@MedicalBooksStore 2013 External

External Fixators
of the Foot and Ankle
LWBK1121-FM_pi-xii.indd 1 05/10/12 1:09 PM

External Fixators
Editors
Paul S. Cooper, MD
Director, Foot and Ankle Center, Associate Professor
Department of Orthopedic Surgery, Medstar Georgetown University
Hospital, Washington, DC.
Vasilios D. Polyzois, MD, PhD

Consultant Orthopaedic Surgeon, 3rd Department of Orthopae-
dic Surgery, KAT General Hospital, University of Athens Medical
School, Athens, Greece.
Thomas Zgonis, DPM, FACFAS

Associate Professor, Fellowship Director in Reconstructive Foot and
Ankle Surgery, Chief, Division of Podiatric Medicine and Surgery,
Department of Orthopaedic Surgery, University of Texas Health
Science Center, San Antonio, Texas.

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Library of Congress Cataloging-in-Publication Data
External fixators of the foot and ankle/editors, Thomas Zgonis, Paul

Cooper, Vasilios Polyzois.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-4511-7182-2
I. Zgonis, Thomas. II. Cooper, Paul. III. Polyzois, Vasilios.
[DNLM: 1. Ankle--surgery. 2. Foot--surgery. 3. External Fixators.
WE 880]
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Contributing Authors
Bradley P. Abicht, DPM Alexandru V. Georgescu, MD, PhD

Chief Resident Professor and Head
Gundersen Lutheran Medical Foundation Department of Plastic and Reconstructive Surgery
La Crosse, Wisconsin, USA. Iuliu Hatieganu University of Medicine and Pharmacy
Cluj-Napoca, Romania.
John G. Birch, MD
Professor Ioannis A. Ignatiadis, MD, PhD
Department of Orthopedics Consultant Orthopaedic Surgeon and Director
UT Southwestern Medical School Department of Reconstructive Microsurgery
Co-Director IASO General Hospital
Center for Excellence in Limb Lengthening and Reconstruction Athens, Greece.
Texas Scottish Rite Hospital for Children
Dallas, Texas, USA. Luke C. Jeffries, DPM
Surgical Attending
Patrick R. Burns, DPM, FACFAS Yale Podiatry Group
Clinical Assistant Professor Ansonia, Connecticut, USA.
Division of Foot and Ankle, Department of Orthopaedic Surgery
University of Pittsburgh School of Medicine Ryan L. McMillen, DPM
Director, Podiatric Medicine and Surgery Residency Program Surgical Attending
University of Pittsburgh Medical Center Steel Valley Orthopaedic Associates
Pittsburgh, Pennsylvania, USA. Jefferson Hills, Pennsylvania, USA.
Claire M. Capobianco, DPM James E. Orsak, BSME

Surgical Attending Mechanical Engineering
Orthopedic Associates of Southern Delaware Memphis, Tennessee, USA.
Lewes, Delaware, USA.
Spyridon G. Pneumaticos, MD
Alexander M. Cherkashin, MD Associate Professor of Orthopaedic Surgery
Assistant Professor 3rd Department of Orthopaedic Surgery
Department of Orthopedics KAT General Hospital
UT Southwestern Medical School University of Athens Medical School
Division of Clinical Implementation & Data Management Athens, Greece.
Center for Excellence in Limb Lengthening and Reconstruction
Texas Scottish Rite Hospital for Children Vasilios D. Polyzois, MD, PhD
Dallas, Texas, USA. Consultant Orthopaedic Surgeon
3rd Department of Orthopaedic Surgery
Paul S. Cooper, MD KAT General Hospital
Director University of Athens Medical School
Foot and Ankle Center Athens, Greece.
Associate Professor
Department of Orthopedic Surgery, Medstar Georgetown University Crystal L. Ramanujam, DPM, MSc
Hospital, Washington, District of Columbia, USA. Assistant Professor/Clinical
Division of Podiatric Medicine and Surgery
Zacharia Facaros, DPM Department of Orthopaedic Surgery
Surgical Attending University of Texas Health Science Center
Weil Foot and Ankle Institute San Antonio, Texas, USA.
Des Plaines, Illinois, USA.

vi Contributing Authors
Edgardo Rodriguez, DPM John J. Stapleton, DPM, FACFAS

Director Associate, Foot and Ankle Surgery, VSAS Orthopedics
Lower Limb Deformity Correction Center Chief of Podiatric Surgery, Lehigh Valley Hospital, Allentown,
Saint Anthony Hospital Pennsylvania, USA
Residency Associate Director Clinical Assistant Professor of Surgery, Penn State College of
Saint Joseph Podiatric Surgical Residency Medicine
Chicago, Illinois, USA. Hershey, Pennsylvania, USA.
Roberto H. Rodriguez, DPM, FACFAS J. Tracy Watson, MD

Assistant Professor Professor and Chief of Orthopaedic Traumatology
Division of Podiatric Medicine and Surgery Department of Orthopaedic Surgery
Department of Orthopaedic Surgery Saint Louis University School of Medicine
University of Texas Health Science Center Saint Louis, Missouri, USA.
San Antonio, Texas, USA.
Thomas S. Roukis, DPM, PhD, FACFAS Associate Professor
Surgical Attending Fellowship Director in Reconstructive Foot and Ankle Surgery
Department of Orthopaedics, Podiatry, and Sports Medicine Chief
Gundersen Lutheran Medical Center Division of Podiatric Medicine and Surgery
La Crosse, Wisconsin, USA. Department of Orthopaedic Surgery
University of Texas Health Science Center
Mikhail L. Samchukov, MD San Antonio, Texas.
Associate Professor
Department of Orthopedics
UT Southwestern Medical School
Co-Director
Center for Excellence in Limb Lengthening and Reconstruction
Texas Scottish Rite Hospital for Children
Dallas, Texas, USA.

Foreword
External fixation as it applies to the foot and ankle has One of the missions of this book is to demystify the aura
only recently become widely accepted for trauma, reconstruc- surrounding fine wire fixators. Typically the finished construct
tion, and limb salvage procedures. The advantages conferred appears a daunting task to all but the most-advanced masters
including use in the presence of infection and gradual ability in fixation. By deconstructing the process through step-by-step
to correct deformities appear to be a logical application of visuals combined with a pre-operative algorithm, the hope
the technology. Surprisingly, little practical applications were is that all surgeons can successfully apply an external fixator
known in the west as recent as 15 years ago. Charcot recon- consistently, and in a timely manner. Much as putting a bicycle
struction was virtually unheard of as a method of diabetic limb together out of the box, the authors have broken the proc-
salvage. Prior to external fixation, Charcot management was ess down to small enough components, injecting pearls and
addressed with either total contact casting or internal fixation. pitfalls along the way to ensure the surgeons can negotiate
Large gaps in management existed from active wounds, osteo- the process while avoiding traps that can become a source of
myelitis, or in osteoporotic bone, which either delayed recon- frustration along the way.
struction or relegated amputation as the only option. External Over the years two people stand out; I owe a debt of grati-
fixation eliminates any windows and can be successfully applied tude for furthering my understanding of fine wire fixation.
during any stage or condition of the limb. First, James Binski, MD for his assistance during a visit in
In addition to limb salvage, several recent applications Kurgan and subsequently for helping me to understand the
unique to the foot and ankle show promise. Distraction arthro- Russian methods for fixation. In addition, a word of thanks
plasty, most popular recently applied to the ankle in interme- to Dr. Maurizio Catagni for providing the equivalent of the
diate stages of arthrosis, shows great potential for delaying Rosetta Stone in translating the Russian techniques into an
end-stage salvage procedures. The same concept may be easier understood “western” method during my stay in Lecco
applied across the subtalar, cuboid-metatarsal(s), and hallux in 2001. Without his guidance, I would have likely given up on
metatarsophalangeal joints to prolong survivorship of these furthering my interest in external fixation as it applies to lower
joints both in isolation, and with augments including articular limb salvage.
cartilage grafts. Severe contractures involving the ankle joint Finally, I would like to thank my wife Michelle for her sacri-
or from prior forefoot surgery required extensive soft tissue fice and unwavering support over the years as I strove to master
releases and plastic skin procedures with high complication the art of external fixation. In addition, thanks is in order to
risks. The use of gradual post-operative correction with an my children Gillian, Daniel, Alex, Alec, and Chloe for the
external fixator can achieve the same goal with minimal soft 6-month displacement from the basement and their assistance
tissue handling. With the principles and techniques discussed in constructing and photographing the myriad of models used
by the expert authors in this text, the only limit for applications for this text.
as applied to the foot and ankle is the surgeon’s imagination.
Paul S. Cooper, MD
vii

Preface
I am honored and humbled to have this opportunity and share or trauma surgery. The multidisciplinary team approach in
with you my deepest inspirations for editing this new textbook treating complex trauma, reconstructive, or diabetic patients
titled External Fixators of the Foot and Ankle. I am most grate- is emphasized throughout this textbook. Extensive surgical
ful to co-edit this unique and specialized edition with two of the training and experience are paramount for the overall patient’s
most experienced orthopedic surgeons in the field of external successful outcome. The surgeon needs to also be aware of
fixation, Paul S. Cooper, MD and Vasilios D. Polyzois, MD, PhD. the potential complications associated with the use of external
My early involvement in academic medicine and especially in fixation and be ready to address them in an expedited man-
treating patients with diabetic foot and ankle complications ner. Continuous patient and family education and thorough
has driven me to create this textbook that can address some of postoperative management and rehabilitation are also very
the most challenging cases in this patient population. Diabetic important throughout the patient’s recovery period.
patients are most commonly encountered with open wounds, I also personally want to thank my co-editors, invited
soft tissue infections, fractures and dislocations, osteomyelitis, authors and the publisher for making this project become a
and poor circulation and surgical fixation methods are often reality and serve as a great reference when dealing with some
limited secondarily to the patient’s local and systemic host fac- of the most complex foot and ankle case scenarios. Finally, I
tors. External fixation becomes ideal in these case scenarios would like to thank and dedicate this textbook to my family,
where it can be utilized through limited incisions and still my wife Kristen, daughters Labrini and Ioanna and all of my
providing stabilization, compression, or off-loading the soft teachers and colleagues who have mentored me throughout
tissue envelope. my academic journey. I am deeply grateful for your support
External fixation is a very powerful surgical tool with numer- and guidance.
ous advantages that can be utilized in elective, reconstructive,
viii

Contents
Contributing Authors v
Foreword vii
Preface viii
1 History and Evolution of External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Bradley P. Abicht and Thomas S. Roukis
2 Safe Lower Extremity Anatomic Zones for External Fixation. . . . . . . . . . . . . 12

Patrick R. Burns and Ryan L. McMillen
3 Biomechanics of External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

James E. Orsak and J. Tracy Watson
4 Circular External Fixation Components and

Design Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Paul S. Cooper
5 Operating Room Preparation and External Fixation Equipment . . . . . . . . . . 50

Paul S. Cooper
6 Stepwise Approach to Transosseous Wire and

Half-Pin Insertion and Tensioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Paul S. Cooper
7 Stepwise Approach to Uniplane, Biplane,

Delta, and Hybrid External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Paul S. Cooper
8 Stepwise Approach to Static Circular External Fixation. . . . . . . . . . . . . . . . . 92

John J. Stapleton, Vasilios D. Polyzois, and Thomas Zgonis
9 Stepwise Approach to Taylor Spatial

Frame for the Foot and Ankle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
10 Stepwise Approach to Forefoot Trauma and External Fixation . . . . . . . . . . 148

Claire M. Capobianco, John J. Stapleton, and Thomas Zgonis
ix

x Contents
11 Stepwise Approach to Midfoot/

Hindfoot Trauma and External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . 162
12 Stepwise Approach to Ankle/

Pilon Trauma and External Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
13 Stepwise Approach to Forefoot Elective and

Reconstructive Surgery with External Fixation. . . . . . . . . . . . . . . . . . . . . . . 207
Paul S. Cooper
14 Stepwise Approach to Midfoot and

Hindfoot Elective and Reconstructive Surgery with External Fixation. . . . . 224
John J. Stapleton and Thomas Zgonis
15 Stepwise Approach to Ankle Elective and

Reconstructive Surgery with External Fixation. . . . . . . . . . . . . . . . . . . . . . . 237
Paul S. Cooper
16 Stepwise Approach to Charcot Midfoot

Reconstruction and External Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Paul S. Cooper, Crystal L. Ramanujam, Zacharia Facaros,
and Thomas Zgonis
17 Stepwise Approach to Charcot Hindfoot/

Ankle Reconstruction and External Fixation . . . . . . . . . . . . . . . . . . . . . . . . 293
Paul S. Cooper and Thomas Zgonis
18 Stepwise Approach to Adult and Pediatric Foot and

Ankle Malunions/Nonunions and External Fixation. . . . . . . . . . . . . . . . . . 318
Alexander M. Cherkashin, Mikhail L. Samchukov, John G. Birch
John J. Stapleton, and Thomas Zgonis
19 Stepwise Approach to Foot and Ankle

Osteomyelitis and External Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Roberto H. Rodriguez, Luke C. Jeffries, and Thomas Zgonis
20 Surgical Off-loading External Fixation and

Plastic Reconstruction of the Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . 360
Crystal L. Ramanujam, Zacharia Facaros, and Thomas Zgonis
21 Stepwise Approach to Bone Loss, Transport, and

Lengthening with External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Vasilios D. Polyzois, Ioannis A. Ignatiadis,
Alexandru V. Georgescu, and Spyridon G. Pneumaticos

Contents xi
22 Stepwise Approach to Equinus Deformity

Correction with Circular External Fixation . . . . . . . . . . . . . . . . . . . . . . . . . 391
Mikhail L. Samchukov, Alexander M. Cherkashin,
Edgardo Rodriguez, and John G. Birch
23 External Fixation Postoperative Care and Rehabilitation. . . . . . . . . . . . . . . 409

Paul S. Cooper
Index 415

Introduction
As reconstructive and limb salvage surgery of the lower extrem- types of external fixators and to also recommend several tips
ity becomes more accepted within the multidisciplinary team and pearls in order to avoid potential post-operative compli-
model, it is clear that every technical aspect of these challeng- cations. This is achieved by describing basic and advanced
ing operative procedures becomes of critical importance. In principles of external fixation biomechanics with illustrations
other words, success and failure are most of the times in close and clinical case scenarios encountered in the foot and ankle.
proximity and often it is those detailed surgical aspects and The collaboration with my co-editors Drs. Cooper and
considerations that may lead to a successful patient’s outcome. Zgonis as leading experts in the field of external fixation as
Reconstructive and revisional lower extremity surgery well as the contributions of the invited outstanding authors
entails a vast knowledge of all various methods of external has made this textbook a dynamic source for all disciplines. I
fixation in addition to the traditional techniques of internal am honored to co-edit this magnificent project always keeping
fixation, intramedullary nailing, or combined fixation. This the promise I made to my father to continue in an academic
becomes extremely beneficial when internal fixation needs to career and share the knowledge and his wisdom at times when
supplement or become the definitive method of fixation after very little was written.
the external fixation removal in certain cases. The capabilities Finally, I would like to dedicate this textbook to my fam-
of external fixation are numerous and versatile in major lower ily, adorable children Demetrios Jr and Ioli and my father
extremity reconstruction and deformity correction. Demetrios G. Polyzois, MD for his lifelong mentorship through-
This textbook was originated to provide knowledge and out my academic career.
awareness for reconstructive surgeons that deal with various
Vasilios D. Polyzois, MD, PhD
xii

C h apt e r
1 Bradley P. Abicht
Thomas S. Roukis
History and Evolution

of External Fixation
Introduction The device consisted of four wooden rods from a cornel tree
that spanned between proximal and distal Egyptian leather
Physicians and surgeons have utilized external fixation as a rings. Taught leather cuffs with sockets were placed at the ankle
method for stabilizing, reconstructing, and treating osseous and and knee. Over-lengthened flexible wooden rods were then
soft tissue pathology for millennia. The materials and methods of bent and positioned in such a manner as to create distraction
fixation devices began with rudimentary supplies such as wooden and realignment capable of maintaining length and establish-
splints, screws, and rods. Over time, with the growth of new ing anatomical alignment. The general principle set forth in
medical knowledge and engineering of superior implements, this primitive device by Hippocrates would remain with time,
the quality of materials has evolved, resulting in more advanced although his rudimentary device would undergo significant
constructs. However, despite improved materials, the principles metamorphosis throughout history.
of external fixation have remained essentially unchanged.
Timeline
First Use
Although the first documentation of external fixation dates back
The first documented use of a true external fixation device more than 2,400 years, most authors agree that the true mean-
dates back to 377 bc when Hippocrates described a rudimen- ingful beginning is credited to the famous professor of surgery
tary device used to treat closed tibial fractures1 (Figure 1.1). Jean-Francois Malgaigne (1806–1865)2,3 (Figure 1.2). In 1840 he
described a “point,” which more correctly was a spike introduced
into the tibia stabilized by straps used for immobilization and pre-
vention of tibial fracture displacement. In 1843 he engineered
a “claw” that resembled a C-shaped clamp. This device had two
transcutaneous prongs at each end with a screw between them
that when turned would approximate the four metal prongs
thereby reducing and maintaining patellar fractures. Malgaigne
did document two problems intrinsic to external fixation devices,
“First, to let the patient have access to the screw; second, to
require a substantial force to tighten and loosen the screw, a force
which caused the whole appliance to move and was very painful
for the patient.”4 Despite advancement in technology associated
with external fixation devices over the ensuing 160 years, these
observations by Malgaigne unfortunately still hold true today.
Following Malgaigne, other surgeons developed exter-
nal fixation constructs employing similar principles. In 1850
Ph. Rigaud (1805–1881) of Strasbourg developed a device
that utilized two wooden screws united by a string.5 This
Figure 1.1. Side view of rudimentary external fixation device uti-
external fixation device was used to treat olecranon fractures.
lized by Hippocrates dating back to 377 BC (1) and anterior view
of rudimentary external fixation device utilized by Hippocrates (2). A The stability of this particular device was further enhanced
& B: Taught leather cuffs; C: Sockets; D: Four overlengthened flexible in 1870 by L.J.B. Berenger-Feroud (1832–1900) who innova-
wooden rods from a cornel tree; E: Twine used to stabilize rods. From tively joined the screws with a wooden bar.6 Additionally, he
Bick EM. Sourcebook of Orthopaedics. Baltimore, MD: Williams & Wilkins; was known for describing an external fixation device useful
1937, with permission. for mandibular fracture stabilization in his classic work
1
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2 Chapter 1
A B C
Figure 1.2. Jean-Francois Malgaigne (1806–1865) (A), “point” (B), and “claw” (C). From Vidal J. External
fixation. Yesterday, today, and tomorrow. Clin Orthop Relat Res. 1983 Nov;(180):7–14, with permission.
“Traité de l’immobilisation directe des fragments osseux dans Clayton Parkhill (1860–1902) was an American anatomist
les fractures.”3 Early external fixation constructs continued to and surgeon born in Vanderbilt, Pennsylvania, who later
be modified and developed, but it was not until the innovations settled in Denver, Colorado, where he became professor of
by Parkhill and Lambotte that the first readily available devices surgery and dean of the medical school at the University of
were available for general use. Colorado (Figure 1.3). Apart from his leadership roles and
Figure 1.3. Clayton Parkhill

(1860–1902) (A) and his bone clamp
(B). (A) from Mardos Memmorial
Library with permission @ Memorial
Library.com, (B) from Browner BD,
Alan M. Levine AM, Jupiter JB et al,
Skeletal Trauma 4th ed. Philadelphia,
A B PA: Elsevier; 2009, with permission.
LWBK1121-C01_p001-011.indd 2 04/10/12 11:08 AM

History and Evolution of External Fixation 3
Figure 1.4. Albin Lambotte (1866–1955)

(A) and his external fixation device (B). From
Vidal J. External fixation. Yesterday, today,
and tomorrow. Clin Orthop Relat Res. 1983
Nov;(180):7–14, with permission. A B
accomplishments as a great anatomist and surgeon, he was In 1902, Albin Lambotte (1866–1955), the pioneer of mod-
known for his inventions in several areas, one being specific ern osteosynthesis, expanded on the concept of unilateral
to external fixation. Parkhill believed that his device was external fixation by joining two longitudinal plates clamped
useful for, as he described, “. . . more accurate fixation of to the sides of four fully threaded metal transverse screws
the bones, both after resection for cases of pseudoarthrosis (Figure 1.4). He detailed his device in his classic publication,
and for malunion, and also for fractures with a tendency to “Chirurgie operatoire des fractures,” describing the use of
displacement, particularly if they be compound.”7 In 1894 external fixation on upper and lower extremities, as well as
he designed a “bone clamp,” most consistent with a unilat- the hand. He was the first to utilize threaded pins and reports
eral type of external fixation device, which consisted of four the advantages of his external fixation device, including the
fracture spanning wing plates with an offset hole at one end.7 ease of use, timeliness of application, and rigidity stabilizing
Four wooden screws were transversely placed adjacent to the osseous fragments. This inherent rigidness permitted passive
fracture site, two proximal and two distal, equidistantly offset and active mobilization of the adjacent joints. Due to his
from the fracture line. A nut to each respective screw then unique design, Lambotte also stated that this device was con-
joined the wing plates. The exposed screw end took on the ducive to dressing application of open wounds, as well as, could
shape of a square, permitting it to be turned by a church be removed without difficulty after osseous consolidation. He
key. Three sizes were developed to accommodate differential repeatedly attributed the decreased incidence of amputation,
lengths of long bones being treated. The strength of this which previously seemed inevitable, to the use of his external
construct was achieved through joining the four wing plates fixation device.8
together as one unit, thereby imparting stability and immo- External fixation devices continued to develop with
bilization across the fracture site. The clamp was also made Alessandro Codivilla (1861–1912) and Fritz Steinmann (1872–
of steel and heavily plated with silver, taking advantage of its 1932) issuing their contributions at the beginning of the
antiseptic properties.2,3,7 Parkhill eventually reported on 14 1900s. Codivilla, in 1902, introduced a method of skeletal trac-
patients successfully treated with his external fixation device, tion and was credited for the first use of full-pin splintage with
for which he proclaimed a 100% cure rate. He also noted external bars used in distraction osteogenesis and treatment
the following observations regarding his device, “We claim of chronic lower extremity deformities.9 This was controversial
for this instrument: first, that it may be easily and accurately and in direct contrast to Steinmann, as the literature varies
adjusted, and prevents both longitudinal and lateral move- on who is rightfully credited for the introduction of pin trac-
ments between the fragments; second, that nothing is left in tion. Nevertheless, in 1907, Steinmann directed two pins into
the tissues which might reduce their vitality and lead to pain the femoral condyles to apply skeletal traction. He enhanced
or infection; third, that no secondary operation is necessary; skeletal traction by redirecting the reduction force directly
fourth, that no method has ever before given 100 percent of onto the bone. The insertion of Steinmann’s pins at the time
cures.”7 was accomplished by exerting longitudinal force on one end
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4 Chapter 1
of the pin with a hammer. Later, in 1916, he perfected the

“through-and-through” technique for skeletal traction. Prior
to this development, external plaster strips were being uti-
lized to transmit distracting forces onto bone through the soft
tissues, but often resulted in complications including severe
pain, skin necrosis, and failures revealed by radiograph analy-
sis.10,11 The German surgeon Martin Kirschner (1879–1942),
in 1909, utilized chromed, non-blazed piano-wire from 0.7 to A
1.5 mm in diameter, which was inserted directly into the bone
with the goal of minimizing soft tissue or osseous trauma, and
also to keep the wire rigidly fixed to avoid transverse wire
movement during skeletal fixation.10 He intuitively developed
a horseshoe-shaped instrument to perfect the tension prin-
ciple, which prevented lateral movement and instability of
the thin wires that occasionally led to pin-track infection and
osteomyelitis. The eponym Kirschner (K)-wire continues to be
commonly utilized to this day, although its first documenta-
tion was by Müller in 1931.12 The K-wire has evolved from its
initial introduction with skeletal traction, and has progressed
to an instrument in fracture reduction, and has revolutionized
the treatment of fracture-dislocations as a guidance tool for
other implants or internal fixation devices (i.e., cannulated B
materials). Figure 1.5. Hoffman external fixator circa 1938 (A). From Vidal
In addition to the substantial contributions of Codivilla, J. External fixation. Yesterday, today, and tomorrow. Clin Orthop Relat
Steinmann, and Kirschner, several additional advancements Res. 1983 Nov;(180):7–14, with permission. Intra-operative photo-
graph demonstrating modern Hoffman external fixator employed for
of external fixation are noteworthy for discussion. E.W. Hey
osseous and soft tissue reconstruction (B).
Groves (1872–1944), in 1912, developed an external fixation
device that provided the option for compression or distrac-
tion, accomplished through a “turn-buckle” attached to pins.13 bridging the units with metal bars. In a similar fashion to
Lorenz Böhler (1885–1973), in 1928, refuted controversial Haynes, Henri Judet described increasing stability of external
thinking at the time by demonstrating that the insertion of fixation constructs by inserting pins through both cortices in
Steinmann pins was a relatively benign process, and that excel- addition to the use of multiple half-pin units.2 The works of
lent results were achieved with pins-and-plaster for treatment these previous surgeons were then once again revolutionized
of fractures.14 This established new standards and redefined by a German-born doctor, Raoul Hoffman (1881–1972).
acceptable treatment for fracture care. In 1938, Raoul Hoffman combined clamps, connecting
In the 1930s, Otto Stader (1894–1962), an American vet- rods, and three parallel pins in each fracture fragment to
erinarian, developed an external fixation device that would impart stability and ensure rigid support (Figure 1.5). He
come to be known as the “Stader splint.” He used this to treat made several advancements based on previous designs, spe-
fractures in a series of over 1,200 canines. The device was com- cifically from Lambotte’s fixator. Lambotte’s fixator required
posed of two half-pin units inserted directly into each fracture open reduction, which contributed to the overall soft tissue
fragment held together by a connecting bar. Advantages of his damage while raising the potential for infection. In an attempt
external fixation device included the ability to allow complete to avoid such complications, Hoffman developed his own tech-
ambulation after fixation, no discernable pain, did not require nique based on the term “ostéotaxis.”15 This process utilized
adjunctive casting, and did not require separate reduction closed reduction and guided percutaneous pin placement for
device.14 His successful results in the veterinary arena trans- minimal disruption of the soft tissue envelope. Through his
lated over to human fracture treatment when his device was combination of half pins, strong clamps (which he termed
first used in 1937 and was utilized on embattled soldiers during “grips”), and a connecting external bar, fracture reduction
World War II. was permitted in three spatial planes. Hoffman’s external
Around the same time period, several other surgeons fixation application technique was the first evidence of mini-
pioneered external fixation devices or modified previously mally invasive surgical technique. The versatility and stability
designed constructs. Roger Anderson, in the 1930s, created an of his fixator was unparalleled at the time, preserving motion
external fixation device that also used half pins. He believed at adjacent joints, lowering risk of infection, and permitting
that it is necessary to supplement the construct with a cast closed manipulation of fractures for anatomical alignment.
and prohibited weight bearing during the first few weeks fol- His device would provide a significant foundation for the
lowing external fixation application. Similarly, Herbert H. future of external fixation, and these principles continue to
Haynes used a half-pin device, but reinforced it with plaster of be followed in present day.
Paris. Intuitively, he inserted pins through both cortices, which From a historical perspective, discussion of external fixation
inherently increased the rigidity and subsequent stability of would not be complete without the mention of “the Magician
the external fixation construct.2,14 Alfred Schanz (1868–1931), from Kurgan.” Gavril A. Ilizarov (1921–1992), a Russian ortho-
Jean-Paul Lamare, and Gustav Riedel all documented the pedic surgeon credited for the development of circular ring
principle of inserting half pins at an angle to each other and external fixation (Figure 1.6). After graduating from medical
LWBK1121-C01_p001-011.indd 4 04/10/12 11:08 AM

Ilizarov performed a corticotomy of the fibula and distracted

it to a length equal to the lateral malleolus. Brumel was able
to successfully return to a high competitive level of jumping,
and Ilizarov was thrust into the national spotlight.13 His innova-
tions were further investigated by the government, and he was
awarded sufficient funds to continue his work. He transformed
the “log cabin” Veteran’s Clinic into the largest orthopedic
center in the world when he built the Institute of Orthopaedics
in Kurgan. In the 1980s, his work spread internationally and
has since spread through all of Europe, Canada, and the United
States. The indications for Ilizarov’s ring fixator are plentiful,
and include, but are not limited to, fracture care, posttraumatic
reconstructions, skeletal defects, chronic refractory osteomyeli-
tis, septic bone cavities, benign bone tumors, limb lengthening,
joint contractures, chronic dislocations, arthrodesis, complex
soft tissue wounds or defects, and limb deformities.
Ilizarov’s principles paved the way for the Taylor spatial
frame (TSF; Smith & Nephew, Memphis, TN), which is the
most current and advanced orthopedic modality in the arena of
external fixation. This advanced modality is typically employed
to correct deformities including complex fractures, severe limb
deformity, and limb length discrepancies utilizing an external
hexapod configuration.16,17 This medical device is composed
Figure 1.6. Gavril A. Ilizarov (1921–1992). of two aluminum rings connected by six telescopic struts, each
of which can be independently lengthened or shortened. This
construct is then connected to the involved bone by wires or
school in the city of Kzyl-Orda in 1943, the USSR government half pins, which permits manipulation of bone segments along
assigned him to work in the village of Dolgovka, in the Kurgan six axes (anterior/posterior, varus/valgus, lengthen/shorten).
district of western Siberia. There, he was the sole physician and The TSF creates three-dimensional correction including trans-
in charge of the only hospital in the region. He worked under lational, rotational, angular, and length correction through
primitive conditions with suboptimal equipment and minimal software that analyzes spatial displacements and transforma-
resources. It was at this site that he treated thousands of wounded tions. This software is based on Paley’s principles of preop-
veterans in Russia following World War II. Many of these patients erative planning and CORAnalysis, which ultimately creates a
had severe complications following fractures secondary to gun- prescription based on treatment parameters set forth by the
shots, often creating bone defects, osteomyelitis, nonunions, operating surgeon, and carried out by the patient through
and malunions. In 1951, Ilizarov developed an apparatus and daily strut adjustments.18 Furthermore, the TSF is based on
technique for repairing complex fractures. This novel apparatus the concepts of projective geometry and is representative of a
originally consisted of two half rings with numerous perforated Stewart platform that uses the Chasles axis. The theory and
holes and would later be modified to full rings. K-wires were natural history of these concepts are beyond the scope of this
delivered through the affected bony segments and secured to chapter’s discussion, but the technology of three-dimensional
the metal rings, inserting the wires both proximal and distal positioning of platforms is not a new concept. It is currently
to the fracture site in a crossing orientation. Manipulation of utilized in the world of robotics, and for controlling the orienta-
the rings then allowed for realignment of the fractured osseous tion of the cockpit in flight simulation.19 In a similar manner,
fragments. Once anatomical realignment was achieved, special this type of software analysis was combined to an external hexa-
connecting rods were then connected between rings to provide pod, which resulted in the ability to accurately correct for angu-
immobilization until the fracture was well healed.13 lar bony deformities of extremities. This concept’s introduction
Although Ilizarov’s pioneering work came in the form of into the orthopedic arena was made in 1994 by Charles Taylor,
treatment of complex fractures, the indications for his novel MD, in Memphis, Tennessee.19 Over the next decade and a half,
frame rapidly expanded, and it has revolutionized the world its indications have evolved and its use has gained in popularity.
of external fixation. Most notably, Ilizarov developed and per-
fected the percutaneous “corticotomy” used in combination
with distraction for “osteogenesis.” He was the first to show Classification/Types
that distraction rather than compression causes the healing of
fractures and pseudarthrosis. Ilizarov’s successful reconstruc- With advancements in medical technology, knowledge gained
tions and limb-lengthening procedures went mostly unno- through research, and treatment success rendered over the
ticed in the USSR for the first two decades. He was not truly past century, highly sophisticated external fixation devices have
recognized until 1967 when Olympic champion high jumper developed for the treatment of a variety of pathologic conditions
Valery Brumel sustained a compound fracture of his left tibia ranging from open fractures with complex soft tissue wounds to
and fibula in a motor vehicle accident. Brumel subsequently distraction osteogenesis and deformity correction procedures.
developed osteomyelitis after the wound became infected, and The use of these devices has increased in popularity over the past
the entire lower segment of the fibula was rendered nonviable. several decades through the advent of widespread educational
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6 Chapter 1
courses and training programs supporting their use. With the infection.21 Contrary to traditional external fixation constructs,
diverse treatment options available through external fixation, this medical device consists of special fixator clamps or “clips”
its principles have not significantly changed. As Behrens stated that rest on the underlying bone surface without penetrating
in 1989, the purpose of an external fixation device is to anchor the medullary canal, therefore minimizing the risk of contigu-
multiple osseous fragments or segments together through the ous bacterial spread as a result of the initial infectious process
use of pins or wires and connecting rods.20 This may be a general or from resultant pin-tract problems.22–26 Indications for the
purposeful definition, but certainly not a limitation, as there pinless external fixator are similar to that of more traditional
remain significant soft tissue indications for its use. Keeping in external fixation devices, but have been particularly shown to
mind the general principles of these devices and their current be advantageous in cases with extensive soft tissue and osseous
indications, there have been several main types or categories defects resulting from deep abscess and osteomyelitis.21 The
of external fixation devices that have evolved. These constructs tips of the pinless clamps contain a sharp trocar which have
include pinless, linear (unilateral, bilateral, or quadrilateral), been demonstrated to only penetrate the affected bone corti-
tube-to-bar, circular (ring-type), hybrid (which is a combination ces an average of 1.2 mm, while still providing osseous stabil-
of unilateral and circular), and spatial frames. ity with only 0.1 mm of plastic deformation occurring at the
The pinless external fixator is an external fixation device clamp–bone interface22,24 (Figure 1.7). Other surgeons have
that provides soft tissue immobilization and osseous stabilization described their preferred configuration of the device during
while limiting the potential for contiguous spread of bacterial foot and ankle reconstruction, with a proximal clamp placed
A B
Figure 1.7. Pinless external fixation components

(A) and clinical example with anteroposterior (B) and
C medial (C) views.
LWBK1121-C01_p001-011.indd 6 04/10/12 11:08 AM

at the proximal tibial metaphysis (i.e., distal to the tibial tuber- isolated joint arthrodesis, lengthening procedures, monopla-
osity and dorsal to the pes anserinus). A distal clamp is then nar deformity correction, osteomyelitis, and stabilization of
placed at the level of the metatarsal bases (i.e., first and fourth soft tissues with maintenance of length and rotation following
metatarsal bases).21 This approach provides a cost-effective open fractures.22,27–40 Triplane motion is possible with articu-
alternative to traditional external fixation devices and permits lated linear fixation devices, allowing rotation for a position
direct access to soft tissue reconstruction sites for frequent of optimum stability. The largest weakness of the linear device
monitoring and dressing changes as needed, all while main- compared with other external fixation device constructs is
taining adequate osseous stabilization. its lack of stability, specifically in the sagittal plane. Gardner
The linear external fixation device is considered the sim- et al. demonstrated this by analyzing five commonly utilized
plest construct. These configurations have been more com- unilateral external fixators for treatment of inherently stable
monly utilized for treatment in several anatomical locations and unstable diaphyseal fractures and showing that plastic- or
within the human body, including the tibia, wrist, femur, ankle, slip-failure occurred prematurely during routine weight bear-
and smaller bones of the hand and foot. There are multiple ing.41 Therefore, axial loading through early weight bearing in
variations available for the linear device, including a straight the immediate postoperative period is contraindicated when
bar format, and others with articulations permitting rotational utilizing a unilateral external fixator.
characteristics. These can be further broken down into unilat- The tube-to-bar external fixator is a device commonly
eral (monolateral), bilateral, or quadrilateral groups. From a employed in the settings of trauma, lower extremity recon-
historical perspective, Parkhill’s original bone clamp and the struction, complex wounds, soft tissue flaps, and grafts. It
frames developed by Stader, Lambotte, and Hoffman would remains a versatile option for external fixation and further-
be considered under the category of linear devices.3 Generally, more embodies a relatively easy application process while pro-
multiple half pins are inserted into the bone fragments, and moting cost-effectiveness. There are many configurations that
these half pins are then attached to the fixator through the use can be employed, but generally speaking a tube-to-bar external
of connecting clamps. A unilateral construct remains on one fixator consists of half or full pins that are delivered proximal
side of the stabilized limb, whereas a bilateral device employs and distal to the anatomical region requiring stabilization.
a rigid bar on both sides of the limb that are connected to full Specialized clamps are then utilized on these pins, which
pins that transfix the osseous segments. Half pins can also be serve to connect carbon fiber or aluminum bars. This may be
utilized to connect to rigid bars on both sides thereby creating accomplished in a trans-articular spanning or non-spanning
a bilateral construct (Figure 1.8). A quadrilateral construct fashion, depending on if stabilization across a joint is desired.
utilizes a total of four bars, with two placed on each side of the Furthermore, application of this type of external fixation can
limb that is then connected to pins that transfix the osseous be placed in a uniplanar (uniplane) or biplanar (biplane)
segments. Like most constructs, there are strengths and weak- orientation. Uniplanar design refers to all pins lying within the
ness of using a linear device. Inherently it will be easier to same plane (aka, “coplanar”). Biplanar design refers to pins
apply due to its simplistic structure. Additionally, it offers inserted at differing angles. An example of biplanar would be
access to soft tissue wounds for dressing changes and limits the a “ V” or “delta” configuration. Biplanar orientations provide
number of transosseous foreign bodies to reduce risk of pin- greater stability than uniplanar, but both have the option of
tract infection. Indications for linear external fixation include being applied unilaterally or bilaterally (Figure 1.9). Tube-to-
fracture treatment, monoplanar distraction or compression, bar external fixation can be employed as a temporary or defini-
tive form of fixation and can be applied intra-operatively in a
timely manner to provide soft tissue protection and osseous
stabilization (Figure 1.10). In addition, its versatility allows it to
be converted to a hybrid design if indicated.
Overall, there exist well-known external fixation principles
that can be applied to increase rigidity and stability of a fixator,
including two levels of fixation per bone segment and spread-
ing the levels near and far on the bone segment will increase
rigidity. Rods must be placed as close to the involved osseous
structure as the soft tissues allow, accounting for edema.
Increasing the diameter of wires and pins as well as increasing
the number of rods will provide increased stability. These prin-
ciples are important to keep in mind when constructing and
applying a tube-to-bar external fixation device.
Circular external fixators, or ring-type fixators, intuitively
involve a round or ring type construct as one may suspect from
its name (Figure 1.11). In essence, a circumferential “exo-
skeleton” is created imparting superior rigidity. Circular devices
are multi-planar, and when compared to other types of external
fixation, provide the greatest degree of stability. Ilizarov most
notably popularized the circular external fixator through his
A B procedures involving surgical repair of tibial nonunion, limb
Figure 1.8. anteroposterior (A) and medial (B) views of a unilat- deformity correction, and limb lengthening. Today, its indica-
eral linear external fixation device. tions have multiplied, now including such procedures as midfoot,
LWBK1121-C01_p001-011.indd 7 04/10/12 11:08 AM

8 Chapter 1
A C
B D
Figure 1.9. anteroposterior (A, B) and axial (C, D) images of two forms of tube-to-bar external fixation
for use in the forefoot.
A, B C
Figure 1.10. Medial (A), anteroposterior (B), and lateral (C) views of a tube-to-bar external fixation
device to protect a medial plantar artery flap from pressure and afford immobilization.
LWBK1121-C01_p001-011.indd 8 04/10/12 11:08 AM

Figure 1.11. anteroposterior

(A) and medial (B) views of a static
circular external fixation device for
Charcot neuroarthropathy recon-
struction. A B
rearfoot and ankle arthrodesis, arthrodiastasis, and compli- contraindications for this type of fixator are similar to other
cated open and/or complex intra-articular fractures. The use types, but hybrids can specifically be utilized when soft tissues
of circular external fixation has also been documented in the preclude proper open reduction and internal fixation of frac-
successful treatment of combined subtalar joint arthrodesis ture fragments, or the pathology is such that Schanz pins and
with ankle arthrodiastasis to provide effective dual treatment standard external fixators are contraindicated. For example,
simultaneously during the same application.42
In general terms, the make-up of a circular external fixator
for the lower extremity consists of circular rings that encompass
the tibia and foot. Available ring sizes may range according to
the manufacturer from 80 to 240 mm in diameter, although the
average adult patient requires a ring size of 150 to 160 mm for
the tibia. The application of tibial rings should allow for proper
expansion of soft tissues, leaving 2 to 3 cm margins between the
skin and the ring to permit transient edema and avoid pressure
necrosis. A variety of types of rings are available, including full
rings, 5/8 rings, half rings, foot rings, and composite half rings.
Wires of 1.5 to 1.8 mm thickness are most typically employed
when transfixing the tibia and are then attached to a given ring
via slotted or cannulated fixation bolts. This placement allows
for proper tensioning of wires, which are most commonly ten-
sioned between 100 to 130 kg of force. Other materials that
may be utilized during construction of a circular external fixa- A
tion device include threaded and/or telescopic rods, rancho
cubes, foot plate, and posts. Additionally, pre-building these
devices outside of the operating room prior to a surgical case
is beneficial when possible, as it saves valuable anesthesia and
operating room time, significantly cutting costs.
Hybrid external fixators offer simplicity, yet significant ver-
satility, although they are not as biomechanically stable as tra-
ditional circular ring external fixators (Figure 1.12). Hybrids
represent a combination of the more traditional frames pre-
viously discussed. Furthermore, construct components may
include a combination of rings, wires, half pins, and clamps. It
combines the general principles of circular ring fixation, with
modular and unilateral external fixation, and thus permits a B
wide variety of external fixation configurations easily modified Figure 1.12. Medial (A, B) images of two forms of hybrid external
depending on the pathology being treated. Indications and fixation.
LWBK1121-C01_p001-011.indd 9 04/10/12 11:09 AM

10 Chapter 1
A C
Figure 1.13. Clinical examples of Taylor spatial frame external fixation for distal tibia (A), ankle (B), and
foot (C) deformity correction.
this may be the case in certain peri-articular, intra-articular, or malunions, nonunions, and congenital or iatrogenic-induced
comminuted fractures of the proximal and distal tibia. Oste- deformities. It has been utilized both in the upper and lower
oporotic bone or injuries with significant soft tissue wounds extremities, although a specialized foot ring is available for
and defects are additional situations in which hybrid external additional treatment of complex foot deformities. Relative con-
fixation may be indicated. traindications to using the TSF include lack of familiarity with
Finally, as mentioned previously, the TSF represents the deformity planning, inexperience with the TSF fixator and/
most current and advanced modality in the arena of external or software, patient noncompliance and/or psychiatric impair-
fixation (Figure 1.13). This medical device is composed of two ment, patient comorbidities prohibiting surgical intervention
aluminum rings connected by six telescopic struts, each of with anesthesia, and lack of indication for external fixation.19
which can be independently lengthened or shortened. This
construct is then connected to the involved bone by wires or
half pins, which permits manipulation of bone segments along Conclusion
six axes (anterior/posterior, varus/valgus, lengthen/shorten).
The TSF creates three-dimensional correction including trans- Through the millennia, we have witnessed significant advances
lational, rotational, angular, and length correction through in components and materials for constructing various external
software that analyzes spatial displacements and transforma- fixation devices, thus increasing and improving indications for
tions. its use as a method for stabilizing, reconstructing, and treat-
Current indications for the TSF are plentiful. Typically this ing osseous and soft tissue pathology. Massive advances have
modality is reserved for severe deformities, which are deemed been achieved from original rudimentary devices based on
non-braceable and non-reconstructable by alternative means. wooden screws and rods, and has evolved to include highly
Other indications include deformities that may not be amenable stable circular external fixation based on sophisticated software
to acute correction due to soft tissue status, severity of deformity, programs with the ability to correct the most severe pathology
active infection, poor soft tissue envelope, or other elements of and deformities. As developments continue, the future appears
the patient’s past medical history.19 The TSF is also indicated in optimistic for a treatment modality that has witnessed its mate-
complex fracture reduction and stabilization, limb-lengthening rials and constructs evolve based on principles that have largely
procedures, Charcot reconstruction, soft tissue contractures, remained unchanged.
LWBK1121-C01_p001-011.indd 10 04/10/12 11:09 AM

References 24. Stene GM, Frigg R, Schlegel U, et al. Biomechanical evaluation of the pinless
external fixator. Injury. 1992;23:S9–S27.
1. Hippocrates. Works of Hippocrates. Baltimore, MD: Williams & Wilkins; 1938. 25. Thomas SR, Giele H, Simpson AH. Advantages and disadvantages of pinless
2. Pettit GD. History of external skeletal fixation. Vet Clin North Am Small Anim external fixation. Injury. 2000;31:805–809.
Pract. 1992;22:1–10. 26. Winkler H, Hochstein P, Wentzensen A. Experience with the pinless fixator
3. Vidal J. External fixation. Yesterday, today, and tomorrow. Clin Orthop Relat in the treatment of fractures of the lower leg. Injury. 1994;25:S-C8–S-C14.
Res. 1983 Nov;(180):7–14. 27. Aldegheri R, Trivella G, Saleh M. Articulated distraction of the hip. Conserva-
4. Malgaigne JF. Pathologie externe. Considérations cliniques sur les fractures de la tive surgery for arthritis in young patients. Clin Orthop Relat Res. 1994;301:
rotule et leur traitement par les griffes. J Conn Med Prat Pharmacol. 1853;21:8–12. 94–101.
5. Cucel LR, Rigaud R. Des vis metalliques enfoncées dans le tissue des os pour 28. Dahl MT, Fischer DA. Lower extremity lengthening by Wagner’s method and
le traitement de certaines fractures. Rev Medicochir Paris. 1850;8:113. by callus distraction. Orthop Clin North Am. 1991;22:643–649.
6. Berenger-Feraud LJB. Traité de l’immobilisation directe dans les fractures. Paris: 29. Elting JJ, Cicoria A, Boman TE. Proximal tibial osteotomy and unilateral
Delahaye; 1870. frame distraction for osteoarthritis of the knee. Int J Orthop Trauma. 1993;
7. Parkhill C. A new apparatus for the fixation of bone after resection and in 3:89–91.
fractures with tendency to displacement. Trans Am Surg Assoc. 1897;15:251. 30. Fowler JL, Gie GA, Maceachern AG. Upper tibial valgus osteotomy using a
8. Lambotte A. Chirurgie Opératoire des Fractures. Paris: Masson; 1913. dynamic external fixator. J Bone Joint Surg Br. 1991;4:690–691.
9. Codivilla A. Means of lengthening in lower limbs the muscles and tissues 31. Frierson M, Ibrahim K, Boles M, et al. Distraction osteogenesis: a comparison
which are shortened through deformity. Am J Orthop Surg. 1904;2:353–363. of corticotomy techniques. Clin Orthop Relat Res. 1994;301:19–24.
10. Huber W. Historical remarks on Martin Kirschner and the development of 32. Gaudinez R, Adar U. Use of Orthofix T-Garche fixator in late-onset tibia vara.
the Kirschner (K)-wire. Indian J Plast Surg. 2008;41:89–92. J Pediatr Orthop. 1996;16:455–460.
11. Peltier LF. A brief history of traction. J Bone Joint Surg Am. 1968;50:1603–1617. 33. Guidera KJ, Hess WF, Highhouse KP, et al. Extremity lengthening: results and
12. Weiber C. Die Knochenbruchbehandlung bei Martin Kirschner und die complications with the Orthofix system. J Pediatr Orthop. 1991;11:190–194.
Entwicklung des “Kirschnerdrahtes”. Anmerkungen zu einer genialen Idee 34. Kenwright J, Spriggins AJ, Cunningham JL. Response of the growth plate to
in der Chirurgie [Article in Spanish]. distraction close to skeletal maturity. Is fracture necessary? Clin Orthop Relat
13. Golyakhovsky V, Gavriel A. Ilizarov: “The magician from Kurgan”. Bull Hosp Jt Res. 1990;250:61–72.
Dis Orthop Inst. 1988;48:12–16. 35. Knapp DR Jr, Price CT. Correction of distal femoral deformity. Clin Orthop
14. Kimmel RB. External fixation of fractures of the tibia. Orthopaedics Today. Relat Res. 1990;255:75–80.
1982;2:8. 36. Maxwell J, Wilson E, Armondo C. Distraction osteogenesis of the first meta-
15. Schwechter EM, Swan KG. Raoul Hoffmann and his external fixator. J Bone tarsal. In: Camasta CA, Vickers NS, Ruch JA, eds. Reconstructive Surgery of the
Joint Surg Am. 2007;89:672–678. Foot and Leg: Update ’93. Tucker, GA: Podiatry Institute; 1993:414.
16. Binski J. Taylor spatial frame in acute fracture care. Tech Orthop. 2000;17:173–184. 37. Price CT. Unilateral fixators and mechanical axis realignment. Orthop Clin
17. Paley D, Maar DC. Ilizarov bone transport for tibial defects. J Orthop Trauma. North Am. 1994;25:499–508.
2000;14:76–85. 38. Price CT, Mann JW. Experience with the Orthofix device for limb lengthen-
18. Paley D. Correction of limb deformities in the 21st century. J Pediatr Orthop. ing. Orthop Clin North Am. 1991;22:651–661.
2000;20:279–281. 39. Saleh M, Hamer AJ. Bifocal limb lengthening: a preliminary report. J Pediatr
19. Wukich DK, Belczyk RJ. An introduction to the Taylor spatial frame for foot Orthop B. 1993;2:42–48.
and ankle applications. Oper Tech Orthop. 2006;16:2–9. 40. Tsuchiya H, Tomita K, Minematsu K, et al. Limb salvage using distraction
20. Behrens F. General theory and principles of external fixation. Clin Orthop osteogenesis. A classification of the technique. J Bone Joint Surg Br. 1997;79:
Relat Res. 1989;241:15–23. 403–411.
21. Roukis TS, Zgonis T. Minimally invasive “pinless” external fixation for foot 41. Gardner TN, Evans M, Kenwright J. A biomechanical study on five unilateral
and ankle reconstruction. Orthopedics. 2006;29:209–212. external fracture fixation devices. Clin Biomech (Bristol, Avon). 1997;12(2):
22. Remiger AR. Mechanical properties of the pinless external fixator on human 87–96.
tibiae. Injury. 1992;23:S28–S43. 42. Zgonis T, Stapleton JJ, Roukis TS. Use of circular external fixation for
23. Remiger AR, Magerl F. The pinless external fixator—relevance of experimen- combined subtalar joint fusion and ankle distraction. Clin Podiatr Med Surg.
tal results in clinical applications. Injury. 1994;25:S-C15–S-C29. 2008;25:745–753.
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Chapter
2 Patrick R. Burns
Ryan L. McMillen
Safe Lower Extremity Anatomic

Zones for External Fixation
Introduction Once the surgeon has learned principles of external fixation

types, the different styles, the materials, the components, the
The use of external fixation continues to grow and evolve in basic physics, and biomechanics, the next step is applying that
foot and ankle surgery. Understanding the basic principles of to pathology. As one begins to understand this form of fixa-
this fixation technique is paramount for improved outcomes. tion, the indications are endless in the lower extremity. Types of
Similar to internal fixation, external has its own unique prop- external fixators will be discussed elsewhere in this text, but the
erties and the surgeon must have fundamental knowledge of main types include pin-to-bar type (Figure 2.1A) predominantly
basic external fixation principles. Without full understanding utilized for temporary and traumatic conditions, and the multi-
of the indications and mechanics—including types of external planar style (Figure 2.1B) which is generally utilized for deform-
fixation devices, components, and application—the surgeon ity correction. Although safe anatomic zones are most important
and his/her constructs will never reach their full potential. in the setting of the through-and-through wires of the circular
As with any fixation technique, external fixation requires a external fixation systems, every external fixator must be applied
thorough knowledge of indications, physical properties, con- with anatomic and biomechanic restrictions in mind.
structs, and materials. Many decisions made before, during, The basic requirements for external fixation application
and after surgery will affect outcomes. The surgeon should include the fixator itself and a way to connect to the osseous
plan ahead when time permits, while being prepared with alter- structures of the patient. The workhorse for most circular
natives. There should be an idea of the type and style of exter- external fixation systems is the transosseous fixation wire. Alter-
nal fixator that may best fit the situation and desired outcome. native names have been interchanged including “transfixation”
A B
Figure 2.1. Examples of a standard “pin-to-bar” or “delta” configuration (A) and multiplanar (B) circular
external fixation systems.
12
LWBK1121-C02_p012-032.indd 12 04/10/12 11:09 AM

Safe Lower Extremity Anatomic Zones for External Fixation 13
A B
Figure 2.2. Examples of specialized tip for skinny wires (A) including a drill point for hard cortical bone.
An example of an olive wire (B). Note the black hash marks denoting the side of the wire the olive is on for
when the external fixator is removed.
wires, “smooth” wires from the smooth stainless steel they are term, the area of bone surrounding the wire may undergo
made, and “skinny” wires in comparison to the size of their necrosis leading to loosening of the wire and weakening of the
half-pin counterparts made popular in the United States. Many overall external fixation construct. Along with tip modifica-
modifications have followed through the years, including dif- tions such as “X” or drill tips that allow easier wire placement,
ferent diameters, tip constructs, and specializations such as off- one may limit overheating by “pulsing” the wire during place-
set enlargements to act as “olive” wires which will be discussed ment instead of drilling constant. Cooling the area during drill-
later (Figure 2.2A and B). ing with saline may also limit the effects of high temperatures.
Traditional smooth wires in adult patients undergoing cir- Too much heat along the skin, in particular the leading edge
cular external fixation are either 1.8 or 2.0 mm. These are of the wire that has done the drilling can burn soft tissue.
standard sizes for most industries providing circular external The tip becomes very hot and can burn the skin leading to
fixators. Over recent years, modifications have been made to irritation, drainage, and infection. When external fixation
the wire tip to aid in placement. This has become useful in constructs consistently have multiple wires with erythema and
particular for certain wires placed in the tibia. Its dense cortical drainage the first weeks following application, one must look
bone can sometimes make placement difficult. Dull or blunt at technique as a possible cause (Figure 2.3A and B). Simply
tips can cause the surgeon to apply increased pressure and use addressing wire placement technique and the heat generated
excessive drill times leading to overheating of the wire. Long can minimize bone and skin thermal necrosis.
A B
Figure 2.3. Examples of a stable external fixation construct with clean wire sites (A) and an external
fixator with multiple locally infected wires typical of an unstable construct (B).
LWBK1121-C02_p012-032.indd 13 04/10/12 11:09 AM

14 Chapter 2
In addition, it is important to review the other chapters in

this text and be familiar with the general principles of exter-
nal fixation. One must have knowledge of the strengths and
weaknesses of external fixation, along with the indications and
limitations. For improved outcomes, the surgeon must have
knowledge about the available components and how to increase
strength and stability to avoid any potential complications. This
chapter is intended to give an overview of anatomic safe zones
so these principles and components can be physically applied.
Without proper knowledge of lower extremity anatomy, the
external fixator and connecting elements can cause damage
to vital structures. Using knowledge of anatomy and available
topographic landmarks will help guide the transfixation wires in
the safest place possible. It is important to note that there are no
consistently safe zones, but there are less safe areas.
One must also realize that in applying the external fixator,
you may not be able to satisfy every biomechanical principle. For
example, the strongest construct for a ring mid-tibia would be
two wires 90 degrees from each other but anatomic constraints
will not permit that construct. A wire cannot be placed directed Figure 2.4. A superior view from a circular external fixator setup
anteroposterior due to the gastrocnemius muscle. Instead, wires for a left lower extremity. Note the typical orientation of the medial
are placed at the largest angle permitted by anatomy. face (1), fibular (2), and axial (3) skinny wires. Also note the tibia
and fibula are offset anterior in the construct to allow for the large
posterior muscle group. L=lateral side; M=medial side.
Terminology
There is no single completely accepted method of describing
wire placement with regard to external fixation about the foot
and ankle. There are however some accepted terms allowing
those in surgery and throughout disciplines to communicate.
Most terminology revolves around anatomy for that particular
segment. For example, a skinny wire placed posterior lateral
from the fibula heading anterior medial through the tibia is
typically termed a “fibular” wire because it goes through the
fibula. This chapter will go through each zone of the leg, ankle,
and foot in attempts to standardize these terms.
For placement of skinny wires in the tibia, nomenclature
remains fairly consistent along its entire course. There are three
main wires utilized on a regular basis. They are termed “axial,”
“medial face,” and “fibular” wires (Figure 2.4). Axial wires are
a workhorse for foot and ankle external fixation. This wire is
typically driven across the anterior tibial crest, parallel with the
weight bearing surface and perpendicular to the long axis of the Figure 2.5. Application of an axial wire through the midshaft
tibia itself (Figure 2.5). When placing this wire, it is paramount tibia. Note the orientation and the axial “reference wire” already
that the wire catches a portion of the medullary space. If this wire placed in the calcaneus.
is too superficial, it becomes unicortical and has the potential for
fracture through the anterior tibial crest (Figure 2.6A and B).
The next wire is the fibular. As mentioned previously, it typi-
cally courses through both the fibula and tibia from a posterior
lateral position to anterior medial (Figure 2.7A and B). There
is some debate as to whether or not to include the fibula, but if
so desired, it is easiest to begin lateral, at the fibula itself. It is
also easier to start at the smaller target and head toward the
larger, allowing more room for error. If including the fibula is
not crucial, one can begin perpendicular to the medial face of
the tibia and head toward the fibula posterior lateral essentially
giving the same outcome. A B
The final common tibial wire is the medial face. It is com- Figure 2.6. Schematic cross section of the tibia showing proper
monly given this term due to the fact that it is essentially paral- insertion of transosseous wire fixation (A). This is depicted in the
lel to the medial face of the tibia. It is driven from lateral to green (2). Improper unicortical placement as shown by the red
medial direction. The start point is on the lateral side of the (1) may lead to fracture (B).
LWBK1121-C02_p012-032.indd 14 04/10/12 11:09 AM

A B
Figure 2.7. Most common insertion of the fibular wire starting point (A) and final position (B).
tibia, just lateral to the anterior crest. It is then driven posterior to the external fixator ring level and even. This minimizes con-
medial basically following and parallel to the medial face of the necting elements. Tensioned skinny wires will have their greatest
tibia (Figure 2.8). Issues with this wire tend to be irritation to strength when they are attached directly to the rings themselves.
the large posterior leg musculature. If wires are attached utilizing washers, posts, and extension plates,
When it comes to the foot, terminology is less standard. there is a loss of strength and stability. Having the wire connect
Starting with the talus, an axial wire is one placed through the directly to the external fixator may be optimal, but in some cases,
body or neck, parallel to the ankle joint, and will be discussed cannot be achieved. Some applications require the wire to be in
later. The calcaneus can be fixed with skinny wires through the a certain orientation and the location of the external fixator is
posterior safe zone. An axial calcaneal skinny wire is placed secondary. When the skinny wire is placed first, irrespective of
parallel to axial wires in the leg. In the midfoot and fore- the external fixator, it is termed “wires first” method (Figure 2.9).
foot, skinny wires tend to follow the normal anatomic arch if The circular external fixator is then “built up” to the pre-inserted
present. In some cases of pes planovalgus or Charcot deform- wires. Common examples in the lower extremity are the midfoot
ity, there is no arch, but in more typical anatomy, the wires are
angled from slightly plantar to dorsal. There is no standard
nomenclature for these wires.
When applying the circular external fixation device, most sur-
geons try to apply the majority of the transosseous wires directly
Figure 2.9. Example of a “wires first” application. Note the skinny

wires are placed without regard to the frame. The circular external
fixator is then built around these wires. This is in contrast to the
Figure 2.8. Most common insertion of the medial face wire being standard circular external fixation system being used as a template for
placed under tension. wire fixation.
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16 Chapter 2
A B
Figure 2.10. Example of a “drop wire” for added fixation. The wire is added either above (A) or below
(B) an existing circular ring and attached with posts.
and forefoot where anatomy dictates the position of the wires. area (Figure 2.10A and B). Stirrups are wires that basically
Here, wires are often connected to the external fixator with posts hold position but not necessarily tensioned. They can be use-
and washers. Another common example is fracture care where a ful in areas such as holding a fracture fragment stable while
particular fragment may need stability but does not correspond manipulating the remaining pieces, or holding the position of
with the external fixator’s design. the digits while moving the remainder of the foot and ankle are
Other terms utilized include “drop wire,” “stirrup,” and corrected so as not to increase their deformity (Figure 2.11A
“motor.” A drop wire is typically a third wire added to a circular and B). Motors are typically threaded rods that compress or
ring for increased stability. The wire is dropped down on a post distract as they are manipulated with differing combinations
and driven in the typical manner as others for that anatomic of posts, wires, and nuts. There are many ways to construct a
A B
Figure 2.11. Example of “stirrup” wires used to hold the posterior facet (A) of a calcaneal fracture while
the remaining fragments are manipulated. Multiple stirrups are utilized to attach the digits (B) to the exter-
nal fixator during cavovarus correction so the entire forefoot moves as a unit. These types of wires are usually
not tensioned.
LWBK1121-C02_p012-032.indd 16 04/10/12 11:10 AM

C D
Figure 2.12. Examples of a skinny wire attached to a slotted threaded rod to create a motor (A) that
would pull the distal fragment. Further examples of a motor utilized to correct an equinus deformity (B–D).
Note the motors in the front and back.
motor and are not to be discussed here, but when the surgeon (Figure 2.13). This helps cool the wire and allows the surgeon
becomes comfortable and creative, it increases the external to guide the wire without being entangled. The correct orien-
fixator’s usefulness (Figure 2.12A–D). tation is decided and the wire is driven straight through to the
other side and then fixed to the circular fixator ring.
When inserting the wire, the surgeon should use the exter-
Principles and Techniques for nal fixator as a guide and slide the smooth wire to the area
Transosseous Wire Application
As discussed in the Introduction, the transosseous wire is the
main component utilized to attach the external fixator to the
patient’s bone. A general understanding of appropriate exter-
nal fixation construct will help the surgeon apply appropriate
techniques for wire application. To obtain maximum stability
the smooth wires should be placed 90 degrees to each other.
They also should be attached directly to the external fixation
rings. The more extending elements added to the construct,
the more likely there will be loosening and potential construct
failure. It is usually helpful to have the external fixator pre-
built so that it can be used as a guide while applying smooth
wires. The leg can be placed in the external fixator, giving a
general idea of position. The leg is placed slightly anterior in
the circumference of the circular tibial ring block. This allows
for clearance for the large posterior muscle group and for
potential swelling. Sterile towels can be utilized to hold the leg
in proper position while maintaining clearances. The skinny
wires can then be applied. The wire is placed directly on Figure 2.13. Applying skinny wire, utilizing a damp saline sponge
the circular fixator ring, held in place with dampened gauze to aid in guiding and cooling the wire.
LWBK1121-C02_p012-032.indd 17 04/10/12 11:10 AM

18 Chapter 2
Figure 2.14. Utilizing a slotted bolt as a guide to aid in driving a

skinny wire.
where they want to begin wire placement. Another technique

involves a slotted bolt as a guide (Figure 2.14). This is a useful Figure 2.15. Example of the initial wires typical for an external
fixator applied to the foot and ankle. Note the two parallel axial wires
technique for the less experienced surgeon to keep the wire
in the calcaneus (1) and tibia (2). This gives some stability but also
on the external fixator ring while inserting the wire. The skin allows the ability to move medial–lateral and anteroposterior for fine
should be pierced and knowledge of surface anatomy along adjustment before being “locked” with further transosseous wires.
with tactile sensation helps guide the wire in the desired ori-
entation. As the surgeon drills the wire, it should be pulsed.
mentioned earlier. The half-pins can either be placed through
This method helps decrease friction which leads to increased
the anterior cortex of the tibia or the medial face of the tibia.
temperature of the wire. Once the second cortex has been
Anatomic landmarks provide the basis for placement of
breached, a mallet should be used to continue the smooth
skinny wires and half-pins. Locations where major nerves and
wire through the distal soft tissues and across the far end of
vessels are located are absolute contraindications for wire
the external fixator. Each smooth wire is then attached to the
placement. Tendon and muscle should be avoided as well, but
external fixator and tensioned appropriately. Smooth wires
never at the expense of injuring a major nerve or vessel. In the
should always be placed from the anatomic location that is
instance of the posterior leg where the tibial nerve and gastroc-
the most vulnerable to the area that is least vulnerable. This
nemius muscle are located, a smooth wire would be uncomfort-
is generally referred to as the “known-to-unknown concept.”
able for the patient and risk possible nerve injury. As such,
For example, when placing a calcaneal wire, the surgeon starts
half-pin placement is ideal when obtaining fixation from ante-
medially and inserts the wire from medial to lateral. With this
rior to posterior direction. Understanding cross-sectional and
technique the neurovascular bundle is better protected, even
topographic anatomy is essential when applying an external
if the aim through the lateral calcaneus is somewhat off, the
fixator. These concepts will be discussed later in this chapter.
medial side remains safe.
An easy technique for application of external fixation for the
foot and ankle involves applying a calcaneal transosseous wire
as the initial wire. This is termed “reference wire” and helps the Half-Pin Application
surgeon set the proximal–distal position of the external fixator.
The external fixator is then held in position, orthogonal to the General principles for half-pin placement are the same as for
foot and leg. More axial wires are then placed on each ring smooth wire placement, with the exception that the anatomic
of the tibial ring block. This sets the position of the external structures that would be on the opposite side of the bone are
fixator along the long axis of the leg. However, because the not at as much risk. Since the half-pin only engages the far
wires are parallel, it can still be translated medially and laterally cortex, the structures lying deep or further are protected. This
along the wires (Figure 2.15). Adjustment, anterior and poste- is one of the major advantages to placing half-pins. In the foot
rior along the holes of the circular rings, can still be performed and ankle it is very useful in areas such as the tibia, where the
until the surgeon is satisfied with the appropriate position. large posterior muscle group and the neurovascular structures
These wires are then attached to the external fixator. At this make placing smooth wires safely almost impossible.
point, the circular external fixator then becomes “locked” by One drawback of the half-pin’s application can be its size.
placing the remaining wires. Once these wires are placed, there The large diameter of half-pins makes exact placement within
are wires at varying angles and the circular external fixator the tibia extremely important. Half-pins come in many diame-
gains stability and will no longer shift. The remaining wires are ters but typically in the tibia they are 5 or 6 mm, in the foot 3 or
placed as previously mentioned depending on anatomic loca- 4 mm. The thread pattern can be cortical or cancellous and is
tion. Half-pins can then be substituted to obtain appropriate consistent or tapered (Figure 2.16). Engaging the distal cortex
90-degree angulation of the wires if so desired. They can also for “bicortical” fixation in the tibia is mandatory (Figure 2.17).
be utilized to just gain more stability similar to the drop wire Tibial fractures increase significantly when a half-pin is placed
LWBK1121-C02_p012-032.indd 18 04/10/12 11:10 AM

