Neglected Stiff Equinocavus Foot Deformity Treated with Cole Osteotomy, Combined with External Ilizarov Hinged Frame Fixation, Soft-Tissue Release, and Achilles Tendon Lengthening: A Case Report

A 41-year-old man who worked as a shepherd and lived in a remote area sustained a tibial and a transverse femoral shaft fracture at the right leg (floating knee fracture) 23 years previously after a road traffic accident. The femur was treated with Kuntscher intramedullary nailing, while the tibia was treated conservatively (Figure 1). Eventually, both fractures healed, but a tibial compartment syndrome developed, leading to fibrosis and posterior compartment muscle shortening, which caused an extreme foot deformity. The patient presented at our clinic complaining of severe pain and inability to perform his daily activities. On clinical examination, he had an extremely stiff equinocavus foot deformity with associated claw toes that led to abnormal painful gait, tiptoe walking, difficulty wearing a normal shoe, and a mild knee flexion deformity of 158 (Figure 2). Mild knee flexion deformity caused leg shortening; thus, tiptoeing compensated the knee flexion, creating an abnormal and painful gait, leading to subsequent inability to perform the activities of daily living of a shepherd. A plain lateral radiograph and computed tomographic scan of the foot were obtained. The Hibbs angle and the tibial-sole angle were calculated preoperatively and after final follow-up to evaluate the degree of cavus and equinus deformity, respectively. After a diligent preoperative assessment, a lengthening of the Achilles tendon, a tarsal tunnel release, and a Cole osteotomy combined with an Ilizarov hinged frame fixation were planned in a single operative session to manage this complex deformity (Figure 3). The Cole osteotomy was stabilized with two cannulated 6.5-cm screws to the medial and lateral site to correct the cavus deformity and also contributed to the correction of claw toes because of relaxation of flexor tendons (Figure 4). Tarsal tunnel release decreased the nerve tension, and the extensive soft-tissue release contributed to the treatment. The equinus deformity was gradually corrected with the use of the hinged Ilizarov frame (0.25 mm, four times per day). The Hibbs angle was 828 preoperatively and 488 at the final follow-up (6 years), whereas the tibial-sole angle was 348 preoperatively and 948 at the final follow-up (Figure 5). The American Orthopaedic Foot and Ankle Society Midfoot Scale score was 12 preoperatively and 81 at the final follow-up. The visual analog scale score was decreased from 10 to 1 at the final follow- up. The ankle joint was corrected nearly up to normal, with 208 of residual plantarflexion, to compensate shortening caused by the lag of knee extension. The patient was given three doses of intravenous antibiotics, one intraoperatively and two postoperatively, and was taught to clean the pin sites with sterile gauzes soaked with chlorhexidine. Three months later, he revisited our department for removal of the Ilizarov device. At the last follow-up, 6 years later, the patient was satisfied with the outcome related to the correction of the deformity, which allowed him to deal with the physical needs of his daily activities (Figure 6 and Figure 7)

In this case report, the combination of Cole osteotomy with external Ilizarov hinged frame fixation, Achilles tendon lengthening, and soft-tissue release in the setting of a neglected equinocavus deformity is found to increase functional ability and to provide satisfactory results in terms of cosmetics and no recurrence during the long-term follow-up. The Ilizarov technique was first described in 1981, allowing a three-dimensional approach for the correction of congenital or posttraumatic foot deformities, and it is considered the standard of care for the management of such lesions [4,6]. Indication for Cole osteotomy includes a cavus deformity with the apex of the deformity in the midfoot [9]. We could identify only one study in the literature concerned with equinocavus foot deformity, but with a different approach than ours. The aforementioned study was conducted by Ferreira et al [2] and included a total of 31 feet in 29 patients with stiff equinocavus foot deformity. Surgical treatment consisted, first, of percutaneous tenotomy of the Achilles and tibialis posterior tendons, and plantar fascia and short plantar muscle release; second, of transverse osteotomy of the midfoot in case of ankylosis or previous midtarsal joint fusion; and third, of a gradual realignment of the foot and ankle using a standard circular foot frame. The outcome was satisfactory in 21 feet, fair in six, and poor in four. Secondary surgery was performed in 14 feet because of symptomatic arthritis, incomplete correction of the deformity, or the need for limp amputation [2]. In our case, the Ilizarov hinged frame was applied for two reasons: first, as a supplementary stabilization of the Cole osteotomy; and second, combined with Achilles tendon lengthening, to gradually correct the equinus deformity, distract, and mobilize the ankle joint. In addition, it was a substantial way to prevent postoperative arthrodesis and arthritis to nearby supporting joints to help the patient withstand the postoperative physiotherapy.

In conclusion, this is the first case in the literature describing the simultaneous use of Cole osteotomy combined with external Ilizarov hinged frame fixation, soft-tissue release, and Achilles tendon lengthening for the treatment of an extreme neglected (for 23 years) stiff equinocavus foot deformity. By the use of this combination in a single operative session, we achieved additional stabilization of Cole osteotomy by the Ilizarov device, less postoperative morbidity, an immediate weightbearing of a plantigrade foot, no need for the placement of plaster in case of Cole osteotomy without the use of the Ilizarov device, and no need for extra intervention for the correction of claw toes. This case report has a principal goal to widen the operative spectrum of orthopedic and traumatology surgeons in cases of complex neglected foot deformities.

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Conflict of Interest: None reported.