Ilizarov for Relasped ClubFoot
Before, During & After Treatment with a midfoot & hindfoot osteotomies with an Ilizarov External Fixator
My foot was considered a severe clubbed foot because my foot had hit whats called spontaneous triple arthodesis. Essentially all the bones in my midfoot & hind foot (talus, calcaneous, cuboid) had calficied as one solid mass of bone and it is suspected that more bones in my forefoot had done the same thing. Because of this simple soft tissue releases were well out of the scope of options for treatment. My heel was also in the wrong place, it wasn't direclty under my tibia, therefore it required an osteotomy as well to shove it back under my tibia. The midfoot bone cut simply cut through the solid mass of bone.
My foot the night before surgery. My heel was far from hitting the floor, I beared all my weight on the front part of the side of my foot. I had about 1 degree of ankle movement & my foot was essentailly frozen in plantar flexion (pointed down) Those are my toes between my ankles, my foot was in a severe C position.
My foot in the ilizarov fully corrected 7 weeks post-op. The ilizarov slowly rotated my midfoot bones back into a flat neutral position.This was done at a rate of about 4mm a day.
The pins in my foot are attached to a metal foot plate, that metal foot plate is then attached to struts. These struts have knobs that were rotated one full turn 4-6 times a day pulling the foot plate up and thus my bones back into a better position. The turns are called distractions, I did distractions for 4 weeks on my midfoot & 1 week on my heel. The midfoot osteotomy made my bone mobile in my foot thus enabling the ilizarov to change the position of it.
My foot in the fixator the day distractions started. My foot is still very swollen from the surgeries.Notice the length of the struts (the stuts are the pieces labled with tape & pink marker, I have 5 struts,2 on the front, one on each side of my foot & one under my foot)
To the right is the fixator about 10-12 days after distractions started!
The fixator from a different view about 10 days after midfoot distractions started & 3.5 weeks post-op.
The entire fixator from the back. About 3 weeks after distractions were completed. Once the distractions are completed the fixator must stay on 2-3 months while the osteotomies heal
My foot in the fixator before distractions started & then fully corrected. Still swollen because I can't move foot or walk on it so the fluid is maintained much longer
The blue strut on the bottom lengthened my foot by an inch. This needed to be done to allow the bone to turn within my foot. By lengthening my foot an inch it made my foot the same size as my left none clubbed foot.
So you can see how big it is in comparison to the rest of my body.
3 months after it was put on my doctor downsized it considerably and removed all the struts that moved the bones within my foot. He left then foot plate in tact since my bones weren't totally healed and the tibial part will lenghthen my leg.
4.5 months after the entire fixator was put on, my foot was freed from the frame! The pins and screws were removed under heavy sedation in the OR. My leg remained in the frame for the 2 inch lengthening in 2009.
Just another picture of the tibial frame. 3 half pins (screws) & 2 wire pins left.
When they removed the foot plate from my fixator I was casted for an AFO
My right foot before the fixator & 3 months after external fixator was removed.
My heel is considered underdeveloped because of the lack of weight baring for so long.
I also have severe sensitivity issues on the parts of my foot where I never bared weight.
My foot flat in a shoe!
This is the x-ray of my foot after the fixator came off compared to an x-ray of a normal foot. You can see I have no joint spaces in my foot because they all consolidation together a few years after my original clubfoot surgery. For unknown reasons my bones sponateously fused together. I also a flat ankle joint joitn due to the fact my foot was left clubbed & in an equinus position for 15 years. My heel is also underdeveloped because I didn't bare weight on it for 15 years.
After my leg lengthening was complete in 2010 a new AFO was made & dorsiflexion straps were added so at night if I want to I am able to stretch my ankle
The good, the bad & the ugly of external fixation for clubfoot deformities-it takes A LOT of WORK!
Read a blog entry I made about external fixation for clubfoot by clicking here and/ or read below!
Feel free to contact me if you have more questions or concerns! My foot before surgery:
My foot was a true Talipes Equinovarus clubfoot. This meant my heel was rolled in & not aligned under my tibia, my midfoot was rolled out 40 degrees (supination), my entire foot was stuck in plantar flexion (flexed down ward) leaving my heel of the ground & my toes were adducted (pointing inward). I was bearing all my weight on my last 3 toes a small section of my 5th metatarsal. I had surgery as an infant for clubfoot but my foot regressed back by the time I was 5 & then by 7 my bones had fused together.