Figure 2.16. Examples of a few different half-pins. Note the Figure 2.17. A “delta” external fixation system showing proper
difference between the consistent and tapered pins as well as the bicortical half-pin fixation in the midshaft tibia.
transfixation pin with threads in the center used in “delta” external
fixation constructs.
unicortical. Care should also be taken if utilizing tapered half- For many surgeons, half-pins are placed after the external
pins. They cannot be reversed or backed-up once they have fixator has been stabilized with smooth wires. They are added
been driven forward. Doing so causes them to lose strength at the end for increased stability and extra points of fixation.
and stability as the tapering threads may no longer engage the Having a stable external fixator prior to their application allows
bone. The final consideration is the amount and orientation a steady platform for the half-pin starting point. Surgeons seem
of the half-pins. Two half-pins should not be “stacked” close to be divided as to the most appropriate place to begin their
in the same carrier or otherwise. These pins remove a large half-pin insertion into the tibia. The two most common loca-
portion of cortical bone and holes too close can cause fracture tions for the tibia are directly anterior, at the tibial crest, and
(Figure 2.18A and B). medially along the medial face of the tibia (Figure 2.19A–E).
A B
Figure 2.18. Example of half-pins too close or “stacked” in the distal tibia (A) causing an area of weak-
ness and eventual fracture (B).
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20 Chapter 2
A B
C D
Figure 2.19. Radiographic (A, B) and clinical

(C) pictures of half-pins placed in the anterior cortex
of the tibia and perpendicular to the medial face of
E the tibia (D, E).
LWBK1121-C02_p012-032.indd 20 04/10/12 11:10 AM

A B
Figure 2.20. Examples of common half-pin connecting elements (A) including the “rancho cube” with its
centering sleeve and lock screw, as well as a more simple half-pin connecting bolt (B). The advantage of the
connecting bolt is its ability to place half-pins at angles to the external fixation construct with more ease (B).
Both locations are subcutaneous and simple to localize intra- tibia. The medial crest of the tibia should also be palpated and
operatively with surface anatomy. The anterior crest of the identified so that the surgeon knows where the medial face
tibia is obvious and should be localized regardless of the final of the tibia is located at all times. The fibula should also be
half-pin orientation. If the surgeon chooses to place the half- palpated at the distal one-third of the leg. Specifically the tip
pin directly anterior to posterior, the crest is easy to palpate. If of the lateral malleolus should be marked out prior to surgical
a medial face pin is chosen, the anterior crest and the posterior procedure. Also, the medial malleolus should be identified and
medial crest of the tibia are also localized. This gives the sur- the ankle joint marked. When the external fixator requires
geon tactile information about the overall width of this surface. smooth wires through the talus, the navicular tuberosity should
The half-pin is inserted at the midpoint of this surface, and be palpated. The body of the calcaneus and the inferior and
driven perpendicular to the medial face and parallel to the posterior portion of the calcaneus should be identified as
longitudinal axis of the tibia. well to determine its safe zone. The first and fifth metatarsal
With the external fixator in place and stable, it can be used shafts including the base of the fifth metatarsal should also be
as a template to increase accuracy of half-pin placement. Most identified and marked. All of these landmarks will be essential
industrial companies have a half-pin carrier or “rancho cube,” when determining starting points for both smooth wires and
which can be used as a guide (Figure 2.20A and B). These half-pins.
cubes have multiple holes or long slots in them which fit drill
guides for the half-pins. It is the surgeon’s preference whether
or not they will pre-drill their half-pins prior to insertion, Cross-Sectional Anatomy
although most tend to pre-drill to remove some of the dense
bone. When drilling for the half-pin, the surgeon relies on tac- In the proximal aspect of the lower leg, the anterior and medial
tile information. The cortex of the tibia is rather dense, but the aspects of the tibia are safe zones. At this level, the popliteal
drilling becomes easier once the medullary space is breached. artery is posterior in the deep compartment of the leg. The
Drilling will once again become difficult as the distal cortex is popliteus muscle is directly between the posterior aspect of
encountered. Drilling should be bicortical and care should be the tibia, the popliteal artery, and the tibial nerve. Laterally,
taken not to plunge through the distal cortex to protect deep the common peroneal nerve runs posterior and immediately
structures. At this point, C-arm fluoroscopy should be used inferior to the head of the fibula.
to confirm bicortical placement of each half-pin. The drill is Within the diaphysis of the tibia, the two main neurovas-
removed and the appropriate length half-pin is then inserted cular bundles are running within the leg. The deep peroneal
through the cube and attached to the external fixator. There nerve and anterior tibial artery are running just anterior to
are modifications to the half-pin attachment allowing more the interosseous membrane between the tibia and fibula in
flexibility in orientation and expanding their use. the anterior compartment musculature. In the deep posterior
compartment, the posterior tibial vessels and the peroneal ves-
sels are just posterior to the tibialis posterior muscle belly. As
Anatomic Landmarks the vessels move more distal, the posterior tibial vessels and
nerve begin to move more medial, and the peroneal vessels
There are many essential landmarks on the distal leg, ankle, pierce through the intraosseous septum laterally. At the level
and foot that must be appreciated. Those applying external of the distal metaphysis, the deep peroneal nerve and anterior
fixators need to be familiar with these landmarks in order to tibial artery lie just deep to the extensor hallucis longus ten-
apply the external fixators appropriately. Starting proximally, don. The tibial nerve and posterior tibial artery now lie just
the fibular head and tibial tuberosity should be palpated. posterior to the medial malleolus and posterior to the posterior
The surgeon then may palpate the entire anterior crest of the tibial tendon.
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22 Chapter 2
In general, directly anteriorly and posteriorly are areas that into the tibia fairly safely. Another smooth wire may be placed
should be avoided with smooth wire and half-pin insertion. Fur- anterior to the fibular head driven medially, crossing the tibia
thermore, if the surgeon can palpate the medial aspect of the and entering slightly posterior on the medial side of the tibia.
tibia, smooth wires can be placed in this direction without dam- The surgeon should be careful not to place the starting point
aging any vital neurovascular structures. The exception to ante- for this wire any more distal, as it could damage the common
rior placement would be a half-pin, which as described earlier is peroneal nerve. Half-pins may also be used at this level. As pre-
only truly violating the anterior aspect of the tibia, and therefore viously described, they may be placed directly anterior along
should not damage the posterior neurovascular structures. the anterior crest of the tibia or perpendicular to the medial
face of the tibia. At this level, the popliteal artery is bifurcating
into the posterior tibial artery and the anterior tibial trunk.
Safe Lower Extremity The posterior arteriovenous network is just posterior to the
Anatomic Zones posterior cortex of the tibia. Care should be taken not to drill
any further than the distal cortex and half-pins should only be
Tibia placed a few millimeters past the distal cortex to avoid injury to
Safe zones for the tibia are generally located in six distinct the neurovascular bundle.
zones (Figure 2.21):
1. The proximal metaphysis of tibia at the level of the fibular Zone 2: Proximal Tibia Metaphyseal/Diaphyseal Junction
head At this level, the common peroneal nerve has divided into its
2. The proximal metaphyseal/diaphyseal junction of the tibia deep and superficial branches. In the anterior compartment,
3. Just proximal to the midshaft of the tibia the neurovascular structures progress along the anterior aspect
4. Just distal to the midshaft of the tibia of the intraosseous membrane. Therefore, smooth wires should
5. The distal metaphyseal/diaphyseal junction be placed as anterior as possible, while still maintaining bicorti-
6. The distal tibial metaphysis approximately 2 cm proximal to cal fixation. If the surgeon desires to insert a second smooth
the ankle joint wire, one can be placed fairly safely running from the posterior
Each zone has certain anatomic structures that are more medial cortex of the tibia, through the anterior lateral portion
at risk and therefore should be identified prior to insertion of the tibia. If these two smooth wires are in place, a half-pin
of any wire or half-pin. Each zone’s relative anatomy will be would be best utilized with placement from the medial cortex
discussed as well as the preferred type of half-pin or smooth of the tibia running posterior and lateral.
wire for insertion.
Zones 3 and 4: Midshaft Tibia
Zone 1: Proximal Tibia Metaphysis
The anatomic landmarks are almost identical at these two
The common peroneal nerve must be identified at this level. zones. However, the surgeon should be cognizant of the
A smooth wire may be placed at the fibular head crossing oftentimes bulky posterior muscle group including the
Figure 2.21. Cross-sectional

anatomy of the proximal and midshaft
leg. Optimal half-pin and skinny wire
placement is shown for each level (A, B).
Half-pins are typically perpendicular to
the anterior tibia crest (1, 4) or medial
face of the tibia (2, 3). Most common
medial face (5, 10), axial (6, 9), and
fibular (7, 8) skinny wire applications
are shown.
LWBK1121-C02_p012-032.indd 22 04/10/12 11:10 AM

gastrocnemius and soleus muscles. Placement of wires can tissues so as not to entrap, or drill through, the neurovascular
be too posterior in zone 3 if the surgeon is not aware of the bundle. A soft tissue drill guide is always recommended at this
anatomy of this large muscle group. Smooth wires at this level.
level can be placed fairly safely in axial fashion (directly per-
pendicular and coaxial to the tibia). This will require pierc-
Zone 6: Distal Tibia Metaphysis
ing through the anterior compartment musculature, but the
neurovascular structure is posterior to this wire. A second In this area, there is much more cortical bone availability
wire can be inserted parallel to the medial face of the tibia. where the surgeon may use to place half-pins and smooth wires.
This requires piercing the anterior compartment musculature Many use the added availability of the osseous structures to
again when the wire exits along the lateral aspect of the tibial place multiple smooth wires and half-pins to increase overall
crest. At these levels, half-pins can be safely placed along the strength. Oftentimes at this level the surgeon will insert at least
anterior crest of the tibia, or the medial face of the tibia. The an axial wire, a fibular wire, and a half-pin. The neurovascular
neurovascular structures posteriorly are now protected by the structure is truly anterior at this level running just deep to the
deep compartment musculature and therefore it is less vital to extensor hallucis longus tendon. The posterior neurovascular
make sure that the half-pins only cross the distal cortex by 1 to structures are now posterior medial behind the medial malleo-
2 mm. Even so, proper surgical technique dictates the surgeon lus. These two areas should be avoided with both smooth wires
to not plunge the drill bit or place the half-pin any further and half-pins.
than is necessary. One needs to also remember the existence of a tibiofibular
recess that extends the ankle joint approximately 2 cm proxi-
mal. Wires placed in this area of the distal tibia are therefore
Zone 5: Distal Tibia Diaphyseal/Metaphyseal Junction
intra-articular and should be avoided to prevent a possible sep-
The transition from zone 4 to zone 5 results in the deep pero- tic joint (Figure 2.22).
neal nerve and anterior tibial artery running along the ante-
rior aspect of the tibia. The posterior neurovascular bundle
Talus
has transitioned from the posterior aspect of the leg to a more
medial position located posterior medially along the tibia. As The overwhelming majority of the talus is articular and sur-
such, both smooth wires and half-pins are placed safely from a rounded by the tibia, fibula, calcaneus, and navicular. Because
medial to lateral direction. Safe choices in this area include an of this, most believe that any talar wire is intra-articular and it
axial smooth wire and a smooth wire running from the fibula is typically avoided unless required by deformity and construct.
laterally exiting the anteromedial aspect of the leg. An anterior Its anatomic position also keeps it well hidden and therefore
to posterior half-pin may still be placed at this level. However, difficult to safely apply wires for external fixation. The area
after the incision one should be sure to spread the underlying with the most access is the talar neck. In cases where the fibula
Figure 2.22. Cross-sectional

anatomy of the distal lower extremity,
heel, and forefoot. Optimal half-pin
and skinny wire placement is shown
for each level (A–C). Half-pins are
typically perpendicular to the anterior
tibia crest (1) or medial face of the
tibia (2). In the heel, the half-pin can
be inserted from the posterior aspect
(3) while in the forefoot, half-pins
must follow the transverse arch of the
foot in order to purchase as much
bone as possible for stability (4A, 4B).
Distal tibia medial face (5), axial (6),
and fibular (7) skinny wires are shown.
In the heel, crossed skinny olive wires 4B
4A
(8, 9) may be placed while in the
forefoot, skinny wires must follow the
transverse arch of the foot in order to
purchase as much bone as possible for
stability (10, 11).
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24 Chapter 2
A B
Figure 2.23. Example of an axial transfixation

pin through the neck of the talus (A) utilized in
many “delta” external fixation configurations. Note
the importance of intraoperative imaging (B, C) to
C be certain about placement.
is osteotomized and removed, there is more room laterally from the distal tip of the medial malleolus to the navicular, wires
and the neck is more exposed for safe wire insertion. Due to placed anterior and superior to this line are safe. Posterior and
its relative size, skinny wires are preferred. In circumstances inferior to this line, the posterior tibial tendon and neurovascu-
where a temporary “delta” external fixation is utilized, a trans- lar structures are at risk. The second technique drives the pin
fixation pin can be placed but care must be taken to center the from a lateral to medial direction. An area just anterior to the
fixation in the talar neck (Figure 2.23A–C). The transosseous lateral malleolus allows access to the lateral talar neck. If a fin-
skinny wire and the transfixation pin in this area follow the ger is placed on the anterior edge of the fibula, just anterior to
same course. The neck of the talus is relatively small and large that gives a good reference for the lateral start point. However,
diameter pins increase the risk of fracture. using the known-to-unknown principle it may be best to place
The safest area for placement of smooth wires into the talus these wires from a medial position when possible. If a second
is the proximal talar neck. Care must be taken when placing wire is desired, it is impossible to have them placed 90 degrees
even smooth wires into the talar neck so that it is not fractured. to each other. In fact, 45 degrees is more than adequate at this
There are two ways to insert the most common talar wire (Fig- level due to the difficulty with the anatomy of the ankle joint
ure 2.24A–D). Either way, the wire is basically axial, parallel to and talus. A second wire can be placed from a posterior lateral
the weight bearing surface and straight medial to lateral direc- position, behind the fibula, in the interval between the pero-
tion, perpendicular to the long axis of the leg. If going from neal tendons and the Achilles tendon. This wire is the next saf-
medial to lateral, anatomic landmarks include the distal tip of est and is driven anterior medial (Figure 2.25A–D). Care must
the medial malleolus and navicular tuberosity. If a line is drawn be taken to avoid the sural nerve at this level.
LWBK1121-C02_p012-032.indd 24 04/10/12 11:10 AM

C D
Figure 2.24. The safest talar wire is axial, placed either from a medial position in the designated safe area above
the line between the tip of the medial malleolus and navicular tuberosity (A) or laterally from an area a finger
breadth anterior to the tip of the lateral malleolus (B, C). The axial talar wire as seen on a saw bone model (D).
A B
C D
Figure 2.25. Placement of the second talar wire (A). The safe zone is posterior to the peroneal tendons
aimed anterior and medial (B). Note the entry and exit points on saw bone models (C, D).
LWBK1121-C02_p012-032.indd 25 04/10/12 11:10 AM

26 Chapter 2
Figure 2.26. Examples of a five-eighth ring (A) and drop wire (B)
technique utilized for fixation of talar skinny wires. This allows safe
zone placement while keeping the external fixator from impinging on
A the anterior ankle.
Another area of difficulty with regard to fixation in the talus due to the surrounding neurovascular structures. Tradition-
involves the external fixator itself. Fixation of the talar wires ally, two wires are placed through the posterior tuberosity
directly to a circular ring may cause the ring to impinge on the (Figure 2.27A and B). For many, an axial wire is placed first,
ankle anteriorly. This can be overcome by utilizing a five-eighth parallel to the axial wires in the tibia. This wire is driven from
circular ring left open anteriorly or by connecting the talar fixa- medial to lateral, parallel to the weight bearing surface, per-
tion with a “drop” wire concept to the rings further proximal pendicular to the longitudinal axis of the leg. As with any wire
or distal depending on the application required (Figure 2.26A placement, anatomic landmarks should guide placement.
and B). For the calcaneus, the safest area is the posterior tuberosity.
Although the medial calcaneal nerve is always at risk, this
area protects the lateral plantar nerve and larger structures
Calcaneus
(Figure 2.28).
The calcaneus is the largest tarsal bone, yet actually has lim- The second skinny wire for the calcaneus is then placed
ited area for application of transosseous wires and half-pins at an angle to the first. This is done at the largest angle one
A B
Figure 2.27. Traditional two skinny wire safe zone fixation for the calcaneus (A, B).
LWBK1121-C02_p012-032.indd 26 04/10/12 11:11 AM

and foot from moving in the external fixator, but caution is

used if a wire is placed from lateral to medial as the neurovas-
cular bundle is at higher risk. As an alternative, some surgeons
will place directly or substitute a half-pin from the posterior
aspect of the calcaneus into the body. This is an extremely safe
zone for fixation and using a half-pin versus a skinny wire allows
for fixation within the bone, eliminating the worry of neurov-
ascular structures in other zones of the calcaneus. Utilizing a
half-pin in the body of the calcaneus can be a useful reduc-
tion tool during the reconstructive process. These half-pins
can either be driven parallel to the weight bearing surface or
angled superior through the body from a posterior direction
(Figure 2.30A–C). The orientation depends on the anatomy,
deformity, and correction desired. Either way, the half-pin can
then be attached to the external fixator for added stability
(Figure 2.31A and B). This is an easy way to achieve stability in
Figure 2.28. Bone model of the medial foot showing the safe area
of the posterior tuberosity of the calcaneus shown with black hashed the rearfoot.
line and the neurovascular danger zone in red. In the temporary “delta” external fixation configuration,
transfixation pins can be placed as well. This pin is very
useful in trauma settings for maintaining the ankle out to
can achieve depending on anatomy and external fixation con- length or holding a reduced deformity. Similar to the talus,
struct. This wire should again be placed from medial to lateral the transfixation pin is placed in the calcaneal tuberosity, run
to avoid injury to the neurovascular bundle. It can be driven medial to lateral direction following safe zone rules, and is
either proximal or distal again depending on the construct, but essentially the same as the axial calcaneal skinny wire used
trying to achieve the largest angle possible. in most circular external fixation applications (Figure 2.32A
Olive wires are commonly utilized in the fixation of the cal- and B).
caneus to prevent migration of the foot in the external fixator.
In this case, “opposing” olives are preferred, one lateral and
Midfoot and Forefoot
one medial (Figure 2.29). This can help prevent the calcaneus
Usually there is a large surgical debate with regard to forefoot
wires. Some believe that they are never a good idea, and that
forefoot wires have a high rate of failure and breakage. This
may be due to a decrease in overall strength secondary to the
decrease in tension applied to wires at this level. The decreased
tension allows more micromotion of the wire, leading to mate-
rial fatigue and ultimate failure (Figure 2.33A and B). If they
are inserted, some surgeons believe that these wires should be
positioned as distal on the foot as possible near the metatarsal
heads. However, other surgeons feel that one or two smooth
wires crossing the cuneiform joints are adequate. Olive wires
are common in this application as well. They prevent move-
ment of the forefoot within the external fixator and may add
some stability to an otherwise less stable construct (Figure 2.34A
and B).
Unfortunately, certain deformities require midfoot and fore-
foot fixation. With deformities at the leg and ankle level, there
are typically enough safe osseous anatomic structures proximal
and distal to the surgical area to leave the forefoot relatively
free. However, for pathologies such as midfoot trauma and
midfoot Charcot neuroarthropathy, the rules of fixation neces-
sitate multiple points of fixation in more distal location. There
are certain requirements for stability. For example, if a midfoot
osteotomy is performed, there needs to be a point of fixation
just proximal and just distal to the surgical site. In addition,
there must be at least one more point distal for added strength
and in case the first one fails (Figure 2.35A–D). Without this
second point, failure of the point just distal to the surgical area
would mean failure of the entire construct.
Figure 2.29. Opposing olive wires utilized for a calcaneal The dorsalis pedis artery is just superior to the cortex of
fracture. The olives help to prevent migration of the foot within the the first and second metatarsals and cuneiforms. The deep
external fixator. peroneal nerve runs in conjunction with the dorsalis pedis
LWBK1121-C02_p012-032.indd 27 04/10/12 11:11 AM

28 Chapter 2
A B
Figure 2.30. Common examples of half-pins

in the calcaneus to augment fixation. They can be
placed either parallel to the weight bearing surface
(A) or angled much like an internal screw fixation
C for subtalar joint arthrodesis (B, C).
A B
Figure 2.31. Examples of half-pins in the calcaneus attached to the external fixator for increased stability (A, B).
LWBK1121-C02_p012-032.indd 28 04/10/12 11:11 AM

A B
Figure 2.32. Transfixation pin of the talus and calcaneus (A, B). Note the threads in the center of the
pin but the smooth ends. These pins should be parallel and axial, following the safest zones for the surround-
ing anatomy.
Figure 2.33. Examples of broken

skinny forefoot wires of an external
fixator (A, B). A B
Figure 2.34. Olive wires placed

in the forefoot to increase stability
and limit foot translation while in the
external fixator (A, B). A B
LWBK1121-C02_p012-032.indd 29 04/10/12 11:11 AM

30 Chapter 2
Figure 2.35. Additional fixation distal to the midfoot

osteotomy can be achieved with Steinmann pins (A), addi-
C tional skinny wires (B, C), or with a circular ring (D).
artery. Plantarly, the branches of the tibial nerve and posterior “wires first” method. Once these forefoot wires are driven,
tibial artery should be relatively spared as wires are not typi- posts, washers, and plates are utilized to make the necessary
cally positioned in superior-to-inferior direction. Regardless connections. Alternatively, the external fixator can be modified
of where these wires are placed, the vast majority of orienta- to have rings meet these wires depending on the needs
tions are safe. Although there is some angle when these wires (Figure 2.37).
are inserted, most fixations in the midfoot and forefoot are As an alternative or for trauma and temporary external
medial-to-lateral and so remain osseous for much of their fixation applications, half-pins can be placed rather safely in
course. This protects the anatomic structures located superior the midfoot and forefoot (Figure 2.38A–D). Half-pins placed
and inferior. in these areas are smaller diameter and as long as the pins
Depending on the external fixation construct, midfoot and are not placed from the plantar surface, the majority of the
forefoot wires may not meet the external fixator ring without midfoot and forefoot osseous structures are safe. Considera-
“building up” for proper connection. Forefoot wires are gen- tion should be made of the dorsal neurovascular area near
erally placed without as much regard to the external fixation the first interspace and care is taken when crossing joints if
construct (Figure 2.36). In this sense they are placed in the necessary.
LWBK1121-C02_p012-032.indd 30 04/10/12 11:11 AM

Figure 2.37. Example of a forefoot ring allowing additional fixa-

tion in multiple planes as an alternative to the traditional external
Figure 2.36. Examples of posts frequently utilized to connect
foot plate.
skinny wires through the midfoot and forefoot. When a foot plate is
used, wires following the correct safe zones are angled off the exter-
nal fixator and therefore these connecting elements are required.
Figure 2.38. Radiographic (A–C) and

clinical (D) pictures of smaller diameter
half-pins in the midfoot and forefoot. C D
LWBK1121-C02_p012-032.indd 31 04/10/12 11:11 AM

32 Chapter 2
successful results. When this knowledge is combined, safe

C l i n i cal Tips and Pearls and effective external fixation application, which maximizes
patient outcomes, can be accomplished.
A. Insert transosseous fixation from known structures to
unknown.
B. Consideration should be taken of joint and tendon
Recommended Readings
position during fixation.
C. Avoid crossing large musculature structures. Barrett MO, Wade AM, Della Rocca GJ, et al. The safety of forefoot metatarsal
D. Avoid crossing joints with fixation (except a select few pins in external fixation of the lower extremity. J Bone Joint Surg Am. 2008;
90:560–564.
of the midfoot).
Casey D, McConnell T, Parekh S, et al. Percutaneous pin placement in the medial
E. Remember the tibiofibular recess extends approxi- calcaneus: is anywhere safe? J Orthop Trauma. 2004;18:S39–S42.
mately proximal 2 cm of the ankle joint. DeCoster TA, Crawford MK, Kraut MA. Safe extracapsular placement of proximal
F. Use damp saline gauze or a slotted bolt as a guide when tibia transfixation pins. J Orthop Trauma. 1999;13:S43–S47.
inserting smooth wires. Gamie Z, Donnelly L, Tsiridis E. The “safe zone” in the medial percutaneous
calcaneal pin placement. Clin Anat. 2009;22:523–529.
G. Palpate and mark bony prominences before surgery. Lee PT, Clarke MT, Bearcroft PW, et al. The proximal extent of the ankle capsule
H. When pre-building an external fixator, use minimal and safety for the insertion of percutaneous fine wires. J Bone Joint Surg Br. 2004;
amounts of threaded rods and connecting elements. 87:668–671.
This allows for more appropriate safe zone insertion Loughenbery PR, Harwood PJ, Tunstall R, et al. The “retro-fibular wire” an
anatomical study describing a safe corridor for placement of fine wires in the
without interference. Additional elements can be
distal tibia. J Bone Joint Surg Br. 2010;92:1041–1044.
added at the end of the surgical procedure. Lui TH, Chan LK. Deep peroneal nerve injury following external fixation of the
ankle: case report and anatomic study. Foot Ankle Int. 2011;32:550–555.
Reid JS, Van Slyke MA, Moulton MJ, et al. Safe placement of proximal tibial
transfixation wires with respect to intracapsular penetration. J Orthop Trauma.
Conclusion 2001;15:10–17.
Stavlas P, Polyzois D. Septic arthritis of the major joints of the lower limb after
External fixation when used properly has unlimited possibili- periarticular external fixation application: are conventional safe corridors
enough to prevent it? Injury. 2005;36:239–247.
ties but application can be a challenging task. Understanding
Topp R, Hayda R, Benedetti G, et al. The incidence of neurovascular injury
topographic and cross-sectional anatomy is a must for proper during external fixator placement without radiographic assistance for lower
application. Applying the principles in this book and chapter extremity diaphyseal fractures: a cadaveric study. J Trauma. 2003;55:955–
will dramatically reduce complications. Knowledge of the six 958.
safe zones within the tibia, as well as the calcaneus, talus, and Tornetta PL, Weiner M, Bergman M. Pilon fractures: treatment with combined
internal and external fixation. J Orthop Trauma. 1993;7:489–496.
midfoot/forefoot allows the surgeon to place smooth wires and Vives MJ, Abidi NA, Ishikawa SN, et al. Soft tissue injuries with the use of safe cor-
half-pins with confidence. This used with the understanding of ridors for transfixation wire placement during external fixation of distal tibia
external fixator components and biomechanics will maximize fractures: an anatomic study. J Orthop Trauma. 2001;15:555–559.
LWBK1121-C02_p012-032.indd 32 04/10/12 11:11 AM

C h a p te r
3 James E. Orsak
J. Tracy Watson
Biomechanics of External Fixation
Introduction
Perhaps one of the biggest advantages of using external fixation
is the ability to modulate the healing environment throughout
the course of treatment. From Julius Wolff’s work in the late
1800s, we know that bone adapts to its mechanical environment.
An external fixator is a structural substitute for intact bone and is
thus greatly influenced by biomechanical principles. The piezo-
electric properties of bone as demonstrated by Fukada and Yas-
uda in the 1950s ensure that the bone architecture is enhanced
by mechanical loading. Julius Wolff’s work was refined by Dr.
Harold Frost in the 1960s who brought attention to an often
overlooked point that bone adapts to dynamic loads as opposed
to static loads which implies that the role of ambulation or weight
bearing may be key to the healing process. This point was further
emphasized by Giovanni DeBastiani in the 1980s. DeBastiani was
an Italian physiologist whose study of bone healing led to the
coining of the term dynamization which is the controlled desta-
bilization of the external fixator after an initial period of absolute
rigidity to allow the bone to begin sharing the axial load.
A
Principles of Dynamization
There are two phases to the dynamization process: The first
phase is a controlled micromotion of less than 2 mm initiated
2 weeks after surgery, and the second phase is a complete
axial collapse initiated at approximately 6 weeks (Figure 3.1).
DeBastiani’s external fixator was designed to restrict bending
movement while allowing axial sliding through a telescopic
tube (Figure 3.2A and B). His design allowed for progressive
load sharing between the external fixator and the bone to
make full use of Wolff’s law. A comparison of a rigidly fixed
versus dynamized fracture results is shown in Figure 3.3.
Inflammation Callus formation Remodeling/Consolidation
~2 WEEKS ~4 WEEKS ~8 WEEKS

Absolute Controlled Axial EXTERNAL
rigidity micromotion dynamization FIXATOR
B
REMOVAL
Figure 3.2. Examples of DeBastiani’s dynamic axial external
Figure 3.1. Dynamization timeline. fixator with silicone cushion collar for micromotion (A, B).
33
LWBK1121-C03_p033-040.indd 33 04/10/12 11:12 AM

34 Chapter 3
A B
Figure 3.3. Effects of dynamization on bone callus formation. A: Rigidly fixed (shows less callus forma-
tion). B: Applied dynamization and micromotion (shows more callus formation). From Rockwood CA, Green
DP, Bucholz RW, et al. Rockwood and Green’s Fractures in Adults. 4th ed. Philadelphia, PA: Lippincott-Raven;
1996, with permission.
The precise amount of dynamization during the control- the healing fracture site encouraged cellular proliferation and
led micromotion phase was studied by Drs. Goodship and promoted ossification.
Kenwright from Oxford University. Their animal study using However, there is little experimental data to support these
sheep found that a fracture gap motion of 0.5 mm is optimal clinical and mathematical findings. Yamagishi and Yoshimura
for stimulation of callus growth whereas motion greater than 2 concluded that shearing force was important in the production
mm was detrimental. In a follow-up study on humans, they were of a pseudarthrosis. In these experiments, the shear forces were
able to demonstrate an improvement in the healing time of 4 poorly controlled as the force was applied with springs. Addition-
to 5 weeks with the dynamized patients. ally, the shear forces were combined with a distraction force. In
a study to determine the effects of controlled intermittent cyclic
microshear, Sauer et al. measured callus formation and density
The Effects of Cyclic Microshear in osteotomized rabbit tibiae that experienced controlled shear
on Fracture Healing versus a control group. The results showed that the osteotomies
experiencing the microshear forces produced more abundant
From the principles of dynamization it has long been believed and denser callus formation corresponding to increased tor-
that while axial loading is beneficial to fracture healing, shear- sional strength and stiffness (Figures 3.4 and 3.5). Their findings,
ing forces have classically been considered to be detrimental contrary to popular belief, showed that within a specific range
to fracture healing. In their clinical studies, Sarmiento et al. microshear forces can actually be beneficial to fracture healing.
observed that fracture treatment with functional casts and
braces that allow shearing motion between the fragments
produces more abundant callus and unites more rapidly and Modes of External Fixation
consistently than fractures that are inherently stable. More
recently, Blenman et al., using two-dimensional finite element In contrast to dynamic loading that produces callus formation
analysis of a healing osteotomy, proposed that shear stresses at (also known as secondary healing), there are the principles of
Mean Change in Bone Mineral Content Mean Change in Bone Mineral Density Mean Change in Area
p = 0.08*
0.8 0.12 p = 0.08*
p = 0.08* 0.9
0.7
0.10 0.8
0.6 0.7
Grams 0.8
0.5 0.6
per Square 0.5
Grams 0.4 0.6
square centimeter 0.4
0.3 centimeter 0.4
0.3
0.2
0.2
0.2
0.1 0.1
0 0 0
Micromotion Rigid Micromotion Rigid Micromotion Rigid
Figure 3.4. Quality of callus formation: Micromotion versus rigid.
LWBK1121-C03_p033-040.indd 34 04/10/12 11:12 AM

Biomechanics of External Fixation 35
Mean maximum torque Mean stiffness

p = 0.14*
p = 0.21*
p = 0.02*
7 p = 0.16*
p = 0.21*
60 p = 0.03* p = 0.82*
6
50 5
Inch
40 pounds 4
Inch per 3
30
pounds degree
20 2
10 1
0 0
Micromotion Rigid Micromotion Rigid Microshear Rigid Microshear Rigid
Study group Control group Study group Control group
(With fixator) (No fixator) (With fixator) (No fixator)
Figure 3.5. Strength and stiffness of callus formation: Micromotion versus rigid.
rigid fixation (resulting in primary healing) popularized by the bone ends. If the fracture pattern is highly comminuted, then
Arbeitsgemeinschaft für Osteosynthesefragen (AO) Founda- a neutralization mode is used to prevent limb shortening at
tion as well as Sir John Charnley who published his work on the fracture site. The distraction mode is used for osteogen-
compression arthrodesis in 1953. Since external fixation is esis or callotasis method for limb lengthening as well as for
positioned away from the bone, there is a natural element of ligamentotaxis to provide stability to intra-articular fracture
flexibility due to the bending stiffness of the materials used and fragments.
therefore the inherent design of the external fixator lends itself
well to dynamic loading. It is by adding compression elements
to the design that the biomechanics of the external fixator can External Fixation Wire/Pin
be modified from a secondary healing approach to a primary and Bone Interface
healing device. Charnley’s external fixator utilized threaded
rods and wing nuts to provide compression to transfixion pins The weakest link in an external fixator is usually the pin/bone
to the point of absolute stability at the fracture site (Figure 3.6). interface and therefore should be the primary focus of design-
Through the mechanical advantage of threaded com- ing an external fixator for biomechanical stability. Without
ponents, external fixators convert the rotational forces of proper bone anchorage, the amount of external fixator bio-
threaded nuts to linear forces that move bone segments in mechanical stability is irrelevant. There are three basic types
compression or distraction. There are three basic biomechani- of pins: Half-pins, transfixion pins, and thin tensioned wires.
cal modes to external fixation: Compression, distraction, and When selecting the pin implant, it is important to understand
neutralization. The choice of which mode to use may depend the difference between cantilever loading and beam loading.
on the treatment objective, fracture pattern, fracture location, In simple terms, a cantilever structure is one which is sup-
or soft tissue condition. The compression mode is often used ported at only one end; whereas a beam-loaded structure is
for joint arthrodesis or simple fractures to impart stability to supported at both ends (Figure 3.7).
Figure 3.6. Example of the Charnley’s external fixator for ankle

arthrodesis. Figure 3.7. Illustration of cantilever versus beam-loading effects.
LWBK1121-C03_p033-040.indd 35 04/10/12 11:12 AM

36 Chapter 3
or arched wire technique. By inserting a transosseous wire straight

and then bending the wire to form an arch before applying ten-
sion, the wire can provide a directional force across a fracture or
joint in a direction toward the concave side of the arch (Figure
3.10A and B).
Olive Transosseous Wires

Another method of achieving interfragmentary compression
Figure 3.8. Illustration of cantilever versus beam stress distribution. is through the use of “olive” transosseous wires which incor-
porate a bead used to contact and control a bone segment.
If there are no anatomic restrictions, opposing olive wires
can direct each bone segment toward each other. A study by
The relevancy of the loading type has to do with stress dis- Shelbrooke et al. provided recommendations for placement
tribution across the bone and implant. Beam-loaded structures of olive wires depending on the obliquity of the fracture
have a more symmetrical stress distribution than cantilever (Figure 3.11A–C).
structures (Figure 3.8). In Figure 3.8, the rotational arrows The study showed that for oblique angles of 30 degrees or
represent bending moments which are calculated as a force less, opposing olive wires placed outside the fracture were given
multiplied by the distance between the force and the support best results, but when the angle increased, olive wires placed
(M = F × D). It is for this reason that monolateral external through the fracture were more effective. In a follow-up clinical
fixators are more stable when they are positioned closer to the study on 50 patients with tibial fractures, it was shown that the
bone and circular external fixators of smaller ring diameter are use of olive wires significantly improved healing times.
more stable than larger diameter ring fixators. External fixator
to skin distance should be optimized to allow just enough room
for postoperative swelling but not too much room to reduce Implant Size and External
the stability of the entire external fixation construct. Fixation Material Considerations
Another advantage to a beam-loaded thin tensioned wire
implant is the adjustability of wire tension to customize the After the type of implant is selected, the next biggest factor is
strength of the implant. Varying amounts of tension can the size of the implant. The formula to calculate the flexural
be used to support different loads in different parts of the anat- rigidity of a uniform circular cross-section pin or wire is
omy. For example, less load-bearing strength would be needed Eπd 4
in the metatarsal bones than in the weight bearing tibia. The
64
external fixator can therefore have varying amounts of tension
depending on the wire location. Tibial wires are typically in the where E is the modulus of elasticity of the material and d is
100 to 130 kg of force range (220 to 286 lb). Calcaneal wires the diameter of the pin or wire. From this formula, we can see
are typically tensioned between 75 and 100 kg of force, and that the biggest contributor to rigidity is the diameter, which
forefoot wires or wires located away from the circular ring on is raised to the fourth power. Any slight increase in diameter
posts are typically in the 50 to 75 kg of force range. These num- has a dramatic increase in overall external fixation stiffness. It
bers are usually case dependent and may vary according to the is important to note that although a half-pin may have a large
patient’s condition, fixation technique, and anatomic location. shaft diameter, if threads are left protruding from the near
In addition, the ability to re-tension wires in the postoperative cortex of bone, there is no longer a uniform cross section of
course allows the surgeon to maintain stability throughout the material and the minor diameter of the protruding thread will
healing process. contribute to a lower stiffness value.
The limitation on the pin diameter is the size of the bone.
In order to prevent a stress riser in the bone from the pinhole,
Steerage Pins the pin diameter should usually not exceed one-third of the
bone diameter. To a lesser degree than diameter, the implant
One of the advantages of cantilever loading through half-pins material also plays a role in stiffness. Table 3.1 shows the
is the ability to direct interfragmentary compression in oblique approximate modulus of elasticity for various implant materials.
fractures. From the experiments of Dr. J. Charles Taylor in
the 1990s, we can see that by placing half-pins parallel to the
fracture line, we can provide direct compression across the Approximate Modulus of
Table 3.1
fracture in a vector that is perpendicular to the shaft of the pin Elasticity Values
(Figure 3.9A–D).
Modulus of Elasticity
Bent Wire Technique Human cortical bone ∼17 GPa

Titanium alloy ∼115 GPa
Stainless steel ∼205 GPa
The same type of interfragmentary compression can be achieved Cobalt chrome ∼240 GPa
using thin tensioned wires through a concept known as the bent
LWBK1121-C03_p033-040.indd 36 04/10/12 11:12 AM

A, B C
Figure 3.9. Steerage pin experiment for interfragmentary compression (A–D) showing
direction of compression forces. From Taylor JC. Poster exhibit. Annual Meeting of the
American Academy of Orthopedic Surgeons; February 26, 1994; New Orleans, LA, with
D permission.
LWBK1121-C03_p033-040.indd 37 04/10/12 11:12 AM

38 Chapter 3
A B
Figure 3.10. Illustration of an arched wire technique for interfragmentary compression (A, B).
From the elasticity values, we can see that stainless steel pins or pins were mixed on all circular ring levels, the self-stiffening
wires will almost double the rigidity of an equivalent titanium effect was lost.
implant.
Optimizing External Fixator

Hybrid Wire/Pin External Construct Stability
Fixation Configurations
There are three common types of external fixator construct:
The combination of wires and pins can also have an effect on Monolateral, bilateral, and circular. The monolateral con-
the external fixation biomechanics. The addition of a half- structs typically use half-pins in a cantilever mode. The bilat-
pin to a thin-wire circular external fixator is most useful when eral constructs use a combination of half-pins and transfixion
wide crossing angles cannot be achieved due to anatomic pins, and the circular constructs can use all types of wire/pin
constraints. A half-pin can dramatically increase the stabil- implants.
ity in the anteroposterior plane where the external fixator With external fixator constructs, the first factor to consider
will experience most of the stresses. In a study by Yang and is distance between the external fixator and the bone. The
Saleh, hybrid external fixators that used both transosseous closer the external fixator is located to the bone, the more
wires and half-pins could still achieve a self-stiffening effect stable the entire construct will be. Thus for circular external
common to pure fixed transosseous wire circular external fixators, a smaller ring diameter is more stable than a larger
fixators as long as at least one bone segment on either side diameter. The limiting factor is the amount of expected swell-
of the fracture contained all wires; however, when wires and ing from the soft tissues postoperatively. The next factor to
A B C
<30° 45° >60°
Figure 3.11. Transosseous wire placement recommendations for oblique fractures (A–C).
LWBK1121-C03_p033-040.indd 38 04/10/12 11:12 AM

A B
Figure 3.12. Divergent pins to increase working length or leverage of the external fixator (A, B).
consider is the distance from fixation elements (pins or wires) When considering location of external fixation elements,
to the point of healing (fracture, osteotomy, or joint). If the it is important to consider the forces in all planes and direc-
bone is considered made up of segments around the point(s) tions. Although the majority of the forces from ambulation
of healing or interest, then the fixation elements should be will be applied in the anteroposterior plane, it is the resulting
spread as far apart in each segment as possible while still respect- alignment in the medial–lateral plane that is very important
ing anatomical considerations. For example, pins should not for long-term results. For the transverse plane, torsional sta-
be placed too close to the joint capsule or fracture hematoma. bility is achieved by spreading the fixation elements across
Spreading pins or wires further apart at each ring level will wide angles. The choices made in positioning wires/pins,
increase the leverage of the external fixator (Figure 3.12A and positioning external fixators, and selecting materials should
B). Circular external fixators with diverging pin configurations always be balanced with considerations for soft tissues, ana-
were studied by Lenarz et al. and their biomechanical test tomic structures, and patient comfort.
results showed that a multiplanar diverging half-pin configu-
ration was stiffer than a traditional tensioned transosseous
Conclusion
wire external fixator.
Biomechanics play an important role in healing. Designing and
constructing external fixators that take advantage of Wolff’s law
C l i n ical Tips and Pearls
and the principles of dynamization can shorten treatment time
A. The three basic biomechanical modes to external fixa- and achieve better results. The primary factor in the stability
tion include compression, distraction, and neutraliza- of an external fixator is the selection of implant diameter fol-
tion. The choice of which mode to use may depend lowed by the implant material. The external fixation implants
on the treatment objective, fracture pattern, fracture should then be positioned in consideration of applied forces
location, or soft tissue condition. in all planes with appropriate leverage obtained by spreading
B. The weakest link in an external fixator is usually the fixation elements across wide angles and long working lengths
pin/bone interface and therefore should be the pri- where anatomically possible.
mary focus of designing an external fixator for biome-
chanical stability.
C. External fixator to skin distance should be optimized to Recommended Readings
allow just enough room for postoperative swelling but Blenman PR, Carter DR, Beaupre GS. Role of mechanical loading in the progres-
not too much room to reduce the stability of the entire sive ossification of a fracture callus. J Orthop Res. 1989;7:398–407.
external fixation construct. Charnley J. Compression Arthrodesis. Edinburgh, UK: E&S Livingstone; 1953.
D. In order to prevent a stress riser in the bone from the Fukada E, Yasuda I. On the piezoelectric effect of bone. J Phys Soc Jpn. 1957;12:
1158–1162.
pinhole, the pin diameter should usually not exceed Goodship AE, Kenwright J. The influence of induced micromovement upon the
one-third of the bone diameter. Spreading pins or wires healing of experimental fractures. J Bone Joint Surg Br. 1985;67:650–655.
further apart at each ring level will increase the lever- Kenwright J, Richardson JB, Cunningham JL, et al. Axial movement and tibial
age of the external fixator. fractures. A controlled, randomised trial of treatment. J Bone Joint Surg Br. 1991;
73:654–659.
E. The choices made in positioning wires/pins, position-
Lenarz C, Bledsoe G, Watson JT. Circular external fixation frames with divergent
ing external fixators, and selecting materials should half pins: a pilot biomechanical study. Clin Orthop Relat Res. 2008;466:2933–2939.
always be balanced with considerations for soft tissues, Metcalfe AJ, Branfoot T, Shelbrooke K, et al. Tibial fractures treated with circular
anatomic structures, and patient comfort. fixation: does the use of olive wires at the fracture site improve healing?
Injury. 2003;34:145–149.
LWBK1121-C03_p033-040.indd 39 04/10/12 11:12 AM

40 Chapter 3
Sarmiento A, Latta LL, Tan RR. The effects of function in fracture healing and Taylor JC. Poster exhibit. Annual meeting of the American Academy of Ortho-
stability. Instr Course Lect. 1984;33:83–106. pedic Surgeons; February 26, 1994; New Orleans, LA.
Sauer PA, Watson JT, Fyhrie DP, et al. Effect of cyclic microshear on fracture heal- Yamagishi M, Yoshimura Y. The biomechanics of fracture healing. J Bone Joint Surg
ing in the rabbit tibia. Presented at the 4th Annual ASAMI Meeting; February Am. 1955;37:1035–1068.
9, 1994; New Orleans, LA. Yang L, Saleh M. The self-stiffening effect of hybrid external fixators with increas-
Shelbrooke K, Ali F, Hashmi M, et al. Fracture site shear motion seen in oblique ing displacement. J Bone Joint Surg Br. 2000;82:262–268.
tibial fractures treated by external fixation can be reduced by additional stabi-
lisation with olive wires. J Bone Joint Surg Br. 2001;83(suppl II):159.
LWBK1121-C03_p033-040.indd 40 04/10/12 11:12 AM

Chapter
4 Paul S. Cooper
Circular External Fixation

Components and Design
Considerations
Introduction
A thorough knowledge of the many components that are
involved in external fixation design and pin/wire attachment
significantly facilitates application of an external fixator to the
lower extremity. In general, there is no limitation to the imagi-
nation on what an external fixator can perform; this has to be
balanced with the time constraint of construction and applica-
tion. The vast majority of foot and ankle cases can be addressed
with a core selection of circular external fixation components.

Components
Figure 4.1. Examples of full, five-eighths, and half external fixation
Circular RINGS, Half Rings and Foot Plates
rings.
The components that make up circular external fixation can be
divided into rings, ring connectors, and fixation hardware. Rings
are either partial (one-half or five-eighths) or full in geometry
(Figure 4.1). While full size rings are typically applied to the
tibia, if postoperative swelling occurs, the ring may need to be
cut off or the circular external fixator taken apart. Two half rings
connected with bolts avoid this complication. Half rings may be
also used in conjunction with the foot ring and complete their
attachment with the tibial circular ring fixation. Five-eighths
rings are typically used either in the proximal tibia to allow for
knee flexion or distally at the ankle joint open anteriorly.
External fixation foot rings are usually “U” shaped in con-
figuration with variable length arms (Figure 4.2). In order to
maximally tension wires off the foot ring, the open front end
needs to be closed off (Figure 4.3). This can be usually accom-
plished by adding a half ring at 90 degrees to the foot ring or
to what is referred by many as the foot plate (Figure 4.4A–C).
Threaded Rods, Telescoping Rods,

and Struts
Rings are connected into segments or blocks by several meth- Figure 4.2. Examples of short and long external fixation foot
ods. The simplest method to build a two or more ring block plates.
41
LWBK1121-C04_p041-049.indd 41 04/10/12 2:40 PM

42 Chapter 4
Figure 4.5. Examples of a ring tibial block or segment. The block

on the left utilizes simple threaded rods with two nuts per side to
Figure 4.3. Examples of external fixation plates with enclosed secure the ring. The sample on the right uses two sockets to achieve
ends and crossbars for anterior to posterior wire placement. the same tibial block configuration.
assembly is with threaded rods and nuts. A minimum of three motion is needed in compression (arthrodesis) cases or distrac-
points dispersed evenly around the ring is recommended; four tion osteogenesis (limb lengthening) (Figure 4.8). The simplest
points confer additional stability of the block (Figure 4.5). way to axially compress or distract between two ring blocks is with
Standard threaded rods are useful in static “tibial block” con- a threaded rod and a compression/distraction nut. The four
figurations where no movement or activity through the block is faces on the nut have one to four dots to correspond with quar-
needed (Figure 4.6A–C). Rings can alternatively be connected ter turns. One full rotation is the equivalent of 1 mm of travel
with variable length struts of threaded sockets or rancho cubes. on the threaded rod, typically recommended in bone transport.
These sockets and cubes can be threaded together with various An effective alternative are telescoping rods. These devices are
lengths of threaded rods (Figures 4.7A–C). pre-assembled with a threaded rod in the core, and by way of
Motion required between ring blocks can be broken down slotted windows and incremental marking, allow measurement of
into single (longitudinal) or multiplanar motion. Longitudinal travel over time (Figure 4.9). Multiplanar motion between ring
A B
Figure 4.4. Parts to construct a closed external fixation foot plate

by using a half ring and a 12-hole crossbar (A). Finished enclosed foot
C plate with a half ring (B) or with an additional crossbar (C).
LWBK1121-C04_p041-049.indd 42 04/10/12 2:40 PM

Circular External Fixation Components and Design Considerations 43
A B
Figure 4.6. Examples of four equal length threaded rods with

attached nuts to both ends ready for fixation of the tibial block (A).
Next, attach and secure the rods with a nut onto the first ring. By feel-
ing with the end of your finger that the rod is secured with the nut,
equal length in each rod is assured (B). Finally, secure each rod with a
C nut onto the ring with a 10 mm crescent wrench (C).
A B
Figure 4.7. Example of an alternative method for constructing a

tibial block by using two sockets with a 30 mm threaded rod and two
16 mm bolts (A). Next, thread the rod into each side of the sockets (B).
C Finally, secure the construct to the tibial block with 16 mm bolts (C).
LWBK1121-C04_p041-049.indd 43 04/10/12 2:40 PM

44 Chapter 4
Figure 4.8. Examples of different struts available (left to right)

include a simple threaded rod with distraction bolt, telescoping rod
with built in distraction/compression mechanism, struts with hinges Figure 4.10. Example of variable strut configuration. This allows
on either end and central sliding mechanism, and universal strut with multiplanar correction in addition to axial compression or distraction.
quick release collar.
segments may consist of one or more combinations of rotational, Wires and Half-pins
translational, sagittal, or coronal plane degrees of freedom.
Methods to affix the rings of an external fixator to the bone fall
More recently, virtual axis concept of struts moving in an infinite
into the categories of wires and half-pins (Figure 4.11). Wires are
number of planes has been advocated. To address multiplanar
further subdivided into smooth and olive. Olive wires have a blis-
correction, a hinged strut is required. These generally combine
ter in the center of the wire used to capture the bone and mini-
hinges at the two ends of the strut with a gradual axial length-
mize translation of the bone traversed on the wire. Olive wires
ening compression/distraction segment in the middle. Newer
can also capture a segment of bone and compress or “dock”
struts allow for quick release of the strut for fast temporary gross
against another segment. Variations on the tips of the wires
reduction and a locking collar for definitive stabilization (Figure
include either a drill tip or a trochar (bayonet) tip (Figure 4.12).
4.10). Virtual axis struts may be used with software programs to
Half-pins are also used for fixation and vary from 4 to 6 mm
determine a schedule for achieving the desired final correction.
in diameter. Depending on the diameter of the pin, half-pins
tend to be stiffer than transosseous wires (Figure 4.13). Half-pin
variations range from self-drilling or blunt tipped, cortical or
cancellous threading, stainless or titanium, and either uncoated
or hydroxyapatite-coated for greater bone fixation (Figure 4.14).
Figure 4.11. Examples of standard wires either smooth or with

olive attachment. Stripes denote side where olive component exists.
Figure 4.9. Example of telescoping rods between two tibial block Longer olive wire is used for axial docking of the foot in the anterior
segments allowing axial compression or distraction only. to posterior orientation.
LWBK1121-C04_p041-049.indd 44 04/10/12 2:40 PM

Figure 4.12. External fixation wire examples of trocar and drill tips. Figure 4.14. Examples of hydroxyapatite-coated pins.
Nuts and Bolts sions off a ring allowing for greater ring stability. Posts come
in variable lengths from one to four holes and in both male
Methods for fixation of wires and half-pins range through
and female ends. Wire fixation bolts are secured through any
degrees of freedom off the parent ring. Standard wire fixation
of the holes, adding another degree of freedom in connection
consists of either an offset or a center fixation bolt (Figure 4.15).
with the parent ring. Half-pin fixation consists of either perpen-
Generally, offset bolts are used most frequently, since the wire is
dicular connectors with a single plane of freedom or ones with
rarely central to the ring hole, and can be slid onto the fixation
multiplanar degrees of freedom (Figures 4.18–4.20).
bolt without the need for bending the wire to thread the center
hole. Newer generation bolts combine the two into the same
bolt. Longer threaded bolts allow for fixation in combination Tensiometer
with washers to elevate the point of fixation a maximum of 8 To achieve optimal tensioning of the wires on the circular
mm. Fixation bolts are secured to the ring by way of hexagonal external fixator, a wire tensiometer allows for variable degrees
nuts. The nut is tightened counterclockwise to capture the wire of tension applied up to the recommended maximum of
against the ring and fixation bolt. In conditions where several 130 kg of force. The older traditional tensiometers have been
fixation bolts are adjacent, crowding may preclude optimal nut modified or upgraded to apply torque through the tensiom-
tightening due to limited wrench access. The use of variable eter without stressing the wrist, which can lead to early fatigue
height nuts or compression/distraction nuts can assure adequate (Figure 4.21). Other tensiometers utilize a ratchet mechanism.
wrench access for optimal tightening (Figure 4.16A and B).
Wrenches
Posts
Wrenches to affix the wire fixation bolts to the ring are numer-
For even greater distances off the ring, wires may be affixed ous in design, but most commonly consist of a standard 10 mm
utilizing a two-, three-, four-, or five-hole male and/or female crescent wrench fixed or articulated (Figure 4.22). This is used
post (Figure 4.17). Posts allow for improved pin spread exten- in conjunction with a counter- or anti-rotation slotted wrench
Figure 4.13. Examples of half-pins ranging from transfixion (left) Figure 4.15. Wire fixation bolts standard and long (top). Note
to cortical pins with either self-drilling or blunt tips (center) and each length comes in both offset and central. Combination bolt
cancellous pin (right). encompasses both (bottom).
LWBK1121-C04_p041-049.indd 45 04/10/12 2:40 PM

46 Chapter 4
A B
Figure 4.16. A: Examples of thin, standard, and distraction/compression nuts. B: Examples of wire
fixation options off the ring. Standard bolt on ring (left), long bolt with up to two 4 mm washers (center),
and three-hole male post with fixation bolt (right). The latter allows for dorsiflexion/plantarflexion directed
wires in addition to rotation off the ring.
Figure 4.17. Examples of posts both male and female. These Figure 4.19. Examples showing various amounts of distance off
allow for extensions off the ring of wire fixation bolts. the ring for half-pin fixation. The half-pin may swivel (rotate) axially
with this construct.
Figure 4.18. Examples of half-pin fixation options. From left to

right: Three-hole rancho cube with 6 mm centering sleeve and Figure 4.20. Examples of half-pin holders with either articulating
12 mm bolt to capture pin, single-hole rancho male, three-hole male hinge or free motion through a slot. In both cases, the half-pin has
post with component off translation buckle, articulated male and additional degrees of freedom to insert proximal/distal in addition to
female single-hole posts. rotation.
LWBK1121-C04_p041-049.indd 46 04/10/12 2:40 PM

Figure 4.22. Various wrenches to tighten nuts on bolts. Left to

Figure 4.21. Examples of older and newer generation traditional right: Articulated and straight crescent wrench, ratchet wrench, and
tensiometers (left) and ratchet tensiometer alternative (right). various angle wrenches.
to avoid bolt malalignment and secondary wire distortion when

tightening the nut on the threaded bolt.
Washers
Washers are used to either extend the reach of a bolt to the
circular external fixator when a wire is not perfectly in align-
ment with the ring. They are usually 2 to 4 mm in thickness
and can be applied either between the wire and the ring or on
the opposite side to elevate the nut seating on the ring (Figure
4.23). Ball and socket washers or wedge washers are available
to accommodate angular attachments to the ring or wither
threaded rods, posts, or fixation bolts (Figure 4.24A–C).
Plates
Plates come in various lengths and orientation. Plates allow
for extensions off the ring in different planes and connections Figure 4.23. Various washers (left to right) range from rectangu-
between rings of different diameters. Plates are either straight lar 2 and 4 mm, slotted circular, conical, and wedge.
or twisted in 90 degrees to permit fixation in perpendicular
AA BB
Figure 4.24. A: Standard perpendicular attachment

of threaded rod to ring. Examples demonstrating conical
washers on both sides of ring allowing for angular fixation
(B) and wedge washers allowing for angular attachment of
CC threaded rod (C).
LWBK1121-C04_p041-049.indd 47 04/10/12 2:40 PM

48 Chapter 4
Figure 4.26. Examples of hinges made from two single-hole

male posts and a 10 mm bolt with nut (left), commercially available
articulating hinge female (center), and a two-plane articulating hinge
made from two single-hole male posts and 90-degree single hole
(right).
Figure 4.27. Example of universal hinges (motors) used between

ring segments for flexion, extension, and varus/valgus plane correc-
tion.
C
Figure 4.25. A: Examples of straight and 90-degree twisted plates.
Plates are helpful in extensions horizontally off the rings. B: Different
sized rings can be connected through the use of plate extensions. C:
Example of a twisted plate extension allowing connection off the ring
at 90 degrees orientation.
orientation (Figure 4.25A–C). Large transverse plate attached

to the front of the foot ring allows for anterior to posterior
directed wires to be secured off the foot ring assembly.
Hinges
Finally, various hinge configurations can be built to address any
deformity correction or malalignment. They can also be com-
mercially available (Figure 4.26). Universal hinges (motors)
can also be used for flexion, extension, or varus/valgus plane
correction (Figure 4.27). Forefoot configurations of universal Figure 4.28. Examples of universal hinges to correct forefoot
hinges are shown in Figure 4.28. supination/pronation.
LWBK1121-C04_p041-049.indd 48 04/10/12 2:41 PM

instrumentation components. A multitude of configurations

C l i n ical Tips and Pearls exist for treatment of complex lower extremity pathology. In
addition to specialized training, detailed surgical planning
A. A great knowledge of the external fixation nomencla-
and creative foresight is necessary when undertaking these
ture, components, and design configurations is neces-
cases.
sary for an efficient and expedite circular external
fixation application.
B. Preoperative planning of certain external fixation
designs including possible components such as tel- Recommended Readings
escoping rods or hinges is paramount for the overall
Augat P, Claes L, Hanselmann KF, et al. Increase of stability in external fracture
patient’s successful outcome.
fixation by hydroxyapatite-coated bone screws. J Appl Biomater. 1995;6:
C. Familiarization with the basic trays where the external 99–104.
fixation components are usually located is necessary for Behrens F. A primer of fixator devices and configurations. Clin Orthop Relat Res.
the surgeon and the operative surgical team. 1989;241:5–14.
D. Duplication of certain core components might be nec- Behrens F. General theory and principles of external fixation. Clin Orthop Relat
Res. 1989;241:15–23.
essary in order to avoid any operative delays in cases of Green SA. The Ilizarov method: rancho technique. Orthop Clin North Am. 1991;22:
instrumentation breakage or malfunctioning. 677–688.
Kummer FJ. Biomechanics of the Ilizarov external fixator. Clin Orthop Relat Res.
1992;280:11–14.
Conclusion Podolsky A, Chao EY. Mechanical performance of Ilizarov circular external
fixators in comparison with other external fixators. Clin Orthop Relat Res.
1993;293:61–70.
Effective use of circular external fixation requires exten- Pugh KJ, Wolinsky PR, Pienkowski D, et al. Comparative biomechanics of hybrid
sive knowledge and familiarity with the variety of available external fixation. J Orthop Trauma. 1999;13:418–425.
LWBK1121-C04_p041-049.indd 49 04/10/12 2:41 PM

Chapter
5 Paul S. Cooper
Operating Room Preparation and

External Fixation Equipment
Introduction is positioned on a standard operating room table if mini

C-arm fluoroscopy is utilized. Alternatively, more proximal
Perioperative planning can significantly improve the efficiency cases involving the tibia, for example, corticotomy with bone
of external fixator application in the operating room. Tem- transport, are best performed on a fluoroscopy operating table.
plate ring sizing can reduce inventory on the back operating Mini fluoroscopy is positioned on the ipsilateral surgical side,
table during setup and the surgeon should have a preliminary while a conventional image intensifier C-arm fluoroscope is
idea of the type and design of external fixation needed for the positioned on the contralateral side (Figure 5.3).
procedure (Figure 5.1). In many of the foot and ankle cases, The patient is positioned with the operative lower extremity
the circular external fixators can be pre-built and sterilized, in neutral position utilizing bolsters under the ipsilateral but-
expediting the operating room time for application (Figure 5.2A tocks and/or shoulder (Figure 5.3). The contralateral lower
and B). extremity is well padded over the fibular head and malleoli to
prevent peroneal nerve compression and pressure sores over
the lateral ankle (Figure 5.4). The use of a pneumatic sequen-
Operating Room Preparation tial compression device for the contralateral lower extremity is
for Circular External Fixation considered on the basis of the time duration of the surgery. A
of the Foot and Ankle thigh tourniquet is placed to allow full access to the tibia and
knee joint. The patella should be draped out and needs to be
The operating table should be positioned in the room so visualized to access for rotation, and the foot should be located
that there is adequate sterile space at the distal end for sur- a few centimeters proximal to the end of the operating table.
geon movement during multiplane wire insertion. The patient The leg may need to be elevated on a leg holder to facilitate
lateral fluoroscopic examination during the procedure (Fig-
ure 5.4). Draping should include multiple layers to minimize
transosseous wire penetration during circular external fixation
application. Additional sterile towels should be available dur-
ing the case for positioning of the lower extremity within the
circular external fixation device.
External fixation application comprises multiple compo-
nents often requiring assembly intraoperatively. An organized
back table is essential for efficient building and application of
the external fixation device (Figure 5.5). The back table should
have the basic trays of components laid out, or to increase
efficiency, a larger single tray with the most frequently used
components (Figure 5.6A–C). If half-pins are planned to be uti-
lized, a separate tray with pins, insertion tools, and pin cutters is
used (Figure 5.7). A pre-built circular external fixation that can
be utilized for most foot and ankle cases is placed on the back
table, or alternatively, a ring tray is added for custom circular
external fixation build out intraoperatively. A separate table
is set up for standard instruments including power saws and
Figure 5.1. Preoperative ring sizing of the lower extremity deter- burrs, osteotomes, and retractors. Extra batteries for the power
mines which rings to have available in the operating room. instrumentation should be readily available. Maintenance of
50
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Operating Room Preparation and External Fixation Equipment 51
A B
Figure 5.2. Examples of a pre-built fixed (A) and adjustable (B) foot rings. These
two constructs can address the majority of foot and ankle procedures.
separation between instrumentation used to address infected or

contaminated tissues and those used during the circular exter-
nal fixation application is critical to reduce risk of postoperative
complications.
The most common components and tensioning instru-
ments are placed on a Mayo stand for efficient repetitive wire
insertion, fixation, and tensioning (Figure 5.8). The items on
the Mayo stand include most frequently used bolts and wire
fixation nuts, washers, smooth and olive wires, tensiometer,
wire cutter, wire bending devices, and wrenches both slotted
and socket. The Mayo stand should also have accommodations
for half-pin insertion including rancho cubes with two, three,
or four holes, centering sleeves, drill sleeve with trochar, drill,
30 and 40 mm threaded half-pins, and power driver. With this
setup, the surgeon has direct access to the items on the Mayo
Figure 5.3. Patient positioning with lower extremity in neutral stand, therefore improving speed and efficiency in the numer-
rotation and a mini C-arm fluoroscopy on ipsilateral side. ous repetitive steps of wire or half-pin insertion.
The general process for lower extremity and foot cases is to
first perform the open procedure. The alignment is stabilized
with temporary threaded or smooth Steinmann pins, and the
surgical wound is closed when feasible. If negative pressure
wound therapy is planned to be used, this may be placed
after the external fixation is applied to minimize wires getting
wrapped up in the wound dressing. In cases where the wound
Figure 5.4. Non-sterile soft bump under lower extremity allows

for easy lateral C-arm fluoroscopy without manipulation of the lower Figure 5.5. Large back operating room table accommodating all
extremity. necessary trays for external fixation application.
LWBK1121-C05_p050-054.indd 51 04/10/12 2:44 PM

52 Chapter 5
A, B C
Figure 5.6. Operating back table demonstrating the wire fixation tray (A), ring tray (B), and newer design
of all small component trays (C).
is left open with a planned delayed closure, a temporary suture

to pull the soft tissues is placed before wires or half-pins are
inserted around the area. A pre-built circular external fixator
may be easily applied over the lower extremity after temporary
stabilization, and threaded pins may or may not be removed
once the definitive stability from the external fixator occurs
(Figure 5.9). The inflated tourniquet is usually deflated before
the percutaneous skeletal fixation of the circular external
fixator.
Figure 5.8. Example of a Mayo stand with most frequently used

components and instrumentation for circular external fixation
application.
Figure 5.9. Example of applying the pre-built circular external

Figure 5.7. Demonstration of a half-pin tray with bolt cutter. fixator over the lower extremity.
LWBK1121-C05_p050-054.indd 52 04/10/12 2:45 PM

Operating Room Preparation and External Fixation Equipment 53
A B
Figure 5.10. Half-pin coverage with a non-adherent dressing, precut sponge (A) and gauze wrap (B).
At the end of the case both incision and wire/pin dressings sponges and a 2 to 3 in. gauze wrap. Alternatively, commercially
need to be addressed. Standard dressings may be difficult to available standard or silver-impregnated sponges and clips are
manage for an incision which may have numerous transosseous available (Figure 5.11A–C).
wires and/or half-pins and limited space around the circular Final adjustments to the circular external fixation system
external fixator. Wires/pins are covered with either betadine are the last procedure before transferring into the recovery
solution or plain non-adherent dressing and partially unrolled room. Compression in arthrodesis cases can be applied, or fine
3 in. gauze wrap and ace bandage that can effectively negotiate tuning residual alignment issues in fractures can be performed
around the tight confines of the external fixator (Figure 5.10A and confirmed with either C-arm fluoroscopy or radiographic
and B). Wire/pin care can be managed with split 4 × 4 gauze series.
A B
Figure 5.11. Examples of half-pins, half-pin covers with

clips (A), clinical application of half-pin cover (B), and
C retaining clip (C).
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54 Chapter 5
Conclusion
C l i n i cal Tips and Pearls
A. For many foot and ankle cases, circular external Careful planning and efficient operating room setup are cru-
fixators can be pre-built and sterilized, expediting the cial for successful application of circular external fixation. The
operating room time for application. surgeon, as well as the entire surgical team, should be well
B. Positioning of the patient and location of the operating versed in these procedures with consideration for alternative
table should allow for extensive use of intraoperative methods in case first-choice options fail intraoperatively.
radiography.
C. Protection of the contralateral lower extremity with
adequate padding is important to avoid iatrogenic com- Recommended Readings
plications. Capobianco CM, Facaros Z, Zgonis T. Perioperative considerations for external
D. Efficient organization of instrumentation on the oper- fixation in foot and ankle surgery. Perioper Nurs Clin. 2011;6:59–66.
ating back table and use of the Mayo stand for the most Catagni MA, Guerreschi F, Lovisetti L. Distraction osteogenesis for bone repair in
the 21st century: lessons learned. Injury. 2011;42:580–586.
common instruments promotes ease of access through-
Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening.
out the case. Clin Orthop Relat Res. 1990;250:8–26.
E. The sequence of surgical procedures should be well
planned to minimize operating time and allow for opti-
mal pin/wire insertion during application of circular
external fixation.
LWBK1121-C05_p050-054.indd 54 04/10/12 2:45 PM

