USE OF ILIZAROV METHODOLOGY FOR COMPLEX FOOT AND ANKLE

PROBLEMS. A PERSONAL EXPERIENCE.

Nuno Craveiro Lopes, M.D.

Orthopaedic Department, Garcia de Orta Hospital, Almada, Portugal

Introduction

Complex foot deformity correction with conventional techniques, has many limitations including
neurovascular problems, skin problems, stiffness and sacrificing foot and leg length.

Ilizarov methodology on the contrary is not limited by deformity magnitude and permits a
comprehensive approach to foot deformity correction treating all present deformities at the same
time, either on foot or leg, combining techniques of soft tissue distraction, bone lengthening and
arthrodesis.

Nevertheless, Ilizarov methodology is not exempt of problems and difficulties. It is a technically

demanding procedure with a long learning curve. For the patient, treatment time is long, the
frame is uncomfortable, pin infection is frequent and other complication rate are also high.

However, if proper technique is used including pre-operative planning, pre-building of the frame,
careful ambulatory handling, this method can be a useful in the management of difficult cases
and in certain circumstances, the sole method to correct complex foot deformities.

Pre-operative planning

Planning is important in any surgical procedure, but it gets crucial if one intend to perform a
closed or almost closed procedure, like on Ilizarov method.

A good planning begins with good plain radiographs, including all bone segments involved and
the contiguous bone extremities in two orthogonal planes, and if necessary in two more oblique
planes. It is advisable to get also plain radiographs of the contra-lateral bone segments to confirm
the normal anatomy and guide the correction. Generally those films are enough to plan the
treatment, but in complex deformities it is advisable to do also an axial computerized
tomography and if available with 2D and 3D reconstruction.

Pre-building of the apparatus

Pre-assemblage of the frame, permits to build a lighter, more comfortable frame and to cut by
half the operation time, compared with frame construction around previously inserted wires and
pins during surgery [4,5].

The basic frame building for foot deformities includes:

1- A solid base from where all the moving pieces will take fulcrum.
2- A posterior half ring to correct the rear-foot deformity
3- A anterior half ring to correct the fore-foot deformity
The base consists of a two-point fixation at the tibia and fibula, as far distant as possible each
other. On the frontal radiogram one can calculate the point of insertion of the distal ring about 10
cm from the ankle and the proximal one, as high as possible but permitting full flexion of the
knee. The two fixation points can be done with two rings or a ring and a bridge pin, half ring or
arch (Fig1A,B,C) [3,4,5,7,11], depending on the needs in stability. The diameter of the rings can
be calculated on the patient, measuring the larger diameter of the limb and adding 6 cm, or fitting
on the limb choosing a ring that overlaps a two-finger breadth, beneath inner edge and skin. The
two fixation points are interconnected with three connecting rods. If more stability is needed as
on heavy patients, one more rod is mounted. After the base assemblage, it is checked on the
patient’s limb to confirm again for ring diameter and alignment with bone structures.

Fig. 1

The rings are fixed to the bone structures with two wires inserted at more than 60º of angulation
from each other, one smooth wire and a half pin at right angle or two half pins depending on the
best combination that permits not to run across vessels, nerves or bulky muscles (Fig.3A,C,D).
When two wires must be introduced with less than 60º angulation from each other, then olive
wires are preferred (Fig.3B). If more stability is needed, more wires or half pins can be added.

Fig. 3
The rear-foot correcting half ring is fixed to the calcaneous with the same slant of the deformity,
utilizing two posterior pins at a 45º angle or a posterior pin and a transverse wire. This arch is
connected to the base with two hinges, one lateral and other medial, centered on the upper
cortical of the calcaneal tuberosity for a cavus correction or the lower cortical of the calcaneal
tuberosity for a equinus correction. A motor rod is mounted posteriorly (Fig.4A,B).

