After the right lower extremity was raised by a pad to 12 cm height, the bilateral buttock transverse striae were symmetrical; (c) The left femur was about 46  cm in length; (d) The length of the right femur was about 30.5 cm; (e) Femur lengthening was performed using Ilizarov fixator

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combined with retrograde intramedullary nailing; (f) The intramedullary nail moved down to 2  cm with the distal segment; (g) After a lengthening of 13 cm, interlocking intramedullary nail was locked; (h) X-ray after locking of intramedullary nail; (i) Fixator removal; (j) 18 months follow-up, the bilateral lower limbs were equal in length; (k) X-ray showed good bone mineralization in lengthened area

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Fig. 18.24 (continued)

Fig. 18.25  Hybrid tibial lengthening system

2. When Ilizarov ring external fixator was installed, the position of fixator should be carefully adjusted to equalize the space between the leg and the whole ring to avoid skin compression. 3. Penetration of K-wires in scar areas should be avoided to prevent pain at the pinhole. 4. For patients after replantation of amputated limbs, limb lengthening should not be performed too early. Since the scar tissue at the anastomotic site is replaced by proliferative smooth muscle cells until 8 weeks after replantation. When vascular compliance is better, the sheer force of local activity and the axial tension will not cause reinjury to blood vessels. 5. In order to achieve good bone regeneration, cortical osteotomy with low energy should be performed as far as possible.

18.7.2.4 Postoperative Management 1. The patient walks on the ground 5 days after surgery. 2. Patients are instructed how to exercise their affected limbs. 3. On the seventh day after surgery, X-ray was taken and the tibia lengthening was started at a speed of 0.75–1 mm/day for 4 times daily. If the patients are older and malnourished with unendurable pain in the lengthening period, the speed should be adjusted appropriately according to the specific conditions. 4. Regular X-ray films can be taken to observe osteogenesis. 18.7.2.5 Complications 1. Pin tract infection. 2. Foot drop deformity: When tibia lengthening, it is easy to produce foot drop deformity. It can be prevented with mini-invasive Achilles tendon release or foot ankle orthosis wearing. 3. Retraction of the lengthened limb: After fixator removal, the stability of the leg is maintained by intramedullary nail. If effective support cannot be provided by the nail, it would easily lead to the retraction of the lengthened limb or the transportated bone segment. For patients with tibia lengthening, the distal hole of intramedullary nail should be locked before fixator removal to prevent retraction of the lengthened limb. 4. New bone fracture: Fracture of the new bone usually occurs after fixator removal because the new bone is fragile and fracture is likely to occur in central fibrous tissue area of distraction gap. Because of the fixation of intramedullary nail, the fracture of new bone will not affect the force line of tibia. Conservative treatment can be adopted for the new bone fracture with no influence of force line, such as immobilization of the affected limb,

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load avoidance, and exercise of isometric contraction of the affected limb. Surgical treatment may be considered if new bone fracture is accompanied by obvious displacement or nonunion.

Personalized orthosis can be made to protect the affected limb after fixator removal for 1–2 months. For tibial lengthening over nail, the protective time of brace can be reduced due to the support of internal fixation.

18.7.2.6 F  ixator Removal and Application of Assistant Devices The time required for lengthened bone healing is usually expressed by external fixator index or healing index. The so-­ called healing index is the time taken from lengthening a length of 1  cm to complete new bone mineralization. The healing index was closely related to the age, pathological features, osteotomy location, adjuvant therapy, total lengthening length, etc. According to literature, the healing index of tibial lengthening is 1.4 months/cm. For tibial lengthening with intramedullary nail and fixator, although intramedullary nailing destroys the bone marrow, according to literature, the healing index of this method is same as that of tibial lengthening only with fixator, for the following reasons:

18.7.2.7 Typical Case This patient was a 16-year-old male, and his left lower limb was shortened by about 11 cm (8 cm in thigh and 3 cm in calf). The lengthening of left thigh and calf with intramedullary nail and fixator were performed (Fig. 18.26).

1. Intramedullary nail significantly increases the stability of the lengthened system, provides a stable bone support, and ensures that the microcirculation reconstruction is not reinjuried by the movement of the fracture. 2. Although reaming can reduce the number of blood vessels, the mechanical stimulation of reaming and inflammatory reaction caused by trauma make the fracture gap congestive and the blood supply increases, which is beneficial to the regeneration of the tissue in the lengthening area. 3. Reaming trauma can cause bone marrow fluid rich in mesenchymal cells and multiple nutritional factors to converge to osteotomy site, which promotes bone healing.

