I would like to have your opinion on external fixators (Ilizarov, Taylor spatial frame, etc.) vs serial casting or active tutors for the correction of foot deformity; is it a question of:
- patient age?
- tissue stiffness or amplitude of required correction?
- acquired or congenital deformity?
Any comments will be greatly appreciated.
Dear Elisabetta, I think your question tackles a big part of orthopaedic pathology of the foot. So it is very difficult to receive an adequate answer. In your explanation you yourself point out several important issues that should be taken in consideration: etiology, age, etc. Shortly said, I would say that serial castings are usually applied in newborns with equinovarus or other congenital deformity, while external fixators are used in combination with bony operations (osteotomy, resection, arthrodesis, etc) in adolescents and adults. Especially effective are the external fixators in traumatic and posttraumatic conditions. As said above the topic is very large and you would be advised to have a look at the corresponding chapters in orthopaedic textbooks.
Specifically which foot deformities are your referring to?
Professor Rothbart
I was thinking, for example, of equino-varus acquired deformity as a consequence of neural damage in a young adolescent.
Clubfoot deformities in neonatals respond exceptionally well to the Ponseti serial casting technique. In fact, in most cases, his technique has almost eliminated the need for surgical intervention.
If the foot pathology is due to a CNS neuropathy, treating the foot directly has proven, in my experience, to be of limited success.
Professor Rothbart
I am sorry to partially disagree with Dr. Rothbart as far as neuropathic foot deformities are concerned. There is a vast range of pathomorphologic types (equinus, equinovarus, excavatus, excavatovarus, planovalgus, etc.). In adolescents and adults surgery is the method of choice. Usually bone corrective techniques are applied. It is true that the complication rate is high (infection, secondary wound healing, etc.) but the results are rewarding in most cases.
For example, excavatus foot in relation to Pierre-Marie-Tooth disease is relatively easy corrected by midtarsal wedge osteotomy (the base of the wedge points upwards). This makes early loading possible because the osteotomy faces come to press against each other. As I said above treatment modality should be decided from case to case.
Dear Elisabetta,
In the case of equinovarus deformity in adults (I think this specifically is your question). There are some classic surgical techniques. One of the most effective is the Stoeren technique which is done in 3 stages. The other is Lambrinudi medio- and subtalar arthrodesis. You may see details in textbooks for orthopaedic surgery.
Dear Elisabetta
referring only about Charcot Foot pathology in diabetic population which is my field of researches and dally activity I would like to stress that in case of any degree of deformity during the acute phase of Charcot neuroarthropathy serial casting is the only correct choice to apply stop decease progression considering lack of evidence for surgical treatment in acute phase. The real problem is manly correlated to time of application on surgical correction of a stable deformity both with internal or external fixation. While in the last ten year strong indication was related only to patients affected by relapsing plantar ulcer due to plantar bony prominence, recently many authors, and I am one of them , underlined the need to apply surgical correction in the chronic phase of the decease but before ulcer onset and bony exposure to avoid surgical complication. As far as my experience is concerned, in a recent paper we have demonstrated that correction of ankle deformity performed at the very beginning of deformity is a safe choice with excellent results (limb salvage and walking ability) in a long term follow up.
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