Fig. 4

The forefoot correcting half ring is fixed to the metatarsal bones with the same slant of the
deformity, utilizing two crossed wires, one thru 5th,4th and 3rd metatarsals and the other thru the
1st and 2nd ones. This arch is connected to the base also with two hinges centered on the upper
cortical of the talus head for a equinus or cavus correction or on the lower cortical of the mid-
tarsal bones for a rocker bottom and planus-valgus foot. One or two anterior motor rods are also
mounted, depending if one wants to correct only a forefoot equinus deformity or a more complex
deformity including equinus and supination or pronation deformity (Fig.4A,B).

Two motor rods can be mounted in between rear-foot and forefoot arches, if forefoot adduction-
abduction must be corrected (Fig.4A.B).

Fig. 5
In a young patient with less than 13-15 years old, no osteotomy is done and an unconstrained
frame can be used, if no foot joints destruction or anquilosis exists. In this case the rear-foot and
forefoot arches are inter-connected solely by the mentioned motor rods, which corrects the
deformity hinging at the foot joints themselves. (Fig.5A,B) [16].

Correction of complex or pronounced deformities of the ankle, foot and forefoot needs
stabilization of the toes and hallux by wires, which are fixed to the forefoot correcting arch
(Fig.4A,B).

The basic frame building for peri-articular ankle fractures includes:

1- A base, as stated before.

2- A anchoring point to fix the wires for reduction and synthesis of peri-articular fragments.
3- A bridge to the calcaneous to do the ligamentotaxis reducing effect or the arthrodiastasis
protecting effect.

Fig. 2

The anchoring point is a ring leveled and measured on the contralateral limb in a position
aligned with the fractured zone and is attached to the base with three or four rods (Fig.2A).

The bridge, composed by a rear-foot arch or a rear-foot and a forefoot arches connected by two
plates, is also leveled and measured on the contra-lateral foot and fixed to the anchoring ring
with three or four rods (Fig.2B) [17].

Application of the frame

For deformity correction

We apply the frame with the patient supine in a normal operating table.

Percutaneous tenotomy and fasciotomy must be done on the main contracted structures, namely
Aquiles tendon and plantar fascia.

We use a V type osteotomy, from the upper cortical of the calcaneal tuberosity to the middle
inferior one and from there, to the upper neck of the talus head. Provisory stabilization is done
with Kirschenner wires. The central part of the talus body must be fixed to the base with a wire
tensioned between two rods with slight arthrodiastasis of the ankle joint (Fig.4A).

The pre-builded frame is opened like a book, wrap around the limb and aligned with the help of
an image intensifier. One wire is inserted in each ring of the base and “fine tuning” is done.
When proper fit is obtained, the remaining wires and pins are inserted. Next, wires and pins are
inserted on the calcaneous and metatarsals and fixed respectively to the rear-foot arch and
forefoot arch.

For peri-articular ankle fractures

We apply the frame with the patient supine in a traction table.

Peri-articular fractures, namely pilon and maleolar fractures, are generally due to the impaction
of the convex articular surface of the talus over the concave surface of the tibia. (Fig.6A),
originating a comminuted osteochondral fracture on the latter. As the main articular fragments
remains attached to the periosteal-capsular envelope, traction across the joint tend to reduce the
fracture fragments; this is the basis of reduction by ligamentotaxis (Fig.6B).

Fig. 6

Generally we apply traction across the joint in a traction table, with a wire in a inverted U shape
on the calcaneous to stabilize the limb and align the fragments. Then, under image intensifier
control, the unreduced intra-articular fragments are mobilized percutaneously or by minimal
incisions, with the tip of a 2.5-3mm wire as a joystick, and fixed with wires olive wires or
screws, one after the other (Fig.7A) [5,6,9,10,18].

The pre-builded frame is then applied, fixing first the base as stated before, then the bridge is
fixed to the calcaneous or foot, and finally the wires or olive wires fixing the articular fragments
are attached to the anchoring ring (Fig.7B).

As an alternative, the initial traction can be done with the frame: The base is fixed to the tibia,
then the bridge to the calcaneous, permitting to do the ligamentotaxis effect. Then, under image
intensifier control, the unreduced intra-articular fragments are mobilized and fixed as stated
before.
 Fig. 7

Special frames

For correction of idiopathic cavus foot

Idiopathic cavus foot can be corrected with a frame without the tibial base, including only the
rear foot and forefoot half rings (Fig.8A and B).