Chapter
6 Paul S. Cooper
Stepwise Approach to Transosseous

Wire and Half-pin Insertion and
Tensioning
Introduction hydroxyapatite or silver coating for bone in-growth or antibac-

terial activity, respectively. However, half-pins are more limited
Circular external fixation wires and half-pins are the primary in orientation insertion.
methods of connection between the external fixator and the
bone. Transosseous wires range from 1.5 to 1.8 mm in thick-
ness have either a bayonet point or a drill tip and they come Transosseous Wire Insertion
in either smooth or olive configurations. Olive wires, enhance and Fixation
buttress strength, are more stable than smooth wires and coun-
teract deforming muscle forces especially with limb lengthen- The standard smooth transosseous wire is typically drilled
ing. Transosseous wires may be tensioned from 50 to 90 kg of percutaneously off the ring to be attached. It is important with
force on open rings or posts and up to a maximum of 130 kg wire insertion to direct the wire gently without pressure on the
of force on a fully enclosed ring. With the variety of fixation ring (Figure 6.1). If too much pressure is applied, the wire is
clamps and methods, transosseous wires may be inserted in directed off the ring proximally and will not land at the same
virtually any axis off any plane to secure on a ring or a series level at the opposite ring side for attachment (Figure 6.2).
of rings. Conversely, if the wire is lifted off the ring, the end of the wire
Half-pins range between 4 and 6 mm in diameter, do not will be distally directed (Figure 6.3). A transosseous wire with
require tensioning and generally add greater stiffness to the incorrect alignment on the ring will serve to create uneven
external fixation construct. Half-pin tips range from self- forces and undesired displacement of the bone segment when
drilling to blunted, cortical and cancellous, and may have tensioned. The wire should be advanced sufficiently that the
Figure 6.2. When too much pressure is applied to the inserted

Figure 6.1. Proper transosseous wire insertion without any pres- wire, it will be reflected proximally and will not land at the same level
sure and directly on the ring. at the opposite ring side for attachment.
55
LWBK1121-C06_p55-70.indd 55 04/10/12 2:48 PM

56 Chapter 6
Figure 6.3. When the wire is lifted off the ring, the end
of the wire will be distally directed.
farthest end has a minimum of two to three finger’s breadth avoid displacement of the wire during tightening (Figure 6.5A
of length beyond the ring, and then secured to the ring using and B). Once secured on the ring, the tip of the wire is cut and
either a central or an offset wire fixation bolt (Figure 6.4A–G). the wire is then curled on to the side of the ring with the end
The transosseous wire is secured by the fixation bolt with a buried into one of the adjacent ring holes to avoid injury (Fig
10 mm crescent wrench and a slotted counter-rotation wrench to ure 6.6A–C). Next, the tensioned side of the wire is secured with
A B
C D
Figure 6.4. A transosseous wire should be advanced sufficiently that the farthest end have a minimum of
two to three finger’s breadth of length beyond the ring (A), and then secured to the ring using either a central
or an offset wire fixation bolt and nut attachments. A central (cannulated) bolt is used when the wire is in
alignment with the hole of the ring (B–D) and an offset wire fixation (slotted) bolt is used when the wire is
not in alignment with the hole of the ring (E–G). (continued)
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Stepwise Approach to Transosseous Wire and Half-pin Insertion and Tensioning 57
E F
G Figure 6.4. (continued)
a similar fixation bolt and tensioned to a maximum of 130 kg is insufficient length of wire for the tensiometer to capture,
against the ring when fully closed (Figure 6.7). If the ring is a a method of in situ manual tensioning can be utilized. In this
5/8 ring or open in any way, the maximum tension is 90 kg. case, as the socket wrench is tightening the bolt on the under-
Once tensioned to the desired amount, the fixation bolt is side of the ring, the fixation bolt is twisted clockwise up to
secured with the same method of a crescent wrench and counter- 90 degrees, tightening the captured transosseous wire (Fig
rotation wrench again, to avoid distortion of the straight line of ure 6.9A–C). Amount of tension, although not quantified, is
the wire on the ring (Figure 6.8A–E). In conditions where the dictated by how much the bolt is rotated as it is tightened.
wire fixation does not permit direct seating of the tensiometer, Optimal stability of the ring segment consists of maximum
a standoff threaded socket or rancho cube is used to apply the transosseous wire spread ideally at 90 degrees, and separation
tension into the transosseous wire. In situations where there of the wires off the ring in all planes. Stability in foot and ankle
A B
Figure 6.5. The transosseous wire is secured by the fixation bolt with a 10 mm crescent wrench (A) and a
slotted counter-rotation wrench to avoid displacement of the wire during tightening (B).
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58 Chapter 6
A B
Figure 6.6. Once secured on the ring, the tip of the transosseous
wire is cut (A) and the wire is then curled on to the side of the ring
(B) with the end buried into one of the adjacent ring holes to avoid
injury (C). Surgeons have described both ways of curling (bending)
C the wire toward the bolt or nut fixation attachment of the ring.
circular external fixators follows the rule of twos: Two limb on the opposite side of the ring. This minimizes one wire hit-
segments, two levels of fixation per segment, and two wires ting and deflecting off the other. A common method for slight
per level of fixation. This means that on the same side of the spacing off the ring is to use a longer fixation bolt with two
ring, the two transosseous wires should be diverging as close to 4 mm washers (Figure 6.11). This has the advantage of simplicity
90 degrees as soft tissue allows. In addition, transosseous wires with fixation and tensioning but will require a threaded socket
should be separated on opposite sides of the ring to allow for to tension. For greater distances off the ring, a male one-, two-,
additional distance between the two wires (Figure 6.10). three-, or four-hole post may be used with the fixation bolt
There are several methods available to achieve optimal dis- attached to the post. This allows not only greater distance for
tance between wires. The simplest is to place the second wire the wire off the ring but also allows for multiple degrees of
Figure 6.7. Example of a tensiometer used to tension

the tibia transosseous wire at approximately 130 kg of
force. Tibial, calcaneal, and forefoot transosseous wires
are usually tensioned in various amounts and according
to the overall external fixation construct, surgical correc-
tion, and patient’s condition.
LWBK1121-C06_p55-70.indd 58 04/10/12 2:48 PM

A B
C D
Figure 6.8. An example showing the opposed side of the secured

and tightened transosseous wire that is tensioned to the desired
amount, followed by tightening of the fixation bolt (A) and appro-
priate cutting, bending, and securing of the transosseous wire’s end
(B–E). It is important to mention that the fixation bolt and nut are
initially attached to the transosseous wire’s ends in a light fashion
and before the tensioning technique is performed. In addition, the
opposed end of the wire needs to be well secured and tightened
E before the initiation of the tensioning process.
freedom in wire placement that standard fixation bolt does not hole on the ring (Figure 6.14A–E). Arched toward the segment
permit (Figure 6.12A–J). Caution should be noted that as the creates compression, whereas away causes distraction. By secur-
transosseous wire is placed further off the ring that the maxi- ing the fixation bolts on the ring itself, tensioning of the wire
mum amount of tensioning diminishes and a bowing effect will serve to compress the segment as increased tensioning is
may be created (Figure 6.13). Maximum tensioning off a post applied. By tensioning the arched wire, compressive forces are
may usually not exceed 90 kg of force. applied axially between segments; however, the control at the
In addition to stabilizing the ring to the lower extremity, compression site is poor and the two segments may slip. The
transosseous wires may be used to mobilize or compress a seg- greater the arching of the wire to the ring, the greater compres-
ment. Two methods utilized are the arched wire and olive wire sive forces and mobilization of the segment will occur. Arched
docking techniques. An arched wire is a method whereby the wires can also be used to mobilize a segment through the ten-
wire is intentionally fixed a set distance away from the ideal sioning (Figure 6.15A and B).
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60 Chapter 6
A B
Figure 6.9. In situations where there is insufficient length of wire

for the tensiometer to capture, a method of in situ manual tensioning
can be utilized. In this case, as the socket wrench is tightening the bolt
on the underside of the ring, the fixation bolt is twisted clockwise up
C to 90 degrees, tightening the captured transosseous wire (A–C).
Another method of compression between osseous segments bone fractures and is very conducive to “docking” a forefoot
or fragments is the olive wire technique (Figure 6.16A–C). The segment to that of the midfoot or the hindfoot segment (Figure
olive end of the wire is driven in direct opposition to the frag- 6.17A–D). This method offers a more controlled compression,
ment or segment to be compressed. Tensioning is applied on since the wire is run axially the length of the segment to be
the contralateral side to pull or reduce the olive and the bone docked. Care should be taken on the degree of tensioning
captured underneath in the direction of the tensioning. This on the contralateral side, as the amount of tension generated
technique is useful in reducing a butterfly fragment of long with the tensiometer can ultimately pull the olive through the
Figure 6.10. Example showing the transosseous wires separated Figure 6.11. A common method for slight spacing off the ring
on opposite sides of the ring to allow for additional distance between when a transosseous wire is inserted is to use a longer fixation bolt
them. with two 4 mm washers (center).
LWBK1121-C06_p55-70.indd 60 04/10/12 2:48 PM

A B
C D
E F
Figure 6.12. For greater distances off the ring, a male one-, two-, three-, or four-hole post may be used
with the fixation bolt attached to the post (A). This allows not only greater distance for the wire off the ring
but also allows for multiple degrees of freedom in wire placement (B, C) that standard fixation bolt does not
permit. (D–J) show appropriate insertion of the wire that is secured and tightened in one end, followed by
tensioning and tightening with the help of a threaded socket on the opposite end. Both ends of the wire are
then cut, bend, and secured inside the ring. (continued)
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62 Chapter 6
G H
I J
Figure 6.12. (continued)
bone. To broaden the area of capture on the osseous segment, Directed only off one side of the external fixator, they have
a small washer to enhance the buttress strength can be applied the advantage of avoiding soft tissues that transosseous wires
under the olive, increasing the area of force applied against frequently must violate on the contralateral ring side. Practical
the bone. applications include in the tibia, calcaneus, and the forefoot
(Figure 6.18A and B).
Standard half-pin insertion technique is through a pin
Half-pin Insertion and Fixation clamp, which can consist of a rancho cube of one, two, three,
or four holes combined with a centering sleeve and a 12 mm
Half-pins offer a greater degree of stiffness compared to tran- bolt (Figure 6.19A and B). A small longitudinal stab incision is
sosseous wires to the bone segment to which they are applied. made where the half-pin dimples the skin. The incision is then
spread longitudinally with a small hemostat (Figure 6.20A–C).
The two methods of insertion include self-drilling and drill
and tap techniques. The self-drilling method comprises direct
drilling of a 4 to 6 mm threaded half-pin on a reamer attach-
ment through a centering sleeve. The half-pin is then stabilized
with a 10 mm bolt to affix the pin to the rancho cube (Fig
ure 6.21A–G). With the drill and tap method, the trochar/
sleeve combination is dimpled to the skin, followed by a longi-
tudinal stab incision with a number 15 blade. After spreading
with the hemostat clamp, the trochar is gently tapped onto the
bone cortex. The trochar is removed, and a drill bit with depth
markings is drilled bicortically, care being taken to decrease
pressure as penetration of the opposite cortex occurs (Fig
ure 6.22A–I).
Normal saline from a bulb syringe minimizes heat genera-
tion during drilling. The depth of the half-pin is measured
Figure 6.13. A transosseous wire inserted further off the ring may off the etched drill or a depth gauge is inserted. The drill
diminish the maximum amount of tensioning. sleeve is removed and the half-pin is manually inserted with a
LWBK1121-C06_p55-70.indd 62 04/10/12 2:48 PM

A B
C D
Figure 6.14. Example of an arched wire technique for provid-

ing compression. This is a method where the wire is inserted in a
straight direction (A) and then is intentionally fixed a set distance
away from the ideal hole on the ring (B–D). Arched toward the
segment creates compression, whereas away causes distraction.
By securing the fixation bolts on the ring itself, tensioning of the
wire will serve to compress the segment as increased tensioning is
applied (E). By tensioning the arched wire, compressive forces are
applied axially between segments. One tensiometer can be used in
one side of the desired compression segments or two tensiometers
can be used on each side of the transosseous wire for simultaneous
and equal distribution of compression. This technique can also be
performed manually by using 10 mm wrenches on each side of the
E fixation bolt and nut at both ends of the transosseous wire.
A B
Figure 6.15. An example of a transosseous wire inserted in a straight direction (A) followed by intention-
ally positioning in an arched fashion preparing for a midtarsal arthrodesis (B).
LWBK1121-C06_p55-70.indd 63 04/10/12 2:48 PM

64 Chapter 6
A B
Figure 6.16. Another method of compression between

osseous segments or fragments is use of the olive wire. The
olive end of the wire is driven in direct opposition to the
fragment or segment to be compressed (A, B). Tensioning is
applied on the contralateral side to pull or reduce the olive and
the bone captured underneath in the direction of the tension-
C ing (C).
A B
C D
Figure 6.17. The olive wire technique for compression of osseous segments is useful in reducing a but-
terfly fragment of long bone fractures (A, B) and is very conducive to “docking” a forefoot segment to that of
the midfoot or the hindfoot segment (C, D). Please note that compression applied through the olive closes
down the fracture (B) or osteotomy site (D).
LWBK1121-C06_p55-70.indd 64 04/10/12 2:49 PM

A B
Figure 6.18. Examples of half-pin insertion in the calcaneus (A) and forefoot (B).
A B
Figure 6.19. Standard half-pin insertion technique is through a pin clamp, which can consist of a rancho
cube of one, two, three, or four holes combined with a centering sleeve and a 12 mm bolt (A, B).
A B
Figure 6.20. Initial steps of half-pin insertion. A small lon-

gitudinal stab incision is made where the half-pin dimples the
skin (A, B). The skin incision is then spread longitudinally with
C a small hemostat (C).
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66 Chapter 6
A B
C D
E F
Figure 6.21. The self-drilling method for half-pin insertion. This

technique comprises direct drilling of a 4 to 6 mm threaded half-
pin on a reamer attachment through a centering sleeve (A–D). The
half-pin is then stabilized with a 10 mm bolt to affix the pin to the
rancho cube (E). Please note that manual tightening is recommended
after the initial self-drilling of the half-pin (C) and that all threads
are underneath the skin surface (D). A second half-pin can also be
G inserted on the same rancho cube (E–G).
LWBK1121-C06_p55-70.indd 66 04/10/12 2:49 PM

A B
C D
E F
Figure 6.22. The drill and tap method for half-pin insertion. The trochar/sleeve combination (A) is
dimpled to the skin, followed by a longitudinal stab incision with a number 15 blade. After spreading with
the hemostat clamp, the trochar is gently tapped onto the bone cortex (B). The trochar is removed (C), and
a drill bit with depth markings is drilled bicortically (D), care being taken to decrease pressure as penetration
of the opposite cortex occurs. The depth of the half-pin is measured off the etched drill or a depth gauge is
inserted (E). The drill sleeve is removed and the half-pin is manually inserted with a half-pin driver (F, G).
All half-pin threads should be underneath the skin surface, with one to two threads proud on the opposite
bone cortex. The outer sleeve is removed and a centering post is inserted (H), followed by the locking
12 mm bolt (I). (continued)
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68 Chapter 6
G H
I Figure 6.22. (continued)
half-pin driver. All half-pin threads should be underneath the tion and rotation (Figure 6.24A and B). In cases where there
skin surface, with one to two threads proud on the opposite is an oblique fracture or osteotomy, steerage half-pins can
bone cortex. The outer sleeve is removed and a centering be used to minimize shear with axial compressive load. The
post is inserted, followed by the locking 12 mm bolt. Alterna- half-pins are oriented parallel to the fracture line obliquity,
tives to rancho cubes involve both straight and articulated pin promoting compression (Figure 6.25A and B). A minimum
clamps (Figure 6.23). A simple half-pin clamp may be fash- of two half-pins per ring should be used, with the ideal orien-
ioned from a translation bolt and a three- or four-hole male tation at 90 degrees and divergent from one another (Fig
post. This clamp allows for translation in addition to angula- ure 6.26A and B).
Figure 6.23. Examples of alternatives to rancho

cubes for half-pin insertion involve both straight and
articulated pin clamps.
LWBK1121-C06_p55-70.indd 68 04/10/12 2:49 PM

A B
Figure 6.24. A simple half-pin clamp may also be fashioned from a translation bolt and a three- or four-
hole male post (A). This clamp allows for translation in addition to angulation and rotation (B).
A B
Figure 6.25. In cases where there is an oblique fracture or osteotomy (A), steerage half-pins can be used
to minimize shear with axial compressive load. The half-pins are oriented parallel to the fracture line obliquity,
promoting compression (B).
A B
Figure 6.26. A minimum of two half-pins per ring should be used, with the ideal orientation at
90 degrees and divergent from one another (A, B).
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70 Chapter 6
Conclusion
A. Transosseous wires, when tensioned, will follow the A thorough understanding of transosseous wire and half-pin
axial line of the wire; it is therefore critical that, when insertion techniques is required for optimal utilization of
inserting wires without the intention of mobilizing a external fixation. Experience, careful attention to anatomical
segment, the wire is attached to its respective ring with- safe zones, and knowledge of numerous possible designs and
out any bending. arrangements to achieve adequate correction can lead to suc-
B. Proximal tibial transosseous wires will often traverse cessful surgical outcomes.
the anterior lateral compartment. This has a tendency
postoperatively to be the first wire to become irritated Recommended Readings
and great knowledge of the safe lower extremity Catagni MA. Treatment of Fractures, Nonunions and Bone Loss of the Tibia with the
anatomic zones is essential to minimize any complica- Ilizarov Method. Copyright 1998, Medi Surgical Video, Milan, Italy.
tions. Catagni MA. Atlas for the Insertion of Transosseous Wires and Half Pins: Ilizarov
Method. Copyright 2003, Medi Surgical Video; Department of Medical Plastic
C. In general, either two transosseous wires with or with-
SRL, via Mercadante, Milan, Italy.
out a half-pin, two to three half-pins, or three transos- Catagni MA, Malzed V, Kirienko A. Advances in Ilizarov Apparatus Assembly. Medi
seous wires are the minimal required for stability per Surgical Video, Department of Medical Plastic SRL, via Mercadante, Milan,
ring in an external fixation segment. Italy; 1999.
D. Half-pins are best utilized along the medial tibial crest, Mehta S, Sheth NP, Freudigman PT, et al. External Fixation: Techniques Using the
Jet-X® System, Featuring Full Freedom Clamps. Philadelphia, PA: Lippincott Wil-
where there is limited soft tissue in the tibia. They are liams & Wilkins; 2007.
also useful to stabilize the hindfoot in the calcaneus Moroni A, Vannini F, Mosca M, et al. State of the art review: techniques to avoid pin
region, directed off the foot ring, or as an adjunct to loosening and infection in external fixation. J Orthop Trauma. 2002;16:189–195.
fixation in the forefoot along the first and fifth meta- Roberts CS, Antoci V, Antoci V Jr, et al. The effect of transfixion wire crossing
angle on the stiffness of fine wire external fixation: a biomechanical study.
tarsals.
Injury. 2005;36:1107–1112.
E. While 5 or 6 mm threaded half-pins are optimal in the Rocchio TM, Younes MB, Bronson DG, et al. Mechanical effect of posterior wire
tibia and/or the hindfoot, the forefoot half-pins should or half-pin configuration on stabilization utilizing a model of circular exter-
be of size 3 or 4 mm in thread diameter. nal fixation of the foot. Foot Ankle Int. 2004;25(3):136–143.
LWBK1121-C06_p55-70.indd 70 04/10/12 2:49 PM

Chapter
7 Paul S. Cooper
Stepwise Approach to Uniplane,

Biplane, Delta, and Hybrid
External Fixation
Introduction site insertion. Longitudinal stab wound followed by dissection

to bone with a small hemostat minimizes the incidence of a
Uniplanar (uniplane) or monolateral (unilateral) exter- calcaneal nerve injury (Figures 7.5–7.7). The ankle construct is
nal fixators are devices applied to one side of the lower then secured and tightened. The ankle hinge is left free, as well
extremity commonly affixed with half-pins. Due to the as the hinges on the proximal and distal ends of the monolateral
limits of half-pin fixation, these external fixation devices fixator. In addition, the compression–distraction segment is set
are viewed for short-term use, when compares with that of at the half-point of excursion. With all mobile segments free,
transosseous wire multiplanar versions. Indications for mon- the upper tibial half-pins are directed medial or anteromedial
olateral external fixation include temporary stabilization in at maximum pin spread (Figures 7.8 and 7.9). Once these half-
acute trauma settings, limb lengthening, ankle arthrodesis pins are secured on the tibia, the ankle is positioned in the
and arthrodiastasis. Additional applications include mid- desired plane with regard to dorsiflexion and plantarflexion,
foot and hindfoot arthrodesis and as an adjunct for wound rotation and varus/valgus alignment, and the articulated hinges
healing through soft tissue stabilization. While technically are locked both proximally and distally (Figures 7.10–7.12).
simpler to apply, these external fixation devices are limited The final adjustment comes at the ankle hinge where the final
in the scope of deformity correction. Hybrid fixation com- degree of ankle sagittal plane position is adjusted. This position
bines advantages of transosseous wires distally and half pin may be unlocked by the patient postoperatively for ankle active
fixation proximally. range of motion if desired (Figures 7.13–7.16 and Clinical
Case I). Following this, the compression–distraction device is
attached and the central unit is unlocked as needed for axial
Uniplane Monolateral Ankle adjustment (Figures 7.17 and 7.18).
External Fixator Technique
With the patient in slight external rotation position, a monola-
teral external fixation device is chosen that has sufficient length
to span the ankle joint and secure half-pins in the tibia above
the level of pathology (Figures 7.1 and 7.2). The first half-pin
inserted is dictated by the talar half-pin, which is directed into
the talar neck perpendicular to the medial talus (Figure 7.3). This
ideal entry point is located about one finger’s breadth anterior
to that of the medial malleolus and advanced to obtain bicorti-
cal fixation. Once this half-pin is confirmed to be in the optimal
location, the ankle clamp of the monolateral external fixator is
slid over the half-pin. This serves as a half-pin template for place-
ment of the second half-pin in the medial calcaneus is directed
(Figure 7.4). The second half-pin is drilled through the medial
calcaneal body with bicortical fixation. Soft tissue considerations
of this half-pin insertion include the calcaneal nerve superficially
and the contents of the tarsal tunnel deeper. Careful exposure Figure 7.1. Examples of uniplane monolateral ankle external fixa-
consists of first creating a dimple corresponding to the half-pin tors. Note each has a compression/distraction central unit.
71
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72 Chapter 7
Figure 7.5. Second half-pin aligned over the calcaneal body. This
approximates the location of the neurovascular bundle and initial
dissection to bone will minimize neurovascular complications.
Figure 7.2. Uniplane monolateral ankle external fixator setup for

application includes the pre-built unit and self-drilling half-pins.
Figure 7.6. Optional third pin inserted into the calcaneal body.
Note orientation of clamp in relation to the talus and calcaneus.
Figure 7.3. First half-pin is inserted into the talar neck in perpen-
dicular orientation to the ankle joint.
Figure 7.4. The pin clamp is applied and used for additional half-
pin insertion template. Figure 7.7. Dorsal view demonstrating half-pin positioning.
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Stepwise Approach to Uniplane, Biplane, Delta, and Hybrid External Fixation 73
Figure 7.8. Proximal half-pin inserted into medial tibia. Note Figure 7.11. The proximal clamp hinge is then tightened.
upper clamp is fully unlocked on ball hinge to allow freedom for
optimal positioning.
Figure 7.9. Second half-pin inserted at the farthest proximal hole Figure 7.12. The central compression/distraction unit is locked.
in the tibia to obtain maximum stability. Additional half-pins may be This can be released later once the unit is applied.
added as needed.
Figure 7.10. Securing the distal hinge first. The ankle should be Figure 7.13. Final ankle sagittal plane position is locked into the
positioned in neutral dorsiflexion/plantarflexion before tightening. ankle hinge joint.
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74 Chapter 7
Figure 7.14. Some uniplane monolateral ankle external fixators

allow for residual correction in other planes. In this example, transla-
tion of the joint can be adjusted.
Figure 7.17. Final construct with compression/distraction unit

applied.
Figure 7.15. Final anterior view of the static uniplane monola-

teral ankle external fixator.
Figure 7.18. Close-up of compression/distraction unit used in

this specific uniplane monolateral ankle external fixator to allow for
axial adjustments.
Figure 7.16. Final medial view of the static uniplane monolateral

ankle external fixator.
LWBK1121-C07_p071_091.indd 74 04/10/12 11:13 AM

CLINICAL CASE I
Example of a uniplane monolateral ankle external fixator used negative pressure wound therapy (A). Note the wound healing
for stabilizing soft tissues across the ankle joint as an adjunct to within the external fixation device (B).
A B
Biplane Ankle External hole to maintain optimal pin spread (Figures 7.25–7.28). Addi-
Fixator Technique tional pins may be inserted between these two pins if additional
fixation deemed necessary (Figures 7.29 and 7.30).
Bars that span the ankle with sufficient length are chosen
With the patient positioned in a supine position, the basic setup
for medial and lateral connections (Figure 7.31). Distally, a
of the biplane external fixator is chosen (Figures 7.19–7.21).
transfixion pin is drilled through the hindfoot in the calcaneal
Next, a four-hole pin fixation clamp is chosen for the proximal
body directed medial to lateral perpendicular to the longi-
tibia. The clamp should have extensions for bar to bar clamps
tudinal axis of the foot (Figures 7.32–7.34). A small incision
on both sides. The first pin is inserted perpendicular to the
with dissection down to the bone minimizes potential injury
tibial crest either with self-drilling half pins, or conventional
methods of stab wound, soft tissue dissection and half-pin inser-
tion (Figures 7.22–7.24). The pin clamp is then positioned two
finger’s breadth from the anterior tibia and lightly tightened,
to be used as a guide for subsequent pin insertions. The next
pin is inserted parallel with the tibial crest using the farthest
Figure 7.19. Basic setup for construction of the biplane ankle

external fixator consisting of four-hole clamp, two pin clamp exten- Figure 7.20. Biplane ankle external fixator used for acute lower
sion bars, four bar to bar large clamps, one bar to bar small clamp, extremity trauma. Note the half-pin extension for the forefoot and
small bar, and half-pins. the threaded transfixion pin for the calcaneus.
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76 Chapter 7
Figure 7.24. The drill sleeve is then inserted.
Figure 7.21. The biplane ankle external fixator consists of two

5 mm threaded half-pins proximally, a 5 mm threaded transfixion
calcaneal pin, and a 4 mm threaded half-pin into the foot.
Figure 7.25. Using the pin clamp apparatus as a template, insert

the second half-pin distal to the first. Use the trochar to align the drill
sleeve against the tibia bone.
Figure 7.22. First step begins with insertion of a half-pin into the
anterior medial central 1/3 of the tibia.
Figure 7.26. The drill is then used to obtain a bicortical drill hole.
Figure 7.23. Pin clamp apparatus is then applied over the first
half-pin and used as a template for additional half-pin locations.
LWBK1121-C07_p071_091.indd 76 04/10/12 11:13 AM

Figure 7.27. The second half-pin is then inserted bicortically.
Figure 7.30. Final dorsal view of the pin clamp construct lined
up with the longitudinal axis of the tibia.
Figure 7.28. Completed tibia pin clamp construct.
Figure 7.31. Example of sizing the appropriate bar to extend

across the ankle joint.
Figure 7.29. Adequate space between the pin clamp and anterior
tibia of a minimum of two finger’s breadth is necessary to avoid soft
tissue impingement with swelling.
Figure 7.32. Transfixion pin directed transversely from medial to

lateral direction into the calcaneal body.
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78 Chapter 7
Figure 7.33. Transfixion pin advanced through the calcaneus. Figure 7.34. Final positioning of transfixion pin into the cal-
caneus.
to the medial calcaneal nerve. The transfixion calcaneal pin pin (Figures 7.37 and 7.38). The ankle is positioned in neutral
is inserted to optimally cover all threads under the subcutane- dorsiflexion, but will fall into equinus with only a single trans-
ous tissue if possible. Following this, medial (Figure 7.35) and fixion pin into the hindfoot (Figures 7.39 and 7.40 and Clinical
lateral (Figure 7.36) extension bars are placed off the tibia pin Case II).
clamp. Proper length connecting bars are chosen and attached Additional fixation may be applied in the hindfoot through
to the tibial fixation block and that of the calcaneal transfixion a second calcaneal transfixion pin or a half-pin unilaterally
CLINICAL CASE II
Example of a severely high-energy pilon fracture with extensive

soft tissue swelling initially managed with the use of a biplane
ankle external fixator (A, B).
A B
LWBK1121-C07_p071_091.indd 78 04/10/12 11:14 AM

Figure 7.35. Extension bar placed medially off the tibia pin
clamp apparatus. Figure 7.38. In a similar fashion, the lateral connection between
the tibia pin to bar clamp and transfixion calcaneal pin is achieved.
Figure 7.36. Second extension bar off the tibia pin clamp Figure 7.39. Medial view with medial and lateral bar connections
apparatus laterally. with the transfixion calcaneal pin.
Figure 7.37. Large bar to pin clamp connects bar distally to the Figure 7.40. Plantar view of transfixion calcaneal pin and connec-
transfixion calcaneal pin medially. tions to long bars.
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80 Chapter 7
CLINICAL CASE III
Example of a biplane ankle external fixator applied for acute calcaneal pins in addition to two forefoot half-pin stabilization
lower extremity trauma. Note the use of two transfixion (A, B).
A B
through the talus (Figures 7.41–7.43). Forefoot fixation may to the main bar with a small to large clamp (Clinical Case III).
be added to keep the forefoot out of equinus by directing a Additional half-pins may be added in a similar method later-
4 mm threaded half-pin into the first metatarsal at a 45-degree ally into either the cuboid or the fifth metatarsal to minimize
angle. A small pin to bar clamp connects the small bar extension supination (Figures 7.44 and 7.45).
Figure 7.41. Optional use of two transfixion pins into the cal- Figure 7.42. Close-up view of two transfixion pins into the cal-
caneus connected to both bars with ankle clamp to bar units. caneus.
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Figure 7.43. Posterior view of two transfixion pins into the Figure 7.45. Final construct of the biplane ankle external fixator
calcaneus. with the forefoot connection.
Delta Variant of Biplane Ankle

For optimal external fixation stability, tibial half-pins should
be placed as close to a 90-degree orientation as possible (Chap-
ter 3). This half-pin spread would result in penetration through
the anterolateral compartment resulting in possible muscle,
nerve, or arterial injury. A “V” orientation in half-pin diver-
gence pattern is more practical and is referred to as the “delta”
design configuration (Figures 7.46 and 7.47). The first group
of half-pins is placed anteromedial off the tibia, followed by a
second group directed anterior off the tibia crest. Care should
be made to avoid slipping laterally off the crest to avoid damag-
ing the soft tissue structures in the anterolateral compartment.
Hybrid Ankle External

Fixator Technique
Hybrid external fixation consists of half-pins on one side
of the monolateral external fixation and transosseous wires Figure 7.46. Variation using delta pin clamp configuration for
added stability.
Figure 7.44. Insertion of 4 mm threaded half-pin into the first Figure 7.47. Delta pin clamp configuration. Note divergent pat-
metatarsal base. tern of paired half-pins.
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82 Chapter 7
Figure 7.48. Setup for a hybrid ankle external fixator. Note the Figure 7.50. Lining up the five-eighths ring with the subtalar
four bar to ring clamp adapters. joint.
connected to a five-eighths or foot rings on the opposite wires are planned for fracture stabilization, or over the subtalar
end. Typically used in comminuted intra-articular fractures on joint if spanning the ankle joint (Figure 7.50). Two diverging
either end of the tibia, the hybrid external fixation method transosseous wires are directed into the talus, to avoid capturing
draws on the advantages of both forms of external fixation. either malleoli so that distraction can occur through the ankle
Cortical purchase is poor in the comminuted periarticular joint (Figures 7.51 and 7.52). Additional transosseous wires may
fractures involving the tibial plateau or pilon regions making be applied in a similar diverging pattern below the ring into
half-pins suboptimal fixation. Transosseous olive wires can be the calcaneus for added stability. When the ring is open, all
used to pull the fragments together or span the involved joint wires are tensioned to 90 kg of force maximum. Medial and lat-
to allow for reduction through ligamentotaxis. Either a tubular eral long bars are then attached from the tibial block to the dis-
or a monolateral external fixator is used for the tibial shaft fixa- tal ring segment for added external fixation stiffness (Figures
tion of the external fixator and is connected through a special- 7.53 and 7.54). Additional posterior bars may also be attached
ized clamp(s) to the open ring distally to permit transosseous and secured to the hybrid system for additional stability
wire fixation (Figure 7.48). (Figures 7.55–7.60). Distraction through the ankle joint allows
The proximal half-pins are inserted in a similar fashion to for reduction, followed by additional wires through the meta-
that of either the tubular or the monolateral pre-built system physeal segment for fracture fixation. When compression or
as described above (Figure 7.49). A five-eighths or foot ring may distraction is needed, a hybrid system which consists of a
be attached distally to the monolateral external fixator with monolateral fixator with a special ring adaptor clamp is used
specialized clamps. The ring is centered over the distal tibia if (Figures 7.61–7.63).
Figure 7.49. Proximal half-pins directed into the midshaft

tibia with pin clamp and clamp extensions medially and laterally as
described in the insertion for the biplane ankle external fixation Figure 7.51. Final position of both transosseous wires capturing
technique. the talus.
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Figure 7.52. Medial view of the two transosseous talar wires.
Figure 7.55. Attachment of anterior bars with additional poste-

rior ring to bar clamps and posterior bar attachments.
Figure 7.56. Clamps secured on the ring once final position is

determined.
Figure 7.53. Attachment of the medial bar with bar to bar clamp
proximally.
Figure 7.54. Lateral bar attachment in a similar fashion. Figure 7.57. Final anterior view of the hybrid ankle external fixator.
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84 Chapter 7
Figure 7.58. Final medial view of the hybrid ankle external fixator. Figure 7.61. Alternative hybrid ankle external fixator construct
using modified monolateral fixator directly attached to a foot external
ring. Struts are added for multiplane stability.
Figure 7.59. Final construct view of the two transosseous wires

into the talar body.
Figure 7.62. Alternative hybrid ankle external fixator applied

to bone saw model.
Figure 7.60. Plantar view of the hybrid ankle external fixator.
Figure 7.63. Anterior view of alternative hybrid ankle external

fixator construct. Note central compression/distraction unit allows
for additional axial adjustments.
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CLINICAL CASE IV
Example of a biplane foot external fixator for the acute man-
agement of a severe midfoot fracture dislocation (A–C).
A B
Uniplane Monolateral Foot navicular or cuboid are at risk with reconstruction for shorten-
External Fixator Technique ing due to compressive forces of spanning tendons. A uniplane
for Arthrodesis monolateral external fixator can negate these forces while the
fracture has time to consolidate. Limited internal fixation may
Uniplane or biplane fixation in the foot can be used for be combined with the external fixation to avoid extensive soft
acute trauma, arthrodesis, and distraction arthroplasty settings tissue dissection which further devascularies the fracture. For
(Clinical Case IV). Comminuted or crush injuries of the tarsal uncomplicated isolated joint fusions, a monolateral external
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86 Chapter 7
Figure 7.64. Example of a medial column biplane osseous wedge Figure 7.66. Second half-pin insertion spanning the talonavicular
resection for arthrodesis of the navicular–cuneiform joints with a joint to maximize half-pin spread.
uniplane monolateral foot external fixator.
fixator can generate sufficient stability and compression to template, with the proximal clamp serving as a pin location
achieve successful union without the need for a circular exter- template. The proximal pin is similarly inserted at an equal
nal fixator. In distraction mode, a monolateral external fixator distance and orientation to the osteotomy as that of the distal
can negate compressive forces on an interpositional arthro- pin (Figure 7.66). The osteotomy site may now be adjusted in
plasty as seen in either the cuboid–metatarsal or the metatar- a dorsal–plantar direction before additional pin insertion. The
sophalangeal joint. Unlike circular external fixators which can half-pins should be spread as much as possible per pin clamp
be applied for months, the longevity of monolateral external (Figures 7.67–7.70). Dependent on the system used, half-pins
fixators are limited to approximately 6 to 8 weeks in duration may either diverge or span adjacent joints to enhance stabil-
before half-pin loosening renders them ineffective. ity. Proximal placed half-pins near the talonavicular joint may
A medial column arthrodesis at the navicular–cuneiform impinge on the medial malleolus with sagittal motion. Com-
joints is described below with the application of a uniplane mon- pression is then applied either acutely or gradually postoperatively
olateral external fixator. A correctional wedge osteotomy is per- as needed (Figures 7.71–7.73 and Clinical Case V).
formed and temporarily stabilized with a threaded Steinmann In cases where spanning across adjacent joints is undesir-
pin if needed (Figure 7.64). The first 4 mm threaded half-pin able, a stacked configuration is used. In this case, multiple half-
is inserted perpendicular or alternatively, angulated toward the pins are directed in different planes off the bar, all oriented
osteotomy site to accomodate 5 to 10 mm from the compression into the specific bones involved with the arthrodesis procedure.
site (Figure 7.65). The monolateral external fixator is applied The added half-pin density, however, increases the potential
with both pin clamps gapped at least 1 cm to allow for compres- for half-pin loosening earlier than those configurations with
sion without impingement. The external fixator is used as a pin maximal half-pin spread (Figures 7.74–7.80).
Figure 7.65. First half-pin insertion into the base of the navicular Figure 7.67. Distal half-pin insertion perpendicular to medial
either perpendicular or slightly convergent pattern. cuneiform base.
LWBK1121-C07_p071_091.indd 86 04/10/12 11:14 AM

Figure 7.68. Second distal half-pin insertion into the base of the Figure 7.71. Method for compression between pin segments
first metatarsal. using a compression clamp.
Figure 7.69. Connection of pin clamps with a bar connected by

Figure 7.72. Full compression achieved across the osteotomy site.
pin to small bar clamps.
Note pin convergence and near apposition of osseous segments.
Figure 7.70. Pin to bar ball hinges allow for optimal positioning
of the uniplane monolateral external fixator. Allow for a minimum of Figure 7.73. Dorsal view of compression through the clamps. Note
1 cm distance from the skin for dressing and pin care. pin convergence and clamp approximation.
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88 Chapter 7
CLINICAL CASE V
Preoperative Charcot neuroarthropathy (A, B) involving period. Salvage with uniplane monolateral external fixa-
the midfoot joints initially addressed with medial column tion placed in compression was achieved (D, E). Postop-
plating (C). Wound dehiscence and deep infection neces- erative radiographs demonstrate successful medial column
sitated plate and screw removal in the early postoperative fusion (F, G).
A B
C D
(continued)
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Clinical case V (continued)
E F
Figure 7.74. Alternative configuration for uniplane monolateral Figure 7.75. Pin to bar clamp placed superiorly with direct
foot external fixator for arthrodesis with parallel half-pin insertion on impingement between the two clamps.
both sides of the osteotomy site.
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90 Chapter 7
Figure 7.76. Optimal half-pin clamp position allows for room Figure 7.79. Compression applied across the half-pins allows for
between clamps for compression. maximum convergence of both sides of the osteotomy without pin or
clamp impingement.
Figure 7.80. Note compression through parallel half-pins results

in pin impingement before maximum compression achieved.
Figure 7.77. Second set of half-pins are inserted dorsally and
directed convergence to maintain location into both the cuneiform
and navicular bones only.
Uniplane Monolateral Foot
for Distraction Arthroplasty
A lateral column distraction arthroplasty at the cuboid–metatar-
sal joints is described below with the application of a uniplane
monolateral external fixator (Figure 7.81). The cuboid–metatar-
sal joint is resected with approximately 5 mm on both sides. A soft
tissue interposition may be inserted from the extensor digitorum
brevis muscle or allograft tissue. Diverging or perpendicular half-
pins are placed into the cuboid 5 mm proximal to the osteotomy.
The monolateral external fixator is applied with 1 cm clear from
the skin surface. The monolateral external fixator is applied with
both clamps closely approximated to allow for maximum distrac-
tion excursion. The second half-pin is inserted either perpen-
dicular or slightly divergent into the base of the fifth metatarsal.
The pin may be driven deep to capture the fourth metatarsal for
added fixation if needed (Figure 7.82). Sagittal plane positioning
may now be adjusted followed by additional half-pins into the
Figure 7.78. Demonstration of maximizing half-pin spread cuboid proximally, and the shaft of the fifth metatarsal distally
directed into only the navicular and cuneiform bones. This is accom- (Figure 7.83). Joint distraction requires no more than 5 mm to
plished by stacking in vertical plane the half-pins. 1 cm (Figure 7.84).
LWBK1121-C07_p071_091.indd 90 04/10/12 11:15 AM

Figure 7.81. Half-pin setup for distraction arthroplasty with a uni- Figure 7.84. Compression/Distraction unit allows for distraction
plane monolateral external fixator. Note the internal compression/ through the segment by turning the collet.
distraction unit built in.
Clinical Tips and Pear l s

A. Indications for monolateral external fixators are acute
trauma for temporary stabilization, lower extremity
lengthening, ankle arthrodesis and arthrodiastasis,
midfoot/hindfoot arthrodesis, and as an adjunct soft
tissue stabilizer in wound care.
B. Comminuted or crush injuries of the tarsal navicular
or cuboid are at risk when reconstructed of shortening
due to compressive forces from spanning tendons. A
uniplane monolateral external fixator can negate these
forces while the fracture has time to consolidate.
C. In comminuted intra-articular fractures on either end of
the tibia, the hybrid external fixation system draws on
the advantages of multiple forms of external fixation.
Figure 7.82. Single half-pin insertion on both sides of the arthro-
plasty allows for each clamp rotated for optimal position of additional
half-pins on both sides.
Conclusion
In this chapter, a detailed surgical approach to various types of
external fixation has been described. It is imperative that the
surgeon is well aware of all different options and methods of
external fixation before choosing the final construct for the
patient’s successful outcome.
Recommended Readings
Bonar SK, Marsh JL. Unilateral external fixation for severe pilon fractures. Foot
Ankle. 1993;14:57–64.
Clemens M, Parikh P, Hall MM, et al. External fixators as an adjunct to wound
healing. Foot Ankle Clin. 2008;13:145–156.
Tornetta PD, Weiner L, Bergman M, et al. Pilon fractures: treatment with com-
bined internal and external fixation. J Orthop Trauma. 1993;7:489–496.
Figure 7.83. Lateral view demonstrating half-pin positions both
proximal in the cuboid and distally in the fifth metatarsal.
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Chapter
8
John J. Stapleton
Vasilios D. Polyzois
Thomas Zgonis
Stepwise Approach to Static

Introduction of a failed ankle arthroplasty. These clinical case scenarios

are often not amenable to the sole use of internal fixation;
The successful outcome for utilizing static circular external therefore, external fixation becomes a salvage tool to achieve
fixation is determined not only by careful procedure and osseous stability while protecting the soft tissue envelope. At
patient selection but also by understanding the fundamental times, the use of internal fixation can be supplemented with
principles and designs of external fixation to prevent the risk external fixation to enhance osseous stability and/or to pro-
of potential complications. The term static, for purposes of this mote an earlier weight bearing status (Clinical Cases I–V).
chapter, will be used for the description of a pre-built circular Static circular external fixation may also be beneficial in the
external fixation that provides osseous stability for various acute management of diabetic ankle fractures and/or disloca-
foot and ankle pathologies. This design can also have dynamic tions to provide further stabilization in the presence of dense
functions such as joint distraction or compression if desired. peripheral neuropathy. Furthermore, static circular external
Pre-built or partially built circular external fixation devices with fixation can provide additional stability when combined with
a similar design can be applied in an expedited manner and internal fixation to avoid the possible development of acute
are used in many case scenarios as they are very beneficial for CN with unstable fracture patterns and anticipated premature
the surgical management of deformities, posttraumatic condi- weight bearing (Clinical Case VI).
tions, neuromuscular disorders, diabetic complications, and Static circular external fixation is indicated for a majority
revisional surgery. of diabetic limb salvage cases involving the midfoot, rearfoot,
The goal of this chapter is to discuss the indications in which and ankle. CN with unstable deformities, malunions, and/or
this design is advantageous along with providing the reader a nonunions of the foot and ankle can often be addressed with
step-by-step technical approach to its application in various foot a pre-built static circular external fixation. Other common
and ankle conditions. Technical pearls and meticulous details indications in the diabetic population include limb-threatening
are also discussed. conditions such as infected hardware and/or previous failed
surgeries with infected wounds and ulcerations. Static circu-
lar external fixation is beneficial to achieve osseous stability,
Indications/Contraindications deformity correction, salvage arthrodesis and to surgically off-
load and stabilize the soft tissue envelope for the majority of
The indications for the utilization of a static circular external diabetic limb salvage cases. Soft tissue immobilization is crucial
fixation are numerous. The main advantage inherent to this among diabetic patients with open wounds that often require
external fixation system is the reproducibility of using a similar plastic surgical reconstruction in addition to their osseous
design to manage a variety of conditions involving the midfoot, procedure(s) (Clinical Cases VII–IX).
rearfoot, and ankle. However, the capability to treat such a The contraindications of static circular external fixation usu-
wide variety of foot and ankle pathology with a static circular ally do not pertain to the application of the device but rather to
external fixation requires a significant learning curve and sur- the procedure that is performed in conjunction. Key points to
gical experience of the complex surgical procedures in order consider as contraindications are the presence of severe periph-
to produce a successful outcome. eral vascular disease with limb ischemia not amenable to revas-
Some of the most common indications for this external fixa- cularization and active infection with systemic manifestations.
tion device include but are not limited to midfoot, rearfoot, External fixation is often utilized to limit soft tissue dissection
and ankle arthrodesis for posttraumatic arthrosis, malunions and to avoid the placement of retained hardware. These two
and/or nonunions, Charcot neuroarthropathy (CN), gross advantages inherent to external fixation often lead to its use in
deformity, neuromuscular disorders, avascular necrosis of the the patient population with peripheral arterial disease and/or
talus, previous history of infection or septic joint, and salvage history of infection. For this reason, a thorough preoperative
92
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Stepwise Approach to Static Circular External Fixation 93
Clinical Case I
Anteroposterior (A) and lateral (B) ankle radiographic views alignment of the lower extremity and the utilization of the tibial
showing the preoperative lower extremity equinocavovarus block connected to the foot plate (C, D). The external fixation
deformity from a post-polio syndrome. The patient had a prior device was maintained for about 10 weeks and the patient was
history of a midfoot arthrodesis, Achilles tendon lengthening, then transitioned to a knee–ankle–foot orthosis with permitted
and resection of the distal fibula with a failed outcome. An weight bearing status. Final radiographic views at 1 year postop-
ankle arthrodesis was performed with the utilization of Stein- eratively showing successful arthrodesis and alignment of the
mann pins and static circular external fixation. Please note the lower extremity (E, F).
A,B C
D,E F
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94 Chapter 8
Clinical Case II
Preoperative anteroposterior (A) and lateral (B) ankle radio- postoperatively and the patient was then transitioned to a non–
graphic views showing the avascular necrosis of the talus weight bearing below the knee cast application for 4 weeks
with collapse after a nonunion of a talus fracture. A tibiota- followed by a weight bearing status with the cast application
localcaneal arthrodesis was performed with the utilization for an additional 2 weeks. Final radiographic views at 9 months
of Steinmann pins and static circular external fixation (C, postoperatively showing successful arthrodesis at the subtalar
D). The external fixation device was removed at 10 weeks joint and stable pseudoarthrosis at the ankle joint (E, F).
A B
C D
(continued)
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Clinical case II (continued)
E F
Clinical Case III
Preoperative anteroposterior (A) and lateral (B) ankle radi- device was removed at about 10 weeks postoperatively and the
ographic views showing posttraumatic arthrosis and varus patient was transitioned to a weight bearing cast for another
deformity of the subtalar and ankle joints secondarily to a 4 weeks. The patient resumed full ambulation with regular
malunion of a distal tibia fracture. A tibiotalocalcaneal arthro- shoes and returned to his normal daily activities. Final radio-
desis was performed with the utilization of Steinmann pins and graphic views at 1 year postoperatively showing successful
static circular external fixation (C, D). The external fixation arthrodesis at both subtalar and ankle joints (E, F).
A B
(continued)
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96 Chapter 8
Clinical case III (continued)
C D
E F
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Clinical Case IV
Preoperative anteroposterior (A) and lateral (B) ankle radio- external fixation device was removed at about 10 weeks postop-
graphic views showing ankle joint arthrosis and equinocavo- eratively and the patient was transitioned to a weight bearing cast
varus deformity after a triple arthrodesis for a neuromuscular for another 4 weeks. The patient resumed an ambulatory status
foot deformity correction. An ankle arthrodesis with an acute with regular shoe gear and without any bracing. Final radio-
deformity correction was performed with the utilization of graphic views at 10 months postoperatively showing successful
Steinmann pins and static circular external fixation (C, D). The arthrodesis at the ankle joint with deformity correction (E, F).
A B
C D
(continued)
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98 Chapter 8
Clinical case IV (continued)
E F
Clinical Case V
Preoperative anteroposterior (A) and lateral (B) ankle radio- arthrodesis was performed with the utilization of Steinmann
graphic views demonstrating osteomyelitis of the ankle joint pins and static circular external fixation (C, D). The external
with resorption of the talar body. The patient had a history of fixation device was removed at about 12 weeks postoperatively
rheumatoid arthritis and a failed triple arthrodesis. Initially, all and the patient was transitioned to a non–weight bearing cast
internal hardware was removed and a thorough surgical debride- for 2 weeks followed by a weight bearing cast for an additional
ment of the remaining talus and distal tibia was performed with 2 weeks. The patient resumed full ambulation with an extra
the insertion of nonabsorbable cemented antibiotic impreg- depth rocker bottom shoe at 5 months postoperatively. Final
nated beads at the ankle joint. The inserted antibiotic beads radiographic views at 1 year postoperatively showing successful
were removed at about 6 weeks and a revisional tibiocalcaneal osseous union at the tibiocalcaneal arthrodesis site (E, F).
A B
(continued)
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C D
E F
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100 Chapter 8
Clinical Case VI
Preoperative anteroposterior (A) and lateral (B) ankle radi- at about 6 weeks and an ankle arthrodesis was performed with
ographic views demonstrating a nonunion/malunion of a the utilization of Steinmann pins and static circular external
bimalleolar ankle fracture. A draining sinus laterally and deep fixation (C, D). The external fixation device was removed at
infection involving the hardware and fibula were evident. Ini- about 12 weeks postoperatively and the patient was transitioned
tially, all infected hardware was removed and the infected bone to a non–weight bearing cast for 2 weeks followed by a weight
was debrided and packed with cemented antibiotic impreg- bearing cast for an additional 4 weeks. Final radiographic views
nated beads. Negative pressure wound therapy was also utilized at about 1 year postoperatively showing successful osseous
at the open wound. The inserted antibiotic beads were removed union at the ankle joint with slight valgus deformity (E, F).
A B
C D
(continued)
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Clinical case VI (continued)
E F
Clinical Case VII
Preoperative anteroposterior (A) and lateral (B) ankle radio- was stabilized with a hybrid external fixation system (C, D). The
graphic views demonstrating an infected nonunion of a tibiota- inserted antibiotic cemented rod was removed at about 6 weeks
localcaneal arthrodesis with an intramedullary rod for a diabetic and a revisional tibiotalocalcaneal arthrodesis was performed
Charcot ankle in a hemodialysis-dependent patient. Initially, the with the utilization of Steinmann pins and static circular exter-
deep infection and osteomyelitis was managed with removal of nal fixation (E–G). The external fixation device was removed at
the intramedullary rod, extensive osseous and soft tissue debri- about 12 weeks postoperatively and the patient was transitioned
dement, and reaming of the entire medullary canal of the tibia. to a non–weight bearing cast for 4 weeks. Final radiographic
An antibiotic impregnated cemented rod was then inserted at views at about 6 months postoperatively showing a stable pseu-
the previous attempted arthrodesis site and the lower extremity doarthrosis without any clinical evidence of infection (H, I).
A,B C
(continued)
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102 Chapter 8
Clinical case VII (continued)
D,E F
G,H I
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Clinical Case VIII
Preoperative anteroposterior (A) and lateral (B) foot radio- external fixation (C–E). The external fixation system pro-
graphic views demonstrating a rocker-bottom diabetic Charcot vided assistance to the acute shortening and compression of
neuroarthropathy deformity. Initially, an extensive osseous the diabetic Charcot foot. The external fixation device was
and soft tissue debridement was performed and intraoperative removed at about 8 weeks postoperatively and the patient
bone biopsy did confirm osteomyelitis of the midfoot bones was transitioned to a non–weight bearing cast for 2 weeks fol-
from the plantar chronic ulceration. After systemic antibiosis lowed by a weight bearing cast for an additional 2 weeks. Final
treatment, the patient was brought back to the operative room radiographic views at about 6 months postoperatively showing
for an “internal” midfoot amputation and stabilization of stable pseudoarthrosis with shortening of the diabetic Charcot
the remaining joints with Steinmann pins and static circular midfoot (F, G).
A B
C D
(continued)
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104 Chapter 8
Clinical case VIII (continued)
E,F G
Clinical Case IX
Preoperative anteroposterior (A) and lateral (B) ankle radio- fixation for further stability and protection of the soft tissue
graphic views demonstrating a high-energy pilon fracture/ envelope. Radiographic (C, D) and clinical (E, F) views at
dislocation in a patient with a history of diabetes mellitus. The 6 weeks postoperatively showing anatomic alignment and heal-
patient underwent reduction of the severe injury with the use ing of the soft tissue injury. The static circular external fixator
of internal fixation supplemented by a static circular external was removed at approximately 18 weeks after surgery (G, H).
A B
(continued)
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Clinical case IX (continued)
C D
E F
(continued)
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106 Chapter 8
G H
vascular examination of the lower extremity determines if static static circular external fixation consists of two tibia circular
circular external fixation with its proposed procedure would rings and an external foot plate. These rings are initially assem-
be contraindicated. A systematic and rational approach to the bled with two threaded rods measuring approximately 120 to
management of deep osseous and soft tissue infections needs 150 mm in size and are placed in opposite directions bisecting
to be performed before the application of the external fixation the center of the ring. The placement of these threaded rods
device. Active, untreated infection is a contraindication to the will align with the anterior crest of the tibia once assembled.
utilization of a static circular external fixation. This “tibial block” which consists of the two tibia rings is then
History of noncompliance with treatment is a relative con- connected to the foot plate with two threaded rods measuring
traindication. Psychosocial issues may need to be addressed approximately 150 to 200 mm in length and located within the
prior to surgery and while they might not be an absolute con- posterior central portion of the foot plate (Clinical Case X).
traindication, they may have implications with the postoperative The positioning of the first threaded rod to the tibial block is
regimen. On the contrary, in certain case scenarios in which the paramount as they provide initial stability to the static circular
need for additional osseous stabilization achieved with a static external fixation while allowing access in the direction that
circular external fixation is required among the noncompli- the wires and/or pins will be inserted. Ring size is dependent
ant patient, the procedure is performed as the anticipation of on the size of the lower extremity while considering possible
hardware failure, nonunion, malunion, and/or amputation is fluctuations in leg size from edema, surgery, preexisting lym-
feasible. Amputation may also be preferable in certain patients phatic conditions, and chronic venous insufficiency. Posttrau-
who are nonambulatory in the presence of a lower extremity matic edema is typically anticipated and can be accounted for
deformity, peripheral vascular disease, and severe infection. when sizing the rings to a patient’s lower extremity. The rings
may be sized preoperatively to expedite the application of a static
circular external fixation. However, preexisting lower extremity
Preoperative Considerations
edema, whether related to lymphedema or venous insufficiency,
may be more difficult to predict and treat once a static circular
Determining the Appropriate Size of the
external fixation is applied. Determining the appropriate size of
Static Circular External Fixation
the circular ring with an edematous lower extremity is vital to
In adults, circular ring sizes that are most commonly utilized are prevent iatrogenic wounds and skin necrosis from pressure of
between 155 and 205 mm while the external foot plates range the circular ring. Chronic edema is not ideal for wound healing
between 155 and 180 mm dependent on the manufacturer. and tends to lead to higher wound dehiscence and infection
Custom made external fixation circular rings and foot plates rates. Poor edema control can increase the rate of a pin/wire
may need to be made if a larger ring diameter is required. The tract irritation and infection from increased motion at the
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Clinical Case X
Preoperative clinical (A) and radiographic (B) views of a patient tenotomy, lengthening of the posterior tibial and flexor digito-
who was initially treated in a different facility for a gunshot injury rum longus tendons, and arthrodesis of the hallux interphalan-
with a right tibia fracture fixated with an intramedullary nail. The geal joint with the utilization of a static circular external fixator
patient had also developed subsequent compartment syndrome (C, D). The tibia intramedullary nail was not removed and the
of the right lower extremity and fasciotomies were required after circular external fixator was applied for approximately 10 weeks.
the initial surgery. Patient underwent a right Achilles tendon Final long-term clinical (E) and radiographic (F) outcomes.
A B
C D
E F
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108 Chapter 8
skin–wire interface that occurs with fluctuation of the edema and ankle deformities are usually heavier and more rigid than
within the lower extremity. A severely edematous extremity can constructs utilized for bone transport and trauma. Discus-
affect the surgeon’s intraoperative ability of wire and/or half- sion of the size and weight of the eternal fixation device with
pin placement especially in the tibia since normal anatomic the patient preoperatively along with those who are going
landmarks cannot be palpated. to be involved with the patient’s postoperative rehabilita-
The combination of lower extremity edema and poorly sized tion and medical management is beneficial. The ambulatory
circular rings can lead to skin necrosis and eventual circu- status in this population is usually limited and dependent
lar external fixation instability. For these reasons, preoperative on assistant devices for minimal weight bearing when neces-
patients who require circular external fixation for an elective sary. However, when circular external fixation is utilized for
surgery are first managed in an edema clinic if possible to reduce other types of deformity correction such as bone transport and
the potential for intraoperative and postoperative complica- posttraumatic arthrodesis procedures, a more active ambula-
tions. It is highly recommended to obtain circumferential meas- tory status is usually permitted in order to facilitate osseous
urements of the patient’s lower extremity at the location in healing while preventing complications. Finally, medical man-
which the rings will be applied during the initial visit and agement and other consultations may be necessary in certain
prior to edema management. The patient is then referred case scenarios to prevent the incidence of a superficial or deep
to an edema clinic for management in which compressive dress- vein thrombosis event in the lower extremity.
ings, medical intervention, and wound precautions are taken
along with patient education. The size of the circular external fix- Evaluating and Addressing
ation may seem slightly oversized since it is based on the patient’s Psychosocial Issues
most edematous presentation; however, it reduces the potential
for applying smaller circular rings that can later become prob- Additional preoperative considerations include the etiology
lematic with postsurgical edema. Another technical tip is for the and severity of the patient’s pain symptoms while considering
surgeon to utilize two half circular rings as opposed to complete the psychological and social issues of the patient. In many cases,
circular rings when pre-building a static circular external fixation when circular external fixation is required for treatment it usu-
for a patient with preexisting conditions that result in an ede- ally presents with a complicated preexisting history of traumatic
matous lower extremity. The utilization of two half circular rings injury, surgery, pain, and/or psychosocial factors. Appropriate
allows the surgeon to modify or remove a circular ring if skin support groups may be consulted perioperatively to prevent
impingement and necrosis was to occur from the circular ring. any unwanted complications while maintaining a patient-
centered approach to the overall treatment. Severe intractable
pain may also be associated with allodynia, diffuse hyperalgesia,
Inherent Difficulties in the Management
and vasomotor/sudomotor disturbances.
of Charcot Neuroarthropathy
Complex lower extremity trauma and related nerve injuries
Static circular external fixation is commonly utilized to manage can also lead to the symptoms and stages of causalgia. In some
complex foot and ankle deformities related to CN. The patho- cases, definable nerve-related injuries could lead to reflex sym-
logic Charcot foot and ankle often presents with multiple frac- pathetic dystrophy. In these circumstances, circular external
ture and dislocation patterns along with significant bone loss fixation should be used with caution to avoid further nerve-
and generalized osteopenia. These factors inherent to CN call related injury or symptoms and/or aggravation of preexisting
for judicial planning of circular external fixation designs that pain conditions. Certain patients may also develop an initial
ensure a stable construct when applied to the lower extremity. hesitation or claustrophobic effect and cannot tolerate the cir-
Often, complications related to the surgical management of CN cular external fixation device. Open discussions with the entire
with external fixation are a result of external fixation instability family and patient during the preoperative visit should include
that leads to pin/wire tract infections, osteomyelitis, malunions, description and explanation of the proposed construct, its pur-
nonunions, and/or amputation. pose and duration time along with the postoperative course and
In contrast, when static circular external fixation is applied clothing accommodations. For these reasons, a healthcare team
correctly it allows the surgeon to perform complex limb salvage approach is advisable in dealing with this patient population
procedures that are not feasible with internal fixation such as that includes but is not limited to pain management specialists,
conditions associated with poor bone quality, osseous defects, anesthesiologists, psychologists, social workers, and physical and
and/or osteomyelitis. When static circular external fixation occupational therapists to coordinate further treatment.
is used for CN foot and ankle deformities, it must be secured
with no motion at any osseous segment at risk which often
requires additional smooth wires or half-pins, circular rings, Detailed Surgical Technique
and threaded rods to prevent instability or loosening during
the postoperative period. Smooth wires are recommended over Proper static circular external fixation application begins with
half-pins when managing CN foot and ankle deformities since appropriate positioning of the patient and the lower extrem-
loss of cortical purchase with half-pin(s) is frequently encoun- ity on the operative table. Patients are positioned supine on a
tered in this patient population that may lead to a higher inci- leveled radiolucent operating table making sure that the patella
dence of pin site infections and/or osteomyelitis. and anterior crest of the tibia is 90 degrees perpendicular to
The static circular external fixation should be routinely the operative table in the frontal plane. This ensures that the
examined during the recovery period to be certain of its sta- lower extremity will not be misaligned within the static circular
bility, and if found unstable it can be addressed immediately. external fixation. The operating table if not wide enough must
The circular external fixation constructs utilized for CN foot also have an extension for positioning of the contralateral
LWBK1121-C08_p092_118.indd 108 04/10/12 3:41 PM

lower extremity as the static circular external fixation is typi- with additional threaded rods and rings as needed. For this
cally bulky and limits the operative field. Patients should also reason, the initial pre-built construct consists of threaded
be positioned with their heels at least 6 in. proximal to the end rods placed anterior and posterior within the tibial block and
of the operating table allowing for the external foot plate to lay posterior between the distal tibia ring and the foot plate. This
appropriately within the operating field. allows for excellent positioning of the static circular external
The pre-built circular external fixation is constructed in fixation while providing ample space for ease of appropriate
such a way to permit access for the insertion of planned wire placement and enough stability to attach the wires to the
smooth wires and/or half-pins and is later further stabilized circular ring and the foot plate (Figure 8.1A–C).
A B
C D
Figure 8.1. The static circular external fixation consists of two tibia circular rings and an external foot
plate. These rings are initially assembled with two threaded rods measuring approximately 120 to 150 mm
in size and are placed in opposite directions bisecting the center of the ring (A). This “tibial block” which
consists of the two tibia rings is then connected to the external foot plate with two threaded rods measuring
approximately 150 to 200 mm in length and located within the posterior central portion of the foot plate
(B, C). The anterior positioned threaded rod of the tibial block is aligned with the anterior crest of the tibia
once assembled (D).
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110 Chapter 8
The next step involves positioning of the pre-built static addition, the transosseous wire can be tapped through with
circular external fixation to the lower extremity and foot a mallet after bicortical purchase is achieved minimizing soft
prior to wire or half-pin insertion. Surgical towels are placed tissue irritation and thermal necrosis. If thermal necrosis
on the posterior aspect of the lower leg, knee, and heel to occurs during insertion of the transosseous wire, it is then
ensure proper anatomic alignment of the lower extremity removed, the area is cooled with a saline-soaked gauze and a
within the static circular external fixation for smooth wire new wire is inserted in a different position. After appropriate
and half-pin insertion. Proper positioning of these towels is insertion, the transosseous wires in the tibia are typically ten-
necessary to ensure equal suspension of the lower extremity sioned between 110 and 130 kg of force, whereas transosseous
within the static circular external fixation. It is recommended wires in the foot are typically tensioned between 70 and 90 kg
that a distance of approximately two to three finger’s breadth of force. Half-pins should be placed after being predrilled
should be between the anterior crest of the tibia and the to avoid unicortical purchase and iatrogenic fractures across
inside of the tibial block (Figure 8.1D). the tibia.
The placement of the external foot plate is critical and The sequence of inserting smooth wires and half-pins
is dependent on the procedure performed and whether the is surgeon dependent but should be planned so that the
patient will be ambulatory or not after surgery. If the patient surgeon can proceed efficiently while avoiding excessive
will regain immediate weight bearing status after surgery, the intraoperative positional changes and unnecessary handling
external foot plate needs to be positioned above the level of of the instrumentation. The static circular external fixation
the metatarsal heads and plantar calcaneal tuberosity and extra is initially stabilized by inserting two smooth tibia axis axial
space may be allowed for an additional bottom circular ring transosseous wires from a lateral to medial direction followed
attached to a postoperative shoe if needed. If the patient will be by one calcaneal axial transosseous olive wire in the frontal
in a limited ambulatory status after surgery, the external foot plane. The two smooth tibia wires are inserted into the tibia
plate is then positioned slightly caudal and aligned with the and the olive wire is placed into the posterior superior one-
plantar aspect of the foot. third of the calcaneal tuberosity. The first transosseous wire
The next step involves the marking of the anterior crest is inserted on the undersurface of the proximal tibia circular
of the tibia which is aligned with the second metatarsal and ring and is driven from a lateral to medial direction across
digit and ensuring that the foot is neither internally nor the tibia being certain to gain bicortical purchase. The sec-
externally rotated. When viewed from a lateral position, the ond transosseous wire is placed on the undersurface of the
foot should be positioned at 90 degrees to the lower extrem- distal tibia circular ring in the same direction as the first
ity in a neutral sagittal position. Often, a surgical assistant or transosseous wire and in parallel alignment with the proxi-
an additional member of the surgical team is needed to hold mal tibia wire. The third transosseous wire insertion is an
the foot in this position while the initial transosseous wires olive wire that is placed in the frontal plane from a lateral to
are inserted. A common mistake that needs to certainly be medial direction and across the posterior superior one-third
avoided is to neglect the foot position during the surgical of the calcaneal tuberosity. This olive wire can be attached
procedure with a final outcome of an unwanted iatrogenic directly to the external foot plate or it can be connected to
equinus deformity. the foot plate with an external post device (Figure 8.2A–C).
The actual application of the static circular external fixa- It is important to mention that the order or direction of the
tion is performed after deflation of the tourniquet and since smooth wires is dependent upon the surgeon’s experience
blood loss is minimal while taking the necessary precautions and according to the external fixation construct and deform-
to prevent a vascular injury. Next, proper sequential inser- ity correction.
tion and anatomic location of smooth wires and/or half- Next, the surgeon makes sure that the static circular exter-
pins is necessary to achieve maximum stability and rigidity nal fixation is well positioned within the lower extremity and
of the static circular external fixation. Properly tensioned before inserting the next three transosseous wires. It is also
transosseous smooth wires and half-pins need to always be important to lightly secure the first three axial transosseous
inserted through bicortical bone. A saline-soaked gauze may wires with nuts and bolts to their respective anatomic external
be used to grasp the transosseous wire during the initial rings or foot plate so that necessary changes can be made
power insertion to minimize cross-contamination, increase if necessary. The fourth transosseous smooth wire is now
manual wire stability, and to also decrease temperature gen- inserted from the opposite side and across the medial face of
erated across the wire during insertion. Tension should the tibia at an angle of approximately 45 to 60 degrees to the
be initially applied to the skin to minimize soft tissue trauma frontal plane wire driven from a medial to lateral direction
while the transosseous wire is manually inserted to the bone seg- along the top surface of the proximal tibia ring. The fifth
ment percutaneously. The transosseous wire should be driven transosseous smooth wire is inserted in a similar fashion to
with steady and even pressure avoiding thermal necrosis and the fourth transosseous wire from a medial to lateral direction
may be tapped with a mallet to exit the opposite site of the bone and from the top surface of the distal tibia circular ring. The
cortex if thermal necrosis occurs. Transosseous wires should orientation for these fourth and fifth transosseous wires is
not deviate from their anticipated course. Nonlinear insertion usually safe if the proximal and distal tibia circular rings are
of transosseous wires is often present when uneven pressure positioned about 10 to 15 cm proximal to the ankle joint.
is administered to the wire power driver during insertion or It is also important to realize the alignment of these medial
inadequate soft tissue tension was placed during the initial wire transosseous wires to avoid any neurovascular injury in the
insertion. posterior aspect of the lower extremity. The fourth and fifth
Transosseous wires that are inappropriately inserted often transosseous wires are also named “fibular” wires since they
result in wire tract irritation, infection, and/or breakage. In may include the fibula while driven from the medial aspect
LWBK1121-C08_p092_118.indd 110 04/10/12 3:41 PM

of the circular external fixator. The sixth transosseous wire in certain case scenarios (Figure 8.2G). Additional medial face
inserted is an olive wire and is placed from a medial to lateral smooth wires can be added to the tibia circular rings that start
direction from the external foot plate. The entrance point of from the lateral aspect of the anterior tibia crest and driven
the sixth transosseous wire on the calcaneus is the posterior posterior medial basically following and parallel to the medial
calcaneal tuberosity slightly inferior to the frontal plane olive face of the tibia.
wire previously inserted into the calcaneus. This wire is driven At this point, the static circular external fixation consists
at an angle aiming toward the proximal aspect of the fifth met- of six transosseous wires (four in the tibia and two in the
atarsal base. At this point, the second set of three wires (fourth calcaneus). Tightening followed by tensioning techniques of
to sixth) are similarly lightly secured with nuts and bolts to the transosseous wires is then performed. It is recommended
their respective anatomic external rings or foot plate and mak- to tighten the transosseous wire(s) at the site in which it was
ing sure that the entire construct is well centered before any driven from and to tension the opposite side. This methodical
tensioning or tightening process begins (Figure 8.2D–F). Half- sequence ensures that each transosseous wire is tensioned and
pins may also be inserted for additional fixation and support if secured in a reproducible manner and with limited error pos-
necessary or instead of the fourth and fifth transosseous wires sibilities. Tensioning in this sequence also ensures that each
Figure 8.2. The first transosseous

wire is inserted on the undersurface
of the proximal tibia circular ring
and is driven from a lateral to medial
direction across the tibia being certain A B
to gain bicortical purchase (A). The
second transosseous wire is placed on
the undersurface of the distal tibia
circular ring in the same direction
as the first transosseous wire and in
parallel alignment with the proximal
tibia wire (B). The two tibia wires are
inserted in a perpendicular fashion
to the longitudinal axis of the tibia.
The third transosseous wire insertion
is an olive wire that is placed in the
frontal plane from a lateral to medial
direction and across the posterior
superior one-third of the calcaneal
tuberosity. This olive wire can be
attached directly to the external foot
plate or it can be connected to the
foot plate with an external post device
(C). The fourth transosseous smooth
wire is now inserted from the opposite
side and across the medial face of
the tibia at an angle of approximately
45 to 60 degrees to the frontal plane
wire driven from a medial to lateral
direction along the top surface of the
proximal tibia ring (D). (continued) C D
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112 Chapter 8
E, F G
Figure 8.2. (continued) The fifth transosseous smooth wire is inserted in a similar fashion to the fourth
transosseous wire from a medial to lateral direction and from the top surface of the distal tibia circular ring
(E). The orientation for these fourth and fifth transosseous wires is usually safe if the proximal and distal
tibia circular rings are positioned about 10 to 15 cm proximal to the ankle joint. The sixth transosseous wire
inserted is an olive wire and is placed from a medial to lateral direction from the external foot plate. The
entrance point of the sixth transosseous wire on the calcaneus is the posterior calcaneal tuberosity slightly
inferior to the frontal plane olive wire previously inserted into the calcaneus. The wire is driven at an angle
aiming toward the proximal aspect of the fifth metatarsal base (F). Half-pins may also be inserted for addi-
tional fixation and support if necessary or instead of the fourth and fifth transosseous wires in certain case
scenarios (G).
circular ring has a transosseous wire tensioned from opposite Finally, additional smooth or “olive” transosseous wires can
directions enhancing circular ring stability while preventing then be inserted through the talus, midfoot, and metatarsals
translation of the entire construct. depending on the procedure to be performed. Modifications
The first and second frontal plane transosseous tibia wires and adjustments can then be performed to further stabilize the
are tightened on the lateral side and the fourth and fifth medial forefoot/midfoot areas and to accomplish various procedures
face transosseous tibia wires are tightened on the medial side. about the hindfoot and ankle. The final step is to provide addi-
Tensioning is performed opposite the side in which the wire was tional stability between the circular external fixation rings and
tightened. While the surgeon is tensioning the wire, it is impor- foot plate with additional threaded rods, connection plates,
tant to have the surgical assistant to manually stabilize the entire and/or off-loading rings if necessary. It is advisable to maintain
construct to prevent any displacement of the device to the lower at least four points of fixation on the tibial block and also four
extremity. Simultaneous attention is also directed toward the points of fixation from the external foot plate to the tibial block.
position of the foot to avoid any unwanted iatrogenic equinus A half ring attached to the external foot plate is then secured
deformity. It is also advisable to tighten and manually tension to the tibial block for more stability and rigidity of the entire
the opposite olive wires in the calcaneus without the dynamic construct. An off-loading ring may also be attached to the bot-
tensioner (Figure 8.3). tom of the external foot plate when necessary in certain case
Next, all initial transosseous wires are cut and bent in a scenarios (Figure 8.5).
specific direction. Three finger’s breadth distance from the Compression across joints prepared for hindfoot and ankle
circular ring toward the tip of the wire is marked and the wire arthrodesis is achieved either by compression of two segments
is cut at this level with a wire cutter. Utilizing a plier, the wire is of the static circular external fixation or by applying tension
bent at a 90 degree angle at each finger’s breadth totaling three through a pre-bent transosseous wire. If the pre-bent transos-
bends that are directed toward the nut of the bolt securing the seous wire technique is utilized, each end of the wire is brought
wire to the circular ring. Bending the wire in this manner pre- toward the joint requiring compression resulting in a bend
vents de-tensioning and weakening of the wire at the secured that when straightened by manual tensioning, the wire from
fixation interface (Figure 8.4). each end will simultaneously transmit tension and compression
LWBK1121-C08_p092_118.indd 112 04/10/12 3:42 PM