The other "options":
The Ilizarov method of clubfoot correction was not the only option I was presented with by the 5 orthopedic doctors I saw. The other option was too do a midfoot osteotomy & remove a wedge of bone from my midfoot. This would have been necessary because the soft tissues wouldn't have stretched over the new position of the bones. This would have left my already shorter (in comparison to my left, non-clubbed foot) foot even shorter, making balance difficult later. The only advantage to this surgery was the fact I would have been out of a cast & walking within 8 weeks.
Why I went with the Ilizarov Method:
I had dealt with open wounds before, after a deformity was reduced acutely in the OR & there wasn't sufficent skin to close the wound. I didn't want to walk this path again if I could avoid it. The Ilizarov method also meant that instead of a surgeon cutting & lengthening tendons & muscles the fixator would simply stretch those soft tissues instead. The fixator was in reality far less invasive because it required only two incision & the surgeon did not need to dissect my foot.
Outside of the normal surgery risks the biggest risk of an external fixator is infection from the pin sites.
Lasted 5 hours & involved double osteotmies, one through my midfoot & one through my heel. My heel deformity (Varus) was immediately reduced in the OR because it wasn't too severe. The other deformities- supination & equinus were not reduced at all; the frame was built around the deformities & built to pull & push my foot into the correct position over time. I had a central line & an epidural for pain management & woke up in PICU.
The frame was a monster & the doctor could not tell me for sure what it would look like before surgery since he built it right there in the OR. The frame went all the way up to just below my knee. It had 2 rings on my tibia & a footplate around my entire foot. I had 5 struts that actual did the work to move my foot. Strut 1 pushed down on my foot to bring it out of 40-degree supination, struts 2 and 3 pulled my foot up & out of equinus & into a 90-degree angle. Strut 4 pulled on my foot out of supination & strut 5 lengthened my foot heel to big toe to accommodate the mid foot rotating into neutral.
Distractions are the actually turning of the struts on the frame to slowly pull or push the foot into the correct position. I started distractions 1 week after surgery. I did between 1 & 6 turns a day on the various struts. I got a new prescription every week on what struts to turn & how many times per day. Each strut had its own number of turns per day & sometime certain struts weren't turned at all.
The Pin Sites:
The pin sites were very weepy the first 6 weeks; they drained a lot of fluid & blood. They needed time for the skin to heel against the pin. These 6 weeks was very painful because the skin would get stuck to the pin because of the dried blood. I ran water over my leg twice a day for about a week to aid in healing & relieve the pain. Once the distractions stopped the pins stopped being weepy.
Pin Care wasn’t started on my pin sites for about 1 week. The pin care was carried out under hospital protocol the first month or so & not my doctors normal protocol. The hospital protocol was cleaning the pin sites using a mix of half- peroxide & sterile water & cotton swabs & then using a different cotton swab with just sterile water to rinse it. Each pin site had to have its own cotton swab to reduce transferring an infection from one to another. This was done 4 times a day the first 2 weeks & I started using the doctor’s protocol of cleaning them in the shower with soap & water once per day. We started using baby wipes to clean around each pin site with the soap & water; it was easier to get the crusted blood off. Pin care was necessary to keep away pain in the pin sites; a pin site that was stuck to the skin because of dried drainage was painful. It was also necessary to push the skin around the pins down, the skin wanted to grow up the pin; this is called "tenting."
Reducing the chance of infection:
Pin tract infections are the most common complications in external fixation & almost everybody experiences an infected or irritated pin. True pin tract infections are when the infection runs along the entire length of the pin through the leg. My doctor’s protocol was to keep all his frame patients on prophylactic antibiotics the entire time they are in the frame. I took keflex 2 times a day if my pin sites weren't excessively weepy & 4 times a day if a pin looked irritated or infected. This amounted to between 1000 to 2000mg of Keflex per day. Keeping the pins clear of drainage was also key to reducing the chance of infection, dried drainage is a breeding ground for bacteria, and so pin care is vital. I have never had a true pin tract infection just irritated pins that required me to take the antibiotics 4 times per day for a few days.
