67: Clubfoot Sequela Treated with a Multilevel, Hexapod, External Fixator

Fig. 1

Note the equinus and varus deformity. The smaller calf of the affected side is evident

Fig. 2

Distal tibial varus deformity showing a plantigrade foot through subtalar compensation

Fig. 3

Saltzman view showing the distal tibial varus

Fig. 4

AP tibias showing the right distal varus

Fig. 5

Distal tibial procurvatum

3 Preoperative Problem List

Distal tibial varus-procurvatum deformity

Tibial and peroneal nerve at risk

3.5 cm tibial shortening

4 Treatment Strategy

Supramalleolar osteotomy (SMO) to correct deformity

Peroneal nerve release to prevent injury

Anterior compartment fasciotomy to prevent compartment syndrome

Tarsal tunnel release

Gastrocnemius recession (Vulpius)

Proximal tibial osteotomy: for lengthening

External fixation to allow for gradual correction of deformity and shortening

5 Basic Principles

A single-level distal tibial TSF to correct the varus-procurvatum and shortening could have been an option. However, in order to decrease the stress on the soft tissues and the ankle joint, a double-level deformity correction was performed. The lengthening through the proximal osteotomy stretches only the gastrocnemius. On the other hand, lengthening through a distal tibial osteotomy stretches all tendons around the ankle joint, the joint itself, and the neurovascular bundle. In cases of equinus and varus correction, an Achilles lengthening procedure and tarsal tunnel release have to be performed prior to the external fixator placement. For a double-level tibial osteotomy, it is recommended to perform a prophylactic anterior compartment fasciotomy.