A,B C
D,E F
Figure 8.3. The first (A) and second (B) frontal plane transosseous tibia wires are tightened on the lateral
side of the static circular external fixation and the fourth (C) and fifth (D) medial face transosseous tibia
wires are tightened on the medial side of the device. Tensioning is performed opposite the side in which
the wire was tightened (E–H). While the surgeon is tensioning the wire it is important to have the surgi-
cal assistant manually stabilize the entire construct to prevent any displacement of the device to the lower
extremity. Simultaneous attention is also directed toward the position of the foot to avoid any unwanted
iatrogenic equinus deformity. It is also advisable to tighten and manually tension the opposite olive wires in
the calcaneus without the dynamic tensioner and especially in patients with decreased cortical stiffness and
generalized osteopenia (I–L). (continued)
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114 Chapter 8
G,H I
J,K L
across the arthrodesis site. Applying excessive bend to the pre- The skin surface between the circular external fixation
bent wire can cause significant tension on the soft tissue when segments that are either compressed or distracted should
manually tensioned and can further result in skin ischemia also be evaluated for signs of ischemia. If the area is cyanotic,
and eventual necrosis. For this reason, after manually tension- then compression or distraction between the circular exter-
ing the pre-bent wire, the underlying skin is assessed for tissue nal fixation segments should be reduced and reinstituted
ischemia, and if evident, tension to the skin is released by incis- gradually postoperatively. It is advisable to utilize segments
ing the skin at the skin–wire interface. If soft tissue ischemia of the circular external fixation to achieve compression of
is still present, the tensioned wire should be repositioned and the ankle and tibiotalocalcaneal joints and rely on manual
re-tensioned (Figures 8.6 and 8.7). tension of pre-bent transosseous wires for compression across
LWBK1121-C08_p092_118.indd 114 04/10/12 3:42 PM

A,B C
Figure 8.4. All initial transosseous wires

are cut and bent in a specific direction.
Three finger’s breadth distance from the
circular ring toward the tip of the wire is
marked (A) and the wire is cut at this level
with a wire cutter. Utilizing a plier, the wire
is bent at a 90-degree angle at each finger’s
breath totaling three bends that are directed
toward the nut of the bolt securing the wire
to the circular ring (B–D). Bending the wire
in this manner prevents de-tensioning and
weakening of the wire at the secured fixa-
D E tion interface (E).
the midfoot and forefoot or for an isolated subtalar or triple plications may be avoided by paying specific attention to the
arthrodesis procedure. After compression is achieved, pro- intrinsic details of the circular external fixation assembly, sizing
visional percutaneous Steinmann pin fixation that was used of the rings, appropriate positioning of the lower extremity,
can be either removed or incorporated into the static circular meticulous wire and pin placement and proper completion
external fixation for additional stability if needed. It is also of the entire construct. Most common complications encoun-
crucial not to forget to complete the entire external fixation tered are due to the result of the external fixation instability,
construct with additional threaded rods, connection plates, improper wire or half-pin placement, improper ring sizes, and
and/or off-loading rings if necessary. malposition of the lower extremity during circular external
fixation application.
Improper wire or half-pin insertion can typically occur
Postoperative Course at multiple levels. In the tibia, a common error is the inser-
and Complications tion of the frontal plane wires into the unicortical aspect
of anterior tibia crest as opposed to obtaining bicortical
The concept of utilizing a pre-built static circular external purchase of the tibia. Neurovascular injury can occur with
fixation in theory reduces operative time but can also have the insertion of transosseous wires across the medial face of
devastating complications if not properly used. Potential com- the tibia. An understanding of the cross-sectional anatomy
LWBK1121-C08_p092_118.indd 115 04/10/12 3:42 PM

116 Chapter 8
Figure 8.5. The final step is to provide

additional stability between the circular
external fixation rings and foot plate with
additional threaded rods, connection plates,
and/or off-loading rings if necessary. It is
advisable to maintain at least four points
of fixation on the tibial block and also four
points of fixation from the external foot
plate to the tibial block (A). A half ring
attached to the external foot plate is then
secured to the tibial block for more stability
A B and rigidity of the entire construct (B).
of the lower extremity and the foot is essential to further Improper ring size as previously mentioned can lead to skin
avoid any soft tissue or neurovascular injury. Insertion of the necrosis or result in revision and complete removal of the static
transosseous olive wires in the calcaneus must be confirmed circular external fixation. The use of solid full circular rings
of good bone purchase. For this reason, the surgeon should does not permit individual removal of a single ring and reappli-
insert the olive wire until it purchases the cortical wall of the cation may be necessary in the operating room. In patients with
calcaneus and making sure not to compromise the cortical preexisting edematous conditions, the utilization of multiple
integrity. connected half rings may be necessary.
A B
Figure 8.6. Immediate postoperative clinical pictures showing the standard static circular external fixa-
tion for diabetic Charcot midfoot deformity correction. Please note the pre-bent transosseous wire at the
external foot plate for applying compression to the midfoot joints (A, B).
LWBK1121-C08_p092_118.indd 116 04/10/12 3:42 PM

A B
C D
Figure 8.7. Intraoperative picture of a tibiotalocalcaneal arthrodesis with the use of allogenic bone
grafting mixed with platelet rich plasma (A). Immediate postoperative clinical pictures showing the standard
static circular external fixation for the hindfoot and ankle arthrodesis procedures (B–D). Please note that the
compression across the joints was achieved by compressing the external foot plate to the tibial block which is
evident by the bending of the two posterior threaded rods in Figure 8.7B.
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118 Chapter 8
Conclusion
A. Determining appropriate circular ring size is para- The authors have presented a stepwise approach to the appli-
mount in the application of a pre-built static circular cation of a pre-built static circular external fixation. Extensive
external fixation. knowledge and experience with the versatility of external fixa-
B. Utilizing two half circular rings is preferred over a solid tors and the proposed procedures is paramount to the over-
full circular ring in patients who present with preexist- all patient’s successful outcome. A steep learning curve and
ing edematous conditions. external fixation training are also required to obtain maximum
C. Static circular external fixation for Charcot neuroar- results and limited postoperative complications.
thropathy foot and ankle deformities may be more rigid
by placing additional threaded rods between osseous Recommended Readings
segments to ensure complete stability of the entire con- Easley ME, Montijo HE, Wilson JB, et al. Revision tibiotalar arthrodesis. J Bone
struct. In addition, off-loading rings may also be applied Joint Surg Am. 2008;90:1212–1223.
to prevent any initial unwanted weight bearing status. Jolly GP, Zgonis T, Polyzois V. External fixation in the management of Charcot
D. The surgical assistant makes sure that the static circular neuroarthropathy. Clin Podiatr Med Surg. 2003;20:741–756.
Pinzur MS. Circular fixation for the nonplantigrade Charcot foot. Hosp Pract
external fixation is manually stabilized in a neutral posi-
(Minneap). 2010;38:56–62.
tion during the entire procedure to avoid any potential Polyzois VD, Papakostas I, Stamatis ED, et al. Current concepts in delayed bone
iatrogenic postoperative deformities. union and non-union. Clin Podiatr Med Surg. 2006;23:445–453.
E. The sequence of wire and/or half-pin insertion and Zgonis T, Jolly GP, Blume P. External fixation use in arthrodesis of the foot and
tensioning previously described allows the surgeon to ankle. Clin Podiatr Med Surg. 2004;21:1–15.
Zgonis T, Stapleton JJ, Polyzois VD, et al. Revisional and reconstructive surgery for
apply these complex devices in a reproducible, safe, the diabetic foot and ankle. In: Zgonis T, ed. Surgical Reconstruction of the Diabetic
and efficient manner. Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:315–343.
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C h a pt e r
9
John J. Stapleton
Thomas Zgonis
Stepwise Approach to Taylor Spatial

Frame for the Foot and Ankle
Introduction Indications/Contraindications
On the basis of the design of the Taylor spatial frame (TSF), Some of the most common indications for the utilization of
one of the main applications is to correct long bone deformi- TSF include and are not limited to deformity corrections of
ties. Deformity analysis requires the interpretation of radio- complex midfoot, rearfoot, ankle, and supramalleolar condi-
graphs to determine the level and plane of deformity. The tions. Its main advantage over a traditional circular external
TSF incorporates the mathematical field of deformity analysis fixator is its inherent stability with precise and more predict-
to develop an external fixator that is capable of creating a able deformity correction outcomes.
single-axis hinge to correct a six-axis deformity. The TSF is a Other common indications for the foot and ankle include
modification of an Ilizarov circular external fixation system severely neglected clubfoot deformities, equinus contractures,
that utilizes six telescoping rods that are free to rotate at their burn injuries, and combined multilevel rearfoot and ankle
fixation points of the proximal and distal circular ring and/ deformities (Clinical Cases I–III). Another indication of the
or external foot plate. Through adjustments of the length of TSF is ankle and/or subtalar joint arthrodiastasis while simul-
each of the telescoping rods between two circular rings, or taneously correcting deformity at the ankle or supramalleolar
a circular ring and an external foot plate, the device can be level (Clinical Case IV).
preconstructed to mimic and resemble any deformity. TSF More common applications at the ankle level include but
has become very advantageous in cases where conventional are not limited to an ankle arthrodesis, revisional tibiotalo-
circular external fixation constructs require extensive modi- calcaneal arthrodesis, and where absolute osseous stability
fications throughout the postoperative period to perform and union is required to achieve bone healing for high-risk
the necessary deformity corrections on various planes. The patients. TSF can also be utilized to perform distraction oste-
purpose of this chapter is not to discuss the intrinsic details ogenesis in combination with deformity corrections and/or
to perform deformity corrections but to provide the reader rearfoot and ankle arthrodesis. Morbidly obese patients who
some of the most common applications in deformity cor- would potentially pose significant stress to a traditional cir-
rection for the foot and ankle. TSF can often become very cular external fixator can be further stabilized with a TSF to
difficult to treat complex foot and ankle deformities since prevent any unwanted postoperative lower leg malposition-
the deformity is not only multiplanar but also coexists in mul- ing and frame instability. Charcot neuroarthropathy (CN) of
tilevel segments within close proximity. When dealing with the midfoot, rearfoot, and/or ankle can also be addressed
deformities of the long bones multiple TSF constructs can be with a TSF. The unique 6 × 6 butt frame is beneficial for select
applied to correct the deformity at each level. At the foot and Charcot rocker-bottom midfoot deformities. Its inherent sta-
ankle level, the proximity of these deformities often prevents bility is beneficial for allowing the TSF to have a static role
proper deformity analysis and radiographic evaluation of the after an acute correction is obtained at the time of surgery
TSF in relation to the deformity. In addition, the realistic and to also perform necessary dynamic corrections if neces-
utilization of multiple TSF constructs at the foot and ankle sary during the postoperative course.
level can become very cumbersome and difficult to manage Relative contraindications include and are not limited
for both the patient and the surgeon. On the contrary, the to surgical procedures that cannot be adequately addressed
strength sustained with a TSF along with its dynamic capa- secondary to the crowding of the TSF struts. An example of
bilities become advantageous to manage various complex foot this is a triple arthrodesis that requires placement of smooth
and ankle pathologies. While conventional circular external transosseous wires in close proximity to adequately compress
fixators can typically be utilized for the majority of foot and the affected joints. A TSF can be cumbersome to perform this
ankle cases, inherent advantages to the TSF are discussed and procedure since the necessary wire fixation on the external
presented throughout this chapter. foot plate is limited to provide compression. For this reason,
119
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120 Chapter 9
Clinical CASE I
Clinical (A) and radiographic anteroposterior (B) and lateral external fixator was removed at approximately 7 weeks and the
(C) views of a right lower extremity showing the severe ankle patient was transitioned to a non–weight bearing cast immo-
equinus deformity and contracted digits as a result of a previ- bilization for approximately 4 weeks followed by appropriate
ous gunshot injury and skin contractures from grafting. Patient surgical boot off-loading and aggressive physical therapy exer-
underwent a percutaneous tendo-Achilles lengthening with cising program. Final clinical (K, L) and radiographic (M, N)
flexor tenotomies and pinning of digits 2 to 5 to the right foot views at 5-month follow-up showing the equinus and multiple
(D–J). Please note the preassembled TSF construct (D, E) that contracted digits correction.
is mimicking the ankle equinus deformity of the patient. The
A,B C
D E
(continued)
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Stepwise Approach to Taylor Spatial Frame for the Foot and Ankle 121
Clinical case I (continued)
F G
H I
(continued)
the surgeon has to carefully assess the degree and planes of The surgeon needs to adequately evaluate the peripheral
deformity in addition to concomitant procedures that may circulation and if compromised appropriate referral to a vas-
need to be performed to adequately determine if a TSF is cular surgeon for a necessary intervention may be warranted
required. prior to the procedure. Absolute contraindications of the
Peripheral vascular disease is often a contraindication to TSF include and are not limited to a noncompliant patient
proceed with deformity correction and application of a TSF. who is not capable of making gradual corrections if required.
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122 Chapter 9
J K
L,M N
Preoperative Considerations lower leg are assessed. Evaluating the range of motion about
the ankle and rearfoot is important to determine compensa-
Deformity Planning tory contractures that may be evident. Limited range of motion
and contractures of the subtalar joint are commonly encoun-
Surgical planning involves a thorough physical examination tered with coronal supramalleolar and/or ankle deformities.
of the patient and deformity analysis interpreting weight Malposition of the talus and limited subtalar joint range of
bearing radiographs of the lower extremity. Examining the motion is commonly encountered with posttraumatic deformi-
patient initially while standing and ambulating if possible is ties involving the ankle and rearfoot. In the normal foot, there
preferred. The surgeon can quickly develop an understanding is considerably less eversion than inversion of the subtalar joint.
of suprastructural deformity or compensatory changes that For this reason, supramalleolar/ankle varus deformities are
are present. Limb length discrepancy, pelvic obliquity, frontal less compensated for than valgus deformities. Equinus contrac-
plane deformity of the knee, and position of the heel to the tures of the ankle are also evaluated to determine if capsular,
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Clinical CASE II
Clinical (A) and radiographic anteroposterior (B) and lateral by the utilization of the TSF construct for compression and
(C) right ankle views of a diabetic patient with a severe equi- stabilization of the right lower extremity (F–J). The external
nocavovarus deformity and chronic ulcerations after a surgical fixator was removed at approximately 7 weeks and the patient
treatment for a transmetatarsal amputation. Patient underwent was transitioned to a non–weight bearing cast immobilization
an initial incision and drainage procedure that was followed for approximately 6 weeks followed by appropriate surgical
6 days later by a total talectomy (D) with tibiocalcaneal arthro- boot off-loading and accommodative orthotic devices. Final
desis, bone allografting, and split thickness skin grafting at the clinical (K, L) and radiographic (M, N) views at 15-month
lateral aspect of the right foot (E). This was accomplished follow-up.
A,B C
D E
(continued)
gastrocnemius, or Achilles deformities need to be addressed at with the plane of deformity compared to the contralateral leg.
the time of surgery. Any coexisting anterior ankle bone block The mechanical axis of the distal tibia should be in alignment
impingement conditions are also assessed when planning for with the mechanical axis of the lower extremity. The mechani-
deformity correction. cal axis extends through the center of the ankle joint under
Planning of deformity correction starts with weight bearing normal circumstances. In addition, the angle formed between
radiographs of bilateral lower extremities. Full-length radio- the mechanical axis and the tibial plafond on a weight bearing
graphs are beneficial to determine limb length discrepancy and anteroposterior and lateral radiographs are determined with
to evaluate the mechanical axis of the lower extremity. Often, normal values averaging 93 and 80 degrees, respectively.
the determination to performing an opening-wedge, dome, or The ultimate goal of performing deformity correction is to
closing-wedge osteotomy is dependent on the limb length along restore the limb to these normal parameters while considering
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124 Chapter 9
F G
H I
(continued)
the position of the contralateral leg. In evaluation of deformi- the calcaneus. For example, a plantarflexed first ray can lead
ties about the ankle, one must consider the position of the to compensatory varus deformity of the calcaneus. Understand-
talus, calcaneus, and forefoot in relation to the tibia. Hindfoot ing these normal parameters is essential before attempting any
and rearfoot malposition is best evaluated on hindfoot align- type of deformity correction for the foot and ankle. In addition,
ment radiographs. The calcaneal axis should be parallel and most of the deformities are multiplanar and can involve coro-
5 mm lateral to the mid-diaphyseal line of the tibia in normal nal and sagittal components that can be present at different
circumstances. Coronal plane deformities of the forefoot must levels. Multiplanar deformities are measured by their center of
be evaluated to determine their influence on the position of rotation and angulation (CORA). The CORA is the bisection of
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J,K L
M N
the mechanical axis of the proximal and distal segment of the performed to prevent further nerve injury to the posterior
deformity to be corrected. If the corrective osteotomy is per- tibial nerve. The soft tissue is a structure at risk with severe
formed at the level of the CORA, then angular and rotational deformity corrections. The surgeon needs to consider previous
deformities can be corrected without translation. The difficulty soft tissue coverage such as flaps, previous scar contractures,
arises when angular and rotational deformities are performed and compromised areas in deciding incision placement and
away from the CORA. In these circumstances, the distal seg- for determining the rate of deformity correction to decrease
ment will need to be translated in addition to the angular and tension of the surrounding soft tissues thereby preventing
rotational corrections to adequately align the lower extremity potential wound complications.
while preventing a secondary translational deformity.
The TSF is commonly utilized to address these types of
severe deformities about the foot and ankle. Typically, the
Detailed Surgical Technique
magnitude of these deformities is high and clinical scenarios
are complex and hence the need for the TSF as opposed to
Taylor Spatial Frame for Supramalleolar
more traditional fixation methods. Careful evaluation of the
Deformity Correction
current neurovascular status is paramount to determine if
these structures are at risk for further injury or if concomitant The circular rings are placed independently to the proximal
prophylactic nerve decompressions need to be performed at and distal segments of deformity correction. The proximal fix-
the time of deformity correction. Commonly, with severe varus ation segment for these types of deformities can be addressed
deformity corrections a tarsal tunnel release may need to be by placing one circular ring or a tibial block to the proximal
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126 Chapter 9
Clinical CASE III
Clinical (A, B) and radiographic anteroposterior (C) and by the utilization of the TSF construct for compression and
lateral (D) right foot views of a patient with a history of a stabilization of the right lower extremity (G–K). Please note
neglected clubfoot deformity and chronic ulcerations to the the local advancement flap (I) for soft tissue closure at the
plantar aspect of the right foot. Patient also presented with a plantar aspect of the foot. The external fixator was removed
Chopart’s amputation to the left foot. Patient underwent an at approximately 8 weeks and the patient was transitioned to
initial incision and drainage procedure to the right foot that a non–weight bearing cast immobilization for approximately
was followed 7 days later by a total naviculectomy (E) with 6 weeks followed by appropriate surgical boot off-loading and
medial column arthrodesis, bone allografting (F), and percu- accommodative insoles. Final radiographic (L, M) views at
taneous tendo-Achilles lengthening. This was accomplished approximately 9-month follow-up.
A,B C
D E
F G
(continued)
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H I
J K
L M
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128 Chapter 9
Clinical CASE IV
Preoperative radiographic anteroposterior (A) and lateral (B) Please note the acute ankle distraction (D) that is showing at
views of a left lower extremity showing the severe ankle equinus the C-arm intraoperative fluoroscopy. The external fixator was
and posttraumatic arthrosis as a result of a previous open reduc- removed at approximately 9 weeks and the patient was tran-
tion and internal fixation of a left ankle fracture. Patient under- sitioned to a weight bearing lower extremity cast for approxi-
went a left ankle arthrotomy with exostectomy (C), percutaneous mately 2 weeks followed by a rigorous physical therapy exercise
tendo-Achilles lengthening, removal of painful hardware, and program. Final radiographic ( J, K) views at 3-year follow-up
arthrodiastasis with the utilization of the TSF construct (D–I). showing the equinus correction and ankle arthrodiastasis result.
A,B C
D E
(continued)
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F,G H
I,J K
segment. The proximal ring or tibial block is placed to opti- The ring is aligned distal to the proposed osteotomy and is
mally fit the proximal leg and is aligned orthogonal to the axis typically aligned with the distal aspect of the tibia metaphysis.
of the proximal tibia. This is typically accomplished by first The distal ring is secured with two crossed smooth wires and
placing a frontal plane smooth wire from a lateral to medial a half-pin. The proximal ring or tibial block is then connected
direction and securing it to the circular ring ensuring that the to the distal tibia ring with the TSF struts. At this point, the
ring is perpendicular to the tibia under C-arm fluoroscopy. origin and the corresponding point along with the mounting
An additional half-pin is also inserted from an anterior to pos- parameters must be established. The origin typically utilized
terior direction across the anterior crest of the tibia securing is the center of the bone segment on the proximal side of the
the alignment of the proximal ring. At this time, an additional deformity while the corresponding point is the center of the
ring is applied if a proximal tibial block is desired. Typically, bone segment on the distal side of the deformity. The goal is
for deformity correction two smooth wires and a half-pin to reduce the moving segment (corresponding point) to the
are applied to each ring if two rings are utilized. If one ring origin. The four mounting parameters required describe the
is placed to secure the proximal segment, then two smooth location of the origin to the reference ring, which is the proximal
wires attached directly to the ring and two to three half-pins tibia ring that was placed orthogonal to the proximal tibia.
extended from the ring with rancho cubes are utilized to The mounting parameters consist of defining the distance
enhance frame stability. The proximal or the distal ring to of the center of the reference ring from the origin and the
the proximal tibial block is then referred to as the “reference” anteroposterior (sagittal), medial/lateral (coronal), axial, and
ring. The next step is to assemble the distal circular ring. rotatory frame offset. Six deformity parameters then establish
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130 Chapter 9
the spatial relationship of the origin and the corresponding speed of correction and structures at risk are determined
point. The deformity parameters describe the rotation and and the program will provide a daily schedule for the patient
translation of the origin and the corresponding point in the to perform adjustments on each numbered of the six struts.
coronal, sagittal, and axial plane. Once the frame, mounting, Close monitoring of the deformity correction and clinical
and deformity parameters are established they can be entered appearance is paramount to the patient’s successful postopera-
into the Internet-based software (www.spatialframe.com). The tive outcome (Clinical Case V).
Clinical CASE V
Preoperative radiographic anteroposterior (A) and lateral (B) The external fixator was removed at 18 weeks and the patient
views of a right lower extremity showing a severe distal tibia was transitioned to a non–weight bearing cast application
malunion from a previous neglected distal tibia and fibula and proper off-loading surgical boot. Radiographic outcomes
fracture. Patient underwent an acute corrective supramalleo- at approximately 7 months postoperatively (E, F).
lar osteotomy by the utilization of a TSF construct (C, D).
A,B C
D,E F
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Taylor Spatial Frame for Rearfoot/Ankle anterior crest of the tibia. The anterior crest should be aligned
Arthrodesis and Arthrodiastasis with the second metatarsal while the foot is held 90 degrees
to the lower leg. After appropriate positioning, the TSF is
Performing an ankle and/or rearfoot arthrodesis or arthro- assembled in similar fashion as described in the application of
diastasis begins with a tibial block connected to an external a static circular external fixator in Chapter 8. After application
foot plate with the TSF struts. The utilization of two stacked of all smooth and/or olive wires and/or half-pins, compres-
foot plates is an excellent alternative to enhance the stability sion of the tibial block with the foot plates (approximately 6
of the external fixator while allowing ample space for place- to 12 mm) can be obtained by sequentially adjusting the TSF
ment of smooth wires into the foot. The initial assembly starts struts. This is accomplished by gradually adjusting each strut
with a tibial block connected with one or two threaded rods in 2 mm increments until the desired amount of compression
anterior and one or two threaded rods posterior and away is achieved radiographically and clinically. Often, the surgeon
from the tabs for the TSF struts to allow subsequent inser- will appreciate an endpoint when compressing an arthrodesis
tion of frontal plane and medial face smooth wires. The tibial site and the strut will not advance further. At this point, the
block is then connected to the foot plate by attaching the six foot plate and the proximal tibial block can be locked into this
TSF struts. The length of the struts is determined by their position if desired by adding further threaded rods between
ability to allow for distraction or compression while permit- the foot plate and the proximal tibial block. In addition, if subtle
ting the tibial block to be approximately 12 to 15 cm from the corrections need to be performed this can be carried out over
ankle joint while the foot plate is aligned with the plantar the following 3 to 5 days with the Internet-based computer
aspect of the foot. The utilization of two stacked foot plates is software. The performance of an ankle arthrodesis or arthro-
assembled such that the second foot plate is positioned at the diastasis requires normal alignment to be established acutely
level of the talus. at the time of joint preparation or distraction and if subtle
The TSF is then aligned to the foot and lower leg by posi- adjustments need to be made they are performed early in the
tioning surgical towels posterior to the heel and lower leg. recovery period and preferably within the first postoperative
The anterior tabs of the tibial block should be aligned with the week (Clinical Cases VI–XI).
Clinical CASE VI
Clinical (A, B) and radiographic anteroposterior (C) and tion of the left lower extremity (G–K). The external fixator
lateral (D) views of a left lower extremity showing the severe was removed at approximately 8 weeks and the patient was
ankle equinus and varus deformity as a result of a previous transitioned to a non–weight bearing cast immobilization for
open reduction and internal fixation of a left ankle fracture. approximately 8 weeks followed by appropriate surgical boot
Patient underwent a left total talectomy (E) with re-implanta- off-loading and accommodative shoe gear for her limb length
tion of the surgically prepared talus and bone allografting (F) discrepancy. Final radiographic (L, M) views at 13-month
for a tibiocalcaneal arthrodesis. This was accomplished by the follow-up showing the equinus correction with successful
utilization of the TSF construct for compression and stabiliza- arthrodesis.
A B
(continued)
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132 Chapter 9
C D
E F
G H
(continued)
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Clinical
G case VI (continued) H
I J
K,L M
Taylor Spatial Frame for Unstable circular ring can be applied proximal to the U plate attached to
Charcot Midfoot Deformities the distal tibia. The U plate and the possible circular tibia ring
represent the proximal tibia segment and are connected to the
The TSF construct for performing a CN midfoot arthrodesis leg with frontal plane and medial face smooth wires. Additional
consists of a 6 × 6 “butt frame” which involves two perpen- half-pins can be utilized at this level to further stabilize the
dicular “U” external foot plates connected to a forefoot ring by construct if needed. Half-pins if utilized are placed into the
the six TSF struts. The distal tibia, talus, and calcaneus can be anterior crest or medial face of the tibia. Two opposing olive
stabilized with the two perpendicular U plates. One U plate is wires are then driven into the safe zone of the calcaneal tuber-
placed around the distal tibia and the other is placed around osity and attached to the U plate that is positioned around the
the calcaneus. If further stability is required, an additional calcaneus. The smooth wires in the tibia are tensioned between
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134 Chapter 9
Clinical CASE VII
Radiographic anteroposterior (A) and lateral (B) views of a fixator was removed at 10 weeks postoperatively followed by
right lower extremity showing a severe varus deformity and a non–weight bearing cast immobilization for approximately
nonunion resulting from an ankle fracture/dislocation in a 4 weeks and by another weight bearing lower extremity cast
diabetic neuropathic patient. The patient was morbidly obese for additional 2 weeks. Accommodative shoe gear was then
with a history of lymphedema and was referred to our center prescribed to the patient. Final radiographic (E, F) views at
6 months after the initial injury. Patient underwent a tibiotalo- approximately 6-month follow-up.
calcaneal arthrodesis with a TSF construct (C, D). The external
A B
C D
(continued)
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E F
Clinical CASE VIII
Radiographic anteroposterior (A) and lateral (B) views of a a TSF construct (C, D). The external fixator was removed at
right lower extremity demonstrating talar avascular necrosis 12 weeks postoperatively followed by a non–weight bearing
with posttraumatic arthritis at the ankle joint. The patient cast immobilization for approximately 4 weeks and by another
had a previous infected subtalar joint arthrodesis at a differ- weight bearing lower extremity cast for additional 2 weeks.
ent institution which was followed by serial surgical debride- Appropriate shoe gear was then prescribed to the patient.
ments, hardware removal, and parenteral antibiotic therapy. Final radiographic (E, F) views at approximately 12-month
The patient eventually underwent an ankle arthrodesis with follow-up.
A B
(continued)
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136 Chapter 9
C D
E F
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Clinical CASE IX
Radiographic anteroposterior (A) and lateral (B) views of a right arthrodiastasis procedure with a TSF construct for aligning the
lower extremity demonstrating a significant varus deformity and ankle and correcting the talar varus rotation (C, D). The exter-
posttraumatic arthritis at the ankle joint. Patient had a previous nal fixator was removed at 8 weeks postoperatively followed by
lateral ankle ligamentous reconstruction with a Dwyer closing- a surgical off-loading boot and appropriate shoe gear. Final
wedge osteotomy of the calcaneus. Patient underwent an ankle radiographic (E, F) views at approximately 24-month follow-up.
A B
C D
(continued)
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138 Chapter 9
E F
Clinical CASE X
Radiographic anteroposterior (A) and lateral (B) views of a followed by a non–weight bearing cast immobilization for
left lower extremity demonstrating a severe fracture disloca- approximately 4 weeks and by another weight bearing lower
tion from Charcot neuroarthropathy at the ankle, rearfoot, extremity cast for additional 4 weeks. Accommodative shoe
and midfoot joints. The patient underwent a total talectomy gear with an ankle-foot-orthosis was then prescribed to the
and tibiocalcaneal arthrodesis with a TSF construct (C, D). patient. Final radiographic (E, F) views at approximately
The external fixator was removed at 16 weeks postoperatively 12-month follow-up.
A B
(continued)
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Clinical case X (continued)
C D
E F
110 and 130 kg of force and the olive wires placed in the cal- foot ring is assembled, it is then attached with six TSF struts to
caneus are typically tensioned by hand to avoid inadvertent the U plate around the calcaneus. At this point, the surgical
subsidence of the olive wire into the calcaneus for patients with assistant maintains proper position of the foot while the TSF
CN. At this point, a circular ring or three-fourth ring is placed struts are placed. An additional smooth wire can be placed
around the forefoot distal to the CN midfoot deformity and is through the talar neck or body and connected to the calcaneal
secured with two to three opposing smooth and/or olive wires. U plate with posts to further stabilize the rearfoot if needed.
Half-pins are typically avoided as the smooth or olive wires offer This construct can be utilized for various acute or chronic
better bone purchase, stability, and control of the forefoot ring CN midfoot procedures and also provide “static” correction if
during manipulation and deformity correction. After the fore- needed. Caution should be taken if this construct is utilized
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140 Chapter 9
Clinical CASE XI
Radiographic right foot, ankle anteroposterior (A, B), and lat- a non–weight bearing cast immobilization for approximately
eral (C) ankle views demonstrating a severe peritalar fracture 2 weeks and by another weight bearing lower extremity cast for
dislocation from Charcot neuroarthropathy at multiple joint additional 4 weeks. Appropriate shoe gear with a lower extrem-
levels. The patient underwent a total talectomy and tibiocal- ity double upright brace was then prescribed to the patient. Final
caneal arthrodesis with a TSF construct (D, E). The external radiographic (F, G) views at 12-month follow-up.
fixator was removed at 14 weeks postoperatively followed by
A,B C
D E
(continued)
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Clinical case XID(continued) E
F G
for the acute phase of CN deformity correction since the risks Weight bearing if permitted is allowed for patients who
for hematoma and/or deep infection are high during the have completed the initial postoperative latency period of 7
gradual correction. This similar construct can also be utilized to 10 days. When patients are allowed to walk with the use of
to compress and align the midfoot after multiple bone wedge assistant devices they are also encouraged to perform daily leg
osteotomies or arthrodesis is performed. Stabilization of the lifts and range of motion of the knee and hip to prevent any
midfoot osteotomy or arthrodesis site is usually accomplished unwanted postoperative joint contractures. Weight bearing is
by a smooth Steinmann pin. The 6 × 6 “butt frame” is applied usually not allowed in patients with diabetic CN correction
and the struts are utilized as fast struts to allow complete free- and/or concomitant soft tissue reconstruction in order to
dom of motion along each strut. The distal forefoot ring is then avoid devastating postoperative complications associated with
manipulated to compress and align the forefoot and midfoot to these high-risk patients. However, daily passive range of motion
the rearfoot while the surgical assistant secures each strut once of the proximal joints and upper extremity strengthening is
the desired position is achieved (Clinical Case XII). highly recommended through the consultation and expertise
of rehabilitation services.
The TSF is usually removed once a sensate patient is walking
Postoperative Course without pain and bone callus is seen on at least three cortices
and Complications of the osteotomy. Determining healing at arthrodesis sites is
more difficult as bone callus is not evident and monitoring
Patients are typically admitted to the hospital after the surgery the fusion site for trabeculation is required. Computed tom-
and necessary medicine consultation is initiated for antibiotic ography may be required to assist the surgeon in determining
coverage and deep vein thrombosis prophylaxis. Rehabilitation healing at fusion sites. The average time the TSF is maintained
programs are also initiated immediately and with the patient for arthrodesis and deformity corrections for the foot and
being evaluated by all medical teams necessary for a successful ankle is approximately 10 to 16 weeks. The TSF is removed
postoperative course. The patient is then followed in the clinical in the hospital setting as it provides the surgeon the ability to
setting for evaluation of the surgical wound and neurovascular disassemble the struts and to examine the osteotomy and/or
status, assessment of further radiographs, and to further discuss arthrodesis sites for further necessary procedures if indicated
the Internet-based daily program when gradual correction is (Clinical Cases XIII and XIV).
desired. Patients are instructed to adjust the labeled struts 1 The utilization of a TSF for the foot and ankle can be chal-
and 2 in the morning, 3 and 4 in the afternoon, and 5 and 6 in lenging at times due to the limited amount of space between
the evening in order to perform 1 mm of total correction daily. the foot and the ankle when multiple procedures are per-
Serial radiographs are then performed approximately every formed. This becomes more evident when trying to correct
2 weeks during the correction phase and every 4 weeks once the CN midfoot deformities with the butt frame and therefore, it is
correction is obtained and osseous union is to be determined. important to utilize short struts while placing the U plate and
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142 Chapter 9
Clinical CASE XII
Radiographic anteroposterior (A) and lateral (B) views of a left nal fixator was removed at 8 weeks postoperatively followed by
foot and ankle demonstrating an unstable midfoot Charcot a non–weight bearing cast immobilization for approximately
neuroarthropathy fracture dislocation with a history of medial 2 weeks and by an off-loading surgical boot for additional
plantar chronic ulcerations. The patient underwent a medial 2 weeks. Appropriate shoe gear was then prescribed to the
column arthrodesis with a TSF butt construct (C–E). The exter- patient. Final radiographic (F, G) views at 12-month follow-up.
A B
C D
(continued)
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Clinical case XII (continued)
E F
forefoot circular ring far enough apart to allow for midfoot prophylactic tarsal tunnel surgical decompression is required
deformity corrections. to prevent nerve injury. At times, the rate of correction may
Fixation of the osseous segments at each ring is paramount need to be slowed to prevent further nerve injury. In addition,
to prevent frame instability, failure of osteotomy separation or surgical decompression of the tarsal tunnel can be performed
correction, and inadequate reductions of the bone segments. during the perioperative period if sensory deficits or paresthe-
The use of appropriately placed bicortical smooth wires and sias become evident.
half-pins avoids these complications. Insertion of multiple The complexity of the TSF requires precise and accurate
smooth wires to stabilize the forefoot ring for midfoot correc- radiographic interpretations of the deformity and mounting
tions is necessary as the anatomy is not conducive for half-pin parameters of the external fixator. At times, malalignment
placement to achieve the required stability to perform deform- of the bone segments can present postoperatively when the
ity corrections. In addition, patients with diabetic CN typically information gathered is inaccurate. For this reason, serial
require very stable external fixation constructs and secured radiographs along with close physical examination of the
osseous segment fixation for reconstructive procedures. extremity are paramount during the postoperative period to
Iatrogenic posterior tibial nerve injury may be encountered prevent iatrogenic malunions and/or nonunions with devastat-
with severe equinus and varus deformity corrections. Often, a ing outcomes.
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144 Chapter 9
Clinical CASE XIII
Clinical (A) and radiographic (B) views of a severe equino- fixator. This is an example of the TSF versatility when multilevel
cavovarus deformity that required the use of a TSF. A total foot or ankle correctional deformities are needed (E, F). Final
talectomy (C) with tibiocalcaneal arthrodesis was achieved with clinical (G–I) and radiographic ( J, K) views at approximately
an acute correction (D). Simultaneous digital corrections were 6-year follow-up.
performed by attaching the smooth digital wires to the external
A B
C D
(continued)
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Clinical case XIII (continued)
E F
G H
I,J K
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146 Chapter 9
Clinical CASE XIV
Clinical (A) and radiographic (B, C) views of a left midshaft patient was brought back to the operating room where the TSF
tibia re-refracture with evidence of hypertrophic nonunion telescoping rods were removed and the union site was exam-
and malunion. The patient had a failed alignment with previ- ined for clinical stiffness and angular stability (F). The circular
ous attempts of fixation with a uniplane monolateral external rings were left intact for another 4 weeks where the patient
fixator. The patient underwent a gradual correction of the was encouraged to continue with the full weight bearing sta-
left lower extremity with the use of a TSF over a period of tus. This is an example demonstrating the correction of long
3 weeks (D, E). At that time, the patient was allowed to have bone deformities with the TSF. Final clinical (G, H) and radio-
a full weight bearing status to promote further potential heal- graphic (I, J) views following the external fixation removal at
ing at the re-alignment site. At 14 weeks postoperatively, the 18 weeks postoperatively.
A,B C,D
E,F G
(continued)
LWBK1121-C09_p119_147.indd 146 04/10/12 11:22 AM

Clinical case XIV (continued)
H,I J
Conclusion
A. Allow ample space between osseous segments when The authors have presented a stepwise approach to the appli-
applying a TSF for midfoot corrections to be certain cation of a TSF for addressing various foot and ankle patholo-
the TSF struts are fitted. gies. Extensive knowledge and surgical experience with the
B. The proximal tibia ring or tibial block for ankle and supr versatility of external fixators and the Internet-based computer
amalleolar deformities needs to be positioned approxi- program for the TSF is paramount to the overall patient’s suc-
mately 12 to 15 cm from the osteotomy site and 12 to cessful outcome.
15 cm from the ankle joint for an ankle arthrodesis.
This ensures adequate stability of the osseous segment
and allows for adequate options of strut lengths to cor- Recommended Readings
rect severe deformities. Floerkemeier T, Stukenborg-Colsman C, Windhagen H, et al. Correction of severe
C. The proximal ring needs to be mounted perpendicular foot deformities using the Taylor spatial frame. Foot Ankle Int. 2011;32:176–182.
(orthogonal) to the tibia and utilized as a reference ring Roukis TS, Zgonis T. The management of acute Charcot fracture-dislocations
for deformity corrections. with the Taylor’s spatial external fixation system. Clin Podiatr Med Surg. 2006;
23:467–483.
D. The CORA needs to be determined and accounted for
Zgonis T, Roukis TS, Polyzois V, et al. Surgical management of the unstable
when osteotomies are placed away from the CORA. diabetic Charcot deformity using the Taylor Spatial Frame. Oper Tech Orthop.
Translation in addition to angular and rotational cor- 2006;16:10–17.
rections is required to compensate for having the oste- Zgonis T, Roukis TS, Stapleton JJ. Use of the Taylor Spatial Frame for arthrodia-
otomy away from the CORA. stasis of the ankle joint. Tech Foot Ankle Surg. 2007;6:201–207.
E. Understanding the way in which the six struts move
to correct deformities is beneficial to analyze the pro-
posed program. The surgeon should become familiar
with various corrections and how the TSF is adjusted to
correct various deformities.
F. The TSF can provide maximum stability by making
sure all osseous segments are adequately fixated and to
prevent postoperative complications.
G. Consider tarsal tunnel surgical decompression for valgus
producing osteotomies that are performed to correct
severe preoperative clubfoot and/or equinocavovarus
deformities.
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Chapter
10
Claire M. Capobianco
John J. Stapleton
Thomas Zgonis
Stepwise Approach to Forefoot

Trauma and External Fixation
Introduction majority of forefoot trauma, other than the case scenarios

previously mentioned, can be addressed more effectively
In severe forefoot trauma, the use of external fixation confers with percutaneous pinning or primary open reduction and
the benefits of osseous stabilization and relief of soft tissue internal fixation (ORIF). If soft tissue edema or fracture
strain in the setting of complicated open fractures, mangled blisters are present on initial evaluation, then a well-padded
soft tissue, compromised vascularity, and compartment syn- lower extremity compressive dressing and splint is applied
drome. This chapter discusses specific forefoot case scenarios and standard ORIF follows within 3 to 14 days once the soft
in which external fixation may be required and details the tissue envelope quiesces.
techniques and designs of the external fixators applied. Unlike rearfoot and ankle, trauma to the forefoot may, at
External fixation can be utilized acutely for osseous stabiliza- times, preclude spanning external fixation. Since placement of
tion in forefoot trauma and may be further utilized for staged half-pins must avoid areas of devitalized tissue, open wounds,
reconstructive procedures such as arthrodesis, staged bone and/or planned incisions, in certain cases, there is limited
grafting, or distraction osteogenesis to manage metatarsal space available for the proper use of an external fixator. In
bone defects. The technical pearls described incorporate these instances, joint and fracture reduction and stabilization
basic external fixation techniques and emphasize appropriate may be better achieved with the utilization of percutaneous
pin placement and external fixation designs that adequately pinning or external splints. In addition, extreme caution is
stabilize the zone of injury. Many of these concepts and exter- needed in applying an external fixator to stabilize severe fore-
nal fixation designs for forefoot trauma have gained popularity foot trauma when the vascular supply to the affected toes may
in the management of forefoot injuries sustained during war be compromised. Slight overdistraction may induce irrevers-
conflicts. ible vascular injury of the digital arteries and result in tissue
loss and/or amputation.
Lastly, relative contraindications for external fixation in
Indications/Contraindications the forefoot include, and are not limited to, patients who suf-
fer serious psychiatric illnesses or lack the social support or
In the forefoot, external fixation is most appropriate for capability to handle the protracted recovery and specific care
select high-energy trauma such as severely comminuted inherent to external fixation.
metatarsal fractures, fractures associated with compartment
syndrome, Lisfranc’s fractures/dislocations not amenable to
internal fixation, gunshot wounds/blast injuries, and severe Preoperative Considerations
soft tissue injuries that require both splinting and frequent
evaluation of the affected soft tissue envelope. Blast injuries In any traumatic setting, evaluation of the surrounding soft
with significant soft tissue compromise, compartment syn- tissue envelope is crucial. Salvage of the severe high-energy
drome, and pulverized fracture patterns are encountered forefoot trauma depends largely on the degree of soft tissue
among the surgeons treating combat injuries during time loss and vascular injury as opposed to the extent of osseous
of war conflict. Likewise, hunting accidents, industrial acci- damage. For this reason, approaches for salvage and final out-
dents, crush injuries, and other mangled forefoot traumas comes for blast injuries, lawn mower injuries, and industrial
may present with similar pathology that may require external crush injuries involving the forefoot are usually dictated by the
fixation. overall management of the soft tissue envelope.
Relative contraindications for external fixation of fore- Injury to individual toe(s) may vary in severity and the sur-
foot trauma include fractures (with or without soft tissue geon needs to determine which toes should be amputated and
injuries) that can be adequately stabilized with standard which should be salvaged. Attempts are usually made to salvage
fixation, splint, or a prefabricated fracture shoe or boot. The the hallux and first metatarsal, if feasible, with the primary goal
148
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Stepwise Approach to Forefoot Trauma and External Fixation 149
of restoration of near-normal push off during gait. Primary complex. This is particularly evident with complete homola-
fusion of the first metatarsophalangeal joint with or without teral Lisfranc’s dislocations (Clinical Cases I–IV).
structural bone grafts is usually required for comminuted intra- External fixation may also be utilized for distraction pur-
articular fracture patterns. Salvage of the lesser toes may be poses to facilitate bone grafting and/or ORIF or arthrodesis
difficult to achieve in the presence of poor soft tissue coverage for bone loss associated with metatarsal fractures. In these
and/or severe vascular compromise. In these cases, primary case scenarios, the external fixation is beneficial in achiev-
amputation may be preferred. Rare cases of external fixation ing fracture reduction and alignment while simultaneously
application for salvage of lesser toes have been described restoring the length to the metatarsal. With open fractures,
but are not routinely performed. Particular attention must be metatarsal bone defects are often initially managed with serial
given to forefoot injuries with large soft tissue defects, bone surgical debridements and antibiotic-impregnated cement
loss, and/or arterial injury because these may be best treated spacers to avoid deep infection until wound healing occurs.
with partial foot, Symes, or major limb amputation to avoid a It is often beneficial to evaluate the contralateral uninjured
resultant painful, infected, or nonfunctional foot. foot to determine the appropriate length of the metatarsal. In
If lower extremity salvage is feasible, the stabilization of addition, marginal sacrifice of metatarsal length is beneficial,
unstable fracture patterns is critical for soft tissue quiescence. as complete restoration of the length may lead to vascular com-
Practically, planned pin placement must avoid any fracture promise of the affected toe. In these cases, fixation is obtained
blisters and be sufficient distance away from any open fracture by placing two half-pins proximal to the bone defect in the
fragments. When possible, placement of half-pins should also metatarsal and/or tarsal bone and one to two additional half-
avoid skin bridges between incisions placed for fasciotomies as pins distal to the bone defect. A half-pin can usually be placed
this may preclude future attempts at delayed primary closure. into the hallux and into the proximal phalanges of the second
As often as possible, one of the dorsal fasciotomy incisions can and third toes without complications. Pinning of the lesser
be closed with delayed primary closure and the others closed digits across the metatarsophalangeal joint is often required to
with a split-thickness skin graft. prevent iatrogenic toe contractures.
In addition, the surgeon must be aware of relative safe zones As mentioned, metatarsal bone defect reconstruction
for pin placement and understand that unstable fracture pat- begins after wound closure is successful and infection has been
terns may become further displaced while inserting half-pins. avoided. After explantation of the antibiotic-impregnated bone
At times, small limited incisions are required to place bone spacer or beads, several strategies for bone defect reconstruc-
clamps, elevators, or retractors against the osseous segment for tion are available: Allogenic structural grafting, autogenous
counterpressure during the placement of the half-pin. In the structural grafting, Papineau technique, or bone transport.
forefoot, this is commonly seen with pin placement in the distal Distraction osteogenesis and bone segment shortening with or
fragment of severely comminuted metatarsal fractures. without arthrodesis have a role in management of metatarsal
With high-energy forefoot trauma, the stabilization of the bone defects. Staged reconstructive procedures typically are
medial, central, and/or lateral columns needs to be deter- not performed until several weeks from the initial injury to
mined and addressed. Medial column stabilization typically avoid deep infection. The spanning external fixation system
involves spanning and/or stabilization of the first metatarsal. typically utilized can be removed if bone grafting can be per-
It is important to consider stability and alignment across the formed with supplemented internal fixation. The external
tarsometatarsal joint as well. Blast injuries or bone defects of fixator is maintained or further modified if bone shortening,
the first metatarsal are best stabilized with half-pin(s) in the distraction osteogenesis, or Papineau is performed. Arthrod-
tarsal bones, in the proximal and/or distal first metatarsal esis can be performed with or without external fixation and the
(dependent on the fracture pattern), and in the proximal condition of the surrounding soft tissue envelope is typically
phalanx of the hallux. Central metatarsal bone defects and/ the deciding factor.
or comminuted fracture patterns are best stabilized with
medial and lateral column spanning external fixation that
can be conjoined with either transfixing pins internally or
a bent bar apparatus externally. Lateral column instability
results from fracture patterns or bone defects involving the
Forefoot Stabilization
fourth and/or fifth metatarsal(s) or fracture–dislocations
involving the tarsometatarsal joints. Laterally, external fixa- Typically, the patient is positioned supine with ipsilateral thigh
tion is best achieved with half-pin(s) in the cuboid and/or padding and thigh tourniquet for hemostasis if open reduction
calcaneus, and in the proximal and distal aspect of the is required. An important concept for forefoot stabilization
fourth and/or fifth metatarsals (depending on the fracture is to have fixation at both proximal and distal regions to the
pattern). Half-pins are typically avoided in the fourth and injured site(s). In most cases, the proximal insertion involves
fifth toes as the phalanges are typically too small to secure placement of a 4 mm half-pin into the navicular (for medial
adequate fixation and vascular compromise of these toes is column stabilization) or the cuboid (for lateral column stabi-
not infrequent. lization).
Lisfranc’s fractures and dislocations that necessitate exter- Medial column stabilization begins with a 4 mm navicular
nal fixation require specific attention to stabilize the medial, half-pin measuring approximately 25 to 30 mm in thread
central, and lateral columns and create a construct that pre- length. The insertion of the pin is at the medial mid-body of the
vents subluxation and motion across the tarsometatarsal joint. navicular between the interval of the anterior and posterior tib-
Often, additional percutaneous and/or internal joint pinning ial tendons. The surgeon must orient the pin perpendicular to
is required to ensure reduction of the tarsometatarsal joint the navicular with a starting point slightly distal and superior to
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150 Chapter 10
Clinical CASE I
Preoperative anteroposterior (A) and lateral (B) radiographic for his tarsometatarsal joint dislocation (C, D). The external
views of a 46-year-old male with past medical history of dia- fixator was maintained for approximately 6 weeks and the
betic neuropathy, cardiac disease, and multiple comorbidities. patient was then transitioned to a non–weight bearing cast for
Patient sustained an injury dropping a heavy object to his right approximately 4 weeks. The patient then started partial weight
foot 2 days prior to his presentation in the emergency depart- bearing in a surgical boot before he returned to a protective
ment. Patient underwent an open reduction and pinning with shoe gear. Final postoperative radiographic views (E, F) at
utilization of a uniplane monolateral external fixation system 1-year follow-up.
A,B C
F E
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Clinical CASE II
Preoperative anteroposterior (A) and lateral (B) radiographic tarsometatarsal articulation. The external fixator was main-
views of a 29-year-old male with a history of trauma to his tained for approximately 7 weeks and the patient was then
right foot. Patient underwent an open reduction and pinning transitioned to a non–weight bearing cast for approximately
with utilization of a uniplane monolateral external fixation 4 weeks. The patient then started partial weight bearing
system for his tarsometatarsal joint dislocation (C, D). Please in a surgical boot before he returned to normal shoe gear.
note the positioning of the external fixator to the medial Final postoperative radiographic views (E, F) at approxi-
column of the foot and the Steinmann pinning of the entire mately 4-month follow-up.
A,B C
F E
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152 Chapter 10
Clinical CASE III
Preoperative anteroposterior (A) and lateral (B) radiographic nosed with concomitant navicular and cuneiform fractures.
views of a 20-year-old male with a history of trauma to his left The external fixator was maintained for approximately 6 weeks
foot. Patient underwent an ORIF and pinning as well as utili- and the patient was then transitioned to a non–weight bearing
zation of a uniplane monolateral external fixation system for cast for approximately 6 weeks. The patient then started partial
his tarsometatarsal joint dislocation (C, D). Please note the weight bearing in a surgical boot before he returned to normal
positioning of the external fixator to the medial column of the shoe gear. Final postoperative radiographic views (E, F) at
foot, as well as internal fixation and Steinmann pinning for approximately 3.5-month follow-up.
the unstable tarsometatarsal articulation. Patient was also diag-
A,B C
F E
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Clinical CASE IV
Preoperative anteroposterior (A) and lateral (B) radiographic to the utilization of a circular external fixator for equinus
views of a patient with past medical history of diabetic neu- correction and stabilization of the right foot and ankle to
ropathy and multiple comorbidities showing a poor outcome the lower extremity (C, D). The external fixator was main-
of a previous attempted repair of a right Lisfranc’s joint dislo- tained for approximately 6 weeks and the patient was then
cation. Patient had a significant equinus, pain, and posttrau- transitioned to a non–weight bearing cast for approximately
matic arthrosis at the Lisfranc’s and subtalar joints. Patient 6 weeks. The patient then started partial weight bearing in a
underwent an open reduction and arthrosesis of the first and surgical boot before he returned to a protective diabetic shoe
second tarsometatarsal and subtalar joints. A percutaneous gear. Final postoperative radiographic views (E, F) at 1-year
tendo-Achilles lengthening was also performed in addition follow-up.
A,B C
F E
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154 Chapter 10
the navicular tuberosity to avoid intra-articular placement. The 30 to 35 mm in thread length is utilized and a small 0.5 to 1
self-drilling half-pin is placed under fluoroscopic guidance to cm incision is carried down to the level of below or between
ensure proper placement. The medial column is then further the peroneal tendons for placement of the half-pin into the
stabilized with two 3 or 4 mm half-pins measuring approxi- distal calcaneus. Please note that it is important to place a
mately 15 to 20 mm in thread length into the shaft of the first soft tissue sleeve directly down to the level of calcaneus to
metatarsal. The self-drilling half-pins are inserted, bicortically prevent any injury to the sural nerve and/or peroneal ten-
and under fluoroscopic guidance, into the proximal and distal dons. After appropriate fixation is achieved in the calcaneus,
metaphyseal/diaphyseal junction of the bone if the fracture half-pin placement can be placed into the cuboid if not
pattern permits. In addition, if first metatarsal comminution fractured. The half-pin is typically placed above or between
exists, 3 mm half-pins (of approximately 10 to 15 mm thread the peroneus brevis and longus tendons and below the level
length) can be placed into the proximal and/or distal phalanx of the peroneus tertius. The starting point for the half-pin
of the hallux to further stabilize the construct. Half-pins are is more dorsally oriented and a 0.5 cm incision is recom-
inserted into the great toe in the central region of the phalanx mended with blunt dissection carried down to the level of
from medial to lateral. the cuboid. Placement of a soft tissue sleeve is placed again
Next, the bar to clamp apparatus is attached, and two fin- to avoid injury to the sural nerve. The self-drilling half-pin is
gerbreadths (2 to 3 cm) spacing is allowed between the bar inserted under power from lateral to medial direction with
and the soft tissues. The bar to clamp apparatus is initially the utilization of C-arm fluoroscopy.
lightly tightened by hand. Distraction and reduction by manip- To further stabilize and span the lateral column of the foot,
ulating the half-pins or the foot is then performed. Following two 3 or 4 mm half-pins measuring approximately 10 to 15 mm
reduction, the bar to clamp apparatus is tightened completely in thread length are then inserted into the fifth metatarsal
by the surgical assistant with wrenches (Figure 10.1 and Clini- at the proximal and distal metaphyseal/diaphyseal junctions.
cal Cases V and VI). Utilization of a self-drilling half-pin is advantageous as the
Lateral column stabilization begins with half-pin place- insertional position of the half-pin can be confirmed under
ment into the anterior process of the calcaneus and/or C-arm fluoroscopy and then the pin can be advanced into the
cuboid. Typically, a 4 mm half-pin measuring approximately metatarsal ensuring bicortical purchase. At this point, a bar to
Clinical CASE V
Preoperative anteroposterior (A) and lateral (B) radiographic tarsometatarsal joint dislocations and fractures (C, D). The
views of a patient with a severe left foot multiple metatarsal external fixator was maintained for approximately 10 weeks
and tarsal fractures and Lisfranc’s dislocation. Patient also and the patient was then transitioned to a non–weight bearing
had a compartment syndrome with previous foot fasciotomies cast followed by partial weight bearing in a surgical boot before
prior to ORIF and Steinmann pinning with utilization of a he returned to a protective shoe gear. Final postoperative
uniplane monolateral external fixation system for his multiple radiographic views (E, F) at 5-month follow-up.
A,B C
(continued)
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Clinical
A,B case V (continued) C
F E
Clinical CASE VI
Preoperative anteroposterior (A) and lateral (B) radiographic external fixator was maintained for approximately 6 weeks
views of a patient with right foot Lisfranc’s fracture–dislocation and the patient was then transitioned to a non–weight
and comminuted fractures at the first and second metatar- bearing cast for approximately 4 weeks. The patient then
sals. Patient underwent an ORIF and Steinmann pinning started partial weight bearing in a protective shoe gear. Final
with utilization of a uniplane monolateral external fixa- postoperative radiographic views (E, F) at approximately 2.5-
tion system at the medial column of the foot (C, D). The month follow-up.
A,B C
(continued)
D
LWBK1121-C10_p148_161.indd 155 04/10/12 11:17 AM
156 Chapter 10
Clinical
A,B case VI (continued) C
F E
A,B C
Figure 10.1. Medial column stabilization begins with a 4 mm navicular

half-pin measuring approximately 25 to 30 mm in thread length. The
insertion of the pin is at the medial mid-body of the navicular between the
interval of the anterior and posterior tibial tendons. The surgeon must ori-
ent the pin perpendicular to the navicular with a starting point slightly distal
and superior to the navicular tuberosity to avoid intra-articular placement.
The self-drilling half-pin is placed under fluoroscopic guidance to ensure
proper placement. The medial column is then further stabilized with two
4 mm half-pins measuring approximately 15 to 20 mm in thread length
into the shaft of the first metatarsal (A). Next, the bar to clamp apparatus
is attached, and two fingerbreadths (2 to 3 cm) spacing is allowed between
the bar and the soft tissues (B). The bar to clamp apparatus is initially lightly
tightened by hand. Distraction and reduction by manipulating the half-pins
D or the foot is then performed. Following reduction, the bar to clamp appa-
ratus is tightened completely by the surgical assistant with wrenches (C, D).
LWBK1121-C10_p148_161.indd 156 04/10/12 11:17 AM

