Clinical Research Of Ilizarov Technique Combined With Limited Surgery On The Treatment Of Adult Neurogenic Talipes Equinovarus

Research backgroundTalipes equinovarus is one of the most common complex soft tissue deformities in foot and ankle surgery,which seriously affects the quality of life of patients.Neurogenic equinovarus is represented by secondary spina bifida,secondary upper motor neuron injury,secondary lower motor neuron or peripheral nerve injury,the pathogenesis has its own characteristics.In addition,due to the abnormal landing force of the equinovarus foot,the skin and soft tissue around the landing site of the abnormal load-bearing area will be worn,and the synovial sac or corpus callosum will be formed after a long time.Neurogenic talipes equinovarus often accompanied by foot sensory disorders and neurotrophic,it is easy to form ulcer at the weight-bearing area,also this type of ulcer is usually attacks repeatedly,and hard to heal.Upon this specific characteristic,we should ensure the orthopedic effect and keep the flexibility of the foot at the same time,thus it is not recommended to do a lot of osteotomy and joint fusion.In addition,as for the characteristic of the disease formation,there are differences between adults and children and adolescents.Children and adolescents often have a lighter incidence,their bone deformity has not been fixed,hence the implementation of bone tendon soft tissue surgery need to take comprehensive consideration that their bone development is not yet close to maturity.This study would focus on the analysis of adult patients whose deformities have already been stable.In clinical practice,we can use Ilizarov technique combined with different limited operations to treat adult neurogenic equinovarus foot with different causes.ObjectiveTo explore the treatment methods of adult neurogenic talipes equinovarus,and to analyze the curative effect of different types of adult neurogenic equinovarus foot operation methods,and to formulate a more systematic classification of ideas for clinical treatment strategies of this type of disease.MethodThe preoperative and postoperative data of 25 patients with neurogenic talipes equinovarus who were treated in the First Affiliated Hospital of Zhengzhou University from February,2014 to October,2017 were analyzed retrospectively.All patients were diagnosed as equinovarus caused by different types of neurogenic causes,with an average age of 24.28 years old,ranging from 14 to 35 as for ages.There were 16 male patients and 10 female patients.11 on the left and 14 on the right.From the etiological point of view,10 of them were non-spastic equinovarus,and most of them were secondary to spina bifida of lumbosacral meningocele type.9 cases of spastic equinovarus were secondary to upper motor neuron injury due to cerebral paralysis.6 cases were paralytic adult neurogenic equinovarus,and the etiology was secondary to lower motor neuron injury.After admission to the hospital,patients underwent general treatment and preoperative preparation.After the situation was stablized,patients underwent surgical treatment.Non-spastic equinovarus foot was treated by subcutaneous achilles tendon lengthening,posterior tibial tendon lengthening,plantar fascia cutting,calcaneal osteotomy in 6 cases,anterior tibial muscle tendon external and three joint facetectomy in 4 cases,all of which were combined with Ilizarov external fixator.Cases of spastic equinovarus were treated by subcutaneous achilles tendon lengthening and calcaneal osteotomy.4 cases were treated by selective tibial neurotomy and 1/2 split of posterior tibial muscle,3 cases by split of posterior tibial muscle tendon and 2 cases by 1/2 anterior tibial muscle tendon with Ilizarov external fixator.Cases of paralytic equinovarus were treated with subcutaneous achilles tendon lengthening,plantar fascia cutting and calcaneal osteotomy,3 cases with posterior tibial tendon lengthening and external third wedge bone of anterior tibial muscle tendon,3 cases with anterior tibial muscle tendon,all of which were treated with Ilizarov external fixator.All the patients were corrected step by step according to Ilizarov external fixator,and the ulcer was treated regularly in patients around weight-bearing area.After long-term follow up,ankle-hind foot AOFAS scoring system was used to statistical analyze the effect of different surgical methods with the comparison of the 3 group of patients in preoperative and postoperative terms.ResultsThe hospitalization duration is 11.3�3.5 days,12.5 days on average.The postoperative follow up observation lasts from 6 to 32 months(19 months on average),there were no other trauma or death occurred during the follow-up period.The patients were followed up regularly for deformity correction and ulcer healing and recurrence.For 11 cases of clubfoot with skin ulcer,the ulcer healed in 18-31 days,with an average of 25 days,and there was no ulcer recurrence occurred during follow-up period.According to AOFAS scoring system,we scored adult neurogenic equinovarus with three different causes,and the data was analyzed statistically,the scores of the three groups were significantly better than those before operation under the statistical perspective.(P<0.05)ConclusionsNon-spastic neurogenic equinovarus foot can be treated by subcutaneous achilles tendon lengthening,posterior tibial tendon lengthening,plantar fascia cutting,calcaneal osteotomy,anterior tibial muscle tendon external and three joint facetectomy combined with Ilizarov external fixator.Spastic neurogenic equinovarus can be treated by subcutaneous achilles tendon lengthening and calcaneal osteotomy,selective tibial neurotomy and 1/2 split of posterior tibial muscle,split of posterior tibial muscle tendon,1/2 anterior tibial muscle tendon with Ilizarov external fixator.Paralytic neurogenic equinovarus can be treated with subcutaneous achilles tendon lengthening,plantar fascia cutting and calcaneal osteotomy,posterior tibial tendon lengthening and external third wedge bone of anterior tibial muscle tendon,anterior tibial muscle tendon,combined with Ilizarov external fixator.