Most of the cases with tibia lengthening above 3 cm can result in different degrees of Achilles tendon contracture, usually presents foot drop, varus, and other deformities. As for this complication, Prof. G.A. Ilizarov added thread rods on both sides of ankle joint when long leg lengthening is implemented, but it is a static device, which can easily induce ankle stiffness and is not conductive to walking exercise. Qin et al. in China added springs on the back of the Ilizarov ring external fixators to form a synchronous elastic device for tibia and Achilles tendon lengthening, for which dynamic apparatus with bionic characteristics was developed (Fig. 18.27).

De Bastiani et al. reported 100 cases of tibial lengthening over intramedullary nail, the average healing index was 1.4  months/cm, which was same as that of tibial lengthening with fixator. This data supports that intramedullary nail does not prolong the time of distraction osteogenesis. There is not an accepted objective index for the optimal period of fixator removal after bone lengthening. The safe method recommended by a large number of clinical literatures is: the affected limb should be fully weight-bearing and able to walk in about 2  months when the average healing index is reached, so that the quality of bone healing is close to the normal and then the external fixator could be removed. In order to remove the external fixator as soon as possible, the second stage of stable operation can be performed, but the patient is often unwilling to undergo the second surgery, so it is necessary to preach to the patient to ensure the effect of the treatment.

18.8 A  pplication of Elastic Apparatus for Tibia Lengthening Sihe Qin, Hetao Xia, Aimin Peng, Xuejian Zheng, Baofeng Guo, and Jiancheng Zang

18.8.1  Background

18.8.2  Details of Elastic Apparatus for Tibia Lengthening The static hinge (Fig.  18.28) on back of the ankle was changed into a non-threaded apparatus and a spring. The innovation is that an elastic apparatus crosses the ankle joint was added on the basis of the tibial lengthening device. It can effectively maintain the ankle joint space and dynamic balance and allow the ankle joint to have a certain range of motion so as to meet the basic need of walking function, and articular cartilage injury can be avoided.

18.8.3  Surgical Procedures 1. Plane and method of the osteotomy are as usual in tibial lengthening. 2. The requirement of elastic apparatus implementation is the same as that of the modified Ilizarov apparatus of tibial lengthening.

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Fig. 18.26  Limb lengthening with fixator over nail. (a) The left lower limb was shortened by about 11 cm preoperatively, and pelvic tilt to left when standing; (b) The lengths of bilateral lower limbs were equal after the left foot sole was raised by a plantar pad by 11 cm; (c) Full length X-ray film of bilateral lower limbs; (d) Femoral lengthening intramedullary nail combined with unilateral fixator and tibial and fibula lengthening of intramedullary nail combined with Ilizarov external fixator

were performed at the same time; (e) X-ray film was taken at 1 week after the operation; (f) X-ray film at the lengthening period; (g) The appearance at the lengthening period; (h) During the lengthening period, the full lengths of bilateral lower limbs were taken; (i) External fixator was removed and intramedullary nail locked, and two pins were retained in the tibia to assist the intramedullary nail fixation; (j) X-ray film after fixator removal

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Fig. 18.26 (continued)

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speed of extension, the exercise methods were all kept at the same level. The clinical data of two groups were evaluated by ankle deformity, symptoms, function, and activity according to Kofoed score standards. The results were analyzed by SPSS 17.0 statistical software as follows: ankle score 79.941 ± 3.88 points in the control group while 91.84 ± 2.40 points in the experimental group; ankle function in the experimental group was significantly better than the control group. The conclusion: Bionic distraction apparatus imitated ankle physiological movement and have many advantages in the cases of lower limb lengthening. Not only is effective in preventing common ­complications of foot drop, varus, and valgus deformities, but also greatly preventing the emergence of complication of ankle stiffness. The modified tibia lengthening device has been recognized and has been widely popularized in China, but it is only used for patients with tibial lengthening and no fixed deformities in the ankle joint.

18.8.5  Typical Case Twenty-three-year-old female with right leg shortening by 4 cm (Fig. 18.29). Synchronous lengthenings of the right calf were performed. The ankle function was good postoperatively.