Figure 10.2. Lateral column stabilization begins with half-pin Figure 10.3. If both medial and lateral column stabilization is
placement into the anterior process of the calcaneus and/or cuboid. required, the surgeon may place a transcalcaneal pin and extend
Typically, a 4 mm half-pin measuring approximately 30 to 35 mm in fixation both to the medial and lateral columns from the transcal-
thread length is utilized and a small 0.5 to 1 cm incision is carried caneal pin or simply connect the medial and lateral stabilization
down to the level of below or between the peroneal tendons for columns with a dorsal bent bar. At this point, the foot can be placed
placement of the half-pin into the anterior process of the calcaneus. into a removable splint to maintain a neutral position at the ankle
After appropriate fixation is achieved in the calcaneus, half-pin level if the external fixator is not extended proximally to stabilize
placement can be placed into the cuboid if not fractured. The half- the ankle.
pin is typically placed above or between the peroneus brevis and
longus tendons and below the level of the peroneus tertius. The
self-drilling half-pin is inserted under power from lateral to medial
under fluoroscopic guidance. To further stabilize and span the lat-
eral column of the foot, two 3 or 4 mm half-pins measuring approxi-
mately 10 to 15 mm in thread length are then inserted into the with a dorsal bent bar. At this point, the foot can be placed into
fifth metatarsal at the proximal and distal metaphyseal/diaphyseal a removable splint to maintain a neutral position at the ankle
junctions. Utilization of a self-drilling half-pin is advantageous as the
level if the external fixator is not extended proximally to stabi-
insertional position of the half-pin can be confirmed under C-arm
lize the ankle (Figure 10.3).
fluoroscopy and then the pin can be advanced into the metatarsal
ensuring bicortical purchase. At this point, a bar to clamp apparatus
is assembled and hand-tightened to the lateral column half-pins, Circular External Fixation
with 2 to 3 fingerbreadths spacing from the soft tissues. Reduction for the Forefoot
is performed with manipulation of the foot and/or distally placed
half-pins and the bar to clamp apparatus is tightened securely by the Circular external fixation for forefoot trauma is beneficial
surgical assistant with wrenches. when soft tissue defects need to be managed and fracture
patterns do not allow placement of half-pins to adequately
stabilize the medial, central, and/or lateral columns of
the foot. The placement of a simple two-ring construct above
clamp apparatus is assembled and hand-tightened to the lat- the level of the ankle and at the level of the metatarsals can
eral column half-pins, with 2 to 3 fingerbreadths spacing from be performed to provide osseous stability while the soft tissue
the soft tissues. Reduction is performed with manipulation of defect is assessed and treated. Initially, a full circular ring is
the foot and/or distally placed half-pins and the bar to clamp placed 7 to 10 cm above the level of the ankle joint. The leg
apparatus is tightened securely by the surgical assistant with is positioned in the center of the ring and maintained in this
wrenches (Figure 10.2). position with surgical towels under the posterior heel. A frontal
If both medial and lateral column stabilization is required, plane 1.8 mm wire is directed from lateral to medial across the
the surgeon may place a transcalcaneal pin and extend fixation tibia. The circular ring is then attached to the frontal plane wire.
to the medial and lateral columns from the transcalcaneal pin A second 1.8 mm wire starting medially is then placed on the
or simply connect the medial and lateral stabilization columns opposite side of the frontal plane wire oriented at an angle of
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158 Chapter 10
Clinical CASE VII
Preoperative clinical (A) and radiographic anteroposterior was removed prematurely at about 5 weeks due to the patient’s
(B) and lateral (C) views of a patient with a severe right foot extreme noncompliance with non–weight bearing status at the
Lisfranc’s fracture–dislocation and a history of multiple comor- postoperative course. He eventually had additional wound deb-
bidities. Patient underwent an open reduction and multiple ridements and clinically healed all his incisions. Final clinical
Steinmann pinning with utilization of a bilateral (both medial ( J) and postoperative radiographic views (K, L) at 10-month
and lateral foot columns) uniplane external fixation system for follow-up showing significant posttraumatic arthrosis at the
his tarsometatarsal joint dislocation (D–I). The external fixator tarsometatarsal joints.
A,B C
D E
(continued)
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F G
H I
J,K L
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160 Chapter 10
45 to 60 degrees. After both smooth wires are inserted, the across an arthrodesis or fracture site, or as the result of an
wires are tensioned while a surgical assistant stabilizes the foot unstable external fixator construct.
and the ring. Pin and/or wire tract infection is the most common
Next, an additional circular ring is placed at the meta- complication with external fixation. Stability of the entire
tarsal level allowed by the fracture pattern (where wire construct and associated wire tension are critical in both uni-
placement is feasible). The metatarsals are stabilized with plane and circular external fixation constructs. If the foot or
two to three smooth 1.8 mm wires. Olive wires may be uti- segment is not secure within the external fixator, the segment
lized if needed for additional stability. One smooth wire is or foot will piston and the motion will induce microtrauma at
placed from medial to lateral across the first and second the pin/wire site which increases the likelihood of soft tissue
metatarsals and attached to the circular ring. The next infection. Without close follow-up and management, pin/
smooth wire is placed from lateral to medial across the third, wire tract infections in the forefoot may progress to osteo-
fourth, and fifth metatarsals. Accurate metatarsal cortical myelitis fairly rapidly secondary to the relative paucity of soft
purchase is necessary to be achieved for the overall stabil- tissue coverage. Deep infections, particularly when half-pins
ity of the external fixation system. If additional fixation is are placed into the toes, can lead to vascular compromise,
required, a third smooth wire can be placed from either necrosis and eventual amputation in certain cases. Loosening
the medial or the lateral direction to further stabilize the of a digital half-pin and/or signs of infection should necessi-
metatarsals. tate removal of the pin (despite the loss of osseous stability) to
The two circular rings are then connected with bar and try and prevent irreversible soft tissue loss and osteomyelitis
hinge constructs medially, laterally, and centrally to stabilize at the toe level.
the two rings. The hinges are fastened once the position of
the forefoot to the rearfoot and lower leg is obtained. The
addition of off-loading bars (connected around the posterior
aspect of the heel and fastened to the threaded rods) ensures
stability and inadvertent motion of the external fixator while Clinical Tips and Pearl s
simultaneously off-loading the heel region. Modifications
A. Avoid inserting half-pins into the phalanges of toes 4 and
of an external fixation device can be made when both
5 as vascular injury and irreversible necrosis can occur.
medial and lateral columns of the foot are affected (Clinical
B. Add an external bent bar to connect and further sta-
Case VII).
bilize medial and lateral column spanning external
fixation systems. In addition, a transcalcaneal pin can
be utilized for proximal fixation when both the medial
Postoperative Course and lateral columns of the forefoot need to be further
and Complications stabilized.
C. Utilize bone clamps, retractors, and/or elevators through
Complications with the use of external fixation in forefoot limited incisions to gain control of grossly displaced and
trauma are usually related to lack of osseous healing of bone unstable metatarsal fractures to allow half-pin place-
defects and/or malunions that require delayed reconstruc- ment.
tive procedures. The goal of external fixation is often to D. Utilize postoperative splints, if feasible, with forefoot
address soft tissue complications, segmental bone loss, pulver- spanning external fixators to prevent iatrogenic ankle
ized fracture patterns, and to re-establish the articulation of equinus. Another alternative is to extend the external
the tarsometatarsal joint and length/alignment of the affected fixator proximal to the ankle joint to avoid the need for
metatarsals. Incongruent alignment of the articular surfaces as postoperative splints.
a result of unstable dislocations or severe osteochondral injury E. The constructs described can be simply modified for
may lead to severe pain and post-traumatic arthritis. Often, sal- delayed salvage and reconstructive procedures such as
vage arthrodesis procedures or amputation in severe cases may distraction osteogenesis or compression for an arthrod-
be required postoperatively. esis by exchanging the bar with a graduated telescoping
Generally, hardware failure and peri-hardware fracture may device between the affected half-pins.
be seen resulting from unicortical pin placement, pins placed
too close to the fracture or osteotomy site, or from excessive
distance between pins and the external fixator. Hardware revi-
sion is accomplished with an additional half-pin inserted about
1 to 2 cm from the previous half-pin if the anatomy allows. Conclusion
Exchange of a half-pin at the same location can be performed
if no clinical signs of infection are present. The loosened In the forefoot, external fixation is a helpful tool commonly
half-pin is removed, the pin site is adequately debrided and used to address comminuted or crush injuries of the metatar-
irrigated, and a 1 mm larger half-pin can be inserted if the size sals or tarsal bones, revisional arthrodesis, delayed bone graft-
of the bone allows. In circular constructs, it is recommended ing, distraction osteogenesis, and for off-loading of complex
to incorporate three forefoot wires so that if one wire fails, it soft tissue repairs. Understanding anatomic safe zones and
may be removed without compromising the overall stability of mechanical principles of static and dynamic external fixation
the construct. Likewise, nonunion/malunion may occur as a application is paramount to successful primary or adjunctive
result of micromotion secondary to inadequate stabilization use of these devices.
LWBK1121-C10_p148_161.indd 160 04/10/12 11:18 AM

Recommended Readings Freschi SA, Dodson N. Analysis of compression forces between varying sizes of
cannulated screws versus rail external fixation for treatment of Jones type
Barrett MO, Wade AM, Della Rocca GJ, et al. The safety of forefoot metatarsal fifth metatarsal fracture. J Foot Ankle Surg. 2008;47(4):295–298.
pins in external fixation of the lower extremity. J Bone Joint Surg Am. 2008; Molloy AP, Roche A, Narayan B. Treatment of nonunion and malunion of trauma
90(3):560–564. of the foot and ankle using external fixation. Foot Ankle Clin. 2009;14(3):
Bernstein B, Guerin L. The use of mini external fixation in central forefoot 563–587.
amputations. J Foot Ankle Surg. 2005;44(4):307–310. Nayagam S. Safe corridors in external fixation: the lower leg (tibia, fibula, hind-
Chandran P, Puttaswamaiah R, Dhillon MS, et al. Management of complex open foot and forefoot). Strategies Trauma Limb Reconstr. 2007;2(2–3):105–110.
fracture injuries of the midfoot with external fixation. J Foot Ankle Surg. 2006; Oznur A, Roukis TS. Minimum-incision ray resection. Clin Podiatr Med Surg. 2008;
45(5):308–315. 25(4):609–622, viii.
Demiralp B, Kurklu M, Bek D, et al. The treatment of comminuted midfoot frac- Roukis TS. Lesser toe salvage with external fixation and autogenous bone graft-
tures with distraction osteogenesis. Acta Orthop Traumatol Turc. 2004;38(2): ing: a case series. Foot Ankle Spec. 2010;3(3):108–111.
130–135. Zgonis T, Roukis TS, Polyzois VD. Lisfranc fracture–dislocations: current
Erdem M, Sen C, Eralp L, et al. Lengthening of short bones by distraction treatment and new surgical approaches. Clin Podiatr Med Surg. 2006;23:
osteogenesis—results and complications. Int Orthop. 2009;33(3):807–813. 303–322.
LWBK1121-C10_p148_161.indd 161 04/10/12 11:18 AM

Chapter
11
John J. Stapleton
Thomas Zgonis
Stepwise Approach to Midfoot/

Hindfoot Trauma and External
Fixation
Introduction tion for calcaneal fractures is not only confined to the diabetic
population but also considered a treatment option for those
The utilization of external fixation for midfoot and hindfoot high-risk patients in which ORIF is not feasible or preferred.
trauma has increased due to the successful outcomes of exter- Unstable midfoot and hindfoot fractures/dislocations are
nal fixation in treating certain ankle and pilon fractures. One also common indications for external fixation. For example,
of the most common indications for external fixation is the partial or total enucleations of the talus are commonly stabilized
management of selected open and/or high-energy midfoot/ with external fixation after the talus has been reduced within the
hindfoot trauma. The focus of this chapter is to discuss in a peritalar joints via an open or closed approach. External fixation
detailed fashion the application of various external fixation becomes particularly advantageous in conjunction with internal
designs for the treatment of midfoot and hindfoot fractures fixation for the management of Hawkins Grade 3 and Grade 4
and/or dislocations. talar neck fractures. Often, total dislocations of the peritalar
joints can still present with slight subluxation and instability
even after a formal ORIF is performed to restore anatomic
Indications/Contraindications alignment. External fixation to stabilize severely subluxed per-
italar joints such as an anterior subluxation of the ankle or
Severe midfoot crush injuries usually present with signifi- posterior subluxation of the subtalar joint is usually combined
cant bone loss and pulverized fracture patterns that involve with internal fixation and to further prevent any complications
the medial column (navicular and/or medial cuneiform), during the postoperative period (Clinical Cases I–III).
the lateral column (cuboid and/or anterior process of the Relative contraindications for external fixation of midfoot
calcaneus), and/or the central column (navicular and inter- and hindfoot trauma are fracture patterns with or without soft
mediate/lateral cuneiforms). External fixation is utilized to tissue injuries that can be adequately stabilized with splinting
stabilize and reestablish these columns and to obtain anatomic and/or casting. In addition, the majority of midfoot and/or
alignment if definitive open reduction and internal fixation hindfoot fractures other than the case scenarios previously
(ORIF) cannot be achieved. In addition, open fractures of the mentioned can be addressed more effectively with a primary
midfoot are also common indications for external fixation and ORIF. If soft tissue edema or fracture blisters are still present
especially when percutaneous pinning itself cannot provide the at the initial time of injury, then a well-padded lower extremity
necessary stability required to treat the associated osseous and compressive dressing is followed by a standard ORIF within 3
soft tissue injuries. Concomitant ankle and/or pilon fractures to 21 days and once the soft tissue envelope permits any type
associated with midfoot trauma is another indication for apply- of skin incisions.
ing external fixation to stabilize the midfoot and the distal leg Unlike trauma to the lower leg, the midfoot at times cannot
simultaneously until definitive fracture reduction and incision be adequately spanned with external fixation. With external
placement is determined (Figure 11.1A–D). fixation, it is preferred to avoid placement of half-pins in areas
External fixation indications for the management of hind- of devitalized tissue and open wounds. Furthermore, in certain
foot trauma are usually reserved for high-risk patients with case scenarios there is limited space available for the proper
known associated comorbidities. For example, most of the use of an external fixator. In these cases, joint and fracture
diabetic patients with dense peripheral neuropathy and/or reduction and stabilization may be better achieved with the
peripheral arterial disease and associated hindfoot trauma are utilization of internal joint pinning.
usually managed with external fixation to minimize potential Calcaneal fractures are usually treated with external fixation
postoperative complications. The utilization of external fixa- if external fixation is the primary and definitive method for
162
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Stepwise Approach to Midfoot/Hindfoot Trauma and External Fixation 163
A,B C
Figure 11.1. The thread diameter of the half-pins to the foot is usually 3 mm for the
metatarsals and 4 mm for the midtarsal bones. (A) and (B) show a hybrid configuration of an
external fixation system that is used for spanning any midfoot fracture/dislocation. Note the
additional tibia external fixation that may consist of one or two circular rings for further
stabilization of the lower extremity and its connection to the bar to clamp midfoot apparatus.
(C) shows the configuration of a uniplane monolateral external fixation system for spanning
an isolated navicular fracture while (D) shows the same principles for spanning a cuboid
D fracture at the lateral column of the foot.
fracture reduction and osseous consolidation. While ankle and Preoperative Considerations
pilon trauma can be adequately spanned with an external fixa-
tor and with the placement of half-pins or smooth wires outside Midfoot Trauma
the zone of injury, fractures of the calcaneus are often required
to have half-pin and/or smooth wire placement within the The initial surgical goal for high-energy midfoot trauma is to
zone of injury. For this reason, if a delayed calcaneal ORIF is maintain the length of medial and/or lateral columns while
to be performed and it was initially spanned with pins and/or stabilizing the keystone central column. This can be accom-
wires, this could compromise the proposed flap for an extensile plished with a primary ORIF if the soft tissue envelope per-
lateral incision placement. Often, calcaneal fractures that are mits or with a temporary spanning external fixation to allow
treated with external fixation can also be supplemented with for delayed reconstructive procedures if feasible. Pulverized
internal fixation through limited skin incisions to anatomically midfoot fractures that result in loss of arch height and/
reduce the articular surface of the posterior facet or the pri- or length of the medial or lateral columns may need to be
mary fracture line. Lastly, it is usually preferable to reduce the anatomically reduced while maintaining the functional axis
calcaneus through a medially or posterior inserted half-pin as related to the ankle and lower extremity. Articular surface res-
opposed to a transcalcaneal or laterally inserted half-pin. toration becomes a secondary goal in these pulverized fracture
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164 Chapter 11
Clinical CASE I
Preoperative lateral radiographic view (A) of a right total talus was removed at 6 weeks postoperatively. Final postoperative
dislocation. The talus was entrapped between the posterior radiographic views at 8 months showing anatomic alignment
tibial and flexor digitorum longus tendons preventing a closed of the peritalar joints (D, E). Avascular necrosis of the talus is
reduction. Open reduction and pinning of the peritalar joints present without any collapse of the peritalar joints. Serial radio-
was performed followed by the use of an ankle-spanning exter- graphs are recommended to assess the incidence of talar col-
nal fixation for stabilization (B, C). The external fixation system lapse and posttraumatic arthrosis versus talar revascularization.
A,B C
D E
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Clinical CASE II
Preoperative lateral (A) and anteriorposterior (B) ankle radio- (C, D). This temporary external fixation system was removed
graphic views showing a total enucleation to the right talus. at 5 weeks postoperatively and was followed by a tibiocalca-
The patient originally presented to the emergency room with neal arthrodesis with a circular external fixation system that
the talar body retained in a sterile specimen cup and gross consisted of two tibia rings, a foot plate, and an off-loading
contamination from the motor vehicle accident. The patient external ring attached to the foot plate (E–G). The circular
underwent multiple serial surgical debridements with inser- external fixator was removed at 14 weeks postoperatively. Final
tion of cemented antibiotic beads. An ankle-spanning delta postoperative radiographic views at approximately 6 months
external fixator was used to further stabilize the peritalar demonstrating successful osseous union of the tibiocalcaneal
joints and allow healing of the injured soft tissue envelope arthrodesis (H, I).
A B
C D
(continued)
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166 Chapter 11
E,F G
H I
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Clinical CASE III
Preoperative lateral radiographic view (A) of a right bimalleolar (B, C). Final postoperative radiographic views at approximately
ankle fracture with an associated talar neck fracture and dislo- 4 months demonstrating successful osseous union of the con-
cation at the subtalar joint. An ORIF was performed for the comitant fractures with anatomic alignment of the peritalar
concomitant fractures and an ankle-spanning external fixator joints and without any evidence of a talar avascular necrosis
was used to further prevent anterior subluxation of the ankle (D, E).
joint by stabilizing the midfoot, hindfoot, and lower extremity
A,B C
D E
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168 Chapter 11
patterns. Often, these fracture patterns are associated with a External fixation may also be utilized as a joint distractor
compromised soft tissue envelope that requires immediate to facilitate ORIF for severe midfoot crush injuries. In these
attention. Stabilizing the foot in its anatomic shape with an case scenarios, the external fixation is beneficial in achieving
external fixator relieves the strain to the surrounding soft tis- fracture reduction and alignment to the columns of the foot.
sues and allows for future staged reconstructive procedures For example, a lateral column spanning external fixator can be
to improve further stability and function to the foot (Clinical utilized as a joint distractor to restore the length in the lateral
Case IV). column of the foot when it is associated with a crushed cuboid.
Clinical CASE IV
Preoperative clinical (A, B) and radiographic (C) views of a postoperatively. The external fixation device was removed at
crush injury to the Lisfranc’s joint fixated with the use of a cir- 10 weeks with adequate osseous healing and anatomic align-
cular external fixator and multiple opposing olive wires. Radio- ment (H).
graphic (D, E) and clinical (F, G) views at approximately 10 days
A,B C
D E
(continued)
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F,G H
Alignment of the foot in this manner also facilitates an ORIF of achieve alignment of the calcaneal tuberosity through traction
the medial and/or central columns. and manipulation (Clinical Cases V and VI). Another option is
to place traction on a half circular ring attached to one or two
opposing smooth or olive wires that are placed across the poste-
Hindfoot Trauma
rior calcaneal tuberosity followed by a circular external fixator to
Partial or total enucleations of the talus commonly present maintain joint reduction (Figure 11.2).
with a transverse to oblique lateral wound associated with a In general, the overall alignment, height, and length of the
medial talus dislocation. In rare circumstances, the talus can calcaneal body can be improved with external fixation. In addi-
be extruded medially or plantarly through the body of the tion, frontal plane alignment of the calcaneal tuberosity can be
calcaneus. Lateral talar dislocations are often closed injuries also reduced with external fixation. In contrast, reduction of
and are not easily amenable to closed reductions as are medial the lateral calcaneal wall and/or articular surface of the poste-
talar dislocations. Often, the talar head lies medial and can be rior facet is often only feasible through a limited open reduc-
entrapped between the posterior tibial and flexor digitorum tion for comminuted calcaneal fractures. Tongue-type and
longus tendons preventing a closed reduction. two-part fractures involving the posterior facet of the subtalar
Open wounds associated with a talus dislocation require joint may be reduced with a limited open exposure technique
surgical debridement and irrigation to remove any retained and combined with external fixation (Clinical Case VII).
debris that can cause infection. The talus is carefully inspected Other calcaneal fracture patterns often require ORIF to
to determine if any soft tissue attachments remain. For cer- achieve near-anatomic alignment. The technique of external
tain case scenarios in which no soft tissue attachments are fixation for calcaneal fracture management is not to achieve
present within the talus, a decision has to be made in regards an anatomic reduction of the articular surface but to reestab-
to reimplantation and stabilization of the talus to its peritalar lish the shape of the calcaneus and to realign the calcaneus
joints with external fixation or to perform a talectomy with the to the talus and lower extremity. This technique is utilized to
insertion of antibiotic-impregnated beads and/or spacer to improve the positioning of the calcaneus and allow for osseous
manage the dead space along with a spanning external fixator. consolidation. Improved overall alignment of the calcaneus
Most commonly reimplantation of the talus is highly preferable facilitates future reconstructive surgical options to relieve pain
unless the open wound is heavily contaminated or the patient is and improve function if deemed necessary.
immunocompromised. Close postoperative observation of the
reimplanted and fixated talus is paramount in order to reduce
any risks of postoperative complications.
External fixation for the management of calcaneal fractures
can be quite challenging secondary to the degree of difficulty for
Stabilizing the Midfoot
joint reduction that can be achieved with the limited placement
of half-pins and smooth wires around the fracture pattern. Typi- An important concept for midfoot stabilization is to have fixa-
cally, a half-pin or threaded transcalcaneal pin can be inserted in tion at both proximal and distal regions to the injured site(s).
either the superior or the inferior aspect of the posterior tuber- In most cases, midfoot trauma stabilization with external fixa-
osity to reduce the primary fracture line, medial wall, and/or tion begins with insertion of a transcalcaneal or half-pin in the
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170 Chapter 11
Clinical CASE V
Preoperative lateral radiographic view (A) of a severely open- initial surgery, the external fixator was removed and a delayed
comminuted calcaneal fracture which was initially treated primary subtalar joint arthrodesis was performed (C, D). The
with a surgical debridement and reduction of the calcaneal use of this external fixation system facilitated the alignment of
tuberosity and body with a simple bar to pin external fixator the calcaneus for the delayed arthrodesis procedure. Successful
(B). Note the position of the calcaneal threaded pin for the osseous union and alignment of the calcaneus was evident at
simultaneous subtalar and ankle distraction. Six weeks after the 4 months postoperatively.
A B
C D
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Clinical CASE VI
Preoperative lateral radiographic view (A) of a severely open- healed. Final postoperative radiographic views (D, E) dem-
comminuted calcaneal fracture that was treated with an initial onstrate an osseous union and near anatomic alignment with
surgical debridement, delayed primary closure and an applica- evidence of subtalar joint posttraumatic arthrosis. The use of
tion of an ankle-spanning external fixator for osseous and soft the external fixation system along with the surgical meticulous
tissue stabilization (B, C). This temporary external fixator was debridement prevented any wound complications and post-
removed 2 weeks after its application. A formal calcaneal ORIF operative infections by reducing the initial open medial wall
was achieved at that time and after the initial wounds were of the calcaneus.
A,B C
D E
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172 Chapter 11
A B
Figure 11.2. (A) demonstrates the option for the use of a half circular ring attached to a smooth wire
that is placed across the posterior calcaneal tuberosity and before the application of the circular external
fixator to maintain joint reduction. (B) demonstrates the same reduction by using a calcaneal transfixion
Steinmann pin attached to a traction table external apparatus for distraction and alignment of the calcaneal
tuberosity and body.
Clinical CASE VII
Preoperative lateral radiographic view (A) of an open calcaneal foot in a slightly plantarflexed position to avoid any tension
tongue-type fracture with severe soft tissue loss at initial presen- on the neurovascular pedicle flap (B–D). The circular external
tation. This patient was transferred from a different institution fixation system was kept for about 8 weeks. Final postoperative
where an initial surgical debridement was performed. This was radiographic views (E, F) at approximately 4 months dem-
followed by an ORIF of the calcaneal fracture and reverse flow onstrating successful osseous union. The patient eventually
sural neurofasciocutaneous pedicle flap for soft tissue coverage healed the wound and was also accommodated in a lower
of the calcaneus. A circular external fixation system was used extremity brace with a custom molded shoe to further prevent
to surgically off-load the pedicle flap while maintaining the any skin ulceration around the calcaneus.
A B
(continued)
LWBK1121-C11_p162_186.indd 172 04/10/12 11:19 AM

C D
E F
calcaneus. A 5 mm threaded transcalcaneal pin is typically uti- the calcaneus, half-pin placement is then carried out at the level
lized if stabilization of both the medial and lateral columns of the of the metatarsals. To further stabilize and span the lateral col-
foot is needed. The transcalcaneal pin is driven from medial to umn of the foot, a 4 mm threaded half-pin is then inserted into
lateral direction and within the junction of the superior and infe- the base of the fifth and fourth metatarsals. The insertion of the
rior portion of the posterior calcaneal tuberosity. An alternative half-pin begins at the proximal region of the metaphyseal/dia-
5 mm threaded half-pin can be driven into the posterior portion physeal region of the fifth metatarsal and is aimed approximately
of the calcaneal tuberosity in a medial or lateral orientation and 15 degrees superiorly to obtain good purchase at the base of the
according to which column of the foot requires stabilization. For fourth metatarsal. Utilization of a self-drilling half-pin is advanta-
the lateral column of the foot, spanning external fixation may geous as positioning of the appropriate insertion of the half-pin
include a second half-pin that can be inserted into the proximal can be confirmed under C-arm fluoroscopy and then driven
region of the anterior process of the calcaneus if not fractured. into the metatarsal bases. Additional stabilization of the lateral
Typically, a 4 mm threaded half-pin is utilized and a small 0.5 column of the foot can be achieved with the insertion of a 3 or
to 1 cm incision is made and carried down to the level of bone 4 mm threaded half-pin into the diaphysis of the fifth metatarsal
below or between the peroneal tendons. Please note that it is shaft. Alternative fixation of the lateral column of the foot is the
important to place a soft tissue sleeve directly down to the level insertion of a 4 mm threaded half-pin into the cuboid if not
of calcaneus and thus prevent any injury to the sural nerve and/ fractured and for management of a crush injury involving the
or peroneal tendons. After appropriate fixation is achieved in anterior process of the calcaneus.
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174 Chapter 11
Stabilization and spanning of the medial column of the in the lower extremity as compared to those half-pins inserted
midfoot is carried out with 4 mm threaded half-pins inserted for the management of ankle/pilon trauma. The rationale for
into the first metatarsal base and shaft from the medial aspect inserting the half-pins from anterior to posterior direction and
of the foot. Additional half-pin insertions can be driven into slightly distally than a typical ankle-spanning external fixator is
the cuneiform(s) if not fractured to stabilize a pulverized to be able to create a direct line of force when distracting and
navicular and/or talar head and neck fracture. After all nec- manipulating the transcalcaneal pin to adequately reduce the
essary half-pins are inserted into the foot, they are secured calcaneal medial wall and tuberosity. In addition, this direct
with a bar to clamp apparatus that incorporates universal line of manual distracting force is placed evenly across the pos-
ball-joint hinges that are secured directly to the half-pins. terior facet of the subtalar joint and aids in fracture reduction
The bar is placed at a distance of about two to three finger’s through ligamentotaxis.
breadth away from the skin to allow space for postoperative Following the insertion of two half-pins in the tibia, a
edema and application of any dressings that need to cover 4 or 5 mm threaded transcalcaneal half-pin is inserted across
the external fixation. Placing the bar further away from the superior or inferior portion of the posterior calcaneal
the zone of injury can compromise stability of the external tuberosity and this is dependent on the fracture pattern. A
fixator. After attachment of the bar to the half-pin sites, the 4 mm threaded half-pin is then inserted across the cuneiforms
bolts of the clamps are lightly tightened allowing the bar to from the medial aspect of the foot and across the cuboid or
still freely move. Reduction is achieved by manipulating the fourth and fifth metatarsal bases from the lateral aspect of
foot and/or by applying distraction to the distal half-pins. the foot. At this point, the transcalcaneal pin is attached to
After the column(s) is reduced and the position of the foot is the half-pins in the tibia and the midfoot with a bar to clamp
improved, the clamps to the external fixator are tightened by apparatus. The connection of the bar to the half-pins is then
the surgical assistant. Additional stability can also be provided tightened. The clamp to the transcalcaneal pin is not tight-
by connecting the medial and lateral spanning external fixa- ened until distraction and manipulation of the transcalcaneal
tors with a dorsal bent bar. Lastly, in cases where stabilization pin against the half-pins of the tibia is performed to achieve
of the ankle joint is required to prevent an equinus contrac- fracture reduction. Often, the transcalcaneal pin is first pulled
ture, the midfoot external fixation construct can be extended posteriorly and inferiorly and thus restoring the calcaneal
proximally to the ankle joint or a well-padded lower extremity length and height, respectively. Frontal plane deformity can
posterior splint can be used to maintain the ankle joint in a then be corrected by joysticking the transcalcaneal pin and
neutral position (Figure 11.1A and B). once the calcaneal tuberosity is disimpacted and more free to
manipulate. Lastly, all connections to the bar and clamp exter-
nal apparatus are secured and reduction is evaluated under
Calcaneal Fracture Management
C-arm fluoroscopy and adjustments are made as needed.
External fixation to address calcaneal fractures requires a Circular external fixation for the management of calcaneal
steep learning curve and surgical experience as precise limited fractures is usually reserved for the following conditions but
incisional approaches, reduction techniques, and meticulous is not limited to high-risk patients for attempted reduction
wire and pin placement is paramount to achieve optimal of the subtalar joint through a limited open lateral approach
reduction results. The first step in the management of calca- with or without supplemented internal fixation, posterior cal-
neal fractures with external fixation is to determine whether a caneal open wounds associated with tongue-type or avulsion
simple bar-to-pin device is more advantageous than a circular fractures of the calcaneal tuberosity, and/or in severely com-
external fixator. A simple bar to pin external apparatus is often minuted fractures where a primary subtalar joint arthrodesis is
beneficial to restore the alignment of the calcaneal tuberosity approached through a limited sinus tarsi incision.
to the talus and lower extremity while improving the calca- This surgical technique of utilizing circular external fixa-
neal loss of height and length. This form of fixation is usually tion for the management of calcaneal fractures begins with
used to achieve osseous consolidation and is useful for the placing the patient on a fracture table that can provide trac-
management of high-energy and open-comminuted calcaneal tion. After the lower extremity is prepped, one to three oppos-
fractures. This simple bar to pin external apparatus is ideal for ing olive wires are inserted across the calcaneal tuberosity
simultaneous serial debridements of the open wound(s) and and tensioned to a 70 to 90 kg of force and attached to a half
to also facilitate a delayed primary subtalar joint arthrodesis if circular ring. This is followed by manual traction to the half
needed at the time of definitive wound closure. The osseous circular ring or by continuous traction and attachment of the
defect is then filled with autogenous bone grafting and further half circular ring to the traction table. Next, a small 3 to 4 cm
stabilization is achieved with the completion of the bar to pin skin incision is made laterally at the level of the posterior facet
external apparatus until osseous consolidation is achieved. of the subtalar joint and through blunt and sharp dissection
The above-mentioned external fixation design consists of the posterior facet of the subtalar joint is exposed. A 0.25 in.
two half-pins inserted into the tibia followed by a transcalcaneal curved osteotome is then used to reflect the lateral calcaneal
pin inserted across the calcaneal tuberosity followed by two wall gaining exposure to the depressed segments of the pos-
half-pins inserted into the midfoot. The first step requires the terior facet. Utilizing the same osteotome, the depressed seg-
insertion of two 5 mm threaded half-pins from anterior to pos- ments are disimpacted, elevated as necessary, and stabilized
terior orientation on the anterior crest of the tibia. The half- with a 0.062 Kirschner wire. The osseous defect is then filled
pins in the tibia are usually predrilled with a 3.2 or 3.5 mm drill with bone graft to prevent re-collapse of the subtalar joint.
bit dependent on the manufacturer. The insertion of each half- Internal fixation can also be used at this time to support
pin is approximately 12 and 15 cm, respectively. It is important and further reduce the posterior facet of the subtalar joint
to note that these half-pins are typically inserted more distally (Figure 11.3).
LWBK1121-C11_p162_186.indd 174 04/10/12 11:19 AM

A
B
C
D
E F
Figure 11.3. (A) and (B) demonstrate the surgical technique of utilizing circular external fixation for the management of a calcaneal frac-
ture and by placing the patient on a fracture table that can provide traction. After the lower extremity is prepped, one to three opposing olive
wires are inserted across the calcaneal tuberosity and tensioned to a 70 to 90 kg of force and attached to a half circular ring or a calcaneal trans-
fixion pin can be initially used and then removed before the open reduction (C). Next, a small 3 to 4 cm skin incision is made laterally at the
level of the posterior facet of the subtalar joint and through blunt and sharp dissection the posterior facet of the subtalar joint is exposed (D). A
0.25 in. curved osteotome is then used to reflect the lateral calcaneal wall gaining exposure to the depressed segments of the posterior facet.
Utilizing the same osteotome, the depressed segments are disimpacted, elevated as necessary, and stabilized with a 0.062 Kirschner wire. The
osseous defect is then filled with bone graft to prevent re-collapse of the subtalar joint (E, F). (continued)
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176 Chapter 11
G H
I J
Figure 11.3. (continued) Internal fixation can also be used at this time to support and further reduce the posterior facet of the subtalar joint
if necessary. After the calcaneal fracture has been reduced, attention is then directed at the circular fixation of the tibia consisting of two tibia
rings located about 10 to 15 cm proximal to the ankle joint. These two circular tibia rings are stabilized initially by inserting two frontal plane
wires across the tibia from lateral to medial direction. Each frontal plane wire is secured and tensioned between 110 and 130 kg of force on its
respective circular ring (G). Additional stabilization can be performed by inserting 5 mm threaded half-pins across the medial face of the tibia
or directly anterior to posterior direction along the anterior crest of the tibia. If smooth wires are utilized, they are inserted across the medial
face of the tibia at approximately 45 to 60 degrees to the frontal plane wire and tensioned between 110 and 130 kg of force. Adequate fixation of
these two circular tibia rings is achieved once the segment cannot move in any direction when manual force is applied. Stabilization of the tuber-
osity can be achieved with crossing olive wires into the superior or inferior aspect of the calcaneal tuberosity. Reduction of the lateral calcaneal
wall is achieved with olive wires placed from lateral to medial direction (F, G). Extra caution is taken to avoid injury to the posterior medial neu-
rovascular bundle with the insertion of any calcaneal wires. Additional olive wires can also be inserted from medial to lateral direction to reduce
the medial calcaneal wall. Typically, a small incision is made and blunt dissection is carried down directly to the medial wall of the calcaneus. An
olive wire can then be inserted directly against the medial wall and angled from posterior medial to anterior lateral direction to avoid injury to
the neurovascular bundle. The crossed olive wires placed into the calcaneal tuberosity are then attached to an external foot plate and tensioned
simultaneously from opposite directions to maintain and secure the calcaneal tuberosity in its desired position. Correction of a calcaneal varus
or valgus deformity can be achieved by first tensioning the olive wire against the medial and lateral calcaneus, respectively (H, I). Aggressive
tensioning particularly in the calcaneus can result in cortical fracture against the olive wire and subsidence of the olive wire within the body of
the calcaneus. In cases without deformity correction, the calcaneal wires may be secured to the external foot plate by very minimal tensioning
or by only secure tightening. After the calcaneus is stabilized to the external foot plate, the remainder of the foot is stabilized by inserting one to
two midfoot smooth wires with an optional forefoot smooth wire (J). The smooth wires are attached to the foot plate and are usually tensioned
between 75 and 90 kg of force. Lastly, the circular external fixation construct is completed by securing the proximal and distal lower extremity
segments with additional threaded rods, half rings, and/or off-loading plantar circular rings (H–J). With permission from Marin LE, DiDomenico
LA, Mandracchia VJ, et al. Diabetic neuropathic forefoot, midfoot, and hindfoot osseous trauma and disclocations [Chapter 25]. In: Zgonis T, ed.
Surgical Reconstruction of the Diabetic Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:352–353.
LWBK1121-C11_p162_186.indd 176 04/10/12 11:19 AM

After the calcaneal fracture has been reduced, attention is Most common modifications to the above-standard circular
then directed at the circular fixation of the tibia consisting of external fixation construct include the utilization of an addi-
two tibia rings located about 10 to 15 cm proximal to the ankle tional one to two talar smooth wire(s) from medial to lateral
joint. These two circular tibia rings are stabilized initially by direction in cases of primary subtalar joint arthrodesis. These
inserting two frontal plane wires across the tibia from lateral to smooth wires are attached to the external foot plate after they
medial direction. Each frontal plane wire is secured and ten- are slightly pre-bent in a proximal and inferior direction of
sioned between 110 and 130 kg of force on its respective circu- their insertions to the talus. They are then tensioned in the
lar ring. Additional stabilization can be performed by inserting usual manner or by manual force and simultaneously from
5 mm threaded half-pins across the medial face of the tibia or both sides in order to provide stabilization and compression
directly anterior to posterior direction along the anterior crest of the talus across the posterior facet of the subtalar joint.
of the tibia. If smooth wires are utilized, they are inserted across This technique is described as a “bent wire” technique and is
the medial face of the tibia at approximately 45 to 60 degrees advantageous to achieve compression across the arthrodesis
to the frontal plane wire and tensioned between 110 and site.
130 kg of force. Adequate fixation of these two circular tibia Other circular external fixation modifications for calca-
rings is achieved once the segment cannot move in any direc- neal fracture management include specific designs to address
tion when manual force is applied. tongue-type or avulsion fractures of the calcaneal tuberosity.
Next, attention is directed to the calcaneal half ring which These designs are slightly different and are used to achieve
was utilized for the distraction by manual force or connected fracture reduction, to off-load the soft tissues of the posterior
to the traction table. In most cases, this circular half ring heel, and to further stabilize the foot in a slightly plantar-
is removed and the olive wires are usually connected to an flexed position during the postoperative period. This can be
external foot plate. Additional olive wires may have to be accomplished with a similar standard construct mentioned
inserted at the calcaneus to further maintain the reduction above and by positioning the foot in a plantarflexed position
achieved in the earlier stages. It is important to note that and gradually correcting it by external hinges or by using
the surgical assistant maintains the foot in a neutral position the same two circular tibia rings and a midfoot circular ring
related to the lower extremity while smooth or olive wires with two to three smooth wires inserted into the midfoot.
are inserted into the calcaneus and attached to the foot The midfoot circular ring is then connected to the proximal
plate. external fixation construct while maintaining the foot in
Stabilization of the tuberosity can be achieved with crossing a plantarflexed position. The tongue-type or avulsion frac-
olive wires into the superior or inferior aspect of the calcaneal ture fragment can be stabilized with Steinmann pins. This
tuberosity. Reduction of the lateral calcaneal wall is achieved construct is beneficial to address any wound complications
with olive wires placed from lateral to medial direction. Extra associated with these injuries and also allows ample room for
caution is taken to avoid injury to the posterior medial neu- close observation of the wound to perform necessary dressing
rovascular bundle with the insertion of any calcaneal wires. changes, utilize negative pressure wound therapy, or off-load
Additional olive wires can also be inserted from medial to lat- any soft tissue closure.
eral direction to reduce the medial calcaneal wall. Typically,
a small incision is made and blunt dissection is carried down
Peritalar Joint Stabilization
directly to the medial wall of the calcaneus. An olive wire can
then be inserted directly against the medial wall and angled External fixation applied for peritalar joint stabilization uti-
from posterior medial to anterior lateral direction to avoid lizes an ankle-spanning external fixator as described in the
injury to the neurovascular bundle. The crossed olive wires ankle/pilon trauma chapter 12. The key aspects to stabilizing
placed into the calcaneal tuberosity are then attached to an the peritalar joints are to have fixation in the proximal tibia,
external foot plate and tensioned simultaneously from oppo- calcaneus, and midfoot to ensure stability across the ankle,
site directions to maintain and secure the calcaneal tuberos- subtalar, and midtarsal joints. The only difference in utilizing
ity in its desired position. Correction of a calcaneal varus or an ankle-spanning external fixator to stabilize the peritalar
valgus deformity can be achieved by first tensioning the olive joints for talus dislocations is to avoid distraction through the
wire against the medial and lateral calcaneus, respectively. transcalcaneal pin. In most cases, the external fixator is applied
Aggressive tensioning particularly in the calcaneus can result in a static fashion and after the talus has been reduced and/
in cortical fracture against the olive wire and subsidence of or fixated and in order to maintain the stability and align-
the olive wire within the body of the calcaneus. In cases with- ment within the lower extremity. Manual distraction is not
out deformity correction, the calcaneal wires may be secured required, and if used could lead to further joint subluxation,
to the external foot plate by very minimal tensioning or by instability, and soft tissue compromise. C-arm fluoroscopy is
only secure tightening. After the calcaneus is stabilized to the utilized to ensure that the peritalar joints are appropriately
external foot plate, the remainder of the foot is stabilized by aligned without any evidence of joint subluxation (Clinical
inserting one to two midfoot smooth wires with an optional Case VIII).
forefoot smooth wire. The smooth wires are attached to the
foot plate and are usually tensioned between 75 and 90 kg of
Total Talar Extrusion
force. Lastly, the circular external fixation construct is com-
pleted by securing the proximal and distal lower extremity Management of a total talar extrusion begins with stabiliza-
segments with additional threaded rods, half rings, and/or tion of the lower extremity. In the acute setting, this can
off-loading plantar circular rings. be accomplished with an ankle-spanning external fixator
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178 Chapter 11
Clinical CASE VIII
Preoperative anteriorposterior (A) and lateral (B) radiographic ankle-spanning external fixation system (D–F). The right foot
views of the left foot showing the complete peritalar disloca- underwent a traditional ORIF of the talar neck fracture (G).
tion along with the patient’s opposite right foot preoperative The external fixation to the left lower extremity was removed
lateral radiographic view (C) showing a talar neck fracture. at 6 weeks. Final postoperative radiographic views (H–L) at
The patient underwent a left foot stabilization of the medial 9 months showing anatomic alignment and without any evi-
and lateral columns as well as the midfoot and subtalar dence of talar avascular necrosis to bilateral lower extremities.
joints with the use of intra-articular joint pinning and an
A B
C,D E
(continued)
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F G
H I
J K
(continued)
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180 Chapter 11
as described in the ankle/pilon trauma chapter 12. During shape of the foot while trying to improve the functional axis of
the postoperative course, any traumatic open wounds and the midfoot and hindfoot to the lower extremity (Clinical Cases
osseous defects can also be managed as necessary. In most IX and X). Incongruent alignment of the articular surfaces as
cases, the osseous and soft tissue defect is initially treated a result of severe osteochondral injury may lead to severe pain
with insertion of an antibiotic-impregnated cement spacer when it involves the midfoot and/or hindfoot. Often, salvage
and/or beads that are exchanged if multiple serial debride- arthrodesis procedures or amputation may be required post-
ments are required. In addition, the spanning ankle external operatively.
fixator can be also converted to a circular external fixator Another complication unique to external fixation of the
to stabilize the lower extremity, achieve a tibiocalcaneal midfoot and hindfoot is potential loosening of the half-pins
arthrodesis, and/or facilitate optional bone transport for seg- most likely when they are inserted in the midfoot and metatar-
mental bone loss. This can be accomplished by the standard sals. Unicortical bone purchase by improperly angulating the
circular external fixator that consists of two tibia rings and a half-pin is a common cause of external fixation loosening and
foot plate as described in the application of a static circular when necessary it should be revised with an additional half-
external fixator chapter 8. Alignment for the arthrodesis is pin inserted about 1 to 2 cm from the previous half-pin if the
maintained by compressing the proximal tibia circular rings anatomy allows. Exchange of a half-pin at the same location can
and external foot plate. Additional proximal ring(s) can also be performed if no clinical signs of infection are present. The
be applied if a proximal tibia osteotomy and bone transport loosened half-pin is removed, the pin site is adequately debri-
is performed to accommodate for the ipsilateral limb length ded and irrigated, and a 1 mm larger half-pin can be inserted
discrepancy. if the size of the bone allows.
Equinus contractures at the ankle joint are commonly
encountered postoperatively in patients with severe midfoot
injuries. As previously described, splinting or application of
Postoperative Course an external fixator extended to the lower extremity can pre-
and Complications vent any ankle and/or heel cord contractures. Any residual
contracture is detrimental for the overall recovery of midfoot
Complications specifically to utilizing external fixation to injuries and particularly when the patient resumes a normal
address midfoot and/or hindfoot trauma are usually related to ambulatory status. Subsequent treatment may include and is
lack of anatomic fracture reduction that require delayed recon- not limited to physical therapy, splinting, gastrocnemius reces-
structive procedures and/or amputation. The goal of external sion, Achilles tendon lengthening, and/or external fixation.
fixation is often to address soft tissue complications, segmental Final treatment options depend on the degree of contracture,
bone loss, pulverized fracture patterns and to reestablish the muscle power, and osseous deformities.
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Clinical CASE IX
Preoperative anteriorposterior (A) and lateral (B) radiographic sive soft tissue debridement, midfoot arthrodesis with the use
views of the left foot showing as severe crush injury to the of autogenous iliac crest bone grafting, and application of
entire midfoot and hindfoot as well. Patient underwent an ini- circular external fixation (G–J). At a later date, a reverse flow
tial stabilization with a modified delta external fixation (C–E). neurofasciocutaneous sural flap was utilized to cover the large
Due to the significant extent of the injury, an angiogram was soft tissue defect in the foot region with a modification of the
ordered to determine if the lower extremity vasculature was circular external fixation to allow for the flap coverage (K–M).
intact before the definitive surgical procedure (F). The patient Final radiographic (N, O) and clinical (P–S) outcomes showing
was then brought back to the operating room for an aggres- the functional left lower extremity.
A,B C
D,E F
G,H I
(continued)
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182 Chapter 11
J K
L M
N O
(continued)
LWBK1121-C11_p162_186.indd 182 04/10/12 11:20 AM

P Q
R S
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184 Chapter 11
Clinical CASE X
Preoperative radiographic (A, B), 3-dimensional computed utilized for lower extremity distraction and realignment of the
tomography (C), and clinical (D, E) views of the right foot dislocated talar fracture. Note the additional Steinmann pin
and ankle showing a severe fracture and dislocation of the fixation at the tibiotalocalcaneal joints for further stability (F,
talar body with a concomitant tibial plafond fracture after a G). Final radiographic (H, I) and clinical ( J, K) outcomes at
motor vehicle accident. A static circular external fixator was approximately 1-year follow-up.
A,B C
D,E F
(continued)
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G H
I J
G H
K
LWBK1121-C11_p162_186.indd 185 04/10/12 11:20 AM

186 Chapter 11
Conclusion
A. Utilize self-drilling half-pins for the calcaneus, midfoot, The authors have presented a stepwise approach to complex
and metatarsals. Predrilling is not usually required, midfoot and hindfoot injuries by utilization of various internal
and improved bone purchase is encountered if the and external fixation methods. Extensive knowledge and expe-
half-pin is inserted initially utilizing a power drill and rience with the versatility of external fixators is paramount to
completed by hand power. the overall patient’s successful outcome.
B. Iatrogenic injury to the sural nerve and peroneal ten-
dons can be avoided when placing half-pins into the
anterior process of the calcaneus by utilizing a 0.5 to Recommended Readings
1 cm incision and an oversized soft tissue sleeve. Beals TC. Applications of ring fixators in complex foot and ankle trauma. Orthop
C. Avoid an iatrogenic equinus contracture after stabiliza- Clin North Am. 2001;32:205–214.
tion of the medial and/or lateral columns of the foot Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am.
2001;32:21–33.
by extending the external fixator proximal to the ankle
Richter M, Wippermann B, Krettek C, et al. Fractures and fracture dislocations
joint or by placing the patient into a well-padded poste- of the midfoot: occurrence, causes and long-term results. Foot Ankle Int.
rior splint in a neutral position. 2001;22:392–398.
D. Reserve the utilization of external fixation for the man- Stapleton JJ, Kolodenker G, Zgonis T. Internal and external fixation approaches
agement of calcaneal fractures to the high-risk patient to the surgical management of calcaneal fractures. Clin Podiatr Med Surg.
2010;27:381–392.
population and for those case scenarios that are not suit- Zgonis T, Roukis TS, Polyzois VD. Lisfranc fracture-dislocations: current treat-
able for traditional open reduction and internal fixation. ment and new surgical approaches. Clin Podiatr Med Surg. 2006;23:303–322.
E. Open-comminuted calcaneal fractures that are man-
aged with external fixation will benefit from serial
surgical debridements and primary subtalar joint
arthrodesis supplemented with autogenous bone graft-
ing at the time of wound closure. Stabilization of the
lower extremity is maintained with the external fixator
to achieve osseous consolidation.
F. External fixation for peritalar stabilization is para-
mount in addressing inherent instability that is evident
for complete talar dislocation and even after anatomic
reduction with a traditional open reduction and inter-
nal fixation. Distraction is not usually required but
static external fixation with appropriate positioning of
the foot may be required.
G. External fixation spanning of the ankle, subtalar, and
midtarsal joints is required for the treatment of partial
or total enucleations of the talus and after they are
reimplanted or relocated.
H. Total extrusion of the talus benefits with serial debride-
ments, antibiotic-impregnated spacer and/or beads,
and delayed tibiocalcaneal arthrodesis with a circular
external fixator. An osteotomy of the proximal tibia
and bone transport can begin at the time of acute
shortening and/or arthrodesis procedures if necessary.
I. Aggressive treatment of equinus contractures may be nec-
essary if they are present after midfoot traumatic injuries
repair.
LWBK1121-C11_p162_186.indd 186 04/10/12 11:20 AM

C h a pt e r
12
John J. Stapleton
Thomas Zgonis
Stepwise Approach to Ankle/Pilon

Trauma and External Fixation
Introduction to off-load any plastic flap coverage even if internal fixation

was performed. External fixation is also indicated for man-
External fixation for management of acute ankle trauma is agement of neuropathic ankle/pilon trauma and for selected
utilized for early skeletal stabilization followed by staged inter- geriatric patients.
nal fixation or as a means for definitive fracture reduction. Contraindications of external fixation for these types of
Temporary spanning external fixation can be applied in an injuries are limited. Patients with low energy rotational ankle/
efficient and simple manner to stabilize the majority of ankle pilon fractures without associated soft tissue injury may better
and/or tibial pilon fractures. Open ankle fractures and high- benefit from an early definitive ORIF. A delay in definitive frac-
energy tibial pilon fractures consistently present with a poor ture reduction of a low energy ankle fracture and/or rotational
soft tissue envelope that typically requires fracture stabilization tibia fracture can be challenging to reduce if the timing for
with a temporary external fixation device until definitive osteo- surgery has been prolonged by applying an external fixation
synthesis is performed if feasible. Definitive open reduction device. For these reasons, the surgeon has to carefully assess the
and internal fixation (ORIF) can only be performed in a staged fracture pattern and soft tissue envelope while considering the
procedure and when there is adequate resolution of the soft tis- patient’s comorbidities when deciding who will benefit from
sue injury. Ankle and tibial pilon fractures involve a spectrum external fixation versus a single-stage ORIF.
of injury patterns from simple to complex with various associ-
ated injuries and/or comorbidities. For these reasons, the care
of these patients requires an individualized treatment plan.
Preoperative Considerations
The authors present a rational stepwise approach to applying a
spanning external fixation device, utilizing external fixation in
Initial Fracture Reduction/Utilizing a
combination with internal fixation, and also demonstrate com-
“Spanning” External Fixator
mon techniques for application of complex circular external
fixation devices for rare cases that are not amenable to defini- The principles of utilizing a spanning external fixator for
tive ORIF. management of high-energy and/or open ankle/pilon trauma
are to restore bone and joint alignment, to preserve the soft
tissue envelope, and to prevent neurovascular compromise.
Indications/Contraindications Once the osseous alignment and stability are achieved with the
application of a spanning external fixator, tissue perfusion and
The extreme versatility of external fixation is advantageous lymphatic drainage is facilitated that promotes healing of the
and indicated for high-energy ankle/pilon trauma. The pri- injured soft tissue envelope. The external fixation device needs
mary indication for utilization of an external fixation device to be designed and applied in a manner that is outside the zone
to manage high-energy ankle/pilon trauma is an open or of injury. Strategic insertion of half-pins is positioned away from
compromised soft tissue envelope. Generally, it is believed the osseous segment that may require placement of internal
that for high-energy comminuted tibial pilon fracture pat- fixation in staged procedures. Inserting plates and screws over
terns, a two-stage approach is preferred. External fixation is bone segments that had previous half-pins are avoided if pos-
used to achieve osseous stability and fracture reduction while sible as this may potentially serve as a nidus for infection. In
promoting healing of the soft tissues. External fixation is also addition, the external fixation device needs to be constructed
indicated for fracture patterns that require or would benefit to sufficiently reduce and stabilize the osseous segments while
from limited internal fixation in conjunction with external allowing adequate exposure to any wounds that may require
fixation to avoid extensile skin incisions. Another indication frequent wound assessments, dressing changes, and/or staged
of external fixation for ankle/pilon trauma is the requirement soft tissue coverage procedures.
187
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188 Chapter 12
Internal Fixation with External tissue injuries are addressed. Once the soft tissue envelope
Fixation for Ankle/Pilon Trauma improves, the majority of ankle/pilon fractures are surgically
managed with internal fixation. This can be accomplished with
A common approach to the surgical management of ankle/ limited insertion of internal fixation, standard ORIF through
pilon fractures is to utilize a spanning external fixator as previ- extensile incisions, or insertion of internal fixation with percu-
ously described until the soft tissue edema subsides and soft taneous plating (Clinical Case I).
CLINICAL CASE I
Preoperative anteriorposterior (A) and lateral (B) radio- fixator was removed at 6 weeks postoperatively and the
graphic views of a pilon fracture that presented with frac- patient was placed in a short leg cast for an additional 2 weeks
ture blisters medially over the tibia. Ten-day postoperative and a walking boot for another 2 weeks. Final postoperative
radiographic views (C, D) demonstrating the application of radiographic views at approximately 3 months demonstrat-
a spanning external fixator and open reduction with limited ing a well-healed tibia and fibula with anatomic alignment
fixation through an anterior-lateral approach. The external (E, F).
A,B C
D,E F
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Stepwise Approach to Ankle/Pilon Trauma and External Fixation 189
Certain case scenarios benefit from internal fixation in con- ankle/pilon fractures present with poor bone quality, and in
junction with external fixation. This technique may be optimal the presence of diabetic neuropathic ankle/pilon fractures
when staged procedures need to be performed to reduce the (Clinical Cases II and III).
tibia and the fibula, when flap coverage is performed in con- An ORIF of the fibula is usually performed only if the
junction with internal fixation, when limited internal fixation fracture pattern of the tibia is addressed in a staged proce-
is performed due to a poor soft tissue envelope, when geriatric dure utilizing a posterior-medial, anterior, or anterior-medial
CLINICAL CASE II
Preoperative anteroposterior (A) and lateral (B) radiographic the spanning external fixator was removed. A short leg cast
views of a pilon fracture with significant comminution and application was applied for additional 8 weeks and a walking
bone loss at the metaphyseal–diaphyseal junction of the boot for another 6 weeks. Final postoperative radiographic
distal tibia. Two weeks postoperative radiographic views views at approximately 8 months demonstrating a well-healed
(C, D) demonstrating staged ORIF of the fibula and spanning tibia and fibula with minimal collapse of the medial aspect
external fixation that was performed the day of the injury. A of the distal tibia. Despite anatomic alignment of the joint
staged ORIF of the tibia with structural allogenic fibula graft surface, mild posttraumatic arthritic changes were already
was performed 4 weeks from the date of the injury at the time evident (E, F).
A,B C
D,E F
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190 Chapter 12
CLINICAL CASE III
The patient originally presented with an open grade 3 distal while maintaining the delta-spanning external fixator (E, F).
tibia fracture and lower extremity compartment syndrome Delayed ORIF of the tibia and a split thickness skin graft was
(A–D). Initial wound debridement, leg fasciotomies, and a finally performed to close the open fasciotomy wounds. Final
delta-spanning external fixation was performed. Postopera- postoperative radiographic views at approximately 6 months
tive lateral radiograph showing the delayed ORIF of the fibula showing interval healing of the distal tibia fracture (G, H).
A,B C
D,E F
(continued)
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G H
approach. In these cases, a posterior-lateral approach to fixate tive fracture reduction with external fixation often require
the fibula is performed to preserve a wide skin bridge for later unique and variable external fixation designs that are patient
planned skin incisions (Clinical Cases IV and V). If the fracture and fracture pattern specific. The versatility of external fixation
pattern needs to be addressed through an anterior-lateral or offers the surgeon the ability to manage difficult fracture pat-
posterior-lateral approach to the tibia, the fibula is not usually terns with poor soft tissue coverage.
addressed during the initial surgery in which the spanning Despite the various designs and configurations, this chapter
external fixator was applied and is fixated in conjunction with discusses the importance of precise wire/half-pin insertion
the tibia by utilizing one extensile incision and once the soft and techniques to adequately reduce the distal metaphysis
tissue envelope permits it. to the diaphysis while restoring the alignment of the joint
Difficulty often arises when patients are treated for a tibial surface. A simple delta-spanning external fixator may be suffi-
pilon fracture with an external fixator and open reduction of cient to stabilize and reduce severely comminuted tibial pilon
the fibula through a standard lateral approach and the frac- fracture patterns through the principle of ligamentotaxis. The
ture pattern requires a posterior or anterior-lateral approach problems that commonly arise with a severely comminuted
to the tibia. This is commonly seen for displaced fractures metaphysis of the tibia are the multiple defects of the articular
of the lateral tibial plafond and posterior distal metaphysis of surface that have little or no soft tissue attachments and can-
the tibia. Limited internal fixation of the tibia during the first not be reduced with ligamentotaxis. In addition, certain case
surgical setting is usually avoided in contrast to the utilization scenarios do arise in which stabilization of the metaphysis
of a spanning external fixation with or without fixation of the and reduction to the diaphysis is not feasible through sim-
fibula. ple distraction of the ankle joint. Often, the only means of
adequately reducing the metaphysis to the diaphysis requires
the levering of a distal tibia external fixation ring or segment
External Fixation for Definitive
to the proximal tibia external fixation segment (Clinical Cases
Fracture Reduction
VI and VII).
High-energy tibial pilon fractures can result in severe soft tissue The utilization of circular or hybrid external fixators that
compromise, neurovascular injury, compartment syndrome, consist of a distal tibia ring is advantageous for these difficult
and/or pulverized fracture patterns and may not always be high-energy fracture patterns that are not amenable to ORIF or
amenable to reconstruction with internal fixation. External fix- reduction with an ankle joint–spanning external fixator. A tem-
ation may be the only reasonable means to achieve osseous sta- porary external fixator to stabilize the lower extremity may be
bility and fracture reduction while permitting protective access considered first and before the definite placement of a circular
to the soft tissue envelope. Case scenarios that require defini- external fixation is determined upon evaluation of the soft tissue
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192 Chapter 12
CLINICAL CASE IV
Preoperative anteriorposterior (A) and lateral (B) radio- injury. Definitive ORIF of the tibia was performed at 3 weeks
graphic views of a pilon fracture with significant comminution from the time of injury and at that time the temporary external
of the tibia plafond. Two weeks postoperative radiographic fixator was removed. Final postoperative radiographic views at
views (C, D) demonstrating ORIF of the fibula and a delta- approximately 6 months showing a healed pilon fracture with
spanning external fixator that were performed at the initial good anatomic alignment (E, F).
A,B C
D,E F
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CLINICAL CASE V
Preoperative clinical (A) and anteriorposterior (B) and lat- additional stability across the ankle joint and to off-load
eral (C) radiographic views of a grade 3 open pilon frac- the posterior leg (G, H). The external fixator was removed
ture demonstrating a pulverized fracture pattern to the 8 weeks postoperatively. A short leg cast was applied for
tibia plafond. Postoperative radiographic views showing additional 8 weeks and a walking boot for another 6 weeks.
ORIF of the fibula, insertion of antibiotic beads, and span- Final postoperative radiographic views at approximately
ning delta-external fixation (D–F). Delayed ORIF of the 2 years demonstrating successful osseous union of the tibia
tibia was performed at 2 weeks from the initial injury in with deformity and posttraumatic arthritis. Despite these
conjunction with a free flap for soft tissue coverage. The conditions, the patient resumed pain-free ambulation without
delta-spanning external fixator was maintained to provide further surgical reconstruction (I, J).
A,B C
D,E F
(continued)
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194 Chapter 12
G,H I,J
CLINICAL CASE VI
Preoperative anteriorposterior (A) and lateral (B) radiographic ing had subsided. Immediate postoperative clinical views (C–E)
views of a pilon fracture with severe comminution at the tibial pla- showing the circular external fixation with the distal tibial
fond. The patient presented with fracture blisters and had a sig- circular ring and anatomic alignment. Two-week postoperative
nificant history of peripheral arterial disease and tobacco abuse. radiographs (F, G) showing the opposing three olive wires to
Initially, the fracture was stabilized in a delta-spanning external achieve fracture reduction. Final postoperative radiographic
fixator and then revised to a definitive circular external fixator views at about 7 months showing a healed pilon fracture with
4 weeks after the initial surgery and once the soft tissue swell- satisfactory joint alignment (H, I).
A,B C
(continued)
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A,B C
D E
F G
(continued)
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196 Chapter 12
H I
CLINICAL CASE VII
Preoperative clinical (A) and radiographic (B) views of a stabilize the ankle and subtalar joints and a local soleus muscle
severely open ankle fracture that was fixated with the use of transfer was performed to cover the soft tissue defect. Radio-
a circular external fixation. Note the use of a tensioned olive graphic (D, E) and clinical (F, G) views at 10 weeks postopera-
wire for the medial malleolus fracture as well as the use of tively showing the anatomic alignment and soft tissue healing.
tensioned fibular olive wires to further stabilize the ankle syn- Final outcome at approximately 3 months postoperatively
desmosis (C). Large Steinmann pin fixation was also used to (H–K).
A,B C
(continued)
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Clinical
A,B case VII (continued) C
D E
F,G H
I,J K
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198 Chapter 12
and other concomitant injuries. A computed tomography scan of two circular rings with four smooth wires or two smooth
may be required to further determine appropriate placement wires supplemented with half-pins. This is a useful alternative
of smooth wires and/or half-pins at the ankle joint level and if if maintenance of the temporary external fixation needs to be
definitive fracture reduction with external fixation is required. extended past 6 weeks, modified for definitive fracture reduc-
Avoiding placement of circular external fixation devices at tion, or when off-loading the soft tissue of the posterior leg is
the distal tibial metaphysis to anatomically reduce severe tibial required. The two circular rings are positioned such that the
pilon fractures may also need to be considered at the first leg is centered within the rings and placed approximately 3 to
operative setting. This will allow insertion of internal fixation 4 cm off the anterior crest of the tibia. The ring size selected
or other proposed methods of reduction if they were necessary needs to allow for potential swelling of the leg and especially
in the treatment plan. In addition, if wire or pin site infections in the traumatic setting. The “tibia external fixation block” is
occur at the ankle joint level, a septic ankle joint can develop initially secured to the leg with the placement of two smooth
precluding any insertion of definitive internal fixation. wires placed in the frontal plane from lateral to medial direc-
tion. It is important to be certain that the smooth wires placed
in this fashion engage the two cortices of the tibia. A common
error is to place the smooth wire too anterior obtaining uni-
cortical purchase of the anterior crest of the tibia. The smooth
wires placed in the tibia are typically tensioned between 110
Ankle Delta–Spanning External
and 130 kg of force. The “tibia external fixation block” can be
Fixation System
completed with the addition of two additional smooth wires
Application of the external fixator requires that the lower placed across the medial aspect of the tibia and attached and
extremity is positioned such that the patella and the anterior tensioned to the opposite side of the ring in which the frontal
tibial crest are perpendicular to the operating table. Com- plane wires were inserted in order to avoid convergence of the
monly the lower extremity lies on the table slightly externally wires and to enhance stability of the construct. If half-pins are
rotated and this can be corrected by placing a well-padded utilized they can be positioned either above or below each of
“bump” under the ipsilateral hip to facilitate appropriate posi- the circular rings until the construct is stable and no motion
tioning of the lower extremity and before applying the external of the “tibia external fixation block” is achieved. This is typi-
fixator. A tourniquet is not typically utilized for application of cally performed with the placement of either two or three half-
an external fixator. pins. The half-pins are inserted as described above either into
Stabilizing the proximal osseous segment is the first step the anterior tibia crest from anterior to posterior or from
in application of an ankle delta–spanning external fixation medial to lateral direction into the medial face of the tibia
system. This is typically accomplished with two 5 mm threaded (Figure 12.1E and F).
half-pins inserted in the proximal diaphysis of the tibia about Attention is then directed to spanning the ankle joint. The
20 to 25 cm proximal to the ankle joint and proximal to the insertion of a centrally threaded “transcalcaneal” pin is then
zone of injury. The possibility of future skin incisions as well as placed from medial to lateral direction and into the poste-
the predicted length of proposed internal fixation plates needs rior tuberosity of the calcaneus. It is preferred to insert the
to be considered when the half-pins are inserted. The insertion transcalcaneal pin midway between the superior and inferior
of these half-pins is usually marked on the skin by slightly plac- portions of the posterior calcaneal tuberosity to ensure good
ing pressure with the soft tissue sleeve to mark the insertion bone purchase and to avoid pulling out of the pin while trac-
of both pins. The skin is then incised with a scalpel and blunt tion is applied. Predrilling is usually not necessary secondary
dissection is carried down to the level of the tibia. A soft tissue to the cancellous composition of the calcaneus. A stab inci-
guide with an internal drill guide is placed directly onto the sion is initially made and blunt dissection with a hemostat is
bone. The bone is typically drilled with a 3.2 or 3.5 mm drill bit performed down to the medial wall of the calcaneus. The pin
that is dependent on the manufacturer of the system; the drill is then driven from medial to lateral direction utilizing a soft
guide is then removed and a 5 mm threaded half-pin is partially tissue sleeve until the pin begins to tent the skin on the lateral
inserted under electric power and completed by hand power side. A small incision is then made and a soft tissue protector
until bicortical purchase is achieved. C-arm fluoroscopy can be can be placed directly down to the bone while the half-pin is
utilized at this point to ensure appropriate bicortical purchase advanced until the centrally threaded portion of the pin is cen-
of the half-pins. Insertion of the half-pins in the proximal tibia tered within the calcaneus (Figure 12.1G).
can be placed anterior to posterior along the anterior tibia At this point the proximal tibia segment, either the two half-
crest. This allows for significant stability and good bicortical pins or the two circular rings, can be connected to the centrally
purchase of the pins. Alternatively, the half-pins can be placed threaded transcalcaneal pin with a bar-to-clamp apparatus. The
medial to lateral along the medial face of the tibia and are bar to clamp apparatus to the two half-pins or “tibia external
angled approximately 45 degrees from the anterior tibia crest. It fixation block” is tightened and fracture reduction can be
is highly recommended that predrilling half-pins are inserted in achieved through ligamentotaxis by placing traction on the
the tibia even if the half-pins utilized are self-drilling. A half-pin transcalcaneal pin. Once reduction is achieved, an assistant
insertion under a significant torque without predrilling can cre- tightens the bar to clamp apparatus attached to the transcalca-
ate a stress riser and iatrogenic tibial fracture. For this reason, neal pin and C-arm fluoroscopy can be performed to evaluate
it is best to initially proceed by placing a soft tissue guide with the reduction. This technique cannot be used if there is an
an internal drill guide directly onto the bone (Figure 12.1A–D). associated calcaneal fracture which limits the insertion of the
Another alternative for stabilizing the proximal tibia seg- transcalcaneal pin. In these case scenarios, distraction can be
ment is to utilize a “tibia external fixation block” which consists accomplished by attaching a foot external fixation plate with
LWBK1121-C12_p187_206.indd 198 04/10/12 11:24 AM