Post-op pain was intense & was partially managed by an epidural & liquid morphine. In the phase where I was doing the distractions I was in excruciating pain all the time unless I was properly medicated. I took an extended release oxycotin every 12 hours and had an order of percoset, as needed every 4-6 hours. I never went more then 6 hours without needing a percoset. Once the distractions stopped my intense pain subsided immediately & I took just Tylenol as needed during the healing phase. I also experienced extreme nerve pain in my foot from the time of surgery until about a month after the frame was removed. They had me on neurontin at very high levels for about 5 months straight.
Physical Therapy & Mobility:
Physical Therapy got me out of bed & into a wheelchair within 2 days of surgery. A week later they gave me crutches to transfer & walk short distances. Due to the fact I have limitations in all 4 limbs, doing crutches long distance was not an option. Not to mention I needed to have my foot elevated as much as possible because of swelling. I had therapy daily since I remained hospitalized during the distraction phase where I worked on keeping the muscles in my fixated leg strong & maintaining range of motion in my knee joint & endurance on my crutches.
I did distractions for 6 weeks & then my foot was left in the fixator to allow the bones to heel. The footplate was removed from my frame 4.5 months after it was placed. I spent about 18 weeks in the full fixator, 12 weeks of just healing.
I stayed in the hospital the entire time I did distractions so I saw my doctor daily, if I hadn't I would have had weekly appointments with my surgeon during the distractions phase & monthly until the bones healed for the fixator to come off.
My foot was constantly swollen the entire time the footplate was in place, it would reduce if I elevated my leg for 12+ hours. Due to the fact I did a leg lengthening after my club foot correction my foot still swells.
My frame was ready to be taken off 12 weeks after I stopped distractions. Due to the fact that the frame was so bulky it was difficult to get a good x-ray of the osteotomy sites so my doctor aired on the side of caution & left it on a bit longer. I had the footplate removed under heavy sedation in the OR. While I was under they casted me for an AFO. I came out of surgery with a removable cast boot type thing under my foot & it was held in place by an ace wrap that was tied to my fixator that remained on my leg. They had bandaged my foot to get the pin sites to stop bleeding & wrapped by foot tight with an ace bandage to try to get the swelling to go down.
Rehab after the fixator was removed was painful & difficult. My foot dropped into plantar flexion (pointed down) very easily so I had to keep it suspended to my frame as much as possible to hold it in 90. I was immediately encouraged to weight bare on my foot, which I did. It was painful through my ankle joint but also because most of my foot hadn't had weight bared through it in 15 years. I had therapy daily since I was remained hospitalized fighting an infection in my foot. They stretched by foot as much as I could tolerate into dorsiflexion (beyond 90) & into plantar flexion. I also worked on weight baring the first few weeks in just the cast boot. Once my AFO was ready my ability to weight bare greatly increased & very quickly. Once the AFO had a lift that was big enough to accommodate my leg length discrepancy I was walking all over the hospital in a few days. After I had enough balance to walk therapy focused on increasing my balance on my right foot because I wasn't spending enough time on my right leg in my gait pattern. In the 8 weeks I had therapy daily my stamina for standing & walking increased considerably & my gait pattern was greatly improved.
Effects of fixation:
There have been some side affects of fixation that may or may not last long term. I have had extreme sensitivity issues along the inside border of my foot & I have yet to regain the ability to pull my big toe down. Both of these issues stem from the fact that the nerve controlling that side of my foot & the tendon controlling my toe were stretched the most while the fixator corrected my foot. Those soft tissues run across the inside of the foot down to the big toe. In a clubfoot this is the short side of the foot. I regained full sensation on that border of my foot after a year of distractions stopping but I have yet to regain my toe flexion, I can pull my big toe up though. I also had a large callous on the side of my foot when it was clubbed, as my foot was corrected that callous moved to the bottom of my foot. Most of that callous is soft tissue & will diminish over time but part of it is bony & that bony spur may need to be removed surgically if it becomes painful while walking.