Plantar fasciotomy is done but no osteotomy is necessary.

Neurological cavus foot (either paralytic or spastic) must be corrected with the standard frame
with a V osteotomy to avoid relapses.

Fig.8

For ankle arthrodesis

For ankle arthrodesis we use the standard frame for peri-articular fractures. After fixing it, ankle
arthrodiastasis is done between the tibial base and the calcaneal bridge and a heavy caliber drill
(6 to 8 mm) is introduced anteriorly through a 10mm incision and cartilage is destroyed
(Fig.9A).

Arthrodiastasis is relieved to 3-5 mm so that subtalar join is not compressed and two pair of
smooth wires are inserted transversally, two in the tibia and two in talus and fixed to the
anchoring ring after tensioning (Fig.9B).

Fig.9

For treatment of lower limb vascular insufficiency and Charcot foot

A standard frame is used for correction of foot deformity.

A proximal tibial longitudinal osteotomy is done, using multiple drill holes and a osteotome to
cut the anterior cortical bone and crack the posterior one by levering the osteotome. Two holes
are done with a 4 mm drill bit on the lateral tibia opposite to the osteotomy zone. Two olive
wires are driven through those holes and fixed with a traction device to the frame (Fig.10A).

Fig.10
Progressive medial transport of 10-20 mm is done at a rate of ¼ turn 4X/day (Fig.10B).
The increase of vascular flow to the limb distal to the regenerate, will improve trophic soft tissue
lesions and cure trophic ulcers.

Ambulatory corrections of the frame

Correction of a congenital or acquired deformity or residual deformity after fracture fixation,

namely by mal-correction or bone loss, can be done on the ambulatory period, beginning about
10 days after frame application. This includes axis correction, lengthening and rotational
correction, and is achieved adapting hinges and motor rods to the initial frame on a out patient
basis.

Planning of those modifications can be done manually or computer assisted. The first technique
is based on geometrical data, drawn on a template of the deformed and normal segment, which
permits to find the hinge points, speed and duration of correction [14,15]. Computer assisted
technique, is based on the introduction of data concerning the spatial position of determined
points of the deformed and normal bone structure, on a special computer software, prepared to
determine the location of rings and hinge points, speed and duration of correction over the motor
rods [14].

Although theoretically less accurate, we prefer to use the manual planning, because it is cheaper,
always available, fast to perform and with less factors of error, as it permits “fitting by the best
try”, introducing small changes over the founded hinge point.

To correct an axial deformity alone or combined with shortening

1- On a radiograph template on the plane of the deformity, draw the axis of the tibial
diaphysis (bb’) and of the distal epiphysis (cc’), a perpendicular to the articular surface
(aa’), finding the CORA – center of rotation of angulation (d’)(Fig.11A). The angle of
deformity is c’d’b’.
Draw the bissectrice (dd’) of the complementary deformity angle (b’d’c)(Fig.11B).

Fig. 11
 2- Superpose the normal bone template to the deformed bone template and draw the line
joining the same point of one well-defined structure (ee’) (Fig.12A). Find the
perpendicular on the middle of that line (ff’).
3- The point X were the two lines dd’ and ff’ intersects, is the hinge point to simultaneously
correct shortening and axial deformity (Fig.12B).
4- To transfer the hinge point from the template to the frameon the leg’s patient, measure on
the template two coordinates, from the hinge point to 2 well defined structures and
transpose them to the patient leg/frame assemble, reconstructing the hinge point in a 3D
environment.

Fig. 12

5- Connect the two rings near the deformity with two hinges centered on the founded 3D
hinge point, with a rotation axis perpendicular to the plane of the deformity (Fig.13A).
Assemble a motor rod on the opposite side, and then dismantle the previous connecting
rods in between the two rings. Rotating the motor rod at a proper speed and duration, will
correct simultaneously the shortening and axis deviation (Fig.13B).