A B
C D
E,F G
Figure 12.1. The insertion of these half-pins is usually marked on the skin by slightly placing pressure with the soft tissue sleeve to mark the
insertion of both pins (A). A soft tissue guide with an internal drill guide is placed directly onto the bone. The bone is typically drilled with a
3.2 or 3.5 mm drill bit (B, C). The drill guide is then removed and a 5 mm threaded half-pin is partially inserted under electric power and
completed by hand power until bicortical purchase is achieved (D). Note that the two 5 mm threaded half-pins inserted in the proximal diaphysis
of the tibia are about 20 to 25 cm proximal to the ankle joint. Another alternative for stabilizing the proximal tibia segment is to utilize a “tibia
external fixation block” which consists of two circular rings with four smooth wires or two smooth wires supplemented with half-pins. The half-
pins are inserted as described above either into the anterior tibia crest from anterior to posterior (E) or from medial to lateral direction into the
medial face of the tibia (F). The insertion of a centrally threaded “transcalcaneal” pin is then placed from medial to lateral direction and into the
posterior tuberosity of the calcaneus (G). (continued)
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200 Chapter 12
H,I J
Figure 12.1. (continued) The proximal

tibia segment whether it is the two half-pins
or the two circular rings can be connected
to the centrally threaded transcalcaneal pin
with a bar to clamp apparatus. The bar to
clamp apparatus to the two half-pins or “tibia
external fixation block” is tightened (H) and
fracture reduction can be achieved through
ligamentotaxis and by placing traction on
the transcalcaneal pin (I). Once reduction
is achieved, an assistant tightens the bar to
clamp apparatus attached to the transcalca-
neal pin ( J). Figure (K) shows the attachment
of the transcalcaneal pin to a “tibia external
fixation block” instead of the two half-pins.
The foot can be dorsiflexed and maintained
in a neutral position by an additional half-
pin(s) placed across the cuneiforms, first
K L and/or fifth metatarsals (L).
multiple smooth wires attached through the midfoot, talus, and the first metatarsal have less stability, might have a risk of iatro-
the calcaneus and by distracting the foot external fixation plate genic neurovascular injury, and often have to be supplemented
that is attached to the proximal tibial segment with threaded with an additional half-pin placed into the fifth metatarsal to sta-
rods (Figure 12.1H–K). bilize the foot. The utilization of an “intercuneiform half-pin” is
After the ankle joint is reduced, the foot can be stabilized better served while the insertion of half-pins in the metatarsals
in a neutral position by inserting additional half-pins. The foot is reserved for concomitant midfoot trauma (Figure 12.1L).
will resume a plantarflexed position if additional fixation is not Alternative stabilization of the foot can be achieved with an
applied and an equinus contracture can be a detrimental late additional circular ring that is placed around the midfoot. This
result. The foot can be dorsiflexed and held with an additional may be indicated in patients who require extended time in the
half-pin(s) placed across the cuneiforms, first and/or fifth external fixation apparatus. Often, the half-pins inserted in the
metatarsals. Typically, self-drilling 4 mm threaded half-pins are midfoot and metatarsals can develop pin site irritation, infec-
placed under C-arm fluoroscopy and connected with a bar to tion, and loss of bone purchase. In these cases, the half-pins
clamp apparatus to the rods that are spanning the ankle joint. can be exchanged with smooth wires connected to a midfoot
Insertion of a single half-pin across the cuneiforms allows for circular ring and to further stabilize the foot. The circular ring
ideal stability and positioning of the foot. Half-pins placed into is positioned such that approximately 3 to 4 cm are separated
LWBK1121-C12_p187_206.indd 200 04/10/12 11:24 AM

from the foot skin surface to the circular ring in all directions. disimpact any other depressed fracture fragments. This is com-
Two to three smooth wires are typically placed across the navic- monly done with a small bone elevator that is placed into the
ular, cuneiforms, and cuboid. Smooth wires inserted across primary fracture line and after slightly reflecting the cortical
the navicular and cuneiforms are driven from medial to lateral wall around the depressed segment. Another approach is to
direction. The navicular wire is placed just above the insertion utilize the blunt tip of a smooth wire to disimpact depressed
of the posterior tibial tendon and driven directly across the segments of the articular surface (Figure 12.2A).
body of the navicular. Smooth wires inserted across the cunei- Attention is then directed to ensure reduction of the
forms are placed from the superior medial aspect of the medial lateral Tillaux–Chaput fracture fragment of the distal tibia
cuneiform and driven slightly inferior to accommodate the and followed by fixation of the medial malleolus if needed.
natural arc of the cuneiforms. A smooth wire across the cuboid Fixation of the lateral Tillaux–Chaput tibia fracture fragment
is inserted from a lateral to medial direction. The cuboid and medial malleolus fracture can be achieved by inserting
wire is driven slightly superior and often engages the lateral additional Kirschner wires that are not attached to the distal
and/or medial cuneiform to avoid iatrogenic neurovascular tibia circular ring. Alternatively, olive wires can be inserted
injury. across the medial malleolus fracture fragment and tensioned
to the ring to achieve reduction. The Tillaux–Chaput fracture
fragment is often not amenable to reduction with an olive
Utilizing Internal Fixation wire and is typically fixated with a Kirschner wire or limited
with External Fixation internal fixation if needed. Insertion of smooth and/or olive
wires placed from anterior to posterior direction should be
The external fixator that was initially placed is often partially
avoided.
disassembled to allow access for definitive placement of inter-
After reduction of the major fracture fragments of the
nal fixation and then reassembled. Removal of the bar and
distal metaphysis of the tibia is achieved, the wires are then
clamp apparatus can be obtained while maintaining the place-
tensioned to the distal tibia circular ring to maintain the reduc-
ment of the half-pins. However, if circular rings were initially
tion at approximately 90 to 110 kg of force. Typically, the distal
utilized for the proximal tibia segment, the rings are usually
tibia circular ring is loosely connected to the proximal “tibia
maintained. The lower extremity is surgically prepared in the
external fixation block” with two to three threaded rods or
usual fashion while a formal ORIF is performed. After wound
with a bar to clamp apparatus and then it is manually levered
closure, the bar to clamp apparatus that spans the ankle joint
against the proximal tibia segment to achieve anatomic reduc-
can be reattached to the half-pins if the external fixator is
tion and alignment of the diaphysis to the metaphysis. After
going to be applied. At times, use of the external fixation as
anatomic reduction is achieved, the threaded rods are fastened
a traction device may facilitate fracture reduction and can be
and additional one to two threaded rods are applied for a
reattached during the procedure.
total of four threaded rods that provide stability in all planes
(Figure 12.2B–D).
Circular External Fixation for Definitive In summary, the application of a circular external fixation
Reduction of Tibial Pilon Fractures device to anatomically reduce severe tibial pilon fractures
at the first operative setting may be limited and especially
The placement of a circular ring around the metaphysis of when internal fixation or other proposed methods of reduc-
the tibia allows better control of this segment once opposing tion might be utilized in staged reconstruction (Clinical
smooth and/or olive wires are tensioned to the circular ring. Case VIII).
Wire placement is dependent on insertion of wires through
the larger osseous segments or subchondral bone of the
articular fracture fragments while considering the safe zones at Postoperative Course
the ankle joint level. Typically, two to three opposing smooth and Complications
and/or olive wires are inserted to stabilize this circular ring.
It is paramount to understand the anatomy of the ankle joint Complications for external fixation as it relates to ankle/pilon
capsule while considering the neurovascular structures when trauma must be understood, recognized early and appropri-
inserting these smooth wires. The ankle joint capsule extends ately addressed. Spanning external fixators that are applied
further proximally along the anterior aspect of the ankle joint initially to distract and temporarily reduce the tibia pilon frac-
as opposed to the posterior aspect. Two smooth or olive wires tures through ligamentotaxis may be prone to skin necrosis
of the distal tibia metaphysis are typically placed from posterior- particularly on the anterior aspect of the ankle joint if exces-
medial to anterior-lateral and posterior-lateral to anterior- sive distraction was performed. Traction should be applied
medial direction with a divergent angle of approximately 60 cautiously to reduce the fracture without over-distracting the
degrees. A third smooth and/or olive wire can be inserted from ankle joint since the purpose of a temporary spanning exter-
medial to lateral direction while avoiding the primary coronal nal fixator is to facilitate soft tissue healing and not impede it.
plane fracture line if present. In severe cases in which neurovascular injury is present along
The first reduction step usually entails the reduction of the with significant bone loss, the surgeon may elect to perform
joint from posterior to anterior direction with the two oppos- an acute shortening with an external fixator to facilitate neu-
ing smooth or olive wires. Often, this is accomplished with rovascular repair while staging a gradual bone lengthening to
the placement of large point or linear bone reduction clamps address the bone loss (Clinical Case IX). In addition, a tempo-
that are placed prior to wire insertions. At times, small inci- rary spanning external fixator does not typically incorporate
sions need to be made to reflect the larger fragments and to fixation of the tibia metaphysis and resulting displacement
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202 Chapter 12
A,B C
Figure 12.2. The first initial step in reducing the pilon

fracture usually entails the reduction of the ankle joint from
posterior to anterior direction with the two opposing smooth or
olive wires. Often, this is accomplished with the placement of a
large point or linear bone reduction clamps that are placed prior
to wire insertions (A). After reduction of the major fracture frag-
ments of the distal metaphysis of the tibia is achieved, the wires
are then tensioned to the distal tibia circular ring to maintain the
reduction at approximately 90 to 110 kg of force (B). Typically,
the distal tibia circular ring is loosely connected to the proximal
tibia external fixation block with two to three threaded rods or
with a bar-to-clamp apparatus and then manually levered against
the proximal tibia segment to achieve anatomic reduction and
alignment of the diaphysis to the metaphysis (C). After anatomic
reduction is achieved, the threaded rods are fastened and addi-
tional one to two threaded rods are applied for a total of four
D threaded rods that provide stability in all planes (D).
through the early postoperative period could exist. For these Unique complications exist for hybrid and circular exter-
reasons, obtaining serial radiographs are necessary to evalu- nal fixators when applied for ankle/pilon trauma. The main
ate the reduction during weekly or bi-weekly assessments until concern is for the smooth and/or olive wires that are attached
definitive fracture reduction is performed either with internal to the distal tibia circular ring that is placed at the level of
fixation or with a more stable form of external fixation. the tibia metaphysis. Wire tract infections can lead to a sep-
Stress fractures and/or iatrogenic fractures of the tibia can tic ankle joint since the smooth wires inadvertently may be
exist secondary to the placement of half-pins in the proximal placed near or within the joint capsule. Usually, localized
tibia. At times, the patient presents with sudden pain to this minimal erythema with scant serous drainage or no drainage
region after they resume a weight bearing status and extreme is treated with local wound care and oral antibiotics and the
discomfort is encountered with any type of rotation of the leg wire site is reevaluated within 3 to 5 days. If the erythema is
along with tenderness to palpation over the previous pin site. extending or purulent drainage is encountered, the wire is
In these cases, the patient is usually immobilized in a long leg removed immediately and the site is debrided and irrigated
cast above the knee to limit rotation across the fracture site. to prevent a septic joint. After resolution of the soft tissue
Initial radiographs may also be negative and the fracture may infection, new wire replacement can be performed within the
only be apparent on a computed tomography scan. following 3 to 5 days.
LWBK1121-C12_p187_206.indd 202 04/10/12 11:24 AM

CLINICAL CASE VIII
Preoperative right (A, B) and left (C) radiographic views of a fixation devices. A static circular external fixator was applied to
severely bilateral pilon fracture dislocations. Note that both frac- bilateral lower extremities (D–F). Final radiographic (G–J) and
tures were restored with a combination of internal and external clinical (K–M) views at approximately 7-month follow-up.
A,B C
D E
(continued)
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204 Chapter 12
F,G H
I,J K
L M
LWBK1121-C12_p187_206.indd 204 04/10/12 11:24 AM

CLINICAL CASE IX
Example of a severely open injury of the distal tibia with signifi- ankle arthrodesis (C). Final radiographic and clinical outcomes
cant bone loss and soft tissue compromise (A, B) that required (D, E) showing the regenerate bone at the corticotomy site
a proximal tibial corticotomy and transportation of a portion with a union at the ankle arthrodesis for a severely distal tibial
of the tibial shaft toward the talus in order to achieve a primary fracture with a significant bone loss.
A,B C
D E
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206 Chapter 12
Conclusion
A. Estimate the zone of injury and possible future fixation This chapter presented a stepwise approach to complex lower
constructs to avoid inadvertent placement of half-pins extremity injuries by utilization of various internal and external
or proximal circular rings. fixation methods. Extensive knowledge and experience with
B. Predrilling of the tibia for placement of half-pins to the versatility of external fixators is paramount to the overall
avoid possible iatrogenic fractures of the tibia is recom- patient’s successful outcome.
mended.
C. Utilization of an intercuneiform half-pin is advanta-
geous to prevent ankle equinus contracture and to Recommended Readings
further stabilize the foot when applying a spanning Chaudhary SB, Liporace FA, Gandhi A, et al. Complications of ankle fracture in
external fixator. patients with diabetes. J Am Acad Orthop Surg. 2008;16:159–170.
D. Initial fixation of the fibula is recommended through DiDomenico LA, Brown D, Zgonis T. The use of Ilizarov technique as a definitive
percutaneous reduction for ankle fractures in patients who have diabetes and
a standard lateral approach at the time the span-
peripheral vascular disease. Clin Podiatr Med Surg. 2009;6:141–148.
ning external fixator is performed, when the soft tis- Facaros Z, Stapleton JJ, Polyzois VD, et al. Management of foot and ankle trauma.
sues allow it and an anterior-lateral or posterior-lateral Perioper Nurs Clin. 2011;6:35–43.
approach is not going to be required for definitive fixa- Jani MM, Ricci WM, Borrelli J Jr, et al. A protocol for treatment of unstable ankle
tion of the tibia. fractures using transarticular fixation in patients with diabetes mellitus and
loss of protective sensibility. Foot Ankle Int. 2003;24:838–844.
E. Maintain the placement of the tibia half-pins and tran- Kline AJ, Gruen GS, Pape HC, et al. Early complications following the opera-
scalcaneal pin when performing a staged ORIF of the tive treatment of pilon fractures with and without diabetes. Foot Ankle Int.
tibia as the reapplication of the bars to pins can aid in 2009;30:1042–1047.
distraction and fracture reduction during the proce- Marin LE, DiDomenico LA, Stamatis ED, et al. Diabetic neuropathic pilon and
ankle osseous trauma and dislocations. In: Zgonis T, ed. Surgical Reconstruction
dure if required.
of the Diabetic Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins;
F. Utilize two circular rings to create a “tibia external fixa- 2009:357–374.
tion block” to adequately off-load the posterior leg if
flap coverage is required.
G. Utilizing external fixation with internal fixation is ben-
eficial for limited internal fixation techniques, geriatric
trauma, neuropathic patients, and adjunctive flap cov-
erage.
H. Computed tomography is paramount to develop a three-
dimensional picture of the fracture pattern to determine
placement of smooth and/or olive wires before a circu-
lar external fixator is used to obtain definitive fracture
reduction.
I. Avoid placement of smooth and/or olive wires within
the ankle joint capsule to limit the possibility of devel-
oping a septic arthritis.
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Chapter
13 Paul S. Cooper
Stepwise Approach to Forefoot

Elective and Reconstructive Surgery
with External Fixation
Introduction Detailed Surgical Technique

Brachymetatarsia
The use of uniplane monolateral external fixation in the fore-
foot comprises bone and joint distraction, scar extension, and Brachymetatarsia consists of a congenitally shortened metatar-
arthrodesis of the metatarsophalangeal joint (MTPJ). Further, sal, most frequently involving the fourth metatarsal. Main indi-
the monolateral external fixator is a useful adjunct for non- cations for surgical correction include transfer metatarsalgia of
healing sub-metatarsal ulcers in conjunction with soft tissue the adjacent bones, often associated with toe drift. While small
repair. Forefoot deformities by virtue of the condensed anat- degrees of shortening may be addressed with direct lengthen-
omy and skeletal geometry are best addressed with uniplane ing and intercalary bone grafting, greater degrees run the risk
monolateral external fixators. External fixator configurations of neurovascular compromise and dislocation of the MTPJ.
consist of rail and hinged designs, with half-pins ranging from External fixation allows for a slow gradual metatarsal lengthen-
threaded 2 to 3 mm in diameter (Figures 13.1 and 13.2). ing minimizing these risks (Clinical Case I).
Figure 13.1. Examples of various

modified uniplane monolateral exter-
nal fixators with and without hinges.
207
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208 Chapter 13
The first half-pin is located under C-arm fluoroscopic guid-

ance distally into the metatarsal head and is directed perpen-
dicular to the longitudinal axis of the metatarsal involved
(Figures 13.3 and 13.4). Once this is confirmed, the desired
uniplane monolateral external fixator is slid over the half-
pin to be used as a drill guide for insertion of the other pins
(Figures 13.5 and 13.6). The adjustment end should be facing
proximal for patient ease in turning daily the necessary bolts.
Following this, the external fixator is adjusted in length to ide-
ally position the proximal pins into the base of the metatarsal
shaft and diaphyseal bone as confirmed under C-arm fluor-
oscopy. In choosing the proper length fixator, factor in the
amount of lengthening involved in the process (Figure 13.7).
The proximal pins are then drilled and locked into place, fol-
lowed by the remaining distal pins (Figures 13.8 and 13.9).
Figure 13.2. Examples of 2 and 3 mm threaded half-pins for the There should be a minimum of two half-pins per corticotomy
application of a monolateral external fixator. side of the uniplane monolateral external fixator.
CLINICAL CASE I
Clinical (A) and radiographic (B) views of a congenital left external fixator (D). Postoperative radiographs (E, F) showing
fourth brachymetatarsal that was symptomatic with an overlap- the mid-diaphyseal corticotomy and final outcome after the
ping fifth digit. Percutaneous metatarsal corticotomy with a external fixation removal (G).
Gigli saw (C) and an application of a uniplane monolateral
A,B C
D,E F,G
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Stepwise Approach to Forefoot Elective and Reconstructive Surgery with External Fixation 209
Figure 13.3. Example of a planned site for corticotomy in the Figure 13.6. Example of a malpositioned half-pin setting the
fourth metatarsal. external fixator divergent from metatarsal shaft.
Figure 13.4. Example showing the distal half-pin insertion per- Figure 13.7. The adjustment end should be facing proximal for
pendicular to the longitudinal axis of the involved metatarsal. patient ease in turning daily the necessary bolts.
Figure 13.5. Example of proper alignment reference with exter- Figure 13.8. Second pin inserted proximal into the metatarsal
nal fixator parallel to the involved metatarsal. base. The external fixator is adjusted prior to half-pin insertion for
maximum lengthening excursion.
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210 Chapter 13
Figure 13.9. Example of a minimum of two half-pins per corti- Figure 13.11. Example of an alternative corticotomy method
cotomy side of the uniplane monolateral external fixator. with power sagittal saw and osteotome completion.
Next, the external fixator is removed, and a small longitu- First Metatarsophalangeal Joint
dinal (less than 1 cm) incision is made at the desired point Arthrodesis and Arthrodiastasis
of mid-diaphyseal or diaphyseal–metaphyseal corticotomy.
Dissection includes preservation of the periosteum protected Arthrodesis of the first MTPJ with external fixation is indi-
by soft tissue Hohmann retractors. The corticotomy may be cated in dysvascular cases where soft tissue dissection is risky,
performed by several methods including multiple drill holes and as a salvage procedure for infected primary arthrodesis
and an osteotome, sagittal saw and osteotome or Gigli wire with conventional internal fixation. The uniplane monolateral
saw (Figures 13.10 and 13.11). Following successful corticot- external fixator may also be used in staged reconstructive cases
omy, the uniplane monolateral external fixator is re-applied of excessive metatarsal or phalangeal shortening, where the
with sufficient distance to allow for soft tissue swelling. Sev- soft tissues are stretched first and followed by arthrodesis at the
eral turns to establish preliminary axial lengthening and lengthened position as a second procedure.
full corticotomy is performed and confirmed under C-arm Following extensive MTPJ preparation, an appropriate mon-
fluoroscopy if the desired lengthening is in axial alignment olateral external fixator is chosen to be applied medially.
with the shaft of the metatarsal (Figure 13.12). Frequently, Factors involved in choosing the appropriate external fixator
the MTPJ of the involved metatarsal may sublux during the include the mechanism for compression and ability to address
lengthening procedure and should be provisionally stabilized rotating, translational and sagittal plane correction. Many
with a 0.062-in. Kirschner wire during the lengthening proc- monolateral external fixators have a cannulated hinge where
ess (Figure 13.13). a guide pin can be placed to determine the MTPJ center
A B
Figure 13.10. Example of performing the corticotomy by multiple drill holes (A, B) transversing the
mid-diaphyseal location and completed by an osteotome. Note that it is highly recommended to temporarily
remove the external fixation rail before performing the corticotomy for easier access but with all half-pins
remaining in their secured location.
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A B
Figure 13.12. Example of a trial lengthening of the uniplane

monolateral external fixator (A). Visual and C-arm fluoroscopic evalu-
ation of travel direction is necessary for ideal linear excursion in both
C anteroposterior (B) and lateral planes (C).
(Figure 13.14A–C). The first half-pin is dictated by the proxi- over the base of the first metatarsal (Figure 13.16). With hinged
mal phalanx and should be inserted perpendicular to the monolateral external fixators, it is important to center the
axial length of the proximal phalanx (Figure 13.15). The mon- hinge over the isometric center point of the MTPJ or otherwise
olateral external fixator is then applied and the distal clamp an asymmetric alignment when correction of the sagittal plane
temporarily tightened to be used as a pin template for the position will occur (Figures 13.17–13.19).
proximal pins. The monolateral external fixator should be set In cases with a non-articulating monolateral external fixation,
to two-thirds maximum length before inserting the proximal the sagittal plane position is based off the hinging on the single
pins so as to allow room in the mechanism for adequate com- proximal and distal pins. Once a plantigrade hallux position is
pression excursion. The second half-pin is inserted proximally determined, the remaining proximal and distal pins are inserted
at the most proximal hole in the metatarsal pin clamp centered by loosening the pin clamp and using it as a pin guide. A mini-
mum of two points of fixation on the metatarsal and one to two
on the proximal phalanx, respectively, are acceptable when
using 3 mm pins; however, smaller size half-pins may require
three points of fixation per segment. Joint distraction and then
compression can also be applied to confirm satisfactory position
of the fixator for desired fusion position (Figure 13.20A–G).
Finally, the application of the monolateral external fixator
may also be used as a supplementation to the internal fixa-
tion for the first MTPJ arthrodesis procedures, as a distraction
device for first MTPJ arthrodiastasis and joint resurfacing, or as
a stabilizer to the medial column of the foot for comminuted
metatarsal or digital fractures (Clinical Cases II–IV).
Clawtoe Correction and Proximal

Phalangeal Lengthening for a
Significantly Shortened Digit
Figure 13.13. Pin or wire stabilization across the involved MTPJ In special circumstances where an infected proximal inter-
minimizes subluxation during the metatarsal lengthening procedure. phalangeal joint (PIPJ) of a lesser toe or an over-resected
LWBK1121-C13_p207_223.indd 211 04/10/12 2:56 PM

A B
Figure 13.14. Example of an isocentric pin location of the

first MTPJ (A). Temporary positioning of a uniplane monolateral
external fixator (B). This external fixator can lengthen or compress
through one side only and has the potential to shift the center axis
of the hinge joint. Figure (C) shows an external fixator with com-
pression/distraction units on both sides of the joint. This device
minimizes the risk for shifting the center point through adjust-
C ments on both sides simultaneously.
Figure 13.15. Example of insertion of the first

half-pin that is determined by geometry of the proxi-
mal phalanx.
Figure 13.16. Once the half-pin locations are determined on the Figure 13.17. The location of metatarsophalangeal pin is
proximal phalanx side, the metatarsal half-pins are positioned ideally removed and the entire construct is then assessed for any shifting or
at the mid-diaphyseal region. displacement.
LWBK1121-C13_p207_223.indd 212 04/10/12 2:56 PM

Figure 13.18. Ideal position of the uniplane monolateral exter- Figure 13.19. Lengthening/compression may be applied equally
nal fixator as viewed from the side. Hinge point is centered in the on both sides of the uniplane monolateral external fixator.
metatarsophalangeal axis.
A B
C D
Figure 13.20. Example of using a non-articulating uniplane monolateral external fixator for first meta-
tarsophalangeal joint arthrodesis. The joint is first temporarily stabilized in the ideal position to create a rec-
tus toe posture (A). Distal reference half-pin is first inserted to the proximal phalanx to determine position of
the monolateral external fixation template (A, B). The unhinged monolateral external fixator as a template
is attached for determination of the proximal metatarsal half-pin insertion. Note that the compression device
is facing the patient for ease of access (B). The temporary metatarsophalangeal pin fixation is then removed
for positioning of the hallux (C). The sagittal plane position is determined through rotation off the proximal
metatarsal half-pin (D). (continued)
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214 Chapter 13
Figure 13.20. (continued) Additional

points of fixation, both proximal and distal to
the arthrodesis site, are then added (E). Dem-
onstration of access for patient to compress
or distract the monolateral external fixation
G device (F, G).
CLINICAL CASE II
Preoperative radiographic views (A, B) of a patient with a pain- monolateral stabilizing external fixator for alignment of the
ful right hallux abducto valgus deformity and severe degen- first ray (C, D). The external fixation device was removed
erative joint disease at the first MTPJ. The patient underwent at approximately 8 weeks. Final outcomes (E, F) at approxi-
a first MTPJ arthrodesis with combined internal and exter- mately 6-month follow-up. Courtesy of Thomas Zgonis, DPM,
nal fixation methods. Note the application of the uniplane FACFAS.
A B
(continued)
LWBK1121-C13_p207_223.indd 214 04/10/12 2:56 PM

C D
E F
proximal phalanx occurs, a mini uniplane monolateral exter- the middle phalanx with the joint reduced. An additional pin is
nal fixation is useful. The size of the bone in the proximal pha- inserted in the proximal phalanx and the distal phalanx since
lanx dictates for a 2 mm threaded half-pins to be used during the middle phalanx is too small to support two half-pins (Figure
the lengthening procedure (Clinical Case V). 13.21 and Clinical Case VI).
The proximal phalanx is exposed dorsally spanning the In the case of lengthening of a shortened proximal phalanx,
MTPJ and PIPJ. For stabilizing a claw toe correction, the first the first half-pin is located at the base of the proximal phalanx
half-pin in inserted at the base of the proximal phalanx. With as above, but the second half-pin distally is placed in the distal
the fixator at maximum compression, a distal pin is placed in most aspect of the proximal phalanx. This means that additional
LWBK1121-C13_p207_223.indd 215 04/10/12 2:56 PM

216 Chapter 13
CLINICAL CASE III
Preoperative radiographic views (A, B) of a patient with a pain- procedures to address the equinus and decreased arch deform-
ful left foot hallux rigidus and concomitant pes planovalgus ities were also performed. Final outcome at approximately
deformity. The patient underwent a combined first MTPJ 3 months and after the external fixation removal (E, F). (Cour-
cheilectomy and arthrodiastasis with the use of a non-articulat- tesy of Thomas Zgonis, DPM, FACFAS).
ing uniplane monolateral external fixator (C, D). Additional
A B
C D
(continued)
LWBK1121-C13_p207_223.indd 216 04/10/12 2:56 PM

E F
CLINICAL CASE IV
Preoperative radiographic views (A, B) of a patient with an and joint distraction by the application of a non-articulating
open gunshot injury to the right great toe. Patient underwent uniplane monolateral external fixator (C, D). Final outcome at
an initial surgical debridement that was followed by repair of approximately 10 weeks and after the external fixation removal
the extensor hallucis longus tendon and fracture alignment (E, F). (Courtesy of Thomas Zgonis, DPM, FACFAS).
A,B C
(continued)
F
LWBK1121-C13_p207_223.indd 217 04/10/12 2:56 PM
218 Chapter 13

A,B C
D,E
points of fixation may require spanning into the metatarsal head open surgery may have the risk of recurrent scar formation,
proximally and into the distal phalanx distally. A corticotomy is a gradual lengthening of the soft tissues either by external
made with a 1 mm drill bit or very small sagittal blade. Distraction fixation alone or in conjunction with fractional percutaneous
is deferred until approximately 10 days postoperatively and is rec- lengthening of soft tissues is preferred (Clinical Case VII).
ommended to lengthen less than 1 mm/day (Figure 13.22A–E). The surgical approach for all significant elevatus contractures
In addition, distraction is also indicated in dorsal postopera- is dorsal. Since the proximal phalanx is hyperextended, the
tive soft tissue contractures of the hallux or lesser MTPJ proce- half-pin should be placed under C-arm fluoroscopic guidance
dures where toe rectus position is not achieved. Since revisional perpendicular to the longitudinal axis for both the proximal
CLINICAL CASE V
Clinical (A) and radiographic (B) views of an iatrogenic short- fixator (C, D) and final outcome after the external fixation
ened right second digit that was followed by proximal phalangeal removal (E).
lengthening procedure with a uniplane monolateral external
A,B C
(continued)
LWBK1121-C13_p207_223.indd 218 04/10/12 2:56 PM

D E
phalanx and metatarsal. A hinged joint external fixator is pre- Diabetic Forefoot Wound Closure
ferred since the extention contracture may be gradually adjusted
followed by lengthening the soft tissue contracture. A minimum Plantar first metatarsal ulceration in the diabetic population is
of two half-pins of the 2 mm thread size are used, and gradual particularly challenging to heal; frequently the wound breaks
correction may be initiated immediately at 1 mm per day. Slight down associated with the high degree of tension seen in the claw
over correction may be recommended due to the elastic nature hallux. A monolateral external fixator can stabilize the first MTPJ
of the scar tissues. thereby speeding wound healing and improved toe posture.
CLINICAL CASE VI
Example of a severe contracture of the third MTPJ following a

failed claw toe correction of the third digit (A) and application
of a uniplane monolateral external fixator (B).
A B
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220 Chapter 13
The technique is similar to that of the first MTPJ arthrod-

esis with the plan to plantarflex the first ray (hallux and meta-
tarsal) 10 degrees or more for final position in order to assist
in a tensionless wound closure under the MTPJ. In most cases,
the infected metatarsal head is partially or totally resected,
affording more motion to plantarflex the hallux. This can be
performed either with a hinged monolateral external fixator,
which is then placed in plantarflexion, or plantarflex the first
ray using the above technique of hinging off a single proxi-
mal metatarsal half-pin. The remainder of the technique
is similar to that of the first MTPJ arthrodesis. Unlike the
MTPJ arthrodesis, however, compression arthrodesis is not
performed and should be refrained from adding additional
compression if maintenance of the metatarsophalangeal
articular surfaces is desired (Figure 13.23A–G and Clinical
Figure 13.21. Example of a mini uniplane monolateral external Case VIII).
fixator on the dorsum of the proximal phalanx. Note the pin clamps
are set adjacent to positioned half-pins in the small space.
A B
C D
Figure 13.22. Example of proximal phalangeal lengthen-

ing with the reference first pin positioned at the base of the
proximal phalanx (A). The mini uniplane monolateral external
fixator is attached to template the distal half-pin site for inser-
tion (B, C). Additional half-pins inserted closer to planned
corticotomy site (D). Axial lengthening of the proximal pha-
E lanx (E).
LWBK1121-C13_p207_223.indd 220 04/10/12 2:56 PM

CLINICAL CASE VII
Example of a uniplane monolateral external fixator to address

severe soft tissue contractures in the forefoot (A). Note the
procedure did not require any incisions (B).
A B
CLINICAL CASE VIII
Example of a preoperative clinical view showing a plantar first olateral external fixation to allow the hallux in a plantarflexed
metatarsal ulceration (A) that was addressed with an ulcer exci- position to minimize wound tension at the soft tissue closure
sion, primary closure, and an application of a uniplane mon- site (B).
A B
LWBK1121-C13_p207_223.indd 221 04/10/12 2:56 PM

222 Chapter 13
A B
C D
E F
Figure 13.23. Example of a sawbone model for a plantar first met-

atarsal ulceration with osteomyelitis and cock up hallux deformity (A).
Metatarsal head resection (B) is performed by beveling the sagittal saw
in a plantar proximal direction (C). Figure (D) shows the first refer-
ence half-pin into the proximal phalanx of the hallux. This is followed
by the hinged uniplane monolateral external fixator as a template
for the proximal half-pin insertion into the metatarsal (E). Additional
half-pins are then inserted into both metatarsal and proximal phalanx
once alignment is acceptable (F). Final plantarflexed position of the
G hallux to minimize wound tension on plantar soft tissue closure (G).
LWBK1121-C13_p207_223.indd 222 04/10/12 2:57 PM

Conclusion
A. In general, smaller uniplane monolateral external fixa- The versatility of uniplane monolateral external fixation allows
tors have a limited lifespan of less than 2 months, due for several indications in forefoot surgery. However, appropri-
to the poorer fixation with smaller half-pins. ate procedure selection to address given pathology should
B. The foot should be protected in an off-loading surgical take into consideration the limitations of forefoot anatomy.
boot or casting material during these types of proce- Detailed knowledge in the utilization of the aforementioned
dures to minimize stress through the forefoot. Forefoot techniques can provide unique solutions for soft tissue and
bone lengthening procedures do not follow the same osseous correction in the forefoot.
distraction guidelines of 1 mm/day as recommended
in larger long bones; generally 0.5 mm/day is more
appropriate but should be individually determined. Recommended Readings
C. In forefoot lengthening cases, the external fixator is Davidson RS. Metatarsal lengthening. Foot Ankle Clin. 2001;6:499–518.
recommended to stay on twice as long as the period of Galli MM, Hyer CF. Hallux rigidus: what lies beyond fusion, resectional arthro-
lengthening or more in certain cases. plasty, and implants. Clin Podiatr Med Surg. 2011;28:385–403.
Levine SE, Davidson RS, Dormans JP, et al. Distraction osteogenesis for congeni-
D. In brachymetatarsia cases, the metatarsal head is often
tally short lesser metatarsals. Foot Ankle Int. 1995;16:196–200.
dystrophic, and the potential for increased symptoms Myerson MS, Miller SD, Henderson MR, et al. Staged arthrodesis for salvage of
with axial lengthening into the joint should be dis- the septic hallux metatarsophalangeal joint. Clin Orthop Relat Res. 1994;307:
cussed with the patient. 174–181.
E. When compression is applied as in a first metatar- Stone C, Smith N. Resection arthroplasty, external fixation and negative pres-
sure dressing for first metatarsophalangeal joint ulcers. Foot Ankle Int. 2011;
sophalangeal arthrodesis, be mindful the external fixa- 32:272–277.
tor, being asymmetric to the line of axial compression
may distort, particularly into varus position.
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Chapter
14 John J. Stapleton
Thomas Zgonis
Stepwise Approach to Midfoot and

Hindfoot Elective and Reconstructive
Surgery with External Fixation
Introduction may result. Circular external fixation with transosseous wire

compression and stabilization is indicated as an alternative to
External fixation for elective and reconstructive arthrodesis screw fixation since it is not dependent on the structural integ-
of the midfoot and hindfoot offers a versatile alternative rity of the osteoporotic bone. Half pins utilized with uniplane
when internal fixation is not feasible. The utilization of circu- monolateral external fixation constructs are advantageous for
lar external fixation with transosseous smooth wires provides certain conditions but are not usually chosen for patients with
increased stability with compression of the desired osteotomy severe osteoporosis since stability is dependent on the cortical
and/or joint(s) to achieve bone healing while allowing imme- integrity. Half pins are commonly combined with transosseous
diate partial or full weight bearing status in certain cases. The wires in hybrid or circular external fixation constructs to pro-
inherent stabilization provided with external fixation is also vide adequate stability in this patient population.
advantageous in preventing of internal fixation failure when Segmental bone loss in the midfoot and hindfoot can be
used in combination. This chapter focuses on the technical quite challenging and various external fixation constructs can
aspects of appropriately applying a circular external fixation be utilized that are typically procedure dependent. Delta and
construct and utilizing the pre-bent transosseous wire technique uniplane monolateral external fixation configurations are usu-
for continuous compression across a single or multiple midfoot ally utilized to stabilize the foot and ankle while maintaining
and/or hindfoot joint(s). This technique has improved the length to the area of bone loss. Large structural bone grafts may
surgeon’s ability to correct severe multiplane foot deformities also be required to manage the osseous defects in the midfoot
and address primary or posttraumatic arthritic joints. High-risk and hindfoot and the time frame for these defects to heal may
patients with multiple comorbidities or local characteristics be prolonged in certain cases. The utilization of combined
that increase the likelihood of failed internal fixation, malun- external with internal fixation is advantageous for these case
ion, nonunion, and/or deep infection may benefit from the scenarios in order to prevent hardware failure, osseous collapse,
utilization of advanced circular external fixation techniques. or malpositioning of the structural bone graft. Circular external
fixation constructs are usually utilized to perform shortening
and primary arthrodesis of the midfoot and hindfoot when
Indications/Contraindications structural bone grafting with internal fixation is not performed.
The capability of stabilizing a difficult-to-heal arthrodesis may
External fixation for elective midfoot and hindfoot arthrodesis be accomplished with a multiplane circular external fixator as
has shown prevalence among surgeons treating patients with opposed to a delta or unilplane monolateral external fixator.
end-stage arthritic conditions and deformities that are further Elective midfoot and hindfoot arthrodesis to salvage chronic
complicated with severe osteoporotic bone, bone deficiency, infected nonunions with osteomyelitis is another indication for
and/or poor soft tissue envelope. The main indications for external fixation. All necrotic and infected bone is surgically
selecting external fixation in these conditions may include and debrided or resected and an external fixator is utilized to stabi-
are not limited to osteoporosis, segmental bone loss, chronic lize the arthrodesis while avoiding the inherent risk of persist-
osteomyelitis, Charcot neuroarthropathy (CN), previous ulcer- ent infection with internal fixation. Retained fixation in these
ations, and complicated failed arthrodesis. cases can present as a nidus for chronic deep infections and
Poor bone stock and osteoporosis pose obvious challenges loosening of the hardware is likely to develop. External fixation
when internal fixation is utilized. In patients with severe disuse may also be indicated in these reconstructive cases since the
and osteopenia, internal screw purchase may not be adequate soft tissue envelope is usually compromised and may limit an
to ensure osseous healing at the arthrodesis site and nonunion open extensive surgical incisional approach.
224
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Stepwise Approach to Midfoot and Hindfoot Elective and Reconstructive Surgery with External Fixation 225
Other indications for external fixation in midfoot and hind- malities may necessitate a vascular surgery consultation and
foot elective and reconstructive cases include diabetic patients intervention if necessary.
with CN. Surgical intervention is usually required in patients External fixation in rheumatoid patients will also require
who present with an unstable deformity or ulceration. In medical and rheumatology consultations to further address
patients in whom the ulcer remains open at the time of surgi- the poor bone quality, antirheumatic pharmacologic use, and
cal reconstruction, internal fixation is relatively contraindi- anesthesia precautions. Wound and osseous complications may
cated. Typically, the ulcer is surgically excised and cultures are also be increased in this patient population and external fixa-
obtained to guide appropriate antibiotic therapy. External fixation offers an alternative method for compression and stabiliza-
tion can be utilized to perform corrective joint alignment and tion across the midfoot and hindfoot joints.
arthrodesis after resection of any osseous prominences. Circular
external fixation can also further stabilize the lower extremity
to prevent an equinus deformity while simultaneously compress- Detailed Surgical Technique
ing the midfoot and/or hindfoot arthrodesis sites.
External fixation is also indicated in previous failed Circular External Fixation for Midfoot
attempted midfoot and hindfoot arthrodesis sites with internal and/or Hindfoot Arthrodesis
fixation. Any retained internal fixation or broken hardware are
surgically removed, the joints are prepared again with or with- After the selected joints are prepared for arthrodesis, provi-
out the use of bone grafting and external fixation is utilized sional fixation with Steinmann pins maintains the necessary
for providing progressive compression until osseous healing alignment across the joint(s) until the external fixator can be
is present. External fixation will also allow for early protective applied. A static circular external fixation construct that con-
partial weight bearing status in selected patients without dense sists of one or two tibia rings with a foot plate can be utilized for
peripheral neuropathy. the majority of midfoot and hindfoot arthrodesis. If one tibia
Severe arterial insufficiency not amenable to revasculariza- ring is to be utilized, the ring is positioned 10 to 15 cm proxi-
tion is a contraindication to elective midfoot and hindfoot mal to the ankle joint and is secured with two crossing smooth
arthrodesis with circular external fixation. Poor edema control wires and/or additional half-pins for further stability. Once the
as a result of venous insufficiency or lymphedema may need to half-pins are inserted, the transosseous smooth wires can then
be addressed prior to these types of procedures with external be tensioned to approximately 110 to 130 kg of force. A second
fixation. The utilization of a wound care team or lymphedema tibia ring with two crossing smooth wires can be placed as an
clinic is beneficial on providing edema control and patient alternative to the half-pins. A foot plate should then be placed
education to prevent any soft tissue compromise during the slightly superior to the plantar surface of the foot if early weight
external fixation utilization. bearing will be permitted after the surgery. The foot plate is
Chronic smoking, recreational drugs and severe alcohol connected to the tibial block with threaded rods and/or hinges.
abuse may have a major effect on wound and osseous healing. At this time, the calcaneus is stabilized with two opposing olive
Smoking cessation programs and counseling may be required wires that are usually tensioned between 70 and 90 kg of force
before these types of surgery along with a patient and family unless the bone is very osteopenic in which case the olive wires
understanding of prompt compliance with treatment through- are tensioned or tightened manually. It is imperative that a sur-
out the patient’s recovery. gical assistant maintains the foot in a neutral position during
this portion of the procedure in order to avoid an iatrogenic
equinus deformity within the external fixator.
Preoperative Considerations Other constructs typically consist of a separate forefoot and
calcaneal ring that can be utilized to compress the midfoot. The
A detailed history, physical examination, gait analysis and advantage to this external fixation construct is the increased
necessary laboratory, radiographic and medical imaging are surgical field for insertion of multiple smooth wires across the
necessary during the preoperative period. Plain weight bear- metatarsal or tarsal bones. Compression of the arthrodesis site
ing radiographic views of the foot, ankle, and lower extremity can be obtained by compressing the forefoot ring to the cal-
are needed in order to evaluate for any deformity. Computed caneal ring. Alternatively, the Taylor spatial frame as described
tomography may demonstrate extensive bone destruction and in Chapter 9 can be utilized for selected midfoot and hindfoot
malalignment and its utilization is beneficial for surgical plan- arthrodesis procedures.
ning of complex nonunions, diseased bone, and broken hard-
ware. Nuclear imaging and magnetic resonance imaging are
Compression Arthrodesis of the
useful to determine if a deep infection and osteomyelitis is
Midfoot and Hindfoot Joints
present. If osteomyelitis is presumed, then intraoperative bone
biopsy and cultures may need to be obtained to guide not Compression across the midfoot and hindfoot joints prepared
only the antibiotic therapy but also the staging of reconstruc- for arthrodesis is achieved through compression of two exter-
tive procedures required to perform a successful midfoot and nal fixation segments of the circular external fixator or by
hindfoot arthrodesis. applying tension through a pre-bent transosseous wire. When
Elective and reconstructive cases in the diabetic popula- the pre-bent wire technique is utilized, each end of the wire is
tion require optimum glycemic control by the internist and/ brought toward the joint requiring compression resulting in
or endocrinologist before and after the surgical procedure. a bend that when straightened by manual tensioning of the
Hyperglycemia may have significant effects in delaying osseous wire at each end simultaneously, it transmits tension and com-
and wound healing. In addition, any vascular testing abnor- pression across the arthrodesis site. If surgical compression is
LWBK1121-C14_p224_236.indd 225 04/10/12 11:25 AM

226 Chapter 14
necessary for multiple joints on the same side of the foot, it seous wires is paramount to provide stability and compression
begins by tensioning manually or by the use of a tensiometer across the selected joints. For example, a triple arthrodesis will
from a proximal to a distal direction in order to avoid any dis- require a navicular wire inserted from a medial to lateral direc-
traction and unequal forces across the joints. tion across the body of the navicular, a cuboid wire inserted
Placing excessive bending to the transosseous compression from a lateral to medial direction across the central portion
wire can cause significant tension to the associated soft tissue of the cuboid, and one or two talar wires from a medial and/
envelope resulting in skin ischemia and eventual necrosis. Any or lateral direction at the junction of the talar neck and body.
signs of skin tensioning will require appropriate releasing by Another alternative for this procedure may include the utili-
incising the skin at the skin/wire interface. If ischemia is still zation of one transosseous wire for the navicular and cuboid
present, the wire should be repositioned and re-tensioned. In bones. Once these wires are inserted, they are then pre-bent in
addition, if the skin between the external fixation segments the direction across the desired arthrodesis sites. Compression
that are either compressed or distracted is compromised it of the talonavicular joint is usually performed first, followed
should also be evaluated for signs of ischemia and addressed by the subtalar and finally the calcaneocuboid joints. After
appropriately. If the area is cyanotic, then compression or dis- compression of all desired joints is achieved, the provisional
traction between the external fixation segments may need to percutaneous Steinmann pin fixation that was used during
be reduced and addressed gradually during the postoperative the procedure can be either removed or incorporated into the
period. external fixation construct if needed. Additional transosseous
Achieving simultaneous compression across the subtalar wire fixation is also secured in the forefoot/midfoot region for
and ankle joints is usually performed by the external fixation further stability (Clinical Cases I–V).
segments such as by compressing the foot plate to the tibial For an isolated subtalar joint arthrodesis or when it is com-
block fixation. The pre-bent transosseous wire technique is usu- bined with an ankle exostectomy and arthrodiastasis, the talar
ally utilized for compression across the midfoot and when an wires are inserted in the same fashion as they were described
isolated hindfoot such as a triple or subtalar joint arthrodesis above. The pre-bent wire technique is first used for the subtalar
is performed. Careful and anatomic insertion of these transos- joint arthrodesis while the combined ankle arthrodiastasis is
CLINICAL CASE I
Preoperative radiographic foot and ankle views (A–C) show- with arthrodiastasis with the use of a circular external fixa-
ing avascular necrosis of the talus from a previous open reduction. Please note that the triple arthrodesis was also supple-
tion and internal fixation. The patient presented with severe mented with the use of internal fixation (D–F). The circular
pain and posttraumatic arthritis to the hindfoot and ankle external fixator was removed at approximately 6 weeks. Final
joints. The patient underwent removal of internal hardware radiographic foot and ankle views at 19-month follow-up
and a combined triple arthrodesis and ankle exostectomy (G–I).
A,B C
(continued)
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A,B C
D E
F,G H
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228 Chapter 14
CLINICAL CASE II
Preoperative radiographic foot and ankle views (A–C) showing with the use of internal fixation (D–F). The patient experi-
a pes planovalgus deformity of a patient with significant pain to enced wire track irritation at approximately 3 weeks and the
the hindfoot and ankle joints. The patient underwent a com- two proximal tibia transosseous wires were removed. The entire
bined triple arthrodesis, ankle arthrotomy, talar resurfacing, circular external fixator was removed at approximately 6 weeks.
and arthrodiastasis with the use of a circular external fixation. Final radiographic foot and ankle views at 9-month follow-up
Please note that the triple arthrodesis was also supplemented (G–I).
A,B C
D E
(continued)
LWBK1121-C14_p224_236.indd 228 04/10/12 11:25 AM

F,G H
CLINICAL CASE III
Preoperative radiographic foot and ankle views (A–C) show- joints were fixated with the use of internal fixation and
ing severe foot collapse and predominant subluxation at the Steinmann pins while the calcaneocuboid joint was primarily
talonavicular joint. The patient also had a history of diabetes fixated with a large Steinmann pin (D, E). The circular
mellitus and Charcot neuroarthropathy. The patient under- external fixator was removed at approximately 7 weeks. Final
went a triple arthrodesis with combined internal and circular radiographic foot and ankle views at 8-month follow-up
external fixation. Note that the talonavicular and subtalar (F–H).
A,B C
(continued)
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230 Chapter 14
D,E F
G H
usually performed by distracting the external fixation segments fixation is also secured distally to the compression wire for fur-
(Clinical Case VI). ther stability (Clinical Case VII).
Same principles are applied in elective midfoot arthrodesis
procedures by utilizing the pre-bent transosseous wire tech-
nique. For example, a tarsometatarsal arthrodesis may require Postoperative Course
a secure proximal hindfoot fixation before the compression
technique is being performed. Proximal fixation may require Pain management, antibiotic therapy, deep vein thrombosis
the insertion of one or two talar wires as described above in prophylaxis if necessary, and rehabilitation are initiated by the
addition to the intercuneiform transosseous olive wire inserted medical and surgical teams. Patient and family are instructed
from a medial to a lateral direction. This olive wire is slightly again regarding the postoperative course and duration of
tensioned manually to provide a secure osseous segment dur- external fixation. Extended health care facilities may also be
ing the compression technique. The metatarsal transosseous required during the patient’s recovery process.
wire is then inserted from a medial to lateral direction across External fixation dressings may be changed if necessary
the metatarsal bases and then pre-bent and secured on the foot at the discretion of the surgical team or in the presence of a
plate. Simultaneous tensioning from each end of this metatar- postoperative event. Postoperative radiographs are obtained
sal wire will provide compression and stabilization across the for further evaluation of the arthrodesis sites or loosening and
desired tarsometatarsal joint(s). Additional transosseous wire breakage of the wires or half-pins. Patients who are permitted
LWBK1121-C14_p224_236.indd 230 04/10/12 11:25 AM

CLINICAL CASE IV
Preoperative radiographic ankle views (A, B) showing severe and a circular external fixator for compression at the tibiota-
ankle valgus collapse from a previous attempted ankle arthro- localcaneal joints (C, D). Previous internal fixation was also
desis. The patient had significant deformity and pain at removed at the time of reconstructive surgery. The circular
both the ankle and subtalar joints. The patient underwent external fixator was removed at approximately 11 weeks.
a revisional ankle arthrodesis combined with a subtalar joint Final radiographic foot and ankle views at 17-month follow-up
arthrodesis by the utilization of large Steinmann pin fixation (E, F).
A,B C
D,E F
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232 Chapter 14
CLINICAL CASE V
Preoperative radiographic ankle views (A, B) showing avascular fixator (C, D). The circular external fixator was removed at
necrosis with collapse of the talus after previous attempted 12 weeks and the patient was slowly progressed into a normal
triple arthrodesis in a patient with rheumatoid arthritis. The shoe gear. Final radiographic views at 3-year follow-up showing
patient underwent a revisional triple arthrodesis with simul- successful hindfoot union at the arthrodesis sites (E, F).
taneous ankle arthrodiastasis with the use of circular external
A B
C D
(continued)
LWBK1121-C14_p224_236.indd 232 04/10/12 11:25 AM

E F
CLINICAL CASE VI
Preoperative radiographic ankle views (A, B) showing posttrau- recession, and simultaneous subtalar joint arthrodesis with an
matic arthritis at both the ankle and subtalar joints. The patient open ankle exostectomy, talar drilling with orthobiologic resur-
had a history of a motor vehicle accident with lower extremity facing, and arthrodiastasis with the use of a circular external
injuries and also a gunshot injury with lower extremity nerve fixator (C–F). The circular external fixator was removed at
damage. The patient underwent a one-stage reconstruction approximately 7 weeks. Final radiographic views at approxi-
with removal of internal ankle hardware, medial gastrocnemius mately 6-month follow-up (G, H).
A,B C
(continued)
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234 Chapter 14
ClinicalA,B
case VI (continued) C
D E
F,G H
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CLINICAL CASE VII
Preoperative radiographic foot and ankle views (A, B) demonstrat- (C, D). The external fixator was removed at 8 weeks. The patient
ing an unstable malunion and nonunion of a Charcot neuroar- was then transitioned to a non–weight bearing cast for 4 weeks
thropathy fracture and dislocation at Lisfranc’s joint. The patient followed by a surgical walking boot for an additional 4 weeks. The
had developed a noninfected superficial ulceration over the plantar patient resumed ambulation with prescribed diabetic shoes and a
medial aspect of the Charcot foot deformity. The patient underwent double upright brace. Final radiographic views (E, F) at 18 months
a medial column alignment and arthrodesis with circular external postoperatively demonstrating a successful medial column align-
fixation and by utilizing the pre-bent wire technique for compression ment and arthrodesis.
A B
C D
(continued)
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236 Chapter 14
E F
for early ambulation are usually fitted for a surgical shoe that and according to additional supplemented fixation. A period
may be attached to a circular ring connected to the foot plate. of a short leg cast immobilization is then followed by a pro-
The patients are also required to use assistant devices to protected weight bearing cast or a surgical boot utilization. Long-
vide additional lower extremity support during ambulation. term follow-up radiographic and medical imaging in addition
Removal of the external fixation device is usually performed to prescribed accommodative shoe gear and/or bracing may
in the operating room and its total duration is case dependent also be necessary for the overall patient’s successful outcome.
C l i n i cal Tips and Pearls Conclusion

A. The utilization of transosseous smooth wires is pre- Circular external fixation for elective and reconstructive mid-
ferred to stabilize the midfoot and hindfoot as opposed foot and hindfoot procedures can be technically challenging
to half-pins in osteopenic patients. and requires knowledge and training with external fixation. A
B. The pre-bent wire technique is advantageous to achieve combined medical and surgical team approach is paramount
continuous compression across the midfoot and hind- for the patient’s successful recovery.
foot joints.
C. A separate forefoot and calcaneal ring allows for ample
surgical space to insert multiple forefoot wires when Recommended Readings
performing a midfoot arthrodesis.
Stapleton JJ, Belczyk R, Zgonis T, et al. Combined medial displacement calcaneal
D. When multiple joints are needed for compression such osteotomy, subtalar joint arthrodesis, and ankle arthrodiastasis for end-stage
as the medial column of the foot, wire compression is posterior tibial tendon dysfunction. Clin Podiatr Med Surg. 2009;26:325–333.
started from proximal to distal direction in order to Stapleton JJ, DiDomenico LA, Zgonis T. Corrective midfoot osteotomie. Clin
avoid iatrogenic joint distraction and movement. Podiatr Med Surg. 2008;25:681–690.
Stapleton JJ, Facaros Z, Polyzois VD, et al. Surgical management of diabetic Char-
E. Increased tensioning of the pre-bent transosseous wire
cot foot and ankle deformities. Perioper Nurs Clin. 2011;6:67–74.
can lead to tissue ischemia and necrosis and will need Zgonis T, Stapleton JJ, Roukis TS. Use of circular external fixation for combined
to be addressed intraoperatively. subtalar joint fusion and ankle distraction. Clin Podiatr Med Surg. 2008;25:
745–753.
LWBK1121-C14_p224_236.indd 236 04/10/12 11:25 AM

Chapter
15 Paul S. Cooper
Stepwise Approach to Ankle

Elective and Reconstructive
Surgery with External Fixation
Introduction internal fixation constructs, requiring additional exposure.

Furthermore, optimal compression across the arthrodesis
Management of intermediate to advanced stage ankle oste- site may not be obtained at the time of the index procedure.
oarthritis has evolved over the past decades incorporating External fixation can address these issues through the use
the use of circular or uniplane monolateral external fixa- of gradual and continuous compression over an extended
tors. Focal areas of intermediate stage ankle osteoarthritis period of time till the desired alignment and compression is
may be addressed through realignment techniques using a achieved for successful bony union. External fixation use for
supramalleolar osteotomy (SMO). Adapted from the con- these methods has the added advantage of minimizing soft
cepts of high-tibial osteotomies, this technique is used to tissue dissection for exposure to achieve the desired goals and
shift the pressure off a focal region of chondral wear to more can even be performed percutaneously in severe dysvascular
healthy zones of the ankle joint. In cases of prior malunion cases.
from trauma or growth plate disturbance, the SMO is used
to restore the normal tibial articular surface angles. In cases
of global involvement, or associated severe ankle ankylosis, Detailed Surgical Technique
arthrodiastasis may be an effective preemptive procedure
prior to salvage options including arthroplasty or arthrodesis. Circular External Fixation
The technique of ankle arthrodiastasis involves gradual joint for Ankle Arthrodesis
distraction of between 5 and 10 mm to allow for healing of a
symptomatic intermediate stage arthritic ankle joint. Although Ankle arthrodesis utilizing circular external fixation has been
the exact mechanism of action is unclear, intermittent hydro- a powerful method for difficult ankle arthrodesis conditions.
static pressure combined with off-loading the ankle joint has These include nonunions from methods of internal fixation,
been proposed. While long-term outcomes are unknown, the pyarthrosis of the ankle joint with associated osteomyelitis,
short-term benefits may require 1 to 2 years to be fully appreci- extensive compromised soft envelope surrounding the ankle
ated by the patient. For end-stage ankle arthritis, ankle arthro- joint, posttraumatic ankle arthrosis with avascular necrosis,
desis remains an effective salvage solution in the foot and and neuropathic-mediated deformities. Unlike conventional
ankle. methods of internal fixation, external fixation allows for
continued application of compression across the ankle joint
in the postoperative period, thus improving union rates. Fur-
thermore, in cases where soft tissue may be compromised with
Indications/Contraindications conventional exposures or active ulcerations, external fixation
permits full access to the soft tissues permitting monitoring
Conventional methods include internal screws, plating, or in the postoperative period. In cases where bone is of poor
retrograde intramedullary nailing. In cases with poor skin quality with potential loss of internal fixation postoperatively
quality, the requisite extensile exposure for internal fixation resulting in nonunion, external fixation with multiple points
may yield an unacceptable high rate of wound complications. of fixation allows for enhanced stability regardless of bone
Severe ankle deformities may also not be amenable to acute quality.
full correction in the operating room from neurovascu- A standard static circular external fixator may be pre-
lar compromise. Poor bone quality can necessitate extensive built in the majority of cases and consists of a tibial block
237
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238 Chapter 15
Figure 15.1. Basic circular external fixation components for Figure 15.3. Basic external fixation components consisting of the
ankle arthrodesis. Threaded rods are used to connect and compress tibial block and the foot plate.
between the tibial block and the foot plate.
comprising two 155 mm rings or alternatively 180 mm rings in nique, the compression amount and frequency can be applied
larger lower extremities. These may be connected with either as desired.
stacked threaded sockets or alternatively threaded rods. A Ankle joint preparation consists of preparation of the
standard external foot plate of the same diameter to that of tibiotalar joint surfaces. This entails minimally denuding the
the tibial ring is used in combination with a half ring attached tibial plafond in addition to the talar surfaces with either
at 90-degree orientation which closes the foot ring and permits a high-speed burr, curettage, or sagittal saw. All ankle joint
maximum wire tensioning as well as additional points of fixa- sclerotic or avascular regions need to be either fully resected
tion. In uncomplicated cases, threaded rods may be used to or perforated to create bleeding channels. The medial gutter
join the segments and serve as a simple method of axial com- should similarly be resected; however, the medial malleolus
pression with the use of compression–distraction nuts (Fig should be preserved to increased bone contact for stability
ures 15.1–15.3). Four equal-size length threaded rods have one with the arthrodesis in addition to vascular preservation
set of nuts on both sides of the threaded rods at equal distances through the deltoid ligaments (Figures 15.9–15.11). One
(Figure 15.4). The threaded rods are equally spaced around the to two threaded Steinmann pins are used to temporarily
foot ring and secured to the corresponding holes on the tibial stabilize across the tibiotalar surface in the optimal posi-
ring using conventional nuts and on the bottom of the foot tion desired. Typically, this consists of the talus being trans-
plate using compression–distraction nuts (Figures 15.5–15.8). lated posteriorly on the tibia combined with slight external
Compression occurs from clockwise turning of the compres- rotation compared to the contralateral side, slight valgus,
sion nut against the foot plate while simultaneously unlocking and neutral dorsiflexion and plantarflexion position (Fig
the nut on the opposite side. Unlike in bone transport tech- ure 15.12).
Figure 15.2. Close-up view demonstrating the use of threaded Figure 15.4. Threaded rods of equal length threaded with nuts
rods, four compression nuts, two-hole male posts, and fixation bolts on both sides.
with corresponding nuts.
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Stepwise Approach to Ankle Elective and Reconstructive Surgery with External Fixation 239
A B
Figure 15.5. Threaded rods are aligned to identical corresponding holes between the distal tibial ring
and the foot plate (A). Failure to properly align may result in jamming or displacement during compression.
Close-up view of the compression nut on the distal end of the foot plate (B).
Figure 15.6. Connection of the tibial block to the foot plate with Figure 15.8. Finished pre-built circular external fixator for ankle
threaded rods. Upper end of threaded rod is secured with nuts arthrodesis.
on both sides of the distal tibial ring, where the lower side of the
threaded rod has the compression nut distally for controlled compres-
sion across the ankle joint.
Figure 15.7. If planned compression is to occur, marking one Figure 15.9. Preparation of tibia for ankle arthrodesis. Note pres-
face of the compression nut will ease in determining a full rotation. ervation of medial malleolus.
LWBK1121-C15_p237_263.indd 239 04/10/12 11:26 AM

240 Chapter 15
Figure 15.10. Talar preparation for ankle arthrodesis.
The pre-built static circular external fixator is slid over

the stabilized ankle and positioned such that the foot plate is
parallel with the subtalar joint which externally is represented
by the junction of the glabrous skin on the plantar foot.
Figure 15.12. One or two Steinmann pin(s) is used for tempo-
Rolled-up sterile towels are used under both calcaneus and
rary fixation.
posterior calf on the proximal tibial ring in order to align and
center the lower extremity within the circular external fixa-
tor (Figure 15.13). The first reference wire is inserted slightly
There should be approximately two fingers’ breadth distance
oblique, directed anteromedial to posterolateral under the
from the back of the anterior ring to the tibial crest. Most
malleoli into the talar body. This avoids capturing either the
importantly is to confirm adequate posterior ring accommo-
medial malleolus or the fibula which would prevent compres-
dations for the calf musculature. If the space is tight, either
sion through the ankle joint. The reference wire is usually
the tibia is anteriorly positioned to one finger’s breath from
tensioned between 110 and 130 kg of force. Overall alignment
the front of the ring, or a larger ring is required. Once overall
is checked with regard to the position of the calcaneus pos-
alignment is felt to be acceptable, any residual medial–lateral
teriorly and medial/laterally in the circular external fixator
translation can be addressed by gently tapping on the circular
once the towels are removed (Figures 15.14 and 15.15). Ide-
external fixator opposite the direction to center the lower
ally, there should be two fingers’ breadth minimum distance
extremity (Figures 15.17 and 15.18). Following this, additional
between the calcaneus and the posterior foot plate with the
wires are inserted into the hindfoot including a second talar
foot centered.
wire directed posteromedial to anterolateral underneath the
Once the distal position is deemed acceptable, a proximal
medial malleolus to avoid capture of either malleoli, again
reference wire is inserted off the proximal tibial ring and
tensioned between 110 and 130 kg of force (Figure 15.16).
Figure 15.13. Alignment of the lower extremity in the circular

fixator can be aided with the use of sterile towels in the operating
Figure 15.11. Note the apposition of the distal end of the tibia to room. Overall alignment is dictated by the foot plate position on the
the talar surface. foot, which usually corresponds with the subtalar joint.
LWBK1121-C15_p237_263.indd 240 04/10/12 11:26 AM