18.9 Foot Lengthening Sihe Qin, Shaofeng Jiao, Qi Pan, and Jiancheng Zang Fig. 18.27  Apparatus of tibia lengthening (combined of tibia frame and Achilles tendon apparatus)

3. Pin fixation plane (a) Wire insertion of tibia and fibula is just same as tibial lengthening. (b) Calcaneus wire insertion: A 2.5-mm wire is penetrated in the calcaneal tubercle level in the same plane with a cross angle of 30°, and another two 3.5-mm pins are inserted respectively on both sides and fixed on the hole of half-ring. 4. Tibia and fibula osteotomy method and other related procedures are the same as the tibial lengthening.

18.8.4  Application of Elasticity Apparatus for Tibia Lengthening In this study, the control group included the ordinary Achilles tendon distraction apparatus used for the tibia lengthening in 257 cases from 1998 to 2008. The experimental group included the new type of bionic Achilles tendon and ankle distraction apparatus used for 96 cases from 2008 to 2010. The case condition, surgical methods, postoperative management, the

18.9.1  Calcaneus Lengthening Severe complications such as calcaneal osteomyelitis, ischemic osteonecrosis, or epiphyseal injury often result in calcaneal defects. As an important supporting structure of foot, calcaneal defect can seriously affect the standing and walking functions of patients. At present, the reference about the treatment of calcaneal defects mainly focus on microsurgery, which uses vascularized fibula flap, iliac bone flap, or myocutaneous flap combined with large bone graft to reconstruct the calcaneus. The operation is complex in design and high in risk. It often involves sacrificing donor tissues and organs to cause new injuries. Ilizarov distraction osteogenesis technique was applied to repair traumatic calcaneal defect and obtained satisfactory curative effect, which provided a new idea and method for the treatment of this kind of disease.

18.9.1.1 Surgical Indications 1. The little calcaneus with congenital calcaneal dysplasia and well-developed subtalar joint. 2. Most calcaneus defects after trauma or calcaneal infection and with relatively intact subtalar joint.

18  Limb Length Discrepancy Fig. 18.28  Elastic apparatus. (a) Hinges; (b) Elastic hinge; (c) Elastic apparatus for tibia lengthening

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3. Open calcaneal fractures with defects, and 1–1.5 cm residue at the distal end of calcaneal.

18.9.1.2 Surgical Procedures 1. Tibial ring mounting: The tibial frame is composed of two rings with a distance of 15–20 cm. The distal ring is fixed by two crossed 2-mm K-wires, and the proximal ring is fixed to the tibia through two pins as the supporting ring. 2. The installation of wires and rings at the proximal end of the talus, scaphoid, and metatarsal: At the proximal end of talus, scaphoid, and metatarsal, a whole ring or a half-­ ring was fixed by crossing K-wires and half-pin to stabilize a section. The neurovascular injury should be avoided when wires and pins were inserted. 3. Installation of calcaneal rings: In consideration of the installation characteristics of hybrid frame, characteristics of the patients’ deformity, the size of the residual calcaneus, the skin and scar situation, the frame is installed preassembled preoperatively. Usually when the frame above subtalar joint is installed, the frame at the calcaneal end is installed. At least 0.5–1.0 cm calcaneus in parallel to subtalar joint is reserved for the osteotomy reference plane, and the distal calcaneal rings is installed. The installation of the ring is based on the selection of a paral-

b

c

lel ring (the normal force line of the hindfoot) and the trapezoid shape (the varus and valgus back foot). A sharp osteotome is used for osteotomy under the fluoroscopic monitoring to prevent the osteotomy surface from being incorrect. The stability of the frame structure is carefully checked, and the bolts are tightened.

18.9.1.3 Postoperative Management 1. At sixth day after surgery, X-ray is taken to observe the osteotomy. The external fixator is adjusted to lengthen the calcaneus at a speed of 1 mm/day, but in consideration of the pain condition of the patient. 2. Appropriate oral analgesic may be taken, especially during the adjustment period. If pain is uncontrollable by drugs, the lengthening rate might be slowed down, or even stopped temporarily. Further lengthening is continued after the pain had disappeared or abated. 3. If the pin tract of the external fixator is dry without redness, swelling and exudation, no special treatment and bandage are needed. If redness, swelling, and pain happened, oral antibiotics could be taken and walking exercise reduced. The wire tract is wrapped with sterile gauze. If uncontrollable infection occurred, the wire is pulled out or replaced in time.