Fig. 13
To calculate the speed of lengthening or correction (Fig.14A), draw a strait line joining the hinge
point (a), the concave cortex (b) and the motor rod (c). Perpendicular to the b point, draw a line,
representing one unit of lengthening (1cm=1mm/day). Drawing a strait line from the hinge point
and passing by the top of the unit b, will indicate over c the velocity of lengthening
(2cm=2mm/day). On this example one must do 2mm per day on the rod to get 1mm on the
concave cortex, which represents a speed of 2 fold ¼ turn 4 times a day.

To calculate the duration of lengthening or correction (Fig.14B), draw the angle of deformity
with the vertice over one of the hinges, finding over the motor rod, the lengthening distance
(ab=7cm). The duration of lengthening and correction on this example will be 35 days
(70mm:2mm=35mm). This means that after 35 days of 2 X ¼ turn – 4X/day, one will get the
pretended lengthening and simultaneous axial correction.

Fig. 14

To correct a translation deformity

This deformity can be corrected at about 10 days after frame application if it is the only residual
deformity, or before maturation of the bone regenerate, after an axial correction and lengthening.
On a radiograph template on the plane of the deformity, draw the axis lines of the two segments
of bone (aa’ and bb’), as above and measure the amount of axis translation (Fig.15A).

Fig. 15
Connect the two rings near the deformity with 4 rods: two with a cylinder that slides on a
horizontal rod mounted as a bridge on the other ring, and other two with a gliding clamp and
traction rods over one of the rings, oriented on the direction of the pretended correction
(Fig.15A).
Rotating the nuts at the standard speed of ¼ turn 4 times a day, will correct the translation
deformity (Fig.15B).

To correct a rotational deformity

This deformity can be also corrected at about 10 days after frame application if it is the only
residual deformity, or before maturation of the bone regenerate after an axial correction and
lengthening.

Rotational deformity is measured clinically or based on a CT scan.

The basic frame device is made up of two rings, connected by three short rods, each with a
sliding foot on one ring and a traction device, which permits a rotation movement between the
two rings. This device must be assembled between the two rings near the deformity, with short
plates, in a way that its center of rotation coincides with the center of the tibia (Fig.16A).
Rotating the nuts of the traction device at the standard speed of ¼ turn 4 times a day during a
period calculated as on Fig.14B, will correct the rotational deformity (Fig.16B).

Fig. 16
Clinical cases

Bimaleolar fracture with bad skin conditions

34 years old male with infected psoriatic lesions, presenting a bimaleolar Weber C fracture
(Fig.17).

Fig.17

A preassembled Ilizarov frame was applied, including a base with two rings on the tibia and an
arch on the calcaneous. Ligamentotaxis was done, reduction and fixation of medial maleolus and
then of the tibio-fibular synostosis were achieved percutaneously with olive wires. 3 weeks
latter, the calcaneous arch was removed and partial weight bearing and movement was begun.
(Fig.18).

Fig.18
Radiological and clinical aspect after 8 weeks in frame and one year of follow up (Fig.19 and
20).

Fig.19

Fig.20
Treatment of ankle arthrosis

35 years old male presenting a post-traumatic ankle arthrosis (Fig.21).

Fig.21

A preassembled Ilizarov frame was applied including a base with two rings on the tibia a bridge
to the calcaneous and a anchoring ring at the level of the ankle (Fig.22).

Fig.22
Initially arthrodiastasis was done to open the ankle joint, a 8mm drill was introduced anteriorly
and both articular surfaces were cut out by drilling. Then acute compression was established
using two pair of smooth wires in talus and tibia, with some arthrodiastasis left to protect the
sub-talar joint (Fig.23).

Fig.23

Radiological and clinical aspect after 8 weeks in frame and 1.5 years of follow up (Fig.24 and
25).

Fig.24
 Fig.25

Correction of relapsed club foot in childwood

6 yo girl presenting a relapsed left clubfoot treated initially with manipulation and casting, and
latter operated with a postero-medial release by Cincinnati method (Fig.26 and 27).

Fig.26
 Fig.27

Percutaneous Aquiles tenotomy and plantar fasciotomy were performed.