A B
Figure 15.14. A reference transosseous wire is directed anterome-

dial to posterolateral below both malleoli (A). Note the transosseous
wire positioned through the talar body (B). Reference transosseous
wire position as viewed inferiorly (C). Tensioning of the reference
transosseous wire between 110 and 130 kg of force (D). Position of
the lower extremity is checked following tensioning of the reference
E transosseous wire for displacement (E).
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242 Chapter 15
Figure 15.17. Removal of the leg surgical sterile towels and

checking for clearance of soft tissues from the posterior aspect of
both tibial rings. Ideally, the tibia should be located with one-third
clearance anteriorly and two-thirds posteriorly within the ring(s).
Figure 15.15. Surgical sterile towels may then be removed to tensioned on the foot ring between 110 and 130 kg of force
confirm adequate space to the posterior aspect of the foot plate.
(Figure 15.19).
Definitive tibia stabilization may be achieved with either
one to two additional transosseous wires per ring on the seg-
ment or alternatively to use half-pins in a delta configuration
to maximize half-pin spread and minimize risk for pathologic
fracture upon external fixation removal (Figure 15.20). Addi-
tional transosseous wires may also be added into both the
hindfoot and the midfoot/forefoot region for added stability
and to minimize wire/pin irritation postoperatively. These
transosseous wires may be directed into the midfoot or forefoot
regions in an oblique pattern with divergence to maximize
stability (Figure 15.21). When definitive stability of the lower
extremity is achieved, the threaded Steinmann pin(s) are
removed and any shifting at the arthrodesis site is observed
(Figure 15.22). Compression is then achieved by loosening the
opposite nut to that of the compression–distraction nut and
advancing in a clockwise fashion proximally on the threaded
rod to the desired degree of compression (Figure 15.23). The
Figure 15.16. Proximal reference wire is directed transversely
into the corresponding holes with the proximal tibial ring.
Figure 15.18. Optimal

position with both proximal and
distal reference transosseous wires
placed and tensioned (A). Note
central location of the foot and
tibia in reference to the circular
external fixation rings. This is the
ideal time to make any fine adjust-
A B ments if needed (B).
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A B
Figure 15.19. Second transosseous talar wire place-

ment posteromedial to anterolateral below both malleoli
(A). Note optimal talar wire fixation below both malleoli to
avoid capture (B). Second transosseous talar wire place-
C ment through the talar body (C).
A A
B B
Figure 15.20. Note divergent pattern of half-pin placement at Figure 15.21. Forefoot stabilization with oblique transosseous
the tibial block for enhanced external fixation stability (A). Delta con- wire fixation (A). Second forefoot transosseous wire inserted obliquely
figuration of proximal half-pins (B). for additional stability (B).
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244 Chapter 15
A B
Figure 15.22. The temporary threaded Steinmann pin(s) can now be removed (A) and the arthrodesis
site is checked for any displacement (B).
A B
Figure 15.23. Ankle joint compression is then achieved by loosen-

ing the opposite nut to that of the compression–distraction nut (A, B)
and advancing it in a clockwise fashion proximally on the threaded
C rod to the desired degree of compression (C).
LWBK1121-C15_p237_263.indd 244 04/10/12 11:27 AM

degree of compression applied should be enough to visually

identify additional bowing on the transosseous wires on the
foot plate in clinical or C-arm fluoroscopic visualization and
confirmation of joint obliteration. In osteoporotic conditions,
additional fixation may be added to the calcaneus by using the
drop-wire technique consisting of a two-hole male post being
connected either to a smooth or to an olive transosseous wire in
an oblique pattern (Figure 15.24 and Clinical Case I).
Threaded rods are suitable for uncomplicated single-plane
deformities with axial compression where quantitative travel of
the amount of compression is not needed. When more control-
led, graduated compression is required, telescoping rods may
be used (Figure 15.25). In cases where a contracture or angular
deformity needs to be addressed, a multiplanar hinge or virtual
axis set of hinges is indicated (Figure 15.26).
Figure 15.24. Optional additional stability is applied through a
Uniplane Monolateral External transosseous wire insertion into the calcaneus. Note the use of two-
Fixation for Ankle Arthrodesis hole male posts to attach drop-transosseous wires off the foot plate for
calcaneus capture.
Current versions of uniplane monolateral external fixators
allow for fixation distally in both the calcaneus and the talus,
as well as proximally in the middle portion of the tibia. Most longitudinal axis of the foot positioned approximately one
uniplane monolateral external fixators consist of hinges on finger’s breadth anterior and distal to the medial malleolus.
the fixation clamps both proximally and distally with a center C-arm fluoroscopic confirmation with the ankle in dorsiflex-
axial compression–distraction unit (Figure 15.27). The same ion and plantarflexion confirms location and avoidance of
configuration can be applied to either compress for ankle malleolar impingement. The distal clamp is then attached
arthrodesis or distract for arthrodiastasis or contracture correc- to the talar half-pin and serves as a placement guide for the
tion of the ankle joint. calcaneal half-pin insertion (Figure 15.29). The half-pins are
The first half-pin to be inserted is in the talar neck medi- directed through a small longitudinal incision onto the wall
ally (Figure 15.28). This is directed perpendicular to the of the medial calcaneus to avoid any neurovascular injury and
CLINICAL CASE I
Total ankle arthroplasty with postoperative deep infection and (E) and split thickness skin grafting (F, G). Postoperative (H, I)
wound dehiscence in a rheumatoid patient (A, B). Non-revas- and final ( J, K) radiographic views reveal successful ankle
cularized lower extremity (C) treated with negative pressure arthrodesis with sufficient wound coverage.
wound therapy (D), application of circular external fixation
A,B C
(continued)
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246 Chapter 15

A,B C
D,E F
G H
I,J K
LWBK1121-C15_p237_263.indd 246 04/10/12 11:27 AM

Figure 15.25. Example of an alternative

circular external fixator with telescoping rods
to allow for more accurate axial compression
at the ankle joint (A, B). A B
Figure 15.26. Example of

another alternative circular external
fixator with virtual axis hinges to
allow for multiplanar correction in
addition to axial compression of the
ankle joint (A, B). A B
Figure 15.27. Basic uniplane monolateral external

fixation components for ankle arthrodesis. Common to
each are distal half-pin clamps for talus and calcaneus,
articulated ankle hinge joint, and compression–
distraction units through the central segment.
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248 Chapter 15
Figure 15.28. Insertion of the talar neck

half-pin medially (A). Ideal position of the talar
A B half-pin is perpendicular to the talar neck (B).
A,B C
Figure 15.29. External fixation

distal clamp is applied and used as
a template for localization of the
other half-pin(s) (A). Insertion of
the second half-pin into the cal-
caneus (B). Direct views (C, D) on
demonstrating half-pin position in
reference to the hindfoot. The half-
D E pin clamps are then tightened (E).
LWBK1121-C15_p237_263.indd 248 04/10/12 11:27 AM

A B
Figure 15.30. Medial view demonstrating positioning of the proxi-

mal pin clamp with the center sliding unit at maximum length (A).
Center unit is demonstrated at minimal length (B). Optimal position
C for the center unit prior to proximal half-pin insertion (C).
typically comprise a size of 30 mm into the calcaneus. A cen- pression and valgus with distraction may occur. For planned
timeter gap between the soft tissues and the pin clamp provides ankle arthrodesis, gradual compression of one full turn, which
adequate clearance for swelling and allows access for dressing equals a millimeter travel per day, is recommended until con-
and half-pin care. The pin clamp is then secured onto the half- solidation, generally 5 to 7 mm from initiation (Figure 15.36).
pins. The hinged ankle articulation is still left unlocked for final In certain cases, maximum compression may be achieved in the
fine adjustments of the ankle position at the end of the case. operating room if needed. For ankle arthrodiastasis, a gradual
Next, attention is directed to placement of the proximal distraction of 1 mm per day for a maximum of between 5 and
half-pins along the middle level of the tibia (Figure 15.30). 10 mm is performed over an equal number of days unless
The uniplane monolateral external fixator should be set at an acute correction is performed in the operating room
the midpoint distance in the central compression/distraction (Figure 15.37).
unit to allow for any necessary axial travel needed at the end of
the case. With the first half-pin being placed in the distal most
hole of the tibial pin clamp, a 30 mm half-pin is placed after a
small incision down onto the soft tissues. The half-pin direction
should be perpendicular to the medial tibial surface, inserted in
a dorsal medial to plantar lateral direction, achieving bicortical
fixation (Figure 15.31). Following this, using the proximal pin
clamp as a template, additional one to two half-pins are added to
the proximal and central pin clamp holes for additional stability
(Figure 15.32). Once the proximal clamp is secured, the ankle
is positioned in the desired final position and the hinge clamp
articulations are locked (Figure 15.33). If overall alignment is
acceptable, the residual adjustments are made through the ankle
hinge in the distal ankle clamp (Figure 15.34). The compression–
distraction unit is then applied and gradual adjustments are
performed axially across the uniplane monolateral external fix-
ator (Figure 15.35). With eccentric force applied through the
compression/distraction unit in uniplane monolateral exter- Figure 15.31. Distal hole of the proximal pin clamp is utilized for
nal fixators, a tendency to pull the ankle into varus with com- the half-pin insertion into the proximal tibia.
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250 Chapter 15
A B
Figure 15.32. With the proximal pin clamp loosened (A), the
clamp may swivel to be used as a template for further half-pin inser-
tions. Second half-pin is inserted in the proximal clamp (B) and
C secured (C).
A,B C
Figure 15.33. The center compression–distraction unit is loosened to mobilize the ankle joint (A).
Hinges are then tightened once the ankle is grossly positioned in acceptable alignment (B, C).
LWBK1121-C15_p237_263.indd 250 04/10/12 11:27 AM

Figure 15.34. Fine-tuning adjustment of the ankle is last made

through the ankle hinge joint which is then tightened.
Figure 15.37. Example of ankle distraction using the compres-

sion–distraction unit.
Circular External Fixation for

Ankle Arthrodiastasis
Ankle joint arthrodiastasis (distraction) through external fixa-
tion can be an acute or most of the times gradual process
performed postoperatively over a 2- to 3-week period. Both uni-
plane monolateral and circular external fixators can be used;
however, a circular external fixator is better tolerated, has less
stiffness by way of the transosseous wires, and weight bearing
in the postoperative period may be initiated. Essential to this
method of distraction is the external fixator’s capacity to both
axially distract and address any ankle equinus. While several
alterations in external fixation design may be used to achieve
these goals, the core external fixation build for this procedure
is one that has a two tibial rings as a segment combined with
Figure 15.35. The center unit is then adjusted and locked to
accommodate the compression–distraction unit.
Figure 15.36. Final construct in compression mode

for ankle arthrodesis (A, B). A B
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252 Chapter 15
A,B C
Figure 15.38. Example of a circular external fixator for ankle arthrodiastasis using distraction rods com-
bined with anterior motor for addressing the equinus deformity frequently associated (A, B). Close-up view of
the ankle distraction apparatus with hinges medially and laterally (C).
either a foot ring or a five-eighth ring for the hindfoot and Case II). A basic version can be created with the combination
talus, respectively (Figure 15.38). of threaded rods and universal hinges. The hinges are applied
In uncomplicated cases, simple axial distraction may be both medial and lateral on the external fixator to correspond
addressed with either threaded or telescoping rods. To manage with the ankle joint center of rotation, commonly attributed to
any associated equinus contracture, telescoping hinged struts a line drawn connecting the tips of both malleoli (Figure 15.39).
or alternatively multiplanar axis struts are required (Clinical This axis may be determined by inserting a transverse wire placed
CLINICAL CASE II
Equinus contracture with ankle ankylosis from talar trauma fixator (C–G). Final clinical outcome before the removal of the
and avascular necrosis with early ankle joint collapse (A, B). external fixator (H). Note the equinus correction (I, J) after
Patient underwent an anterior ankle exostectomy with tendo- the external fixation removal.
Achilles lengthening and application of a circular external
A,B C
(continued)
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Clinical
A,Bcase II (continued) C
D E
F G
H,I J
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254 Chapter 15
A B
C D
E F
Figure 15.39. Demonstration of a medial hinge construct. First, thread rod with one nut distally and
one distraction nut proximally (A). Then, secure universal hinge to the one side as shown (B). Add a short
threaded rod (30 mm) to the hinge (C). Tighten the threaded rod with another nut (D). Add a second nut to
the end of the rod (E). Secure small threaded socket to the threaded rod end (F). (continued)
inferior to both malleoli that dictates the center axis of rotation similar to that of the ankle arthrodesis technique (Figure 15.42).
of the ankle joint. The medial and lateral hinge centers are Due to the stiffness conferred by half-pins, the distal fixa-
aligned with the transverse reference and distraction occurs tion in the talus, calcaneus, and forefoot should be limited
proximal to these hinges to avoid changing the relationship. to transosseous wires only. This allows, with the initiation of
A third connection is made between the foot plate anteriorly weight bearing, some flexibility in the circular external fixator
and the distal most tibial ring with a twisted plate extension which permits intermittent fluid pressures theorized as the
(Figure 15.40). This anterior strut is used as a “motor” to bring mechanism while avoiding mechanical loading. The arthro-
the ankle out of plantarflexion (Figure 15.41). The tibial ring diastasis technique first involves axial distraction of the ankle
block may use either fine wires, half-pins, or a combination joint followed by gradual dorsiflexion to address the equinus
LWBK1121-C15_p237_263.indd 254 04/10/12 11:28 AM

G H
I,J K
Figure 15.39. (continued) Attach medial hinge to isometric point

on foot plate with 16 mm bolt (G). Medial hinge on foot plate show-
ing placement of center point corresponding to ideal position for
the ankle (H). Tibial ring block connected to open end of medial
hinge (I). Lateral hinge attached at isocentric position to the medial
hinge (J). Open end of lateral hinge attached to distal tibial ring (K).
L Circular external fixator with both hinges attached (L).
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256 Chapter 15
A B
C,D E
Figure 15.40. Demonstration of an anterior motor construct. A three-hole twist

plate is attached to the front of the distal tibial ring (A). Motor assembly components
are shown (B). Next, place two nuts onto a threaded rod, then female one-hole post
on one end. Line up 90-degree two-hole post onto the front of half ring (C). Secure
the threaded rod assembly with 12 mm bolt and nut (D). One-hole male post is then
attached to the twist plate (E). Threaded rod is inserted into the single-hole male post
F and secured with a compression/distraction nut (F).
LWBK1121-C15_p237_263.indd 256 04/10/12 11:28 AM

A,B C
Figure 15.41. Final pre-built articulated circular external fixator with anterior motor unit for dorsiflex-
ion. The external fixator is shown in equinus position as initially attached to lower extremity (A). Final pre-
built circular external fixator with dorsiflexion added to the anterior motor (B). Side hinges being distracted
through compression/distraction nut (C).
(Figure 15.43). This minimizes the potential for jamming of the of the ankle joint resulting from injury. More recently, SMOs
anterior ankle joint when addressing the equinus contracture. have been used to off-load asymmetric areas of ankle joint
Ankle arthrodiastasis achieved by the utilization of a uni- articular wear onto healthy zones in an attempt to extend the
plane monolateral external fixation method is identical as that longevity of a partially arthritic ankle joint. Several methods
described above in the ankle arthrodesis section (Figure 15.37 and osteotomy techniques are available for SMO including
and Clinical Case III). Several modifications include the initial either an opening wedge medially or closing wedge laterally to
setting of the compression/distraction unit to 75% of maximal create a valgus osteotomy, while alternatively a closing wedge
shorten excursion, permitting adequate axial travel for ankle medially or opening wedge laterally osteotomy for varus correc-
joint distraction in the postoperative period. tion. Each of these methods however may alter the mechanical
axis of the lower extremity, requiring a translation correction
at the same time. Other disadvantages of wedge osteotomies
Circular External Fixation for
include lengthening or shortening of the lower extremity and
Supramalleolar Osteotomy
extended times for healing with intercalary bone grafts in
SMO is a distal osteotomy involving the tibia and the fibula open osteotomies. An alternative method involves a crescentic
indicated for correction of malunions and angular deformities or dome osteotomy, which allows for a rotation of the distal
Figure 15.42. Finished construct in a medial

view with the foot in equinus position as ini-
tially applied (A). Additional transosseous wires
may be added to the midfoot as needed. Medial
view with the foot corrected for equinus (B). A B
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258 Chapter 15
A B
C D
E,F G
Figure 15.43. First step following the pre-built circular external fixation application is to distract the
ankle joint using the medial and lateral distraction nuts (A, B). Joint is now distracted 5 to 10 mm (C). Next
step is to dorsiflex the ankle through the anterior motor (D, E). Final correction with the ankle distracted
and the equinus corrected (F, G).
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CLINICAL CASE III
Example of a uniplane monolateral external fixation for ankle

distraction arthroplasty and osteoarticular transfer system pro-
cedure (A–C).
A,B C
fragment without altering length or requiring an intercalary distally (Figure 15.44). The external fixator may be pre-built
bone graft. Fixation methods range from either internal fixa- and applied following the SMO. The osteotomy, depending
tion plating of both tibia and fibula osteotomies or external on the type of correction, may be performed percutaneously
fixation. External fixation is advantageous in cases where a on both the tibia and the fibula (Figure 15.45). Alternatively,
gradual correction is needed or poor soft tissue envelope pre- a small anterior exposure will allow for a dome or crescentic
cludes conventional extensile soft tissue exposure. osteotomy. A longitudinal incision 4 cm in length correspond-
The external fixation design for SMO consists of a standard ing with the distal third tibia is made and dissection is carried
tibial block segment proximally joined through multi–axial- down to the bone in the interval between the tibialis anterior
hinged struts to a five-eighth ring attached to the foot plate and the extensor hallucis longus tendons. A four-hole Rancho
Figure 15.44. Example of a pre-built circular

external fixator for SMO of the distal tibia. Note
the addition of five-eighth ring connection to the
foot plate for additional points of fixation into the
distal tibia (A, B). If ankle distraction is simultane-
ously required, threaded sockets could be replaced
with threaded rods and distraction nut. A B
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260 Chapter 15
cube is secured at one point using one of the proximal holes,

and then swung off the distal point of fixation using a half-pin
to create an arc that is used as a template to drill a series of
holes through both the tibia and the fibula (Figure 15.46). An
osteotome is used to complete the corticotomy on both the
tibia and the fibula, and temporarily stabilize in neutral posi-
tion using a threaded Steinmann pin spanning the osteotomy
directed from the medial malleolus into the tibia (Figure
15.47). With the temporary Steinmann pin fixation achieved,
the circular external fixator is slid over the foot and ankle with
the five-eighth ring distally used as the reference ring aligned
at the distal tibia approximately 1 to 2 cm above the ankle
joint corresponding to the level of the physeal scar (Figure
15.48). A reference transosseous wire is inserted transversely to
capture the tibia at this level (Figure 15.49). Once alignment
is satisfactory in all planes, the proximal tibial reference wire
is then inserted and additional points of tibial fixation using
either wires or half-pins are added (Figure 15.50). A drop
half pin from a longer Rancho cube of the distal tibial ring
block confers additional stiffness and stability closer to the
osteotomy site (Figure 15.51). Transosseous wire fixation of
the ankle joint is performed with a series of olive or smooth
Figure 15.45. Planned dome osteotomy into the metaphyseal wires directed into the talus and tensioned on the foot plate
region of distal tibia. (Figure 15.52). If no secondary distraction across the ankle
A B
Figure 15.46. Method for creating distal tibia dome osteotomy involves insertion of half-pin
proximally followed with an attachment of Rancho cube (A). Using the upper half-pin as a pivot
point, a series of drill holes are made into the metaphyseal region of the tibia (B) Cresentic series
C of holes are made into both the tibia and the fibula (C).
LWBK1121-C15_p237_263.indd 260 04/10/12 11:28 AM

Figure 15.47. The osteotomies are then

completed with a sharp osteotome (A). Com-
pletion of the osteotomy is confirmed through
mobilizing the fragments and the tibia is stabi-
lized temporarily with a threaded Steinmann
pin fixation (B). A B
Figure 15.48. External fixation application with five-eighth ring Figure 15.50. Additional proximal tibial fixation should include
centered over the distal metaphyseal segment of tibia. fibula capturing.
Figure 15.49. A reference transosseous wire is then inserted Figure 15.51. Drop half-pin for added stability off the distal tibial
transversely into the distal tibial metaphyseal segment. This wire is ring near the osteotomy site, using a Rancho cube for anchor.
tensioned between 90 and 130 kg of force dependent on external
fixator’s stability.
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262 Chapter 15
A B
Figure 15.52. View of the olive transosseous wire into the talus
directed anteromedial to posterolateral and tensioned between 110
and 130 kg of force (A). Second olive wire capturing the fibular seg-
ment if no ankle joint distraction is needed during the time in the
external fixator (B). If ankle distraction is planned, then the fibula
should not be captured at this level. Plantar view demonstrating
C crossed olive wires into the talus secured to the foot plate (C).
joint is desired, the fibula is captured with the transosseous on each ring of the proximal tibia. The threaded Steinmann
olive wire to stabilize the distal fibula from subluxing during pin is removed and observation of any shifting of the oste-
the correction phase (Figure 15.53). Additional transosseous otomy is made (Figure 15.54). The struts may be adjusted for
smooth or olive wires or alternatively half-pins are used to sta- distraction to confirm that the osteotomies are complete and
bilize the distal tibial fragment. Adequate fixation consists of a either an acute correction on the operating table or alterna-
minimum of two transosseous olive wires in the talus and distal tively a gradual correction postoperatively may be performed
tibial fragment and two transosseous wires and/or half-pins (Figure 15.55).
Figure 15.53. Additional olive transosseous wire to capture fibula Figure 15.54. The temporary Steinmann pin is then removed
on the five-eighth ring. This serves to stabilize the distal tibiofibular without any evidence of shifting at the osteotomy site. This represents
joint during correction. a balanced lower extremity in the circular external fixation construct.
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A,B C
Figure 15.55. Gradual correction into varus applied through the struts (A). Final construct with correc-
tion applied into the osteotomy site (B). Close-up view of the osteotomy site (C).
Conclusion
A. Uniplane monolateral external fixators may create Circular external fixation for elective and reconstructive
asymmetric compression when used for ankle arthro- ankle procedures can be technically challenging and requires
desis. Compensate by positioning the ankle in slight knowledge and training with external fixation. A multidiscipli-
valgus through the distal hinge of the external fixa- nary team approach is paramount for the patient’s successful
tor. recovery.
B. Due to the limited points of fixation distally into the
hindfoot, uniplane monolateral external fixators are
limited to about 6 to 8 weeks before half-pin loosen- Recommended Readings
ing occurs. This method should be reserved for only Chen CM, Su AW, Chiu FY, et al. A surgical protocol of ankle arthrodesis with
uncomplicated arthrodesis, or as a temporary method combined Ilizarov’s distraction–compression osteogenesis and locked nailing
for wound management until a circular external fixator for osteomyelitis around the ankle joint. J Trauma. 2010;69:660–665.
Cierny G 3rd, Cook WG, Mader JT. Ankle arthrodesis in the presence of ongoing
can be utilized.
sepsis. Indications, methods, and results. Orthop Clin North Am. 1989;20:709–721.
C. Circular external fixation is recommended for arthro- Stamatis ED, Cooper PS, Myerson MS. Supramalleolar osteotomy for the treat-
diastasis of the ankle and/or subtalar joints. This allows ment of distal tibial angular deformities and arthritis of the ankle joint. Foot
for some spring in the circular external fixator with Ankle Int. 2003;24:754–764.
weight bearing status, optimal for hydrostatic pressures Tellisi N, Fragomen AT, Kleinman D, et al. Joint preservation of the osteoarthritic
ankle using distraction arthroplasty. Foot Ankle Int. 2007;30:318–325.
in the ankle joint. Thordardson DB, Markolf K, Cracchiolo A 3rd. Stability of an ankle arthrodesis
D. Circular external fixation is advantageous in supramalle- fixed by cancellous-bone screws compared with that fixed by an external fixa-
olar osteotomies where a gradual correction is needed tor. A biomechanical study. J Bone Joint Surg Am. 1992;74:1050–1055.
or poor soft tissue envelope precludes conventional van Valburg AA, van Roermund PM, Marijnissen ACA, et al. Joint distraction in
the treatment of osteoarthritis: a two-year follow-up of the ankle. Osteoarthritis
extensile soft tissue exposure.
Cartilage. 1999;7:474–479.
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Chapter Paul S. Cooper
16
Crystal L. Ramanujam
Zacharia Facaros
Thomas Zgonis
Stepwise Approach to Charcot

Midfoot Reconstruction and
External Fixation
Introduction Preoperative Considerations

The management of Charcot neuroarthropathy (CN) midfoot Due to CN being a bone destructive process, joint subluxation
deformities has evolved from a nonoperative approach using and deformity is clinically seen, leading to compromise of soft
total contact casting and off-loading, to that of a surgical one. tissue integrity and often resulting in ulceration. For correction
Challenges in reconstruction and especially in patients with of the underlying deformity, which in turn provides long-term
diabetes mellitus include compliance, osteoporosis, diminished eradication of this type of ulceration, osseous reconstruction
bone stock, severe deformities, and wound healing. External involving multiple joint arthrodesis is required. Both internal
fixation as a treatment method can address most of these and external fixation are often utilized, yet the approach is case
issues, and in many cases it is safer for the patient. In the pres- specific, depending on the apex of deformity and numerous
ence of active wounds or associated osteomyelitis, it is the only patient variables, such as the patient’s age, weight, physical
viable option to consider. demands, and the presence of concomitant deformities. Proper
The most common CN midfoot deformities occur at the assessment of underlying infection and instability of the mid-
tarsometatarsal, intercuneiform, or transverse tarsal joint level. foot are essential components in treating these conditions.
As a rule, the more proximal the point of involvement, the Immediate surgical intervention is indicated when a limb-
greater instability and need for surgical stabilization. Charcot threatening infectious process requires decompression and
deformities at Lisfranc’s level are divided into two subcatego- stabilization.
ries. The first involves a dorsal subluxation of the metatarsals The primary objective in the CN midfoot deformity is to
in relation to the midtarsus. This may create a high-pressure establish a functional ambulatory lower extremity by restoring
point under the medial cuneiform leading to ulceration a stable, plantigrade foot without residual skin breakdown. In
plantar-medially. Surgical correction involves an osteotomy the presence of midfoot infection and/or osteomyelitis, staged
through the deformity and translation plantarly to restore the surgical interventions may be necessary in order to eradicate
medial longitudinal arch. The second is the classic rocker bot- the infection followed by the definitive reconstruction.
tom deformity, which is a slow chronic deformity with extensive Extended medial column arthrodesis is a valuable option to
joint reorganization over time. Correction involves a biplanar establish a stable ambulatory foot, performed with internal fixa-
wedge resection to correct both forefoot abduction and dorsal tion, external fixation, or a combination of both methods. Pro-
angulation. cedure selection is based on multiple factors including the
Surgical techniques vary from acute correction with osseous integrity, presence of bone loss, extent of fracture–
either internal, external, or combination fixation to gradual dislocations, integrity of soft tissue envelope, history of deep
postoperative correction with external fixation. Factors to infection, and the patient’s medical and ambulatory status. In
consider in choosing type of fixation and methods of corre some cases, the talocalcaneal and tibiotalar joints are frequently
ction include porosity of bone, rigidity of deformity, soft stabilized, maintaining foot and ankle neutral alignment while
tissue stiffness, skin healing potential, and existence of the midfoot arthrodesis site consolidates. This may be config-
superficial or deep infection. In general, the majority of CN ured with internal Steinmann pin fixation or by way of the exter-
midfoot deformities can be adequately addressed with nal fixator construct. The theory supporting this approach is
an acute reduction of the deformity with definitive stabiliza- that elimination of any frontal plane movement during the heal-
tion achieved (Table 16.1). ing process inhibits disruption to the midfoot arthrodesis site.
264
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Stepwise Approach to Charcot Midfoot Reconstruction and External Fixation 265
urgical Algorithm for Approaching a Charcot

S
Table 16.1
Midfoot Deformity
Deformity?
No Yes
Subluxation Rocker bottom
Transverse tarsal Midfoot /

Subtalar joint joint tarsometatarsal
Talectomy and Reduce Forefoot plantar Biplanar wedge

tibiocalcaneal subtalar joint and translation osteotomy Exostectomy
arthrodesis triple arthrodesis and arthrodesis and arthrodesis
The Achilles tendon is characterized as a major deforming this patient population, including and not limited to, history of
force in the diabetic patient, particularly among Charcot foot cigarette smoking, advanced age, impaired glucose tolerance,
and ankle pathologies. The tendon is composed of the soleus hyperlipidemia, and hypertension, patient counseling is required
and gastrocnemius muscles, the former originating on the pos- to discuss the potential perioperative risks and complications
terior aspect of the tibia and fibula, while the latter originates and any recommended alternatives to surgical intervention.
on the posterior aspect of the distal femoral condyles. Both Basic non-invasive testing and assessment for PVD includes
muscle bellies and supportive connective tissue combine to obtaining an ankle-brachial index (ABI), toe-brachial index
form the Achilles tendon, the insertion of which is into the (TBI), segmental limb pressures, segmental volume plethysmog-
posterior aspect of the calcaneus, functioning to plantarflex raphy, or otherwise known as pulse-volume recording (PVR),
the ankle joint while supinating the subtalar joint during ambu- and transcutaneous oxygen tension (TcPO2). A handheld Dop-
lation. The tendon externally rotates beginning approximately pler probe is a convenient instrument for initial examination
12 cm proximal to the insertion, a critical component when when pulses are not readily palpable. Otherwise, the tests men-
performing an Achilles tendon lengthening procedure, a com- tioned are typically ordered through the vascular lab, followed
mon step of the reconstructive process. Ankle joint dorsiflexion by a formal vascular surgery consultation when indicated.
is needed for normal gait, roughly 10 degrees being the con- The clinical presentation of CN is typically categorized into
sensus value. Equinus is the limitation of this motion, occurring acute or chronic phases. In the acute phase, proper assessment
when the ankle joint is restricted. It may result from a tight calls for recognition of soft tissue abnormalities and/or subtle
joint capsule, scar tissue, or adhesions, or as in the case of the structural compromise. The objective is to stabilize the lower
diabetic population, tendon thickening having evolved with extremity so as to ease the disease progression from the acute to
increased density and structural disorganization. This disor- the chronic phase. Further monitoring appreciates the presence
ganization has been linked to glycation-induced collagen cross- of early fragmentation with fracture–dislocation in the acute
linking resulting in increased stiffness and a decrease in tensile episode, followed by eventual trabecular bridging, bony ankylo-
strength and elasticity. These changes may ultimately lead to sis, and sclerosis of the affected joints when transitioned to the
the equinus deformity and subsequently elevated peak plantar chronic phase. Radiographic assessment and further medical
pressures, providing a significant alteration in contact forces imaging is paramount, providing visualization of bony deformi-
promoting further instability. The majority of Charcot foot col- ties and prominences to determine the full extent of pathology.
lapse is typically seen at the medial column and particularly at Careful clinical monitoring of patients is essential to optimize
Lisfranc’s joint articulation. Biomechanical compensation may treatment for CN and improve the long-term outcome.
be seen within adjacent joints, causing further breakdown and
collapse when the deformity is neglected. Detailed Surgical Technique
Diabetic CN patients commonly present with undiagnosed
peripheral vascular disease (PVD), and in many cases, a thor- When needed, the tendo-Achilles lengthening (TAL) or gas-
ough workup by the foot and ankle specialist can determine the trocnemius recession procedure is executed initially. One
extent of the disease. When various risk factors are present in must decide which procedure is most appropriate and when
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266 Chapter 16
Figure 16.1. Example of a Charcot

neuroarthropathy midfoot rocker
bottom deformity. Note the ankle
equinus associated with the midfoot
A B collapse (A, B).
performing the TAL, an open versus percutaneous incision ing and to assist in orientation. In addition, surgical towels are
will dictate if the patient requires placement in prone position. placed along the outside of the entire construct to prevent any
Various gastrocnemius recession procedures are available and rotation or angulation of the lower extremity. This external fixator
implemented accordingly. Osseous deformities may pertain to consists of two segments: One segment incorporating the two full
both the medial and lateral columns of the midfoot, with the rings, which may be referred to as the tibial block, while the second
medial aspect being more commonly affected. The pneumatic segment consists of the foot plate (Figure 16.6B–D). For scenarios
tourniquet is inflated prior to skin incision and is deflated before involving internal fixation, regardless of whether it is pins, screws,
surgical wound closure and the application of the circular exter- or a plate, this apparatus is primarily utilized for neutralization
nal fixator. Tourniquet use is contraindicated in those instances and stabilization but may also include compression augmentation
when local perfusion is significantly compromised or in patients when desired. Each respective segment is then connected to the
with a recent history of major lower extremity revascularization. underlying anatomy by way of smooth wires, olive wires, and/or
half-pins. The ring and adjoined pin or wires may be thought of as
a stable block, at which point the individual segments require fixa-
Charcot Midfoot Arthrodesis with
tion to one another for further adequate stability. Multiple threaded
Compression Through Olive Wire Docking
rods are utilized to achieve this. Once in position, multiple wires
The deformity apex typically dictates a medial longitudinal and/or half-pins are driven adjacent to both tibial rings and involve
exposure (Figure 16.1A and B). Alternatively, a bony wedge opposing wire placement in a similar fashion (Figure 16.7A–C).
resection of the CN midfoot deformity may be addressed
through a plantar ulcer if sufficient size and depth permits
access. Any associated equinus deformity is first addressed and
stabilized with a threaded Steinmann pin (Figure 16.2). If a
medial longitudinal incision is made, a biplanar midfoot wedge
resection is outlined by inserting two smooth 2 mm Kirschner
(K) wires, placed at the apex of the deformity (Figure 16.3A
and B). The biplanar wedge resection typically consists of an
apex dorsally and laterally to perform a closing wedge resulting
in plantarflexion and adduction reduction of the forefoot.
Optimal reduction is confirmed when the two K-wires achieve
parallelism following resection (Figure 16.4A and B). The oste-
otomy is then temporarily stabilized using a 2 mm threaded
Steinmann pin across the midfoot directed distal-medial to
proximal-lateral (Figure 16.5A and B).
A standard static circular external fixator for CN midfoot
arthrodesis involves a multiplane configuration with two distal Figure 16.2. Note the equinus correction and ankle stabilization
tibial rings and a foot plate (Figure 16.6A). The prebuilt construct with a threaded Steinmann pin fixation. A greater prominence of the
is placed over the foot and leg with folded sterile towels placed midfoot rocker bottom deformity is seen after surgical correction of
between the leg and the external fixator to maintain proper spac- the equinus deformity.
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A B
Figure 16.3. Example of two smooth K-wires to create a biplanar osseous wedge resection of the midfoot
deformity (A). Note the segment to be resected in black outlined by the two smooth K-wires (B).
A B
Figure 16.4. Example of the midfoot alignment after resection of the osseous segment resulting in
parallel K-wires (A, B).
A B
Figure 16.5. Example of the forefoot held in alignment with a threaded Steinmann pin fixation (A, B).
LWBK1121-C16_p264_292.indd 267 04/10/12 11:30 AM

268 Chapter 16
A B
C D
Figure 16.6. Example of the basic components to construct a static circular external fixator for Charcot
neuroarthropathy midfoot arthrodesis (A). Note the foot ring is preassembled to the foot plate (A) and the
construction of the tibial block (B). Example of the prebuilt static circular external fixator with threaded rods
as connection between the tibial block and the foot plate (C). Additional points of fixation may be necessary
according to the reconstruction and external fixation purposes. An assembly of a forefoot crossbar for
Charcot neuroarthropathy midfoot arthrodesis with compression through olive wire docking (D).
Refer to Chapter 8 and Figures 8.1–8.5 for detailed descrip- neutral alignment of the foot and lower leg is maintained for
tion and visualization of the following six transosseous wires desired postoperative healing. In the arrangement involving
combined with half-pins when necessary. The first wires are two transosseous wires for each ring, manual tightening with
initially driven from a lateral-to-medial direction and inferior to wrench instrumentation is done starting laterally and to the
the respective tibial rings. The opposing wires are then driven inferior fixation points on both rings, at which time tightening
from a medial-to-lateral direction and superior to the tibial transpires medially and to the corresponding anterior fixation
rings. Four wires are used in total, placed in a bicortical fash- points. Tensioning with a dynamometric tensiometer is first to
ion, driven with steady and even pressure and should not devi- the medial wires connected along the posterior aspects in
ate from their intended course. The laterally inserted tibial which further tightening is required to secure and lock the
wires are at 90 degrees to the longitudinal axis of the lower wires into position. Tensioning is then carried out laterally. The
extremity while the medially placed wires are roughly 45 smooth wires placed in the tibia are typically tensioned between
degrees to the same axis. The angles between the two should be 110 and 130 kg of force, but at times, 90 to 110 kg of force will
as large as possible without compromising balance. Once suffice in the diabetic population. Appropriate cutting and
again, half-pins may be interchanged accordingly, particularly bending of the wires conclude this portion of the procedure at
implemented when the static circular external fixator requires the tibial block fixation.
placement for longer durations. A third transosseous wire may Regarding the foot plate, axial calcaneal olive wires are now
also be driven in place of a half-pin. Wire fixation bolts and incorporated, providing additional stabilization without trans-
nuts are configured to attach the wires to the rings, while lation. The first olive wire is driven from a lateral-to-medial
LWBK1121-C16_p264_292.indd 268 04/10/12 11:30 AM

A B
Figure 16.7. Example of the foot

positioned within the static circular external
fixator. The calcaneus is usually set two to
three fingers’ breadths anterior to the edge
of the foot plate and the foot is aligned
parallel with the arms of the foot plate (A).
Example of the lower extremity alignment
within the static circular external fixator is
shown (B). Note that the space should have
enough room posteriorly for the calf
musculature (B). Anteriorly, general
recommendations are one to two fingers’
breadths between the anterior circular ring
C and the tibial crest (C).
direction, placed firmly in the posterior-superior calcaneal Once the hindfoot and lower extremity is stable, the
process, making sure to engage both cortices. This ensures that threaded Steinmann pin is removed from spanning the ankle
the neurovascular bundle located on the medial aspect is joint (Figure 16.8). With the hindfoot and tibia secured,
avoided and uncompromised. As the olive wire approaches the attention is now directed to docking the forefoot onto the
skin, the drilling stops and a minimal percutaneous stab inci- hindfoot. This can be achieved through several methods. The
sion, followed by blunt soft tissue dissection by way of a curved
hemostat is performed. This provides a clear, uninhibited entry
point of the olive portion into the skin. The drilling then
resumes until light resistance against the olive is felt and a mal-
let is now used to complete entrance of the wire, resulting in a
parallel wire with olive abutment against the lateral calcaneal
wall. A second olive wire is driven in an opposite direction,
from medial to lateral, attempting to orient the wire away from
the neurovascular bundle, thus, typically driven from a proxi-
mal-medial direction into the posterior-inferior aspect, exiting
distal-laterally. Again, the driven wire is ceased before the olive
portion reaches the skin, at which time a small percutaneous
stab incision is placed followed by blunt dissection, and so
forth. Two olive wires are now abutting the calcaneus for rota-
tional and angular stability and avoidance of frontal plane
translation. The wires are connected to the foot plate by way of
posts, fixation bolts, and nuts. In the diabetic population, these
wires are not usually tensioned but if one was to do so, typical Figure 16.8. With the ankle joint and lower extremity stabilized,
force ranges from 70 to 90 kg of force. the ankle transfixion Steinmann pin is removed.
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270 Chapter 16
Figure 16.11. Olive wire is directed from anterior to posterior

capturing the base of the first metatarsal.
Figure 16.9. Final appearance of the static circular external

fixator before the midfoot arthrodesis procedure.
most consistent and stable of which is to direct olive wires in

an anterior-to-posterior direction to compress across the oste-
otomy site. These olive wires are in a different orientation
than that of the foot ring and require a transverse bar
attached to the half ring off the foot plate (Figure 16.9). The
olive wires are directed to capture the first metatarsal through
the calcaneus and subsequently tensioned (Figures 16.10–
16.13). Unlike the remainder of wires attached to the entire
construct, which are tensioned as mentioned above, care
should be taken due to the porosity of the bone to the degree
Figure 16.12. Lateral view showing the orientation of the medial

olive wire. Please note that the threaded forefoot stabilization
Steinmann pin is still maintained throughout this process.
Figure 16.10. Stabilization and compression of the forefoot onto the

hindfoot by using the forefoot crossbar. A single or double male post is Figure 16.13. Note that the wire is brought out and posteriorly
dropped off the forefoot crossbar directed into the medial column. onto the foot plate.
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A B
C D
E F
Figure 16.14. The wire is tensioned (A) pulling the olive against the metatarsal (B) and compressing onto
the midfoot. Note that the distal wire fixation bolt is loosened up until this moment. Once the proper amount of
compression is applied, the distal fixation bolt is secured (C). The tensioner may now be increased to a maximum
110 to 130 kg of force (D). The distal ends of the wires are now cut and bent appropriately (E). The threaded
forefoot Steinmann pin can now be removed and the docking site is examined for any shifting or instability (F).
of tension applied across the olive wire. The temporary Stability is checked through the midfoot and additional
Steinmann pin is removed and the olive wire is tensioned wires as needed would be inserted along the central column
posteriorly such that the stability is checked in the midfoot. either in the second or third metatarsals posteriorly directed
Once proper compression is applied, the tension is halted through the calcaneus and a third wire as needed through the
posteriorly. The forefoot connection is then secured and the fourth or fifth metatarsals laterally (Figure 16.15A–F). Once
remainder of the tension applied between 110 and 130 kg of these wires have all been adequately tensioned, a final assess-
force can now be placed posteriorly with the posterior fixa- ment of the stability of the midfoot is performed. Additional
tion bolt then tightened (Figure 16.14A–F). wires either in neutral or in arched orientation may be inserted
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272 Chapter 16
A B
Figure 16.15. A second olive wire (A, B) is inserted toward the

second or third metatarsal and exiting posteriorly. If needed, a third
olive wire (C–E) is directed off the base of the fifth metatarsal. A
close-up view of a three-olive wire docking of the forefoot for the
Charcot neuroarthropathy midfoot arthrodesis (F). F
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A B
Figure 16.16. An additional forefoot transosseous wire is inserted to stabilize the distal forefoot. This
transosseous wire may be tensioned in neutral (A) or alternatively arched for added compression (B).
in the forefoot for added stabilization (Figure 16.16A and B). wires (Figure 16.20). Following this, telescoping struts with a
Typically, an additional plantar foot plate, ring or commercially full circular ring is adjusted onto the forefoot perpendicular
available foot rocker is attached at the end of the procedure in to the longitudinal axis of the forefoot. Forefoot wires are
order to off-load the foot with unwanted weight bearing activi- then inserted in a crossed fashion whereby one wire will cap-
ties and to assure protection of any associated plantar wounds ture the first and second metatarsals and the second wire to
(Figure 16.17A and B and Clinical Case I). capture the lesser metatarsals, three through five (Figure
16.21A and B). Additional fixation out of the plane of the
forefoot ring may be used with wires or half-pins as needed.
Charcot Midfoot Arthrodesis with
Typically, an additional 3 to 4 mm half-pin may be placed in
Compression Through Struts
the medial and lateral columns, respectively, and attached to
An alternative method of compressing through the osteotomy the foot ring with a two- or three-hole rancho cube. The fore-
site may be performed using hinged compressible struts. foot is then adjusted through the struts acutely on the operat-
A mitered foot ring is used to secure the tibia and hindfoot ing table to place the forefoot in the desired position for
as a stable, neutral block (Figure 16.18A and B). Reference compression or alternatively a gradual correction over time in
wires are positioned on the tibia and calcaneus and additional the postoperative course if concerned about neurovascular
wires are placed to stabilize the tibial block (Figure 16.19A and B). or wound healing issues (Figure 16.22A–D and Clinical
The calcaneus and ankle joint are then stabilized with fine Cases II–IV).
Figure 16.17. Final anterior (A) and

lateral (B) views of the entire static
circular external fixation construct for
the Charcot neuroarthropathy midfoot
arthrodesis with compression through
olive wire docking. A B
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274 Chapter 16
Clinical CASE I
Chronic Charcot midfoot deformity after partial fourth and with docking of the forefoot for the Charcot midfoot arthrod-
fifth ray amputations. Note the severe forefoot adduction in esis with a circular external fixator (C, D). Final correction with
combination with dorsal translation (A, B). Surgical reduction restoration of the medial longitudinal arch (E, F).
A,B C
D,E F
Charcot Midfoot Arthrodesis Various external fixation constructs may be chosen from
with Compression Through with no absolute correct configuration agreed upon. A bent
Bent Wire Technique wire compression technique has been proven to allow adequate
When soft tissue wounds are involved and treated accordingly, compression and stabilization in patients with CN midfoot
the circular external fixation provides an effective means of reconstruction. When using this technique as the only method
inhibiting premature pressure, friction, or movement to the for providing compression in the midfoot, additional transos-
area. For CN midfoot reconstruction, this method of fixation seous wires are conventionally inserted proximally first and
can achieve bridging across defective or unsupportive bone carried out distally to the arthrodesis area. The bent wire com-
that is not capable of retaining internal fixation. Some patients pression technique may be accomplished, taking caution to
are permitted to initially begin weight bearing following circu- compress rather than distract the involved segments. This is
lar external fixation application, a theory based on load shar- accomplished by placing the ends of the respective transos-
ing that may potentially expedite the fusion process; however, seous wire toward the joint that will become straightened after
it is not usually permitted in this patient population. manual tensioning that transmit force across the joint producing
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Figure 16.18. Prebuilt construct for Charcot

neuroarthropathy midfoot arthrodesis with
compression through struts (A). The prebuilt
construct is applied to the lower extremity centered
over the longitudinal axis of the tibia (B). A B
A B
Figure 16.19. Example of the first tibia and calcaneus transosseous wire fixation secured to their
respective rings/plates (A) followed by additional wire insertions (B).
Figure 16.20. Example of the talar stabilization transosseous wire

to prevent subluxation and stabilize the hindfoot without any equinus
deformity forcing.
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276 Chapter 16
A B
Figure 16.21. Diverging cross wires inserted into the forefoot off the circular ring. Typically, the medial
oblique wire will capture the first and second metatarsals (A) while the second lateral wire captures the lesser
three metatarsals (B).
A B
Figure 16.22. Following the midfoot

osteotomy (A), the forefoot is reduced and
compressed utilizing the struts (B). Final
views (C, D) of the entire construct for
Charcot neuroarthropathy midfoot
C D arthrodesis with compression through struts.
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Clinical CASE II
Chronic Charcot midfoot deformity with dorsal subluxation at tion with struts and external fixation (C). Final correction with
the tarsometatarsal level (A, B). Acute reduction and stabiliza- restoration of the medial longitudinal arch (D, E).
A,B C
D E
compression. When over bending the wire, the soft tissue enve- Charcot Midfoot Arthrodesis with
lope will become compromised and requires inspection for Combined Internal and External Fixation
ischemic changes. Repositioning and tensioning the wire
should transpire if the ischemia persists. If the surgeon decides Various techniques are available when planning for permanent
not to complete additional compression, an additional fore- fixation, including internal fixation, external fixation, or a
foot and/or midfoot transosseous wire is still inserted to main- combination of both. The use of internal fixation generally
tain alignment and control of the forefoot/midfoot regions. involves Steinmann pins, large-diameter cannulated screws,
This added transosseous wire is commonly inserted parallel and plating technology, specifically locking plates that pertain
in the transverse plane, engaging as many bony cortices as to the plate and locked screws functioning as one unit. Stein-
possible. mann pin fixation may be buried into the soft tissue or inserted
Lastly, long threaded rods, connection plates, and threaded in a percutaneous fashion, requiring removal at a later date.
hinges are applied to connect and stabilize the foot plate to the Larger diameter threaded or smooth Steinmann pins are more
tibial block. Furthermore, an additional plantar ring or foot appropriate for stability and control, multiple pins placed per
plate may be included, connected to the foot plate for increased area of correction. When used, they are usually incorporated
off-loading and protection (Clinical Cases V and VI). within the circular external fixation construct.
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278 Chapter 16
Clinical CASE III
Preoperative anteroposterior (A) and lateral (B) radiographic compressed by using the Taylor spatial frame construct (C, D).
views of a right Charcot midfoot unstable deformity with a history The external fixator was removed at approximately 7 weeks and
of medial plantar ulcerations. The patient underwent a percuta- the patient was transitioned to a non–weight bearing cast immo-
neous tendo-Achilles lengthening with a multiple medial column bilization for approximately 6 weeks followed by appropriate sur-
joint arthrodesis, allogenic bone grafting, and ulcer excision. gical boot off-loading and accommodative orthotic devices. Final
The joints were stabilized with the use of a Steinmann pin and radiographic views (E, F) at approximately 4-month follow-up.
A B
C,D E
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Clinical CASE IV
Clinical (A) and radiographic anteroposterior (B) and lateral flap closure with the use of a Taylor spatial frame butt construct
(C) views of a right Charcot midfoot unstable deformity with (D–J). The external fixator was removed at approximately
a history of chronic plantar ulcerations and failed split thick- 6 weeks with further wound debridement and the patient was
ness skin grafting at the plantar aspect of the foot. The patient transitioned to a serial non–weight and weight bearing lower
underwent serial wound debridements followed by a percuta- extremity casting for several months with final accommodative
neous tendo-Achilles lengthening, fifth metatarsal resection, shoe gear and orthotic devices. Final clinical (K) and radio-
arthrodesis of the fourth metatarsal to cuboid joint, and local graphic (L, M) views at approximately 4-year follow-up.
A,B C
D,E F
(continued)
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280 Chapter 16
G,H I
J,K L
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Clinical CASE V
Clinical (A, B) and radiographic (C–E) views of right chronic at approximately 2 months and an entire medial column
Charcot midfoot deformity with osteomyelitis and severe dis- arthrodesis with a subtalar and ankle joint stabilization with
location of the medial cuneiform. The patient underwent an a static circular external fixation was performed (I–O). Note
initial incision and drainage procedure with bone biopsy and that the bent wire technique was utilized for the midfoot
total excision of the medial cuneiform (F). This was followed arthrodesis (I, M). The circular external fixator was removed
by a repeated surgical debridement with the application of at 7 weeks postoperatively. Final outcome at approximately
cemented non–biodegradable antibiotic beads at the medial 11-month follow-up (P–V).
column of the foot (G, H). The antibiotic beads were removed
A,B C
D,E F
(continued)
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282 Chapter 16
G,H I
J K
L,M N
(continued)
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O P
Q,R S
T,U V
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284 Chapter 16
Clinical CASE VI
Clinical (A, B) and radiographic (C, D) views of right chronic (G–M). Note that the bent wire technique was utilized for the
Charcot midfoot deformity with severe dislocation of the Charcot midfoot arthrodesis (G, K). An additional circular ring
medial cuneiform. The patient underwent total excision of the was also added for protection of the plantar weight bearing
medial and intermediate cuneiforms (E) followed by an entire surfaces of the neuropathic foot (G–M). The circular external
medial column arthrodesis (F) and simultaneous subtalar and fixator was removed at 8 weeks postoperatively. Final outcome
ankle joint stabilization with a static circular external fixation at approximately 1-year follow-up (N–Q).
A,B C
D E
(continued)
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F,G H
I,J K
L M
(continued)
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286 Chapter 16

L M
N,O P
Large-diameter screws have been sufficient when executing threaded screw holes, which allow screws to thread into the
a “beaming” technique. The beaming approach can be applied plate and function as a fixed-angle device, also containing a
to both the medial and lateral columns of the midfoot, typically mixture of holes that allow placement of both locking and tra-
inserted from a distal to proximal direction. The medial col- ditional non-locking screws. An important step when applying
umn screw has been found to absorb the loads of the medial these plates is to accurately contour the plate to the underlying
longitudinal arch and can realign the forefoot to the midfoot/ bone prior to screw insertion. They may be applied to either
hindfoot regions. This screw is driven from the head of the column but typically are used for the medial column of the CN
first metatarsal and most of the time ending proximally in the foot. The size of the plate and respective screws may vary
talus. A lateral column placed screw can efficiently stabilize depending on the extent of coverage and size of anatomic
the instability, particularly when the cuboid has been dislocated structures prepared for arthrodesis. C-arm fluoroscopic guid-
and collapsed. This screw should enter the base of either the ance is also commonly used when inserting the plate and
third or the fourth metatarsal and inserted proximally into the screws to ensure adequate purchase of bone and avoidance of
cuboid and calcaneus. Variation of placement for either col- intra-articular joint placement. Furthermore, larger diameter
umn will depend once again on the apex of deformity and screws may also be independently inserted for augmentation of
bone integrity. Additional screws may also be inserted depend- the involved segments.
ing on the extent of bone destruction. It is well accepted that Adjunctive procedures may be needed for further strength-
internal fixation may not be used in cases of open large ening when the hindfoot/ankle complex is also involved and
wounds, infections, osteomyelitis, or in any cases that there is a can be executed through stabilization via skeletal fixation and/
high suspicion of underlying infection. or arthrodesis. Skeletal stabilization is utilized when combining
Plating technology has significantly advanced over recent internal and external fixation in order to further reinforce and
years in the lower extremity and especially for CN reconstruc- aid in structural support. This skeletal fixation technique main-
tive procedures. Obtaining stability in the Charcot midfoot is tains the foot and lower leg in a well-aligned position and
instrumental and plating is a viable way to resist strain across essentially limits motion in the proximal joints to establish
the arthrodesis site(s). Locking plates are fixation devices with an overall stable foot. Skeletal stabilization is frequently
LWBK1121-C16_p264_292.indd 286 04/10/12 11:31 AM

performed with a Steinmann pin, sizes of which vary depend- secured to their respective midfoot ring. Following attachment
ing on the location and anatomy targeted, commonly ranging of connection points by way of wire fixation bolts and nuts,
from 2.7 to 3.5 mm. The hindfoot/ankle articulations com- further manual tightening is carried out with wrenches; how-
monly stabilized are the talocalcaneal and tibiotalar joints, ever, no tensioning is typically performed to this midfoot ring.
either the talocalcaneal joint by itself or combining both to This is because the stabilizing and off-loading external fixator
solidify the tibiotalocalcaneal structure while midfoot arthrod- is usually implemented after internal fixation reconstruction,
esis sites consolidate. The Steinmann pin fixation is inserted and tensioning may disrupt the underlying correction. The
percutaneously under the guidance of C-arm fluoroscopy to tibial block and midfoot ring are now connected to one another
confirm accurate placement and alignment. Multiple Stein- by way of threaded rods, hinges, and connection plates in
mann pins are generally used and appropriately cut at the which variable hinges are available to the surgeon in order to
entry point while the exposed portions are protected by pin stabilize the entire external fixation construct.
caps. The final component of the stabilizing and off-loading
External fixation configurations when combined with inter- external fixator is the kickstand portion that commonly inte-
nal fixation may present in the standard static circular external grates a combination of clamps and bars. Two rod-to-bar and
fixation or in a stabilizing and off-loading external fixation two hybrid bar-to-bar clamps are commonly used; however, ring
construct. For a self-built stabilizing and off-loading external clamps may also be implemented when a half or full ring is
fixation construct, the distal tibial ring(s) is placed just proxi- assembled. One clamp is first attached to the distally oriented
mal to the ankle joint, no less than 20 mm from the tibiotalar threaded hinge, either medially or laterally, and more specifi-
joint to avoid intra-articular placement of the wire, thereby cally, the threaded rod positioned anteriorly to the involved
decreasing the risk of creating a septic joint. Bicortical transos- hinge. A second clamp is now attached to the opposite threaded
seous wires are then inserted in a typical fashion and secured rod. Two bars, one for each side, are now clamped into place,
to their appropriate tibial ring(s). This is followed by the utili- oriented in a vertical alignment pointing plantarly, followed by
zation of a circular ring positioned over the midfoot region. two additional clamps now attached to the ends of the previ-
While maintaining the foot and lower leg in a neutral align- ously placed vertical bars. A longer bar, oriented in a transverse
ment, visualization of additional wire placement dictates the alignment, now connects the vertical bars through the third
ring position while continuing equal spacing. Two additional and fourth bar-to-bar clamps required for the kickstand com-
smooth or olive wires are inserted in a crossed fashion and plex (Clinical Cases VII–IX).
Clinical CASE VII
Preoperative radiographic views (A, B) of a left chronic Char- off-loading external fixation construct (C–E). The circular
cot midfoot deformity with multiple fracture–dislocations. external fixator was removed at 7 weeks postoperatively. Final
The patient underwent an entire medial column arthrodesis outcome at approximately 16-month follow-up (F, G).
with the use of an internal locking plate and a stabilizing/
A,B C
(continued)
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288 Chapter 16

A,B C
D,E F
Clinical CASE VIII
Preoperative radiographic views (A, B) of a left chronic Charcot (C–E). Note the skeletal stabilization of the ankle joint with the
midfoot/rearfoot deformity with multiple fracture–dislocations. use of the Steinmann pin from the subtalar joint arthrodesis.
The patient underwent an entire medial column and triple The circular external fixator was removed at 4 weeks postopera-
arthrodesis with the use of an internal locking plate, Steinmann tively due to patient’s noncompliance issues. Final outcome at
pins, and a stabilizing/off-loading external fixation construct approximately 8-month follow-up (F, G).
A,B C
(continued)
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D,E F
Clinical CASE IX
Preoperative radiographic views (A, B) of a left chronic Char- bilizing/off-loading external fixation construct (C, D). The cir-
cot midfoot deformity with multiple fracture–dislocations. cular external fixator was removed at 5 weeks postoperatively.
The patient underwent a tarsometatarsal and medial column Final outcome at approximately 14-month follow-up (E, F).
arthrodesis with the use of an internal locking plate and a sta-
A,B C
(continued)
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290 Chapter 16
F E
Charcot Midfoot Arthrodesis with oriented half-pins are 3 mm. For a medial column arthrode-
Uniplane Monolateral External Fixation sis, a 4 mm half-pin may be inserted in the talus and/or
navicular, followed by two 3 mm pins into the medial cunei-
In certain cases where a circular external fixator is not suita-
form and/or first metatarsal or possibly both into the first
ble for the patient due to a variety of medical and lower
metatarsal. The same approach is taken for a lateral column
extremity conditions, a uniplane monolateral external fixator
arthrodesis, again determined by location and bones involved.
can be utilized to achieve reconstruction in the CN midfoot
One long composite bar and multiple pin-to-bar and bar-to-
region. This external fixator will normally involve two half-
bar clamps are attached in order to provide the localized
pins proximal to the arthrodesis site and two pins positioned
compression. Initially, the pin-to-bar clamps are tightened,
distally. The number and length of half-pins will vary depend-
followed by tightening of the proximal bar-to-bar clamp, and
ing on the strength of cortical bone. One half-pin may only be
while simultaneously applying proximal pressure on the distal
needed proximally; however, two half-pins may be necessary
pins, the remaining bar-to-bar clamps are tightened (Clinical
for insertion distal to the arthrodesis site. The proximally
Case X).
placed half-pins are typically 4 mm in size, whereas the distally
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Clinical CASE X
Preoperative radiographic views (A, B) of a left acute navicular the use of a uniplane monolateral external fixator (C, D). The
fracture in a diabetic neuropathic patient with early signs of a external fixator was removed at 7 weeks postoperatively. Final
Charcot dislocation. The patient underwent a total naviculec- outcome at approximately 7-month follow-up (E, F).
tomy, bone grafting, and a medial column arthrodesis with
A,B C
F E
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292 Chapter 16
Conclusion
A. Equinus deformity associated with a Charcot neuroar- Successful surgical reconstruction of midfoot CN relies on
thropathy midfoot collapse needs to be addressed first detailed knowledge in the use of internal fixation, external
in order to determine the extent of midfoot deformity. fixation, and combined approaches. Appropriate selection of
B. Translational deformities where the forefoot is dorsally procedures and careful execution of these techniques can pro-
subluxed may only require an osteotomy through the vide a stable construct to achieve and maintain correction of
deformity. the deformity.
C. Charcot neuroarthropathy midfoot rocker bottom
deformities usually require a biplanar osteotomy for
correction. Recommended Readings
D. Once the transosseous wires are in place, work from Cooper PS. Application of external fixators for management of Charcot deformi-
proximal to distal with the forefoot docking as the last ties of the foot and ankle. Foot Ankle Clin. 2002;7:207–254.
component. Jolly GP, Zgonis T, Polyzois V. External fixation in the management of Charcot
neuroarthropathy. Clin Podiatr Med Surg. 2003;20:741–756.
E. Add a plantar foot ring/plate or commercially available
Pinzur MS. Current concepts review: Charcot arthropathy of the foot and ankle.
foot rocker to the secured external plantar foot plate. Foot Ankle Int. 2007;28:952–959.
In addition to off-loading plantar soft tissues, the loads Sammarco VJ. Superconstructs in the treatment of charcot foot deformity:
are transmitted through the circular external fixator plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin.
instead of the osteotomy. 2009;14:393–407.
Schon LC, Easley ME, Weinfeld SB. Charcot neuroarthropathy of the foot and
ankle. Clin Orthop Relat Res. 1998;349:116–131.
Zgonis T, Roukis TS, Lamm BM. Charcot foot and ankle reconstruction: current
thinking and surgical approaches. Clin Podiatr Med Surg. 2007;24:505–517.
Zgonis T, Roukis TS, Polyzois V, et al. Surgical management of the unstable
diabetic Charcot deformity using the Taylor spatial frame. Oper Tech Orthop.
2006;16:10–17.
LWBK1121-C16_p264_292.indd 292 04/10/12 11:32 AM

C h a pt e r
17 Paul S. Cooper
Thomas Zgonis
Stepwise Approach to Charcot

Hindfoot/Ankle Reconstruction
and External Fixation
Introduction arthrodesis. Typically, there is a balance between the degree

of skeletal shortening and the realignment. In addition to
Charcot neuroarthropathy (CN) hindfoot/ankle deformities anatomic location, CN deformities are based on the Eichen-
are the most unstable and therefore the most urgent of all holtz classification of radiographic findings. The stage 1, or
Charcot locations in the lower extremity to be treated surgi- dissolution phase, involves acute inflammation with erythema,
cally. While cast immobilization is effective for various CN warmth, swelling, and regional bone demineralization. There
deformities in the midfoot, the inherent instability associated are also periarticular fragmentation and joint dislocations.
with CN destruction of the hindfoot/ankle joints leaves little Stage 2, the stage of coalescence, involves diminished inflam-
time interval between the subfibular ulceration and the osteo- mation and decreased fluctuation of swelling, absorption of
myelitis with deep abscess formation. bone debris, reorganization, and early healing of fragments or
A deep infection in association with an active Charcot periosteal bone formation. Stage 3, the final stage of resolu-
process in the ankle joint frequently necessitates a lower-limb tion, involves swelling being replaced by the final fixed deform-
amputation. Charcot hindfoot/ankle deformities, unlike the ity, normalization of skin temperatures, and enlargement of
foot counterparts, are inherently unstable resulting in collapse the foot and/or ankle. Radiographic findings include bony or
even while immobilized in a cast. Surgical intervention either fibrous ankylosis and smoothing of bone fragments.
with internal, external, or with combination fixation is impera- The timing for surgical intervention is usually optimal in
tive and sometimes urgent in these case scenarios. The goals of late stage 2 to stage 3; however, in Charcot involvement of the
operative management of a CN hindfoot/ankle are the same as hindfoot/ankle joints, early intervention takes precedence
they were described with the CN midfoot including, but are not over the stage. Typically, the patient will be in early stage 1
limited to restoring alignment, achieving stability for bracing, where advanced destruction and bone porosity makes tradi-
decompression of bony prominences, and prevention of skin tional internal fixation difficult. External fixation with pin or
breakdown in addition to shortening the course of CN process wire stabilization confers an optimal method of stabilization
(Table 17.1). in any Eichenholtz stage. In addition, due to the limited expo-
sures required for stabilization compared to internal fixation
with extended internal plating, soft tissue dissection is kept to
Preoperative Considerations a minimum. In most cases, external fixation adjustment can
be performed postoperatively allowing for continued compres-
Basic principle in surgical management of CN hindfoot/ankle sion, and correction of residual deformity that could not be
deformity is to achieve a stable arthrodesis or, as an alternative, addressed at the time of the index procedure.
a stable painless pseudoarthrosis that allows for bracing. Joint In general, there are three patterns involving the hindfoot/
reconstruction, total ankle arthroplasties, and limb lengthen- ankle in CN. The first, tibial involvement is generally felt to be
ing should be avoided when planning for Charcot foot and more unstable, drifting into varus position and it is seen most
ankle reconstruction. The technical challenges involved with often following an open reduction and internal fixation of the
CN reconstruction of the hindfoot/ankle include bone quality ankle (Figure 17.1A–C). The fibula by being prominent, com-
such as osteoporosis and various degrees of bone loss, patient bined with the instability of the ankle joint, creates a pressure
noncompliance, and severe soft tissue compromise. ulceration under the fibula in a short period of time early in
General principles in approaching the surgical correction the Charcot development. The tibial Charcot pattern, however,
of a CN deformity include full thickness incisions, spanning is easier to salvage with either a tibiotalar or a tibiotalocalcaneal
uninvolved joints to achieve adequate fixation for primary arthrodesis. The talar Charcot process while less common, tends
293
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294 Chapter 17
Surgical Algorithm for Approaching a Charcot

Table 17.1
Hindfoot/Ankle Deformity
Active ulcer/infection?
No Yes
Talus salvageable? Talus salvageable?
Yes No
Yes No
Ankle/tibiotalocalcaneal Talectomy with

Talectomy with tibiocalcaneal Ankle/tibiotalocalcaneal
arthrodesis with blade plate tibiocalcaneal
arthrodesis arthrodesis with
or intramedullary nail arthrodesis
+/- leg lengthening external fixation
+/- external fixation with external fixation
Talectomy with intercallary

bone block
to be more stable, is seen more frequently in diabetics with difficult to reduce and requires frequently either a gradual
end-stage renal disease and has a tendency to axially collapse reduction of the hindfoot and forefoot around the talus or sal-
or drift into valgus (Figure 17.2A and B). While not as quick vage with a talectomy and resulting tibiocalcaneal arthrodesis.
to develop skin breakdown as the tibial variant, this pattern of Due to the increased expenditure associated with below-the-
involvement is more difficult to salvage due to the absence and knee amputation (BKA) in the diabetic patient, limb salvage
resolution of the talus in most cases. Salvage consists of either with reconstructive hindfoot/ankle arthrodesis confers advan-
a primary tibiocalcaneal or a pantalar arthrodesis. The rarest tages over the BKA with regard to both energy expenditure
pattern, peritalar collapse, involves a Charcot process around and lifetime prosthetic costs. However, in cases where the host
the talus whereby the calcaneus and foot sublux and rotate is severely compromised in combination with extensive bone
off the talus laterally (Figure 17.3A–C). Due to the secondary loss, large open wounds, or osteomyelitis, limb salvage may not
soft tissue contractures and shortening, this pattern is the most be preferable over BKA.
A,B C
Figure 17.1. Examples of acute Charcot neuroarthropathy fracture/dislocation at the ankle joint (A, B).
In this type, the tibial involvement is extremely unstable, drifting into varus position and it is seen most often
following an open reduction and internal fixation of the ankle (C).
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Stepwise Approach to Charcot Hindfoot/Ankle Reconstruction and External Fixation 295
A B
Figure 17.2. Examples of Charcot neuroarthropathy talar variant (A, B). Note complete destruction
of the talus with axial collapse.
A B
Figure 17.3. Examples of Charcot neuroar-

thropathy peritalar variant (A–C). Note complete
C lateralization of the foot from the intact talus.
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296 Chapter 17
Figure 17.4. Standard lateral approach for Charcot neuroar-

thropathy hindfoot/ankle and tibiocalcaneal deformities (A). Resec-
A tion of fibula for lateral access of both ankle and subtalar joints (B).
Detailed Surgical Technique be used for recalcitrant or fixed varus deformities that cannot
be corrected through the lateral approach alone. Transverse
Charcot Ankle Arthrodesis joint articular resections with either an osteotome or a sagittal
saw perpendicular to the longitudinal axis of the tibia are made
The deformity is primarily approached through a longitudinal to both the tibial and talar articular surfaces, respectively (Fig-
incision over the distal third of the fibula (Figure 17.4A and ures 17.5A and B and 17.6A–C). The resected segments are
B). The incision curves under the talus to extend into the then temporarily stabilized with the ankle aligned in neutral
subtalar joint. Following the subperiosteal dissection, the distal dorsiflexion/plantarflexion, approximate 5 to 10 degrees val-
approximate 20% of the fibula is resected. This fibular bone gus and posterior translation of the talus on the tibia using a
should be avoided for use as autogenous grafting especially in series of large threaded Steinmann pins (Figure 17.7A and B).
infected and osteomyelitic cases. A second optional incision External fixation designs for the CN hindfoot/ankle
medially over the distal medial malleolus, 4 cm in length, may deformity involve assessment of bone quantity, bone quality,
Figure 17.5. Transfibular approach with resection of the distal