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Fig. 18.29  Tibial lengthening. (a) Clinical appearance presented the right calf was shortened by 4 cm preoperatively; (b) The patient with synchronous lengthening apparatus, front view; (c) The patient with synchronous lengthening apparatus, lateral view; (d) Schematic dia-

gram of synchronous lengthening apparatus; (e, f) X-ray of ankle joint during tibia lengthening; (g) X-ray after fixator removal; (h) The motion of ankle joint was normal

4. Lengthening should be stop when a predetermined length reached. Fixation maintained until bone union, in which weight-bearing walking can be taken.

and had not been treated with orthopedic surgery (Fig. 18.30). Physical examination: Left foot with severe equinus and cavus deformity resulted in bearing weight and walking only with five metatarsal heads and toes. There was an extensive scar in the skin of the posterior medial leg and heel with foot plantar flexion in 35° and ankle joint movement of 0–5°. Most of the calcaneal was absent. The movement of flexion and extension of toes were fine. The pulsation of the dorsal artery of the foot was normal. The foot sensation was normal. X-ray films and CT 3D-reconstruction suggested severe left foot drooping, a joint formed between lower tibia and posterior segment of the talus and calcaneus defect. There is a space between the talus and tibial joint. Maryland foot function score of left foot was 48. The patient was treated in two stages. First stage: the scar on left leg was resected and repaired by the free anterolateral femoral flap. The area square of the flap was up to 14 cm × 7 cm.

18.9.1.4 Rehabilitation One of the advantages of Ilizarov external fixator is that early weight-bearing walking, which can increase blood circulation of lower limbs, prevent joint stiffness and shorten recovery time. 18.9.1.5 Typical Case Case 1 The patient was a 44-year-old male with left severe equinus foot deformity and calcaneal defect for 22  years. He suffered from a large area of tissue defects in the left calf and heel and comminuted calcaneal fracture in a traffic accident at the age of 22 years. After debridement and skin grafting the wound healed with scars. The patient was left with equinus and cavus deformity and partial calcaneal defect. In recent years, the left foot deformity had gradually worsened

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Fig. 18.30  Severe equinus foot deformity with calcaneal defect. (a–c) Preoperative appearance and X-ray; (d–f) Subcutaneous release of Achilles tendon and calcaneal osteotomy were done; (g, h) Ilizarov external fixator was started to adjust from 10 days after surgery. During the lengthening period the patient can carry double crutches and take

partial weight-bearing by the affected limb; (i) Postoperative Appearance; (j–m) At 1 year after surgery, lateral radiography showed that the lengthened bone healed well, the calcaneal shape and the arch of the foot restored to normal

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Fig. 18.30 (continued)

The second stage operation was performed 4  months after surgery: subcutaneous release surgery of left Achilles tendon was performed. Ilizarov apparatus was applied with partial correction of equinus foot deformity during surgery. At the same time, Ilizarov calcaneal lengthening device was installed according to the preoperative plan. The calcaneus osteotomy was performed at the posterior margin plane. At 10 days after surgery, the Ilizarov fixator was adjusted to correct the residual equinus foot deformity together with the synchronous calcaneal lengthening at a speed of 0.5 mm/ day, which was adjusted between 0.4 and 1.0  mm/day according to the patient’s pain tolerance. At 132 days after surgery, the equinus foot deformity was corrected satisfactory and the calcaneus was lengthened. During the lengthening period, the patient can have partial weight-bearing with crutches. After 67 days of lengthening, the radiographs of bilateral feet were taken, on which the calcaneal lengthening was measured. The lengthening was stop after the lengths of bilateral feet were equal.

The bone healing was achieved after 86  days of fixation, and the external fixator was removed. At 1-year follow-up, the radiographs showed that the bone healed well. The calcaneal bone morphology and the arch of the foot were returned to the normal. At one and a half years after surgery, the X-ray AP and lateral view showed the foot was corrected well. Maryland foot function score of the left foot was 84. Case 2 Twenty-year-old male with left cavus foot deformity underwent ankle fusion surgery 15 months before admission to the hospital. X-ray showed that the ankle joint had been fused with screw fixation, but the fusion site was nearly at the back talus and the arch of the foot decreased. The screws were removed and the calcaneus was lengthened by 2  cm, the cavus foot deformity was corrected, the walking function was improved, and the pain of the foot disappeared (Fig. 18.31).