A preassembled unconstrained Ilizarov frame was applied, including a base with two rings on the
tibia, and arch on the calcaneous and another arch on the metatarsus. Two motor rods were
applied between the base and calcaneal arch to correct rear foot varus and equinus, one motor
rod in between calcaneal and metatarsal arches to correct forefoot adductus, and another motor
rod in between base and metatarsal arch, to correct forefoot equinus. If forefoot supination
existed, two motor rods will be connected here to derotate de forefoot (Fig.28).

Fig.28
This frame has no bars or hinges on the lateral aspect of the frame because the hinge points are
the foot joints themselves. One of the main characteristics of this methodology is the ability to
lengthen the foot to its original dimensions.We use this type of frame we call open frame, in
children with less than 13-15 years old with mobile joints.

Fig.29

Treatment lasted for 3 moths: one month for correction with the frame, one month with the frame
static and one month with a plaster boot. After that the patient used a night splint until the end of
growth.

Radiological and clinical aspect after 8 weeks in frame and 2 years of follow up (Fig.29, 30 and
31).

Fig.30
 Fig.31

Correction of club foot sequel in adulthood

40 years old female presenting a neglected bilateral clubfoot with destruction of the talus (Fig.32
and 33).

Fig.32
 Fig.33

A constrained frame was planed with a base with two rings on proximal and medial tibia, a distal
ring to do a tibial lengthening, a half ring on the calcaneous and other on metatarsal bones to do
rear foot and fore foot correction (Fig.34).

Fig.34
Corticotomy of distal tibia and V osteotomy of calcaneous and mid tarsus was done, plantar
fasciotomy and pinning of the toes was also performed (Fig.35 and 36).

Fig.35

Clinical and radiological aspect after 4 months in frame and 2 years of follow up (Fig.37, 38 and
39).

Fig.36
Fig.37

Fig.38
 Fig.39

Correction of idiopathic cavus foot

12 years old male presenting a bilateral symptomatic idiopathic cavus foot (Fig.40 and 41).

Fig.40
 Fig.41

A bilateral foot frame was assembled with a half ring on the calcaneous and a half ring on the
metatarsal bones, connected with a hinge laterally and a motor rod medially (Fig.42).

Fig.42
Plantar fasciotomy was done at right foot only. That foot evolved without pain or flexion
deformity, comparing with the opposite one, where fasciotomy was not done (Fig.43).

Fig.43

Hypercorrection of 15º was done counting with some loss of correction. Weight bearing
radiograph before and after correction (Fig.44).

Fig.44
Clinical and podographic aspect after 2 months in frame and 2 years of follow up (Fig.45 and 46)

Fig.45

Fig.46
Correction of spastic equinus-varus foot

13 years old male presenting a cerebral palsy with an equinus-cavus foot (Fig.47 and 48).

Percutaneous Aquiles tenotomy and plantar fasciotomy were performed.

Fig.47

Fig.48
A preassembled unconstrained Ilizarov frame was applied, including a base with two rings on the
tibia, and arch on the calcaneous and another arch on the metatarsus. Two motor rods were
applied between the base and calcaneal arch to correct rear foot varus and equinus, one motor
rod in between calcaneal and metatarsal arches to correct forefoot adductus, and another motor
rod in between base and metatarsal arch, to correct forefoot equinus (Fig.49 and 50).

Fig.49

Fig.50
This frame has no bars or hinges on the lateral aspect of the frame because the hinge points are
the foot joints themselves. One of the main characteristics of this methodology is the ability to
lengthen the foot to its original dimensions.

Treatment lasted for 3 moths: one month for correction with the frame, one month with the frame
static and one month with a plaster boot. After that the patient used a night splint until the end of
growth.

Clinical and radiological aspect after 4 months in frame and 2 years of follow up (Fig.51 and
52).

Fig.51

Fig.52
Correction of polio sequel of leg and foot

34 Years old male presenting a polio sequel with 4,5 cm leg shortening, calf atrophy and
posterior cavus foot (Fig.53, 54, 55 and 56).

