Management of Equinus Foot by Ilizarov Technique Sureshwar Pandey, RA Agrawal, Ustiantsev Vasilli Ivanovich
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1Step by Step Management of Equinus Foot by Ilizarov Technique
2Step by Step Management of Equinus Foot by Ilizarov Technique
R.A. Agrawal MS (Ortho) Director Agrawal Orthopaedic Hospital Gorakhpur, Uttar Pradesh Emeritus Prof. Sureshwar Pandey MBBS (Hons), MS, FICS, MS (Ortho), FIAMS, FAC, FAS, FACS, FNAMS Ex-Head of the Department Department of Orthopaedics Rajendra Medical College, Ranchi, Jharkand Prof. Ustiantsev Vasilli Ivanovich MD Clinical Director The Federal Scientific Practical Centre of Medico-Social Expertise and Rehabilitation of the Invalids Moscow (Russia)
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Step by Step Management of Equinus Foot by Ilizarov Technique
© 2006, Authors
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.
First Edition: 2006
9788180617102
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4Preface
A deformity in whatever form, at whichever site, and in whatever age is not acceptable by any one. Not surprisingly, in the pre-civilization era, the disabled persons were put to crucible tests for survivorship, i.e. if they could work hard, earn their livelihood and help their community in their needs, then only they had the right to survive. On the other hand, those who could not prove their worth on the above fronts were done to death. Deformities produce physical disfigurement and physical disabilities. It also produces psychological depression, needs more energy consumption in executing even the routine functions and subsequently it leads to secondary deformities locally and even distantly resulting into ultimate premature degenerative changes in various joints. Therefore, any deformity must be corrected as far as possible.
With the dawn of the civilization, the disabled persons started to expect their right to survive in the world. Gradually, society started to accept them, treat them, rehabilitate them and provide them the dignity of life. Ultimately, the medical world took the challenge of preventing, managing and rehabilitating these disabled/ deformed persons. There has been variable success on all fronts. However, the maximum success has been 5achieved in correcting the deformity and minimizing the deformity. In this very direction, the birth of the “third dimension (rehabilitation medicine) of medicine” took place. Most of the initial deformities are amenable to controlled, graduated, stretching schedule and proper physiotherapy. However, as the deformities advance, they become stiff and some semi-invasive or invasive method for management has to be employed.
The old standard treatment methods include plaster wedge technique; percutaneous, subtotal / total tenotomy; and taking care of other deforming tissues. Beyond that, surgeries on tendon and / or bones and joints help a lot in correcting the deformity. The introduction of 3-D pictures of any deformed and corresponding normal portion helps a lot in deciding the modality and time factor in bringing the normal architecture in that region of the limb.
In this very direction, the Kurgan surgeon G.A. Ilizarov introduced his technique for tackling various problems and one of them has been for the correction of fixed deformity. The principle behind Ilizarov technique has great depth. However, against the speed with which Ilizarov technique was accepted all over the world, its decline unfortunately is also being palpably observed. There can be several reasons but its overuse, uncalculated use, misuse and under-use have a definite role to play for its decline. And nonetheless the improper passing of K-wire, 6injudicious selection of point of entry of wires and improper placement of rings have a definite role to play in bringing disrepute to Ilizarov technique. Let us not blame the young enthusiastic surgeons who want to master any technology in minimum time and minimum effort. We feel there is hardly any monograph detailing the basics of Ilizarov technique, which includes acquaintance with the hardware, proper selection of patient, pin-pointing the placement of the K-wires and the direction of the wire advancement.
The biomechanics itself is a tough subject and we want to avoid intricacies of the biomechanics in our practical life. However, the understanding of the basic kinematics, anatomical localization of the suitable points and basic physiology of execution of function are mandatory before attempting to master any technique.
We have tried to tackle the above problems in a lucid and descriptive manner so that this manual may be useful even to the beginners who want to know, learn, execute and get effective result after the use of the Ilizarov technique.
We all want to put our best to make this monograph acceptable by all, however, there may be many shortcomings for which apology is solicited.