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Fig. 18.31  Calcaneal lengthening for equinus and cavus foot. (a) Preoperative appearance; (b) Preoperative X-ray; (c) Ankle screw removal, calcaneal osteotomy and Ilizarov external fixation was applied; (d) 10  days after surgery; (e) X-ray film was taken 10  days

after surgery; (f) The calcaneus was lengthened by about 12 mm on the 25th day after surgery, and the calcaneus was distracted backwards to correct the cavus deformity; (g) The appearance 83 days after surgery; (h) The appearance 1 year follow up; (i) X-ray 1 year follow up

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f

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Fig. 18.31 (continued)

18  Limb Length Discrepancy

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Fig. 18.31 (continued)

18.9.2  Midfoot Lengthening Foot trauma, frostbite, infection, and other factors can cause metatarsal and tarsal bone defects, leading to short feet and lack of arch. Some patients can have secondary foot deformities (such as equinovarus), resulting in unstable walking and shoe wearing difficulty, which has great influence on patients’ physical and mental health.

18.9.2.1 Clinical Manifestations The defects of the forefoot and the midfoot present different manifestations because of the different degrees and positions of the defects, but the common feature is mainly short feet (Fig. 18.32), which affects the stability during loading and difficulty in wearing shoes due to an unequal length of feet. X-ray films show partial or total metatarsal defects or tarsal defects (Fig. 18.33). Because of trauma or inflammation, the intertarsal joint of the midfoot is often fused or the interarticular space is narrowed. 18.9.2.2 P  rinciples and Methods of Surgical Treatment The aim of these patients’ treatment is to increase the length of the feet and restore the shape of the feet, thereby to increase the stability of both feet when walking. The other main demand is to solve the problem of wearing shoes caused by the unequal length of the feet. Ilizarov technology can reconstruct the length and shape of the feet. As mild metatarsal

Fig. 18.32  Shortening deformity of the left forefoot

defect, the metatarsal bone can be lengthened. When the remaining metatarsal bone cannot meet the need of osteotomy, the tarsal bone osteotomy and lengthening are selected. Because the midfoot had with more intertarsal joints and complicated anatomical structure, two medial and lateral lon-

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Fig. 18.33  X-ray shows metatarsal defect

Fig. 18.34  Osteotomy incision

gitudinal incisions are selected for osteotomy. The soft tissue of the back of the foot is dissected with a splitter (Fig. 18.34) to avoid the injury of the dorsal foot artery. Then the tarsal bone is transected by osteotome through these two incisions, and the osteotomy should be complete to disconnect the osseous connection between the forefoot and hind foot. Finally, the incision is sutured and the Ilizarov fixator is applied.

18.9.2.3 Installation of Ilizarov Fixator Because the long muscles of the foot start from the lower leg and span the ankle stop at the foot, the steel ring of the calf should be designed to span the ankle, when the frame

Fig. 18.35  Ilizarov foot lengthening frame

is designed (Fig. 18.35). When the osteotomy is completed, the Ilizarov device is applied on calcaneus, tibia and distal tarsal bone to establish the basic frame. The fixation is strengthened at distal and proximal end of osteotomy respectively.

18.9.2.4 Postoperative Management 1. The patient’s toe sensation and blood circulation were observed.

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2. During rest in bed, patients are encouraged to take active and passive activities to improve the circulation of affected limbs. 3. On the third to fifth day after surgery, patient is encouraged to gradually walk with weight-bearing on the ground, depending on the condition of the operation. 4. At 7 days after surgery, the lengthening is begun at a rate of 1.0 mm/day for 5 times. After a lengthening length of 1.0  cm, the X-ray film is taken and showed that the ­osteotomy end is separated, and the callus grew in fog shape. It is continued to be lengthened by 0.66 mm/day for 4 times, and another length of 1.0 cm is achieved and the radiographs taken. If the callus grew well at the osteotomy site, it continued to be lengthened until reaching its intended length. 5. During deformity correction, patients are encouraged to exercise and walk weight-bearing with walker. 6. When midfoot is lengthened by more than 1 cm, the tensions of flexor and extensor digitorum longus muscles increased. The patient should be asked to pull the toes passively. If the toe deformity occurred due to tendon contracture, it can be corrected by the longitudinal wire inserted through toes.