Fig.53
Fig.54

Fig.55

Fig.56
A constrained Ilizarov frame was applied to correct the deformities at four levels: proximal
tibial lengthening, aesthetic widening of the leg with a medial longitudinal corticotomy of the
tibia and medial transport of 2cm, correction of the rear-foot deformity with a calcaneous
corticotomy and correction of fore-foot deformity with a mid-tarsal corticotomy and gradual
correction (Fig.57, 58 and 59).

Fig.57

Fig.58
 Fig.59

The treatment lasted for 5 months and got correction of the deformities and aesthetic
improvement of the member.

Clinical and radiological aspect after 2 years of follow up (Fig.60, 61, 62 and 63).

Fig.60

Fig.61
Fig.63

Fig.62
Correction of myelomeningocele sequel of leg and foot.

15 years old male presenting a myelomeningocele sequel with shortening and valgus of the leg
and multi-operated equinus-adductus short foot with a plantar ulcer (Fig.64).

Fig.64

A constrained Ilizarov frame was pre-assembled, to simultaneously correct the valgus and
shortening of the leg and the equinus-adductus short foot, acting over a proximal tibial
corticotomy and a V osteotomy of the calcaneous and tarsus. Stabilization of toes was done by
pining with wires (Fig.65).

Fig.65
Radiological and clinical aspect after 5 months in frame and 1 years of follow up (Fig.66 and
67).

Fig.66

Fig.67
Correction of arthrogrypotic foot.

42 years old male presenting a arthrogryposis syndrome with a bilateral equinus-cavus-adductus

foot, needing special footwear to walk (Fig.68, 69 and 70).

Fig.68

Fig.69
 Fig.70

A constrained Ilizarov frame was assembled to correct the foot through a V osteotomy of
calcaneous and tarsus. Pinning of the toes was done with smooth wires (Fig.71).

Fig.71
Clinical and radiological aspect after 5 months in frame and 2 years of follow up (Fig.72 and 73).

Fig.72

Fig.73
Correction and treatment of Charcot foot.

72 years old female suffering of Charcot neuro-arthropaty associated to a vascular insufficiency

of distal left limb secondary to a diabetic micro-vasculopaty. She presented a ankle medial
dislocation and a trophic ulcer of the lateral side of the leg (Fig.74 and 75).

Fig.74

Fig.75
We planed to simultaneous correct the foot with a constrained Ilizarov frame with hinges and to
do a vascular stimulation of the limb with a medial transport after a longitudinal corticotomy of
the proximal tibia (Fig. 76).

Fig.76

Evolution of leg ulcer and soft tissues improve and healed after 45 days (Fig.77).

Fig.77
Foot was translated under the tibia and arthrodesis was done by ankle join compression (Fig.78).

Fig.78

Clinical and radiological aspect after 6 months in frame (Fig.79).

Fig.79
Treatment of hypertrophic pseudarthrosis of distal tibia

23 years old male presenting a hypertrophic pseudarthrosis of distal tibia and fibula with valgus
deformity, after an open fracture (Fig.80 and 81).

Fig.80

Fig.81
A Ilizarov frame with a tibial base and a correcting ring was assembled, with two hinges centred
on the hinge point and a motor rod on the opposite side (Fig.82 and 83).

Fig.82

Fig.83
The hypertrophic pseudartrosis was compressed and distracted 5mm on alternate days and then
progressive distraction was done until axial correction and lengthening was achieved.

Clinical and radiological aspect after 6 months in frame and 1 year of follow up (Fig 84 and 85).

Fig.84

Fig.85
Treatment of infected pseudarthrosis with soft tissue loss of distal tibia.

35 years old male presenting a infected pseudarthrosis of the tibia with bone and soft tissue loss
after a open fracture (Fig.86).

Fig.86

A Ilizarov frame was assembled prepared to do a bipolar treatment. After necrotic tissue
debridements, a 10X6 cm deep ulcer remained (Fig.87).

Fig.87
A 6 cm bone resection was done, with acute shortening to close the ulcer, permitting a primary
closure. A proximal tibial corticotomy was also done to lengthen the bone loss (Fig.88 and 89).

Fig.88

Fig.89
Clinical and radiological aspect after 10 months in frame and 1 years of follow up (Fig.90 and
91).

Fig.90

Fig.91
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