In preparing this monograph we have consulted many books and journals, derived in ideas and inspiration and have been educated through different sources. However, 7we are particularly indebted to the books given in bibliography which we have consulted several times. We have no hesitation in giving full credit to these sources. We acknowledge the constant help of our sincere colleagues and friends like Dr. S.S. Jha, Dr. Anil Juyal, Dr. Anuj Jain, Dr. B.L. Agrawal, Dr. Mukesh Chandra, Dr. R.C. Srivastava, Dr. K.N. Mishra PT, Dr. Pradeep, Mr. Arun, Mr. Girja Shankar, Mr. Anoop, Er. D.N. Srivastava, Mr. Sajjad, Mr. Ajay and Mr. Shankar Joshi. The typing, aligning the manuscript and improving the script is the real tough job in preparing any book—and all that have been done tirelessly by Mr. Shyam Ji Srivastava who remained alert and active for this work at all the time.
The authors could not have concentrated on the work unless the family members had provided them full cooperation. And to this, the dear family of Dr. R.A. Agrawal has stood the test of time accepting all the eccentricities during the preparation of this book. The contribution of Dr. R.A. Agrawal's wife Mrs. Rashmi, son Dr. Rajat, the young budding of orthopaedic surgeon and daughter Miss. Richa, the software engineer simply deserve all credit in uninterrupted production of this book.
Dr. R.A. Agrawal
Prof. Sureshwar Pandey
Prof. Ustiantsev Vasilli Ivanovich
8Prolog
The deformities, anywhere in the body right from head to foot, throw an exciting challenge for correction. However, the foot and ankle deformities pose further problems because of their strategic location at the base of the body for receiving, distributing and propelling the weight both in stance and locomotion.
There can be several causes of deformities but the more common are congenital, paralytic, traumatic, infective and neurogenic disorders. Of these, congenital and paralytic ones are most common.
Paralytic foot deformities are either due to flaccid paralysis such as in poliomyelitis, traumatic paraplegia or spastic problems as seen in cerebral palsy, residual hemiplegia, etc. The foot deformities are hardly in one plane, since multiplaner and multiaxial involvements automatically creep-in the process of development and progression of deformity. Proper understanding of the planes and biomechanics of normal foot and ankle, and proper analysis of pathodynamics of deformity(ies) are quite essential before contemplating to correct any type of deformity.9
There have been many methods and techniques to correct the deformity of the foot but none is fullproof and several limitations and complications have been encountered in the process of correction, to mention a few — problems in skin closure, neurovascular problems, infections, stiffness, leg length discrepancy, etc. All are notorious to tackle but the management of neurovascular problems and leg length discrepancy are more demanding.
Conventional management of the deformity usually consists of gradual stretching, plaster wedge correction and operative interference and like tendon transfer procedures, tenotomy, osteotomy, stabilization and fusion of the joints. However, the advent of Ilizarov technology ushered in a new hope of dynamic correction of these deformities, albeit with the associated shortcomings like prolonged treatment, bulky hardware, pin tract infection and difficult proper patient compliance.
If done, after properly analyzing the pathodynamics of the deformity compared to the normal biomechanics, the Ilizarov technology has a definite edge over other methods as enumerated above. The basic principle of Ilizarov methodology is gradual and controlled stretching of the soft tissues which induces minimal fibrosis and thus, recurrence of the deformity is minimized with proper preoperative planning, preconstruction of the frames, insertion of wires, selection of rings, fixation of rods, postoperative 10monitoring and inducing steps to gain the patient's compliance, ultimate results are more gratifying.
Though, Ilizarov technique became acceptable all over the globe in comparatively short period, its acceptability is gradually dwindling. There may be several factors but one factor appears apparent that probably there is no monograph detailing the exact basic procedure for selecting the proper patient and handling the instrument and selecting and positioning the wires according to the various indications. The present monograph is an initial attempt to outline the basic procedure of Ilizarov technique in different corrective procedures of different deformities. This monograph has been prepared with a mind to simplify the practical procedure involved in managing the equinus deformity of the foot by Ilizarov method.