18.9.2.5 Complications 1. Care is taken to avoid injury to the dorsalis pedis artery and the medial and lateral metatarsal arteries during osteotomy. 2. X-ray is taken in time to observe the osteotomy space, lengthening failure due to premature bone healing should be avoided. 3. During the processing of deformity correction, attention should be paid to observe the local skin tension, blood flow, and sensation to avoid serious problems such as toe necrosis and so on. 4. Keep pin tract clean to prevent infection. 5. If the pin loosened or cut out of the bone, it should be replaced in time. 18.9.2.6 Fixator Removal 1. When midfoot lengthening is completed, the external fixator is maintained firmly fixed. 2. X-ray films are taken regularly every 2 months, and the fixators can be removed when osteotomy is healed. 18.9.2.7 Typical Case Seventeen-year-old female with short foot and toe deformity severely affected walking suffered from open injury in a car accident 14 years ago. X-ray showed that the left metatarsal and tarsal bone were shorter than right (Fig.  18.36). The tarsal lengthening was

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done by 8 cm, the gap of bipedal length was reduced, and the walking function was improved.

18.10 T  he Complications of Lower Limb Lengthening Shaofeng Jiao, Sihe Qin, and Jiancheng Zang

18.10.1  Introduction 18.10.1.1 The Definition of Complication In the process of disease diagnosis and treatment, the complications, the pathological symptoms, are derived from the patient’s own pathological development or still unavoidable during the treatment by routine diagnosis and treatment. The characteristics are as follows: 1 . With clear cause. 2. There is a causal relationship (direct or indirect) with the primary disease. 3. Coexisting with primary disease. 4. It is difficult to avoid in the routine diagnosis and treatment.

18.10.1.2 Classification of Complications Paley Classification Dr. Paley (US) divided complications in limb lengthening into problems, obstacles, and complications. 1. Problems. It indicates the difficulties that can be solved without operation, such as mild pin infection and mild joint dysfunction. 2. Obstacles. Difficulties that require surgical treatment, such as a broken wire in the body, bone malunion, and so on. 3. Complications. Complications are caused by injuries during the surgeries and problems during the treatment which cannot be solved before the end of the treatment. Xia Classification Dr. Xia (China) divided complications into reversible and irreversible one. 1. Reversible complications (a) Mild: problems that can be cured only by general surgical treatment or recovered without surgical treatment, such as wire infection, wire breakage, slight bone, and joint deformities such as angulation of osteotomy and mild clubfoot..

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Fig. 18.36  Left foot short deformity after trauma. (a) Preoperative clinical appearance, bipedal length difference of about 8 cm; (b) X-ray film showed that the metatarsal bone and tarsal bone left side were shorter than the right foot; (c) The midfoot osteotomy was performed through the medial and lateral incision; (d) Ilizarov external fixator was

mounted; (e) The midfoot had been distracted by 15 mm 26 days after surgery; (f) The appearance 186 days after surgery; (g) X-ray film was taken 210 days after surgery; (h) The appearance 260 days after surgery; (i) Bilateral feet with equal length in plantar view; (j) X-ray 45 days after fixator removal

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Fig. 18.36 (continued)

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(b) Moderate: problems that require systemic medical treatment or simple surgery to cure, such as incomplete osteotomy, severe wire infection, delayed union of bone, and malunion. (c) Severe: problems that require reoperation such as fascial compartment syndrome, joint dislocation, joint stiffness, nonunion, and refracture. 2. Irreversible complications, also called sequelae (a) Mild: It caused by damage to articular cartilage in major joints such as hip, knee, ankle dislocation and sensory disturbance caused by peripheral nerve injury and so on. (b) Moderate: Muscle paralysis caused by muscle and nerve injuries or joint stiffness and so on. (c) Severe: Limb necrosis caused by severe vascular injury, or extensive muscle necrosis caused by severe compartment syndrome.

18.10.2  Intraoperative Complications 18.10.2.1 Thermal Injury When the wire penetrates with high speed, it also causes thermal injury to the soft tissue and skin around the pin. Preventive methods: 1. The K-wire with a sharp tip should be selected to perform rapid penetration and reduce the friction time between the wire and bone cortex. 2. The speed of an electric drill should be controlled. In order to reduce the heat occurrence and promote the thermal diffusion, the speed of electric drill should be slowed down and can be inserted intermittently. 3. A piece of alcohol gauze can be used during wire insertion. On the one hand, it can help to reduce the local temperature; on the other hand, it can reduce the friction between the soft tissue and the fixed wire. 4. Pins are used as less as possible without affecting fixed strength. If the thermal injury to skin and soft tissue occurs carelessly, the seriously searing skin and subcutaneous tissue around the pin tract should be excised until active bleeding on the edge of the skin.

18.10.2.2 Neurovascular Injury 1. Injury mode: direct pricking wound, laceration by wire and thermal injury. 2. There are a few nerves and blood vessels that are easily damaged during wire puncture. Common peroneal nerve: the wire should be inserted from the fibula head rather than fibula neck. Fig. 18.36 (continued)

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The posterior tibial nerve and blood vessel: wire inserting from the anterior lateral side to posterior medial side above the ankle is prone to the injury to the ankle canal. The great saphenous vein: when the wire was penetrated on lower leg, the direction should be from lateral side to medial side. It should be hammered through contralateral cortex, and the subcutaneous saphenous vein should be pushed to avoid injury. Continuous active bleeding along the pin can be seen when the small vessel injured, the wire or pin should be removed immediately and then the limb was elevated, the pin tract should be compressed in same time. Muscle movement occurs in the distal extremity when wire inserting, which indicate that nerve is stimulated, the wire should be rapidly pulled out and changed to other points. If it is discovered after surgery, the possible site and extent of nerve injury should be analyzed and judged according to the specific clinical manifestation, and then the response wire should be removed as soon as possible, nutrition treatment should be given, and the surgical exploration should be carried out if necessary.

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Fig. 18.37  The pin tract was wrapped with gauze, which could not only prevent contamination, but also prevent interface slipping between soft tissue and wire

18.10.2.3 Broken Drill Bit It happens more frequently when a drill is used to drill holes for an osteotomy. When drilling with a drill, the surgeon should hold the drill steadily to avoid rocking. It is most easily broken when the drill bit reaches the edge of bone cortex, therefore, it is better to replace the drill with K-wire of the same diameter for the further drilling. If the drill bit breaks at the edge of the bone cortex, the incision should be enlarged to find it and take it out. If the bit is broken in the bone, an osteotome can be used to cut the bone. After the gap of the osteotomy is widened, the drill bit that breaks in the bone can be removed. However, care should be taken to prevent the broken bit falling into the medullary cavity.

18.10.3  Complications Before Lengthening 18.10.3.1 Pin Tract Infection Pin tract infection is the most common complication in the application of external fixator. For the mild pin infection, disinfection with iodophor or alcohol is carried out and the pin tract is wrapped with sterile gauze (Fig. 18.37) without antibiotics. As for moderate wire infections, except for local disinfection and wrapping, activities on the ground should be reduced or suspended. In the case of severe pin infection (Fig.  18.38), the wire should be removed in time, and effective antibiotics should be given. The affected limb should be elevated and reduce exercise.

Fig. 18.38  In severe pin infection, the wire should be directly pulled out

18.10.3.2 Joint Dysfunction Because the muscle is restricted by the wire, the extension and flexion of the adjacent joints can be influent. Standardized wire manipulation and early functional exercise is the most effective way to avoid the joint dysfunction. As for external fixation on femur, functional exercise of the knee flexion and extension can be carried out at fifth to

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varus deformity appears. During the lengthening process, the toe flexor tendon cannot be regenerated synchronously, and the relative contractures result in the flexion toe deformities. Prevention and treatment: The secondary deformity can be corrected by means of functional training and manual correction. If it is not effective, should be corrected by orthosis or reoperation.

Fig. 18.39  Knee bending exercise by the weight of the calf

Fig. 18.40  Knee flexion exercise in the prone position: (a) Active flexion exercise; (b) Passive flexion exercise

seventh day after surgery. Patients can sit on the side of the bed with the calf suspended. The knee is pulled flexed by the weight of the lower leg. Most of them can reach the ideal angle of flexion (Fig. 18.39). Active and passive knee flexion can also be practiced in prone position (Fig. 18.40).

18.10.4  Complications During the Lengthening Period 18.10.4.1 Joint Deformity In the process of tibia lengthening, knee flexion deformity (Fig. 18.41), equinovarus foot deformity (Fig. 18.42) and toe flexion deformity (Fig. 18.43) are more common. The cause of knee flexion is gastrocnemius contracture, which can be corrected by extension of gastrocnemius aponeurosis or extension of knee joint. When the pulling force of the posterior tibial muscle and the fibula muscle are not balanced, the equinovarus

18.10.4.2 Joint Dislocation Dislocation of the hip joint may occur in patients who underwent femoral lengthening. If there is an acetabular dysplasia, the adductor muscle contracture results from the femoral lengthening and increases the adductive strength of the hip, which enhances the pressure of the femoral head on the edge of the acetabulum, hip dislocation may occur if it was not alleviated for a long time (Figs. 18.44 and 18.45). For the patient with the length exceeding 4–5 cm during the femoral lengthening, and muscles imbalance from the quadriceps, and the hamstring does not regenerate simultaneously, the knee joint exists in the risk of dislocation. If it is not detected and treated in time, the posterior dislocation of the knee joint will gradually occur. When the length of femoral lengthening >5 cm, another Ilizarov ring fixator can be mounted in the proximal tibia and connected to the fixator of femoral lengthening by the hinges span the knee. The space of the knee joint can be distracted to prevent the dislocation and the compression injury. If the dislocation of the joint has occurred during femoral lengthening, it can be gradually restored by configuration changing or add special device to increase the pulling reduction. 18.10.4.3 Wire Breaking The breaking of the whole wire occurs mostly at the edge of the fixed clamp (Fig. 18.46), where the stress is concentrated and easily broken. For the breakage of thread half-pin is usually at the junction of the thread and the end of pin (Fig. 18.47), where it often requires reoperation to remove. Whether another wire or pin is necessary depends on the fixed strength for limb lengthening.

18.10.5  Complications in Bone Mineralization 1. Delayed healing at the osteotomy site Most of the delayed bone healing occurred in the following conditions: (a) Special osteopathy: osteogenesis imperfecta, congenital pseudarthrosis of tibia, etc. (b) Stress shielding produced by external fixator. (c) Not enough weight-bearing exercise.

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Fig. 18.41  Knee flexion deformity occurred after tibia lengthening. (a) 25-year-old male suffered knee flexion deformity with tibia lengthened by 4 cm; (b) Gastrocnemius aponeurosis lengthened, the orthosis

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should install in the femur for knee joint distraction; (c) After correction of flexion deformity, an orthosis can be applied to maintain orthopedic effect

Fig. 18.43  Toe flexion deformity occurred during tibia lengthening

Fig. 18.42  Tibia lengthening by 6  cm, accompanied by bilateral equinovarus deformities

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Figs. 18.44 and 18.45  Femoral lengthening with dislocation of hip joint. Twenty-one-year-old female with 6 cm femoral lengthening intramedullary and extramedullary, dislocation of the hip occurred when the last follow-up

The treatment methods include increasing the fixation time, reducing the fixation intensity, strengthening the functional exercise, and so on. It is generally possible to heal smoothly. If necessary, bone graft can also be performed with secondary surgery to promote bone healing. 2 . Pin Infection and breakage may also occur in this period.

18.10.6  Complications After Fixator Removal

Fig. 18.46  Wire break at the edge of fixed clamp (red arrow)

The fracture of the lengthened area should be prevented in early stage after fixator removal. The external fixator should be removed gradually, when callus of fracture or osteotomy healed to a certain extent of strength. If the

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external fixator is removed at one time and the trabecular structure is not adapted to the local mechanical environment, a slight torsional force may cause refracture (Fig. 18.48).

18.10.7  Other Complications 18.10.7.1 Erythra In a few patients, skin rash can happen in the operated limb during limb lengthening, which appeared as red rice grain papules (Fig. 18.49) and is considered as an allergic reaction to the metal wire. But some patients are effectively treated with antiallergic drugs. Others are insensitive to antiallergic drugs. These patients had no history of metal allergies, and these eruptions often occurred in later stage of lengthening period. Therefore, it is considered to be related to sympathetic response after nerve distraction, but the exact cause remained to be studied.

Fig. 18.47  Wire break intraosseous (red arrow)

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18.10.7.2 Skin Compression Most of them occur in children and adolescents. In the processing of treatment, the limbs grow rapidly in diameter, which leading to the relative narrowing of steel rings (Fig. 18.50) and severe skin ulceration. This problem should focus on prevention. For the patient in children or adolescents, a larger steel ring should be prepared to reserve a growth space. b

Fig. 18.48  Refracture after fixator removal. (a) 14-year-old male with poliomyelitis sequelae underwent the surgery of left femur lengthened by 6 cm; (b) Refracture after fixator removal

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Fig. 18.49  15-year-old male underwent left tibial lengthening surgery, skin rash occurred during treatment

Fig. 18.50  In the processing of femur lengthening, the proximal steel ring entraped the thigh and formed compression skin ulcer