20% of the fibula. Note beveling to allow for bracing postoperatively
(A). Articular surfaces of tibia and talus are resected perpendicular
A to anatomic axis of tibia (B).
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A B
Figure 17.6. Resection of the tibiotalar articular surfaces with

C preservation of the medial malleolus (A–C).
Figure 17.7. Temporary ankle transfixation

with 3.2 mm threaded Steinmann pins for posi-
tioning into the circular external fixator (A, B). A B
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298 Chapter 17
Figure 17.10. Lateral view with overall alignment of the lower

extremity with tibial block and foot plate fixation.
or multiaxial struts depending on whether axial compression

or angular deformities need to be corrected in the postopera-
tive period. If active wounds are present and need access for
dressing changes or additional surgery in the postoperative
Figure 17.8. Example of a variable hinge construct for Charcot
ankle arthrodesis and deformity correction.
period, adjustable struts are preferred over rods due to ease
of correction.
The circular external fixator once constructed is slid over
and residual deformity not corrected through the resection the lower leg and lined up with the subtalar joint correspond-
osteotomy on the tibia and talus. Circular external fixation is ing to the glabrous skin junction. As was previously described
constructed with a standard tibial block of two rings connected in Chapter 16, the tibial block and the foot ring are first secured
by either threaded rods or alternatively threaded sockets (Fig- by their respective anatomic transosseous wires (Figure 17.10).
ures 17.8 and 17.9). In addition, a standard foot plate (ring) With these transosseous reference wires in place, residual
construct is utilized consisting of an enclosed half ring at the translation medial to lateral can now be adjusted. The tibial
distal end of the ring, stabilizing both the hindfoot and the block segment is definitively stabilized with either transosseous
forefoot. Options for connections between the tibial block and wires, half-pins, or a combination of each. Pin spread is critical
the foot ring consist of either threaded rods, telescoping rods, especially with the use of half-pins. Multiple half-pins in a linear
pattern will increase the risk for pathologic fracture following
removal (Figure 17.11A–C).
Attention is then turned to both hindfoot and talar stabiliza-
tion. Two to three transosseous wires are added in a divergent
pattern through the calcaneus and tensioned or tightened
appropriately (Figure 17.12). Without talar transosseous wires,
the primary focus of compression is through the subtalar
joint. Transverse tensioned wires inserted through the talus
redistribute most of the compression applied to that across the
tibiotalar joint (Figure 17.13A–C). These talar wires require
posts connected to the wire fixation bolts on the foot plate for
appropriate securing. Olive wires minimize the potential for
subluxation of the talus while compression is applied following
completion of the external fixation construct (Figure 17.14).
If additional fixation is needed into the forefoot, the wires/
pins are directed into the metatarsals. Generally, two transos-
seous wires are recommended, one through the first and sec-
ond metatarsals, the other through metatarsals three through
five with each tensioned or tightened in a cross pattern onto
the foot plate. Once stability on the foot plate is achieved, the
threaded ankle transfixation Steinmann pins are removed, and
any displacement at the arthrodesis site is noted (Figure 17.15A
and B). Compression is then applied across the ankle joint and
both visually and through C-arm fluoroscopic guidance the
Figure 17.9. Prebuilt static circular external fixation construct ankle joint is checked for any subluxation or change in align-
allows for only axial compression of the ankle and hindfoot joints. ment (Figure 17.16). Postoperative adjustments and instructions
LWBK1121-C17_p293_317.indd 298 04/10/12 11:33 AM

A B
Figure 17.11. Proximal half-pin inser-

tion at the tibial block (A) followed by a
second half-pin insertion on the same ran-
cho cube (B). Second rancho cube aligned
to the distal tibial ring of the tibial block.
Note divergent insertion of the second set
of half-pins for added stability of the tibial
C block (C).
Figure 17.12. Note the additional transosseous

wires inserted with divergence into the calcaneus.
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300 Chapter 17
A B
Figure 17.13. The first talar olive wire is directed from anterolateral
to posteromedial direction to avoid malleolar capture (A). The second
talar olive wire is directed from anteromedial to posterolateral orienta-
tion (B). Final close-up view demonstrating transosseous fixation wires
C into both the talus and the calcaneus (C).
on weight bearing status are case dependent according to the

patient’s medical and ambulatory status, presence of wounds
or infection, and social issues (Figure 17.17A–D and Clinical
Cases I–III).
Charcot Tibiocalcaneal Arthrodesis

In situations where an intact talus is unavailable, a primary
tibiocalcaneal compression arthrodesis is performed. In addi-
tion to the normal resection of the distal tibia and articular
surface, the calcaneus and anterior distal tibia are squared
off, making a matching L-shape to the distal tibia as that of
the calcaneus and part of the talus if present (Figure 17.18A
and B). In the absence of a talar body, a primary docking
of the tibia onto the calcaneus is performed, fashioning
a horizontal bevel osteotomy on the posterior facet of the
calcaneus. The short arm of the L-shaped cut consists of a
vertical cut to the talar neck at 90 degrees to the calcaneal
osteotomy. This L-shaped cut increases the arthrodesis area to
include the talar neck and the anterior tibia. Once temporar-
ily held with threaded Steinmann pins, the external fixator is
slid over the leg and is centered over the remaining calcaneus
(Figure 17.19A and B).
The circular external fixator is designed to allow for com-
pression of the calcaneus off the foot plate (Figure 17.20A–C).
The tibial block and foot ring are first secured by their respec-
Figure 17.14. Final circular external fixation construct ready for tive anatomic transosseous wires as it was described above in
ankle compression. the Charcot ankle arthrodesis technique (Figure 17.21). With
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A B
Figure 17.15. Ankle transfixation threaded Steinmann pins are removed and evidence of any shift at the
arthrodesis site is evaluated (A, B).
a similar process the tibial block is further stabilized with addi- Forefoot transosseous wires or half-pins are then inserted
tional half-pins and/or transosseous wires (Figure 17.22A and B). to gain additional foot stability (Figure 17.25A and B). Once
Additional one to two divergent calcaneal transosseous wires axial compression occurs across the tibiocalcaneal site, an olive
are inserted in the remaining calcaneal tuberosity and body wire can be inserted, capturing the talar body, neck, or part of
and secured appropriately (Figure 17.23). Due to poor quantity the distal tibia and tensioned posteriorly on the foot plate off a
and quality of bone stock in the remaining calcaneus, a half-pin male post (Figure 17.26). This docking technique into the dis-
may alternatively be directed from the posterior inferior calca- tal anterior aspect of the tibia will increase contact surface area
neal body or tuberosity and secured to the foot plate using a to the arthrodesis adding stability. The other end of the wire
variety of half-pin clamp options (Figure 17.24A and B). may be brought off the foot plate and secured once docking
compression is applied through the posterior wire. A total of
one to two olives may be inserted in this manner to stabilize the
talar neck against the distal tibia (Figure 17.27A–F and Clinical
Cases IV and V).
Correction of Charcot
Peritalar Subluxation
Unlike the other CN ankle patterns, the peritalar variation has
an intact ankle joint with complete dissociation laterally of the
calcaneus and foot. The challenge is to reduce the hindfoot
and midfoot back over from the “perched” position on the
lateral calcaneus to that of under the talus. Due to extensive
contracture of the surrounding soft tissues, including the Achil-
les and peroneal tendons, the reduction may not be possible
directly in the operating room but requires a gradual reduction
postoperatively. The alternative is to resect the talar body and
take advantage of the skeletal shortening to acutely reduce the
calcaneus onto the tibia, converting the peritalar pattern to
that of the talar deficient one.
The approach centers on the talonavicular joint, which
frequently is associated with a pressure ulcer intrinsically from
talar head prominence. The subtalar joint is resected through
a medial exposure with either a Cobb elevator, osteotome, or a
high speed motorized burr. Tenotomies of the contracted per-
Figure 17.16. Threaded struts or rods adjusted for ankle oneals are made percutaneously in addition to the lateralized
compression across the arthrodesis site. contracted Achilles tendon. An attempt is first made to acutely
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302 Chapter 17
A B
Figure 17.17. Final circular external fixa-

tion construct for Charcot neuroarthropathy
C D ankle arthrodesis (A–D).
reduce the calcaneus with either a large reduction clamp or a drop olive directed medial to lateral off the distal tibial ring
insertion into the calcaneus of a large threaded Steinmann pin to minimize tibiotalar deformation through the reduction
used as a joystick. If possible, the forefoot is then reduced and process. The initial reference transosseous wire is positioned
stabilized through the talonavicular joint. More frequently, in the plane perpendicular to the calcaneal body. The foot
the subtalar joint is only partially reducible and will require plate is applied in this offset position, followed by additional
gradual reduction postoperatively through struts correction transosseous wires into the calcaneus, midfoot, and forefoot.
between the foot plate and the tibial rings. The correction pro- Proximally, the tibial ring block is placed in line with the lon-
tocol is to first distract, then translate medially the foot onto gitudinal anatomic axis of the tibia and wires or half-pins are
the talar body, and finally axially compress through the subtalar placed orthogonally. Struts are placed between the distal tibial
joint. ring and that of the foot plate. A drop wire or two are directed
The external fixation design is similar to that of the tibiota- into the talar body and attached off posts or rancho cubes
lar and tibiocalcaneal arthrodesis technique with several nota- from the distal tibial ring. Correction consists of first axially
ble exceptions. If the subtalar joint cannot be acutely reduced, distracting, then translating the calcaneus under the talus
then adjustable hinges will be required for gradual reduction (Figure 17.28A and B). Once alignment is achieved, axial
in the postoperative period. Further, since the reduction is compression through the subtalar joint is performed (Fig-
through the subtalar joint, the talus must be stabilized through ure 17.29A and B and Clinical Case VI).
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Clinical CASE I
Preoperative radiographic views (A, B) of a Charcot neuroar- removal of internal hardware followed by primary ankle com-
thropathy ankle joint after an open reduction and internal pressive arthrodesis using a circular external fixator (C, D).
fixation of a trimalleolar repair of an ankle fracture. There was Final postoperative outcomes demonstrating a well-aligned
a significant varus deformity with an ulceration at the distal ankle arthrodesis and a plantigrade foot (E, F).
end of the fibula and deep infection. The patient underwent
A B
C D
E F
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304 Chapter 17
Clinical CASE II
Preoperative radiographic views (A, B) of a Charcot neuroar- intramedullary nail and circular external fixator for postopera-
thropathy ankle joint with talar axial collapse and without any tive controlled compression was achieved (C, D). Final postoper-
history of osteomyelitis or open wounds. Compression tibiocal- ative outcomes demonstrating anatomic alignment with a stable
caneal arthrodesis utilizing combined fixation of a retrograde pseudoarthrosis at the tibiocalcaneal arthrodesis site (E, F).
A,B C
D,E F
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Clinical CASE III
Preoperative radiographic views (A, B) of a 46-year-old male bone allografting (D). The tibiotalocalcaneal arthrodesis was
with a Charcot neuroarthropathy ankle after a failed open achieved by the use of a Taylor spatial frame and an external
reduction and internal fixation of his left ankle fracture. bone stimulator (E–H). Postoperative radiographic views (I, J)
The patient underwent removal of internal hardware with showing the arthrodesis compression technique by utilizing the
primary arthrodesis and allografting of both the ankle and telescoping struts. The external fixator was removed at 9 weeks.
subtalar joints. Please note the transfibular approach (C) and Final outcome at approximately 2-year follow-up (K, L).
A,B C
D E
F,G H
(continued)
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306 Chapter 17
Clinical caseF,G
III (continued) H
I J
K L
A B
Figure 17.18. Sawbone model representing Charcot talar deficient state (A, B).
LWBK1121-C17_p293_317.indd 306 04/10/12 11:33 AM

A B
Figure 17.19. Primary tibiocalcaneal docking with additional apposition of the anterior tibia and talar
neck (A, B).
A B
Figure 17.20. Prebuilt static circular external fixator for compression through threaded
C rods (A–C). Note the compression square nuts on end of the foot plate for advancement (A, B).
LWBK1121-C17_p293_317.indd 307 04/10/12 11:33 AM

308 Chapter 17
Figure 17.21. Anterior view with overall alignment of the lower Figure 17.23. Note divergent pattern of added calcaneal transos-
extremity with tibial block and foot plate fixation. seous wire.
A A
B B
Figure 17.22. Note divergent pattern of half-pins off the proxi- Figure 17.24. Additional stability into the calcaneus with a half-
pin axial stabilized with a pin clamp made from translation buckle
mal and distal tibial rings (A, B).
and a three-hole male post (A, B).
LWBK1121-C17_p293_317.indd 308 04/10/12 11:34 AM

A B
Figure 17.25. Forefoot/midfoot stabilization with a 4 mm half-pin medially into the first metatarsal (A)
and laterally into the cuboid (B).
Figure 17.26. Compression applied to the

foot plate by tightening the compression nuts.
A B
Figure 17.27. Once axial tibiocalcaneal compression is completed, an anterior to posterior directed
transosseous olive wire captures the talar neck to the anterior distal surface of the tibia (A). This olive wire is
secured anteriorly and posteriorly on the foot plate (B, C) and compression by tensioning the posterior wire
pulls the olive against the talus into the distal tibia (D). Note that at this point the anterior fixation portion is
loose which is then secured after the tensioning compression technique is complete posteriorly. Close-up view
demonstrating the docking of the anterior tibia and talar neck (E). Final circular external fixation construct
for Charcot neuroarthropathy tibiocalcaneal arthrodesis (F). (continued)
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310 Chapter 17
C D
E F Figure 17.27. (continued)
Clinical CASE IV
Preoperative clinical (A) and radiographic views (B, C) of a with bone allografting (D, E). The tibiocalcaneal arthrodesis was
56-year-old female with a Charcot neuroarthropathy ankle after achieved by the use of a Taylor spatial frame (F, G). Postoperative
a failed open reduction and internal fixation of her right ankle radiographic views (H, I) showing the arthrodesis compression
fracture. The patient presented with severe soft tissue infection technique by utilizing the telescoping struts. The external fixator
and osteomyelitis of the talus. The patient underwent an initial was removed at 8 weeks with subsequent surgical debridement and
surgical debridement with removal of the internal hardware fol- application of a split thickness skin graft. Final clinical and radio-
lowed by a staged total talectomy and tibiocalcaneal arthrodesis graphic outcomes at approximately 8-month follow-up (J–M).
A,B C
(continued)
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D,E F
G,H I
J,K
(continued)
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312 Chapter 17
L M
Clinical CASE V
Preoperative clinical (A, B) and radiographic anteroposterior This was accomplished by the utilization of the Taylor spatial
(C) and lateral (D) left ankle views of a diabetic patient with a frame construct for compression and stabilization of the left
severe equinocavovarus Charcot deformity and chronic ulcera- lower extremity (H, I). The external fixator was removed at
tions after an ankle fracture injury. The patient underwent an approximately 11 weeks and the patient was transitioned to
initial incision and drainage procedure with a lateral malleolus a non–weight bearing cast immobilization for approximately
resection that was followed 9 days later by a total talectomy (E) 8 weeks (J) followed by appropriate surgical boot off-loading
with tibiocalcaneal arthrodesis, bone allografting (F), and split and accommodative orthotic devices. Final radiographic (K, L)
thickness skin grafting at the lateral aspect of the left ankle (G). views at approximately 5-month follow-up.
A,B C
(continued)
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Clinical
A,B case V (continued) C
D,E F
G H
I J
(continued)
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314 Chapter 17
Clinical
I case V (continued) J
K L
A B
Figure 17.28. Example of a peritalar dislocation. Note insertion of stabilizing talar olive wire directed
medial to lateral. An opposed lateral to medial directed olive wire is also inserted in the calcaneus (A, B).
LWBK1121-C17_p293_317.indd 314 04/10/12 11:34 AM

A B
Figure 17.29. Method of direct reduction is to pull the calcaneal olive wire to translate the body medi-
ally and then compress axially through the subtalar joint (A, B).
Clinical CASE VI
Preoperative clinical (A, B) and radiographic views (C–E) arthrodesis was achieved by the use of a Taylor spatial frame
of a diabetic neuropathic patient with a Charcot ankle varus (G–J). Postoperative radiographic views (K–M) showing the
deformity and fractured talus. The patient underwent total talec- arthrodesis compression technique by utilizing the telescoping
tomy with tibiocalcaneal arthrodesis. Please note that allogenic struts. The external fixator was removed at approximately 8
combined with autogenous bone grafting from the resected weeks with subsequent cast immobilization and bracing. Final
talus was used at the arthrodesis site (F). The tibiocalcaneal outcome at approximately 9-month follow-up (N–P).
A,B C
(continued)
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316 Chapter 17

A,B C
D,E F
G H
I J
(continued)
LWBK1121-C17_p293_317.indd 316 04/10/12 11:35 AM

K,L M
N,O P
to BKA in the correct clinical scenario. The typical instability of

C l i n ical Tips and Pear ls these deformities poses a significant reconstructive challenge;
however, the authors advocate identification of the main pat-
A. General principles in approaching the surgical correc- tern of anatomical involvement, either tibial, talar, or peritalar,
tion of a Charcot neuroarthropathy deformity include to determine the optimal surgical approach. The use of exter-
full thickness incisions, spanning uninvolved joints to nal fixation can creatively address both the osseous and soft
achieve adequate fixation for primary arthrodesis. tissue complications associated with these conditions.
B. Surgical treatment of the Charcot neuroarthropathy
hindfoot/ankle is typically guided by the main pattern
of involvement: Tibial, talar, or peritalar. Recommended Readings
C. External fixation designs for the Charcot neuroar-
Cierny G 3rd, Crook WG, Mader JT. Ankle arthrodesis in the presence of ongo-
thropathy hindfoot/ankle deformity involve assessment ing sepsis. Indications, methods, and results. Orthop Clin North Am. 1989;
of bone quantity, bone quality, and residual deformity 20:709–721.
not corrected through the resection osteotomy on the Cooper PS. Application of external fixators for management of Charcot deformi-
tibia and talus. ties of the foot and ankle. Foot Ankle Clin. 2002;7:207–254.
Eichenholtz SN. Charcot Joints. Springfield, IL: C.C. Thomas; 1966.
D. External fixation adjustment can be performed post- Herbst SA. External fixation of Charcot arthropathy. Foot Ankle Clin. 2004;9:
operatively allowing for continued compression, and 595–609.
correction of residual deformity that could not be Jolly GP, Zgonis T, Polyzois V. External fixation in the management of Charcot
addressed at the time of the index procedure. neuroarthropathy. Clin Podiatr Med Surg. 2003;20:741–756.
Pinzur MS. The role of ring external fixation in Charcot foot arthropathy. Foot
Ankle Clin. 2006;11:837–847.
Saltzman CL. Salvage of diffuse ankle osteomyelitis by single stage resection and
Conclusion circumferential frank compression arthrodesis. Iowa Orthop J. 2005;25:47–52.
Schon LC, Easley ME, Weinfield SB. Charcot neuroarthropathy of the foot and
ankle. Clin Orthop Relat Res. 1998;349:116–131.
Surgical reconstruction of CN of the hindfoot/ankle using Zarutsky E, Rush SM, Schuberth JM. The use of circular wire external fixation in
internal, external, or combined fixation is a viable alternative the treatment of ankle arthrodesis. J Foot Ankle Surg. 2005;44:22–31.
LWBK1121-C17_p293_317.indd 317 04/10/12 11:35 AM

Alexander M. Cherkashin
Chapter Mikhail L. Samchukov
18
John G. Birch
John J. Stapleton
Thomas Zgonis
Stepwise Approach to Adult and

Pediatric Foot and Ankle Malunions/
Nonunions and External Fixation
Introduction Deciding which patients are proper candidates for revi-

sional and reconstructive surgery with circular external fixa-
Management of foot and ankle deformities as a result of a tion depends on multiple factors. Adequate discussion with the
malunion and/or nonunion is a clinical challenge. Most of patient and patient’s family regarding the proposed surgery,
these deformities arise from complex pathology and/or failed risks, benefits, surgical and anesthesia complications as well as
surgical intervention. Wound healing at the foot and ankle external fixation application, and estimated recovery time are
level is often challenging during traumatic and/or subsequent required for a successful outcome. At times, patients may be
surgical procedures. Correction of severe deformities about more suitable to proceed with a limb amputation and prosthe-
the foot and ankle can cause devastating wound complica- sis in the presence of severe local and systemic infection, mul-
tions unless surgical measures are taken to diminish the stress tiple sites of osteomyelitis, severe peripheral vascular disease,
and strain on the surrounding soft tissues. The utilization of and/or morbidly associated medical conditions.
internal fixation may not be feasible with a poor soft tissue Revisional foot and ankle surgery for these conditions is
envelope and contraindicated in the presence of infection. often indicated for failed open reduction and internal fixation
Circular external fixation is well suited for the management (ORIF) cases. Breakage or loosening of retained hardware asso-
of complex deformities and/or bone loss with a poor soft ciated with an unstable or malunited fracture with pain and/
tissue envelope and history or presence of infection. The or deformity is an indication for circular external fixation. The
technique of utilizing circular external fixation allows for presence of infection or soft tissue loss may necessitate urgent
skeletal or soft tissue correction either through acute or surgery followed by staged surgical procedures to achieve
gradual corrections and revisional arthrodesis when indicated. functional limb salvage. Acute infections are usually managed
Additionally, external fixation allows for percutaneous tech- with an initial surgical debridement and are followed by staged
niques, minimal incisions, or the closure of incisions without debridements with or without antibiotic spacers and external
skin tension that would be present from otherwise underly- fixation. External fixation is indicated to stabilize an unstable
ing hardware. In certain complex scenarios, external fixators fracture(s) and/or deformity and to relieve any strain on the
are utilized in conjunction with internal fixation to provide soft tissue for subsequent closure.
additional support to avoid hardware failure and residual The development of Charcot neuroarthropathy (CN) in
deformity. diabetic patients with dense peripheral neuropathy and after
failed operative fracture care is an entity that is very commonly
seen among the diabetic population. Acute CN joints after
failed ORIF techniques may be a limb-threatening condition
Indications/Contraindications especially in the presence of extensive soft tissue and bone loss.
The utilization of circular external fixation may be advanta-
The ultimate surgical goal for managing these conditions is to geous in any stage of the previous failed surgery and help in
address an ongoing infection if present, resect all nonviable stabilization or staged arthrodesis procedures.
bone and soft tissue, realign osseous deformities, and also pro- Malunions and/or nonunions as a result of failed elective
vide adequate osseous stability to promote healing and regen- midfoot and hindfoot/ankle arthrodesis procedures can be
eration of both the soft tissue and bone. The utilization of successfully managed by the use of circular external fixa-
circular external fixation can be extremely helpful in address- tion. In many cases, nonunions can present with a significant
ing most midfoot and hindfoot/ankle malunions and/or non- bone loss due to avascular necrosis or concomitant infection
unions and especially in the high-risk patient population. and osteomyelitis. Infected nonunions pose additional clinical
318
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Stepwise Approach to Adult and Pediatric Foot and Ankle Malunions/Nonunions and External Fixation 319
challenges and require staged surgical procedures with exter- Planning for external fixation surgery is important not only
nal fixation and before performing a definitive arthrodesis. in preparation for the treatment process, but as an important
Circular external fixation is also beneficial in managing neu- step in preventing and reducing possible complications. Acute
romuscular and paralytic malunions and/or nonunions. The correction of the deformity is always preferable, but cannot
residual deformities can be acutely or gradually corrected with always be performed. If a distal tibial deformity is present,
external fixation and may be converted to an arthrodesis once preoperative planning should evaluate the amount and level
alignment is achieved. Certain neuromuscular or paralytic hind- of the deformity in order to accurately position the external
foot/ankle deformities can be corrected with a total talectomy, fixation hinges. The selected level of osteotomy should be at
tibiocalcaneal arthrodesis, and circular external fixation. Bone or close to the level of deformity. When a tibial deformity is
grafting or bone transport procedures may also be necessary to located too distally, it becomes quite challenging to perform
address for the bone loss and/or limb length discrepancy in any the osteotomy at the deformity level. In these cases, the exter-
malunion or nonunion case if acute compression is not possible. nal fixation hinges are placed at the level of deformity and the
proposed osteotomy is performed at approximately 1.5 to 2 cm
above the distal tibial fixation segment. In these case scenarios,
Preoperative Considerations translation at the osteotomy site must be considered. In other
cases, a distal tibial dome osteotomy can be performed in order
Important factors that need to be considered in the preop- to minimize the effect of translation. If a tibial lengthening is
erative period include and are not limited to patient’s age, intended, it is usually better to perform it through a separate
ambulatory status, multiple comorbidities, noncompliance proximal tibial osteotomy. Performing a proximal distraction
with treatment, severity and progressiveness of deformity, and osteogenesis is preferred in these cases in order to promote
associated compensatory and joint contractures. Deformity improved vascularity to the bone segments and to decrease the
analysis is paramount when managing these conditions and total time of the external fixator.
each case may require a different surgical approach and treat- A pre-built external fixation device is always preferable if
ment. A thorough history and physical examination along with possible and can be tried on the patient as a part of the preop-
pertinent laboratory, radiographic, neurologic testing, and erative patient and family education process. This method can
medical imaging are necessary before the surgical reconstruc- help the patient in understanding of the postoperative process
tion. Vascular studies may also be necessary in the diabetic and can also improve patient compliance. Preoperative exter-
population or in patients with chronic smoking history and nal fixation assembly saves time in surgery, allows for additional
peripheral arterial disease. At times, with severe foot and ankle validation of the treatment plan, and also assures that the
contractures the topography of the vascular structures may be external fixation hinges and angular distractors are functional.
displaced secondary to multiplane deformities. Preoperative If this entire process is not feasible, it is highly recommended
Doppler signals and skin markings if needed can address such to pre-build the proposed circular external fixator in the oper-
anatomic variations in order to avoid any potential vascular ating room before inserting the necessary transosseous wires
injury. Appropriate medical and anesthesiology consultations and half-pins. Circular external fixation pre-assembly helps to
are equally important during the preoperative period. construct the external fixator according to existing deformities
Additional complicating factors such as segmental bone and allows using it as a template for transosseous wire and half-
loss, avascular segments of bone, infected bone with or without pin insertion.
previous hardware also need to be considered. Segmental bone
loss is evaluated in order to determine if structural or non-
structural bone grafting will suffice or if bone transport may be
required. In addition, patients with long-standing malunions
and/or nonunions may also present with associated painful
Realignment Hindfoot/Ankle
hip and knee contractures, limb length discrepancies, neural-
Osteotomies and Arthrodesis Procedures
gia, and a poor soft tissue envelope that require consideration
before any revisional surgery. Corrective osteotomy and/or joint resection combined with
A thorough musculoskeletal examination of the entire lower or without hindfoot/ankle arthrodesis can be achieved acutely
extremity combined with radiographic imaging is necessary for or gradually with external fixation. The specific advantage of
defining the associated deformity. Computed tomography is use- external fixation is that adjustments throughout the post-
ful to evaluate nonunions, degenerative joints, and multiplane operative period can be performed to achieve the desired
deformities about the midfoot and hindfoot/ankle. Magnetic alignment.
resonance imaging and nuclear imaging are beneficial in cases The ability to deliberately translate the bone ends to achieve
of osteomyelitis and/or in addition to the intraoperative bone the desired alignment is critical. For this reason, the type of
biopsy and culture results. osteotomy or joint resection performed has to consider the
Select osteotomies, arthrodesis procedures, ligamentous shape of the deformed bone ends to permit translation while
reconstruction, tendon lengthening, transfer or release are creating two stable bone surfaces to allow successful bone
some of the major reconstructive options to address these com- healing. Poor bone quality surrounding the pathologic entity
plex conditions. The choice of opening or closing wedge- and may be a limiting factor where the corrective osteotomy may
dome-shaped osteotomies are based on the plane of deformity require placement at a different location to avoid the potential
and associated length of the osseous segments in consideration for nonunion. In certain scenarios where the osteotomy and/
with the surrounding neurovascular structures and soft tissue or joint resection are necessary to be performed at the patho-
envelope at risk. logic site, bone grafting either initially if an acute correction
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320 Chapter 18
is performed or in delayed fashion for gradual correction will dynamic strut constructs of the Taylor spatial frame (TSF).
need to be considered. The TSF application becomes advantageous when translation
Anatomic alignment can be performed acutely and sta- and rotation needs to be performed in addition to multi-
bilized with temporary fixation until the external fixator is level angular corrections. Gradual corrections are usually
utilized or the external fixator can be partially assembled prior performed approximately 7 to 10 days following the osteotomy
to the osteotomy and/or joint resection and then completed at with a recommended maximum distraction of 1 mm/day
the end of the procedure for the process of gradual deformity when indicated (Chapter 15).
correction. For gradual corrections, the circular external fixator Joint arthrodesis can be performed by applying uniform
may be applied initially to mimic the associated deformity and compression with the external fixator after anatomical osseous
gradually adjust it to a neutral position correcting the deformity. alignment and adequate joint preparation has been achieved.
For supramalleolar osteotomies, the proximal external Articular joint surfaces need adequate resection and joint
fixation segment consists of two tibial rings “tibial block” and microfracturing with an osteotome or pre-drilling may help
the foot plate along with a circular ring at the distal level of induce vascular ingrowth at the arthrodesis site. Joint compres-
the tibial metaphysis are placed. The osteotomy can then be sion arthrodesis can then be performed with a static circular
carried out with low-energy techniques to divide the bone. external fixator or a TSF construct (Clinical Cases I–V).
Such osteotomy can be performed with osteotome, multiple
drill holes and osteotome, or with a Gigli saw. A combination
Realignment Midfoot Osteotomies
of multiple drill holes with an oscillating drill bit and an oste-
and Arthrodesis Procedures
otome to complete the osteotomy is usually preferred. After
completion of the osteotomy, the surgeon can manipulate the Severe midfoot deformities that require correction with circu-
distal external fixation segment consisting of the tibial ring lar external fixation are often a result of malunion from high-
and the foot plate while stabilizing the tibial block to ensure energy trauma or from conditions such as CN. High-energy
that the bone is osteotomized. The circular external fixator trauma and/or the development of CN after a midfoot fracture
is then assembled around the osteotomy with hinges and/or can result in severe malunion and/or nonunion that are associ-
motors for a traditional Ilizarov technique or by utilizing the ated with axial, sagittal, and horizontal plane deformities.
CLINICAL CASE I
Preoperative anteroposterior (A) and lateral (B) radiographic fixator was removed at approximately 10 weeks. The patient
right ankle views demonstrating posttraumatic arthritis of the was kept in a non–weight bearing cast for about 2 weeks with
ankle and subtalar joint that resulted from a malunion of a an additional weight bearing cast for another 4 weeks. Final
talus fracture. Patient underwent a tibiotalocalcaneal arthro- radiographic views at 6-month follow-up showing successful
desis with a circular external fixation (C, D). The external alignment and union at the ankle and subtalar joints (E, F).
A,B C
(continued)
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A,B C
D,E F
CLINICAL CASE II
Preoperative clinical (A) and radiographic (B, C) views of for deformity and equinus correction (D–H). The external
a talar neck and body fracture with a severe malunion and fixator was removed at approximately 8 weeks where a post-
deformity. Patient underwent an osteotomy and acute cor- operative wound dehiscence was addressed. Final clinical
rection of the talus fracture with a primary subtalar joint (I–K) and radiographic (L, M) views at approximately 1-year
arthrodesis and an application of a Taylor spatial frame follow-up.
A,B C
(continued)
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322 Chapter 18
Clinical
A,Bcase II (continued) C
D E
F,G H
I J
(continued)
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Clinical Icase II (continued) J
K,L M
CLINICAL CASE III
Preoperative radiographic views (A–C) demonstrating a severe removed at approximately 12 weeks. The patient was kept in a
talar varus malunion with avascular necrosis after a talus frac- non–weight bearing cast for about 2 weeks with an additional
ture/dislocation in a morbidly obese patient. Patient under- weight bearing cast for another 4 weeks. Final radiographic
went re-alignment and pantalar arthrodesis with internal and views at 2-year follow-up showing successful alignment and
circular external fixation (D, E). The external fixator was union at the pantalar arthrodesis (F–H).
A,B C
(continued)
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324 Chapter 18

A,B C
D,E F
G H
These types of deformities may require a tri-plane wedge The foot and ankle positioning within the circular external
resection across the entire midfoot or an osteotomy with grad- fixator is paramount when applying the tibia rings and calca-
ual correction. Gradual midfoot correction may be beneficial neal fixation which are attached to the foot plate. It is impor-
in severe cases of rotational valgus and/or varus deformities. tant to establish a neutral ankle position in the sagittal plane as
In cases of a midfoot wedge resection, preoperative planning equinus positioning will lead to detrimental forces through the
based on weight bearing radiographs will determine the apex midfoot once the external fixator is removed. Proximal to the
of the deformity and template for the osteotomy. Intraopera- midfoot osteotomy or arthrodesis, a midfoot and/or talar tran-
tive guide wires may also be used along the bone segments of sosseous wire can be inserted in order to stabilize the midfoot
the proposed osteotomy in order to ensure correct positioning and hindfoot. Additional smooth transosseous wires are then
under the guidance of C-arm fluoroscopy. The osteotomy is inserted across the midfoot and/or forefoot.
usually performed with a large oscillating saw and/or oste- The smooth wire distal to the osteotomy is then bent proxi-
otome. After the resected wedge of bone is removed, anatomic mally about two to three holes on the foot plate. The surgeon and
alignment is performed acutely and temporarily stabilized an assistant can then simultaneously straighten the wire by utiliz-
with two or more Steinmann pins. The circular external fixa- ing the pre-bent wire technique or dynamic tensiometers. This will
tor can now be applied to stabilize and compress the midfoot provide equal compression across the osteotomy and arthrodesis
osteotomy. site. Other common alternatives to compress a midfoot osteotomy
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CLINICAL CASE IV
Preoperative radiographic views (A, B) demonstrating a malun- fixator was removed at 12 weeks. The patient was kept in a non–
ion of a distal tibia and fibula fracture with mild ankle valgus weight bearing cast for about 2 weeks with an additional weight
deformity. Patient presented with significant ankle pain and bearing cast for another 4 weeks. Final radiographic views at
ambulatory dysfunction. Patient eventually underwent an ankle 2 years postoperatively demonstrating successful ankle arthrod-
arthrodesis with a circular external fixation (C, D). The external esis with compensatory subtalar joint arthritis (E, F).
A,B C
D,E F
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326 Chapter 18
CLINICAL CASE V
Preoperative radiographic views (A–C) demonstrating a severe and tibiocalcaneal arthrodesis with circular external fixation
paralytic malunion after previous attempted deformity correc- (D, E). The external fixator was removed at 14 weeks. Final radi-
tion with external fixation. Patient had a fifth ray amputation ographic views at 6-month follow-up demonstrating the deform-
for previous infection. Patient underwent a subtotal talectomy ity correction and successful tibiocalcaneal arthrodesis (F, G).
A,B C
D,E F,G
consist of a tibial block combined with a separate calcaneal half- with the utilization of external fixation in the presence of unsta-
ring and a full forefoot circular ring. This construct allows the ble deformities. Infected osseous defects are best managed
insertion of multiple transosseous wires for stabilization of the with antibiotic-impregnated cement spacers, beads, or antibiotic-
midfoot osteotomy or correction of severe rotational midfoot impregnated cement intramedullary rods to provide stability to
and/or hindfoot deformities (Clinical Case VI). the resected osteomyelitic bone segments while eluting a local
concentration of antibiotic to the pathologic area. These tech-
niques are usually indicated in the initial stages of surgical deb-
Infected Nonunions of The
ridement and are followed by further definitive reconstructive
Foot and Ankle
procedures.
Basic principles for management of infection and osteomyelitis Hybrid or modified circular external fixation constructs
are applied including adequate bone and soft tissue debride- are placed to provide better stability in conjunction with the
ment or resection. Multiple staged reconstructive procedures antibiotic-impregnated cement spacers and/or beads. Often,
to address a large bone void or soft tissue loss may be necessary these temporary constructs have to be modified or removed to
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CLINICAL CASE VI
Preoperative radiographic views (A, B) demonstrating a external fixation (C, D). The external fixator was removed at
medial column nonunion and malunion with posttraumatic 8 weeks. Final radiographic views (E, F) at 12 months reveal
deformity and broken hardware. Patient underwent removal a successful alignment and interval healing of the midfoot
of hardware with a tri-plane midfoot osteotomy and circular osteotomy.
A,B C
D,E F
allow the placement of more elaborate circular external fixa- a sufficient soft tissue envelope without any evidence of remain-
tion constructs to perform definitive reconstructive procedures ing deep infection.
and osseous healing. External fixators are not only employed Two main external fixation constructs are usually indicated
to achieve osseous stabilization but are useful for effectively for the management of foot and ankle infected nonunions.
off-loading the soft tissues while allowing easy access for wound Temporary external fixation constructs utilized to stabilize the
assessments and wound care as needed. rearfoot and/or ankle after septic surgery is usually consisted
In certain cases, revisional fracture management and/or of a “tibial block” attached to a separate forefoot or midfoot
major arthrodesis is required to salvage these difficult scenar- circular ring. This allows insertion of all transosseous wires
ios. This can be accomplished with external fixation or with a and/or half-pins outside the zone of infection. The tibial block
combination of external and internal fixation. The utilization is typically secured to the forefoot or midfoot ring with a bar
of internal fixation to provide further osseous stability requires to clamp apparatus or with the attachment of threaded rods
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328 Chapter 18
and multiple hinges. Either construct can be further modified stability that is required for multiplane deformity correction
with off-loading components for the posterior heel and plantar or arthrodesis procedures. After insertion of the transosseous
aspect of the foot if required. a bar to clamp apparatus is typi- wires, the foot plate can be further secured to the tibial block
cally utilized if serial surgical debridements and/or exchange with the addition of threaded rods with hinges. Once the cir-
of antibiotic-impregnated spacers are required as disassem- cular external fixator is stable and secured, compression of the
bling the bars and clamps are easier and faster to remove. In selected osteotomy or arthrodesis site can be performed with
addition, the removed portion of the external fixator can be compression of the threaded rods between the proximal and
easily re-applied at the completion of the debridement, wound distal external fixation segments (Clinical Case VII).
lavage, or antibiotic cement exchange.
Definitive external fixation constructs for revisional deform-
Pediatric Foot and Ankle
ity correction and/or arthrodesis are unique and patient
Malunions and Nonunions
dependent. In general, the majority of hindfoot/ankle oste-
otomies and/or revisional arthrodesis procedures involve a Nonunions in the region of the foot and ankle are rare in chil-
construct that can be further assembled with the pre-existing dren. More often nonunions are reported as a result of massive
tibial block. Commonly, the separated forefoot or midfoot ring bone and soft tissue loss, infection, or as a failed attempt of
is removed along with the bar to clamp apparatus that secured deformity correction or ankle arthrodesis. Malunions in the
it to the tibial block. A foot plate with or without a talar circular foot and ankle, on the other hand, are quite frequent in pedi-
half-ring can be attached to the tibial external fixation block atric patients. However, the presence of the growth plate adds
with threaded rods. Preferably, the foot plate is connected a higher level of complexity to the existing problem. Growth
to the tibial block with two threaded rods placed posteriorly. plate disturbance can lead to additional deformity and shorten-
This allows ample space for the insertion of the transosseous ing and increases chances for recurrence (Clinical Case VIII).
wires securing the foot to the foot plate. An alternative to this Growth ability can lead to compensatory deformities above
construct is to utilize the TSF struts and even though they may or below the malunion region through the growing foot.
limit the surgeon’s operative field, they provide enhanced Therefore, evaluation of a growing patient with malunited
CLINICAL CASE VII
Preoperative clinical (A) and radiographic views (B, C) of malleoli for alignment and application of a Taylor spatial
a distal lower extremity fracture with a history of infected frame at approximately 10 months after the original sur-
hardware and abscess after an ORIF. Patient presented with gery (D–I). The external fixator was removed prematurely
a severe malunion and nonunion of the previously attempted at approximately 5 weeks postoperatively and the patient
surgical corrections and also with a history of lateral malle- received a prolonged course of cast immobilization and
olus ulceration. Patient underwent a staged reconstruc- bracing. Note the internal fixation screw for simultaneous
tion with an initial surgical debridement of the ankle joint subtalar joint stabilization and ankle compression. Final clini-
with fibular exostectomy. Patient eventually healed all his cal (J–L) and radiographic (M, N) views at 13-month follow-
lower extremity wounds and was followed with an open up with the patient achieving an uneventful ambulatory
ankle arthrodesis and an osteotomy of the talus and both status.
A,B C
(continued)
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A,B C
D,E F
G,H I
J,K L
(continued)
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330 Chapter 18
M N
CLINICAL CASE VIII
Preoperative clinical (A) and radiographic (B) views of a correction with fibular resection and stabilization with a
6-year-old male with a history of severe open right distal tibial circular external fixation device. Proximal tibial and fibular
and fibular fractures 4 years before presentation, requiring osteotomies for lengthening performed at 8 weeks after the
debridement and plastic surgery closure. Despite previous use initial acute deformity correction by utilizing the same circu-
of internal fixation the fractures progressed to a nonunion. lar external fixation device (E). Postoperative radiographic
Note the radiographic view (B) demonstrating distal tibial view (F) after the external fixation removal which was
nonunion with fibular overgrowth and severe ankle varus as applied for a total of 5 months. Final clinical presentation
a result of tibial growth plate damage. Postoperative clinical (G) showing the lower extremity alignment and plantigrade
(C) and radiographic (D) views after an acute tibial deformity foot.
A,B C
(continued)
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A,B C
D,E F,G
distal tibial or foot deformity should include projected discrep- independent fibular lengthening and/or deformity correction
ancy and any additional deformities that could develop as a should be performed. This technique can be performed by
result of the damaged growth plate. Often, deformity correc- introducing an independent distal fibular fixation system with
tion should be planned in conjunction with ipsilateral or con- additional external support connected to only the distal end
tralateral epiphysiodesis to prevent recurrence of the deformity of the fibula. Any concomitant ankle subluxation and foot
and/or limb length discrepancy. deformity should be corrected acutely if possible. A mini-
Regardless of which external fixator is used, the princi- mal amount of simultaneous ankle distraction can also help
ples of deformity correction remain the same for all circular in joint protection during the deformity correction process
external fixators. Circular external fixation (TrueLok Circular (Clinical Case X).
External Fixation System, Orthofix, Lewisville, TX, for Clinical During a distal tibial deformity correction, additional foot
Cases VIII–XIII) application usually starts with the tibial block stabilization can improve the stability of the short distal tibial
stabilization. It is usually easy to align the pre-built external fragment and allow protection of the ankle joint (Clinical
fixator to the tibial longitudinal axis. To aid in alignment, it is Case X). The use of a modular foot support is preferable
recommended to mark the skin identifying the tibial longitudi- as it allows for flexible and stable foot fixation. Calcaneal
nal axis, level of growth plates, osteotomy, and hinge position fixation can be performed either using half-pins or transos-
(Clinical Case IX). The tibial block may consist of a simple double- seous wires. Transosseous wires are usually better tolerated
ring block to provide stabilization for deformity correction at by pediatric patients but require more time in the operat-
the ankle joint and/or foot. In cases when a proximal tibial ing room and very careful equal tensioning to not less than
lengthening or additional deformity correction is needed, the 100 kg of force. Calcaneal half-pins are usually easier to insert
tibial external fixation components should be assembled with and they are also well tolerated by children but not for a pro-
hinges at the level of proximal deformity (Clinical Case IX) or longed period of external fixation. If midfoot stabilization
distraction rods between the proximal segment and the rest of is necessary, it is usually performed using olive transosseous
the external fixation device (Clinical Case VIII). In such cases, wires inserted in the direction of correction or in opposite
a proximal fibular fixation is necessary and in order to avoid direction for better stability. When insertion of the meta-
injury of the common peroneal nerve, it is recommended to tarsal wires is necessary, it is best to have two opposing olive
use a single half-pin from the tibia to the fibula fixation level. transosseous wires introduced from both sides of the foot
First, a guide wire is introduced from the fibular head through (Clinical Case XI).
the tibia. Next, a cannulated drill bit is used to pre-drill the Remodeling potential in a growing child often allows for
medullary canal at just to the outer cortex of the fibula, which the use of closed foot deformity correction. In these cases, it is
is followed by a 5 mm or 6 mm half-pin introduced manually beneficial to perform joint distraction prior to acute deform-
through the tibia and grasping the proximal end of the fibula. ity correction. Distraction of the subtalar joint, for example,
Upon completion of the tibial block fixation, the hinge position would create release of soft tissues necessary to perform
is checked under C-arm fluoroscopic guidance and adjusted if correction without too much tension of the skin. After acute
necessary (Clinical Case IX). correction of foot deformities, the external fixator should
Other common pediatric deformities include damage of be left in place for at least 4 to 6 weeks for stabilization and
the distal fibula that can cause asymmetric growth disturbance followed by cast immobilization after the external fixation
resulting in a short fibula and unstable ankle joint. In such cases, removal (Clinical Case XII).
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332 Chapter 18
CLINICAL CASE IX
Preoperative clinical (A, B) and radiographic (C, D) views of radiographic imaging (H). Note that the completed external
a 9-year-old female with a history of osteomyelitis sequelae of fixation device orientation mimics the deformities of the tibia
malunited arthrodesis with proximal tibial valgus deformity and foot (I). Additional external fixation foot support is used to
and shortening. Note the severe calcaneal deformity, malunited supplement for the short distal tibial fragment stabilization (I).
ankle arthrodesis site, and relative fibular overgrowth. Preopera- Clinical view ( J) of the patient undergoing distal deformity cor-
tive planning of deformity correction is shown in sagittal (E) and rection after completion of the proximal valgus correction and
frontal (F) planes. The distal tibial recurvatum deformity and continuation of lengthening proximally. Radiographic views (K,
proximal tibial lengthening is planned along with fibular trans- L) at the end of correction with circular external fixation. Note
port to bring the proximal end to the level distal to the knee that the bone fragment position is matching the preoperative
joint (E, F). Intraoperative view (G) showing the pre-assembled correctional planning. Final weight bearing radiographic views
external fixator aligned with the deformity along with mark- (M, N) after external fixation removal demonstrating anatomi-
ings on the skin representing the anatomical axes of segments, cal alignment. Final clinical outcome with a plantigrade foot
planned osteotomy level and hinge position. The hinge level and after the patient underwent an additional lengthening 2 years
orientation is confirmed on intraoperative C-arm fluoroscopic since the first surgery (O, P).
A,B C
D E
(continued)
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F
G
H I
J,K L
(continued)
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334 Chapter 18
Clinical
J,K case IX (continued) L
M,N O,P
CLINICAL CASE X
Preoperative radiographic (A, B) and clinical (C) views of distal fibula fixation with transosseous wire and half-pin in
a 12-year-old female with a history of a left ankle valgus a separate external support, connected to the proximal fixa-
deformity secondary to posttraumatic partial distal tibial and tion block with three threaded rods with plastic distraction
distal fibular growth arrest, ankle instability, and 1 cm of nuts to perform lengthening. The external foot support
tibial shortening. Note the distal tibial valgus as a result of (plate) is also connected to the distal tibial ring. The foot is
lateral distal tibial growth plate damage and relatively short stabilized with two calcaneal half-pins, two metatarsal wires,
fibula creating pronounced ankle instability with lateral and an olive wire through the talus. An intraoperative ankle
subluxation (A–C). Long lower extremity radiographic view distraction of 2 mm was performed acutely in the operating
(D) and preoperative planning (E). Note the distal tibial room (G). Clinical views (H, I) at the end of surgery dem-
valgus deformity correction with hinges positioned at the onstrating the circular external fixator applied according to
level of the tibial deformity (E). Linear fibular lengthening the preoperative planning. Note the outboard hinges placed
is planned with independent external fixation support con- at the level of tibial deformity on the medial side of the tibia
nected to the distal end of the fibula only (E). Intraopera- below the distal tibial ring (H, I). Postoperative radiographic
tive radiographic view (F) with the circular external fixator view ( J) after deformity correction and fibular lengthening.
aligned to the tibia and hinges placed at the level of deform- Note that the external foot support is removed after comple-
ity. Note the acute reduction of the ankle subluxation with tion of correction to allow ankle joint exercises during the
the use of an olive transosseous wire inserted through the consolidation period. Note the horizontal position of ankle
talus from lateral side to hold the foot in the desired position joint and absence of subluxation ( J). Final radiographic (K)
during deformity correction and fibular lengthening (F). and clinical (L, M) views two and a half years after surgery
Close-up intraoperative view (G) of the ankle and foot stabili- showing restored alignment of the lower extremities with a
zation in the circular external fixator. Note the independent plantigrade left foot.
A,B C
(continued)
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D,E F
G H
I,J K
(continued)
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336 Chapter 18
L M
Pediatric infected nonunions and malunions require surgi- remaining healthy distal tibial end is very short or in cases
cal debridement and may leave a large defect in the area of the of complete ankle joint obliteration, a foot external fixation
ankle joint. If acute compression is not possible, the external support is necessary. Upon completion of the bone transport
fixator should be applied for stabilization of the osseous defect process, a docking site debridement and compression with or
and soft tissues, performing some safe shortening at the defect without the bone graft is necessary. Additional lower extremity
site. Bone transport should be performed either at the same lengthening may continue through the proximal regenerate
time or after a period of managing the infected area. If the after docking (see Chapter 21).
CLINICAL CASE XI
Example of foot stabilization with two calcaneal half-pins and patient undergoing distal tibial deformity correction for a
two opposing metatarsal olive transosseous wires in a 14-year-old malunited ankle fusion.
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CLINICAL CASE XII
Preoperative clinical (A, B) and radiographic (C–E) views of a Immediate postoperative radiographic view (H) demonstrat-
13-year-old male with posttraumatic right ankle valgus deforming the distal tibial ring being parallel to the ankle joint and
ity as a result of severe open lower extremity fracture with the foot stabilized in the external foot plate connected to
bone and tissue loss. An acute compression at the proximal the distal tibial ring with acute distraction performed at the
tibial defect side combined with a rotational flap and external time of surgery. Radiographic view at the end of distal tibial
fixation were used to initially manage a 10 cm bone defect. A deformity correction and fibular lengthening (I). Note that the
limb lengthening of 3 cm was performed. Damage of the distal ankle joint alignment and fibular lengthening improved the
tibial and fibular growth plates resulted in ankle valgus with anatomic structure of the ankle joint. Clinical view ( J) of
compensatory subtalar varus deformity. Note the severe distal the patient at the end of the tibial deformity correction.
tibial valgus and relative shortening of the fibula with compen- Clinical views (K, L) of the external fixation adjustments in
satory subtalar varus deformity (C–E). Preoperative planning the operating room. Distraction of the foot joints was released
of the tibia valgus deformity correction and independent and the foot was acutely moved in a plantigrade position. Con-
fibular lengthening is shown (F). Additional distraction is nection rods between the external foot support and tibial block
planned for both the ankle and subtalar joints during deform- were re-applied to further stabilize the foot in the corrected
ity correction. This should help in future acute closed foot position for additional 4 weeks. A walking cast was applied
deformity correction. Immediate postoperative clinical view after the external fixation removal. Clinical (M, N) and radio-
(G) of the circular external fixator for tibial deformity correc- graphic (O, P) views one and a half years after surgery showing
tion and fibular lengthening. Acute 4 mm distraction for both restored alignment of the lower extremities with a plantigrade
ankle and subtalar joints was applied at the time of surgery. right foot.
A,B C
D,E F
(continued)
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338 Chapter 18
G,H I
J K
L M
(continued)
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N,O P
Postoperative Course is questioned, the surgeon can elect to remove the threaded
rods between the proximal and distal external fixation seg-
The duration of external fixation application may vary in each ments before removing the circular rings. If excessive motion
case and the external fixators are not usually removed until is present, the threaded rods and re-assembly of the device can
there is evidence of a solid osseous union. External fixation easily be performed in addition to further stabilization with
removal is typically performed in the operating room setting as Steinmann pin(s) and/or percutaneous versus open internal
this provides an opportunity for the surgeon to evaluate for any fixation. By removing the external fixator in the operating
motion and instability at the osseous segments. If bone healing room, it also allows the surgeon to debride and lavage any
CLINICAL CASE XIII
Example of an additional foot plate connected to the bottom the ability to walk with full weight bearing while in the external
of the foot external fixation support to provide the patient with fixation device (A).
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340 Chapter 18
pin/wire sites that may be contaminated or infected. Once the Conclusion

external fixator is removed, the patient is usually placed into
a short-leg non–weight bearing cast/splint. A period of serial The goal of correcting foot and ankle deformities with circular
non–weight bearing and weight bearing casting and surgical external fixation as a result of a malunion and/or nonunion
boots may be required before transition is made to shoe gear is to restore and preserve limb function while providing pain
and/or bracing. External bone stimulation may also be utilized relief. As with any surgical procedure, the utilization of exter-
at that time. nal fixation may present with its own complications. Preopera-
In children, the presence of a healthy sensate foot allows to tive planning with detailed surgical and postoperative course of
start early weight bearing. The pediatric patient is encouraged treatment helps monitor the correction process and allows for
and instructed to walk with crutches the day after surgery with early detection and successful management of complications.
weight bearing status as tolerated and gradually increasing by Surgical experience with these types of deformities and utiliza-
each day. It is also important to provide a modified comfortable tion of external fixation is paramount to the overall patient’s
and safe shoe that can be used in the presence of an external successful outcome.
foot plate or extend the distal end of the external fixation
device with additional support for ease of weight bearing activi-
ties (Clinical Case XIII). In cases where the ankle joint is not Recommended Readings
involved, its immobilization should be kept to a minimum.
Finally, upon completion of a distal tibial deformity correction, Birch JG, Samchukov ML. Use of the Ilizarov method to correct lower limb
deformities in children and adolescents. J Am Acad Orthop Surg. 2004;12:
the external foot plate should be removed within the following 144–154.
2 to 4 weeks after the deformity correction or hinges should be Birch JG, Samchukov ML. Ilizarov’s apparatus for correction of metaphyseal-
introduced to initiate ankle range of motion exercises. epiphyseal deformities of the tibia in skeletally immature patients. Oper Orthop
Traumatol. 2010;12:220–233.
Cherkashin AM, Samchukov ML, Birch JG. Leg perfect computerized preopera-
tive planning for deformity correction. J Child Orthop. 2010;4:S51.
Facaros Z, Ramanujam CL, Zgonis T. Primary subtalar joint arthrodesis with
C l i n i cal Tips and Pearls internal and external fixation for the repair of a diabetic comminuted calca-
neal fracture. Clin Podiatr Med Surg. 2011;28:203–209.
A. Extensive preoperative evaluation may be necessary to Katsenis D, Bhave A, Paley D, et al. Treatment of malunion and nonunion at
determine if a nonunion is infected in order to avoid the site of an ankle fusion with the Ilizarov apparatus. J Bone Joint Surg Am.
potential complications with revisional surgery. 2005;87:302–309.
B. The nonunion site is carefully evaluated in order to Molloy AP, Roche A, Narayan B. Treatment of nonunion and malunion of trauma
of the foot and ankle using external fixation. Foot Ankle Clin. 2009;14:563–587.
determine the amount of osseous resection in the pres- Paley D, Lamm BM, Katsenis D, et al. Treatment of malunion and nonunion at
ence of a significant sclerotic or avascular bone necrosis. the site of an ankle fusion with the Ilizarov apparatus. Surgical technique.
C. Consider utilizing a combination of a tibial block and J Bone Joint Surg Am. 2006;88:119–134.
midfoot or forefoot circular ring connected with a Polyzois VD, Papakostas I, Stamatis ED, et al. Current concepts in delayed bone
union and non-union. Clin Podiatr Med Surg. 2006;23:445–453.
simple bar to clamp apparatus when serial surgical
Rozbruch SR, Pugsley JS, Fragomen AT, et al. Repair of tibial nonunions and
debridements of an infected nonunion and antibiotic bone defects with the Taylor Spatial Frame. J Orthop Trauma. 2008;22:88–95.
cement exchange may be required.
D. If acute deformity correction is impossible to achieve,
gradual correction is usually performed with an exter-
nal fixator that mimics the deformity and later adjusted
to a neutral position.
E. Comprehensive preoperative planning and external
fixation pre-assembly helps reduce surgical time and
minimize complications.
F. Remodeling potential in a growing child often allows
for the use of closed foot deformity correction and
initial joint distraction can be beneficial in such cases.
G. Utilizing Taylor spatial frame struts are advantageous
when bone segment translation and rotation along
with angular deformity correction is required.
H. Combined external and internal fixation constructs for
foot and ankle malunion and/or nonunion deformi-
ties may be required if the soft tissue envelope permits
and no active signs of infection are present.
I. Careful incisional approaches are paramount when sig-
nificant acute corrections and/or bone resections are
performed since a large gapping and difficult wound
closure could occur.
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Chapter
19
Roberto H. Rodriguez
Luke C. Jeffries
Thomas Zgonis
Stepwise Approach to Foot

and Ankle Osteomyelitis and
External Fixation
Introduction heat-stable local antibiotics in the form of polymethyl methacr-

ylate (PMMA) antibiotic-loaded cement spacers or beads. Cir-
Osteomyelitis of the foot and ankle remains a serious and cular external fixation allows off-loading of the surgical lower
common complication associated with traumatic, iatrogenic, extremity while simultaneously providing access to soft tissue
diabetic, and ischemic etiologies. Advances in technology and defects for interim NPWT in lieu of definitive soft tissue cover-
surgical strategies have sharpened the surgeon’s ability to diag- age through advanced plastic surgery techniques, such as local
nose and treat osteomyelitis of the foot and ankle. The judicious muscle, pedicle, or free flaps. Soft tissue closure is deferred
use of external fixation in conjunction with wide surgical deb- after the complete eradication of osteomyelitis. Furthermore,
ridement, heat-stable impregnated antibiotic-loaded cement, external fixation can stabilize the osseous segments adjacent to
negative pressure wound therapy (NPWT), orthobiologics, soft the surgical wound and allow utilization of bone grafts during
tissue coverage procedures, and final stage arthrodesis has the final reconstructive stage.
become a useful approach in foot and ankle salvage surgery. Compression techniques through the use of external fixa-
Because of the relatively superficial depth of osseous struction can provide a stable, plantigrade foot through arthrodesis
tures, vulnerable vasculature, abundance of avascular tendinous without the use of internal fixation at the previously infected
and ligamentous structures, the foot is particularly at high risk of site. The use of NPWT improves the postoperative manage-
infection in the setting of a wound, whether it is traumatically or ment of surgical wounds and allows joint arthrodesis with
surgically induced. When there is a history of diabetes, peripheral exposed bone graft through the Papineau technique. External
vascular disease, or tobacco use, this risk is compounded. The fixation can be adjusted gradually to achieve proper alignment
presence of normal skin flora on the lower extremity may con- and length. Rigid stability of bone and soft tissue can prevent
vert traumatically induced soft tissue deficits into grossly infected further infection, while promoting continual osseous consoli-
wounds with contiguous involvement of adjacent osseous struc- dation and soft tissue closure.
tures. Aggressive surgical resection, intravenous antibiotics, and Given its complexity, the successful management of lower
the stabilization of osseous segments have become the standard extremity osteomyelitis requires the cooperative efforts of
approach for managing lower extremity osteomyelitis. Definitive multidisciplinary specialties, including and not limited to a
reconstruction of osseous defects through arthrodesis of involved reconstructive foot and ankle surgeon, vascular surgeons, infec-
joints with a stable and functional soft tissue envelope represents tious disease specialists, and internal medicine, among others.
the ultimate goal in creating a functional plantigrade foot. This The benefits of a multidisciplinary team approach have been
goal, however, can be a major challenge to even the most experi- validated in the literature, and the failure to recognize this will
enced reconstructive surgeon. Relatively minor bone loss can be likely result in a poor outcome.
addressed with bone grafting; more significant loss requires more
challenging procedures, including distraction osteogenesis, alone Indications/Contraindications
or in combination with soft tissue reconstructive procedures.
Selective digital or ray amputation for the management of termi- Most common clinical scenarios in which the use of external
nal sites of osteomyelitis may be required to avoid total limb loss. fixation is indicated for the management of osteomyelitis in
The primary intraoperative goal in the treatment of osteo- the foot and ankle include and are not limited to the following:
myelitis is the radical debridement of infected and devitalized Presence of broken or loosened hardware, Charcot neuroar-
bone, which often conflicts with the simultaneous desire to thropathy (CN), nonunions, unstable deformities, significant
maintain limb length and function. External fixation allows bone loss, osteopenia, osteonecrosis, and exposed bone and
the spanning of osseous segments with simultaneous use of joint structures (Clinical Cases I–IV).
341
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342 Chapter 19
CLINICAL CASE I
Clinical (A–C) and radiographic anteroposterior (D) and lat- later, the patient returned to the operating room for removal
eral (E) views showing an infected diabetic Charcot neuroar- of any retained nonbiodegradable antibiotic-cemented spacers
thropathy right foot with abscess and osteomyelitis. The patient and beads and further obtaining of intraoperative cultures.
presented with systemic signs of infection and had a history The final-staged reconstructive procedure was performed
of open wounds and partial fifth ray amputation. The patient 5 days later with a medial column arthrodesis and osteotomy,
underwent an initial multiple incision and drainage procedure allogenic bone grafting (K), and skeletal fixation of the sub-
and obtaining of deep intraoperative bone and soft tissue cul- talar and ankle joints by using a Taylor spatial frame (L–Q).
tures and bone biopsy (F, G). Cultures were positive for osteo- The external fixation device was removed at approximately
myelitis of the medial cuneiform and base of fifth metatarsal. 7 weeks and the patient was transitioned to a non–weight
The patient returned to the operating room 2 days after the bearing cast immobilization for approximately 6 weeks followed
first surgery for an entire resection of the medial cuneiform by appropriate surgical boot off-loading and accommodative
(H) and fifth metatarsal base and insertion of a nonbiodegrada- orthotic devices. The patient required an additional incision
ble antibiotic-cemented spacer (I) and beads at the medial and drainage procedure medially and eventually healed at his
and lateral columns of the foot, respectively ( J). Three months last 14-month follow-up (R–V).
A,B C
D,E F
(continued)
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Stepwise Approach to Foot and Ankle Osteomyelitis and External Fixation 343
G,H I
J,K L
M,N O
(continued)
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344 Chapter 19

M,N O
P,Q R
S,T U
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CLINICAL CASE II
Clinical (A, B) and radiographic anteroposterior (C) and plantar soft tissue deficit as well ( J). At approximately 3 months
lateral (D) views showing a severely infected Charcot neuroar- later, the patient returned to the operating room for removal
thropathy left foot with abscess and osteomyelitis. The patient of the retained nonbiodegradable antibiotic-cemented spacers
presented with systemic signs of infection and had a history of and beads and further obtaining of intraoperative cultures. The
open wounds to the left foot with associated trauma and non- final-staged reconstructive procedure was performed 5 days later
diagnosed diabetes mellitus. The patient underwent an initial with a medial column arthrodesis and osteotomy, allogenic bone
multiple incision and drainage procedure and obtaining of grafting, plantar local advancement flap with NPWT (K–N), and
deep intraoperative bone and soft tissue cultures and bone skeletal fixation of the subtalar and ankle joints by using an off-
biopsy (E, F). Cultures were positive for osteomyelitis and the loading and stabilization external fixation (O, P). The external
patient returned to the operating room 5 days after the first fixation device was removed at approximately 7 weeks and the
surgery for an entire resection of the navicular and medial patient was transitioned to a non–weight bearing cast immobili-
cuneiform with partial resection of the fifth metatarsal base and zation for approximately 6 weeks followed by appropriate surgi-
insertion of nonbiodegradable antibiotic-cemented beads (G) cal boot off-loading and accommodative orthotic devices. The
and spacer (H) at the lateral and medial columns of the foot, patient required an additional incision and drainage procedure
respectively (I). An intraoperative negative pressure wound medially and eventually healed at his last 14-month follow-up
therapy (NPWT) device was also utilized to cover the large (Q–U).
A,B C
D,E F
(continued)
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346 Chapter 19
G,H I
J,K L
M,N O
(continued)
LWBK1121-C19_p341_359.indd 346 04/10/12 3:17 PM

P,Q R
S,T U
The contraindications to lower extremity salvage with exter- uncontrolled hyperglycemia, renal insufficiency, cardiovascular
nal fixation belong to two categories. The first has to do with disease, peripheral vascular disease, severe infection with sys-
the extent and location of infection. Superficial or localized temic manifestations, smoking history, poor nutrition, immu-
osteomyelitis away from a load-bearing part of the lower nosuppression, and psychosocial difficulties, if not addressed
extremity may be successfully treated with staged surgical deb- appropriately, will compromise the ability to obtain favorable
ridement followed by delayed soft tissue coverage. The second outcomes. The Cierny–Mader classification system may be useful
consideration depends on the patient’s recuperative poten- in helping the surgeon to predict which patients are good can-
tial. Extremely debilitated patients or those with irreversible didates for lower extremity salvage with the use of external fixa-
ischemia are poor candidates for lower extremity salvage with tion. Similarly, those patients with significant comorbidities can
external fixation. The functional demands and expectations of be classified according to the Cierny–Mader scheme and may be
the patient should be considered when determining if recon- better candidates for primary lower extremity amputation.
struction will be beneficial over amputation. In addition, local factors may preclude the patient from
Patients with chronic and long-standing comorbid condi- undergoing lower extremity salvage. Chronic lymphedema,
tions are considered high risk and may require a single, pri- venous stasis dermatitis, and venous insufficiency are often not
mary amputation. These high-risk patients may not tolerate the amenable to correction with external fixation. Furthermore,
energy expenditure involved in multiple-staged procedures. A patients with critical lower extremity ischemia or life-threatening
thorough review of the patient’s past medical history is vital in infections, such as gas gangrene and necrotizing fasciitis, may
recognizing potential complications associated with the patient not be suitable for external fixation usage and may require
and planned reconstructive procedures. Diabetes mellitus with immediate amputation.
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348 Chapter 19
CLINICAL CASE III
Clinical (A, B) and radiographic anteroposterior (C) and room for removal of the external fixator and cast application
lateral (D) views showing a severely infected Charcot neu- below the knee. The patient subsequently developed a deep
roarthropathy right foot with a deep abscess. The patient abscess and severe infection 4 months after the external fixa-
presented with systemic signs of infection and had a history tion removal. At that time, the internal fixation was removed
of open wounds to the right foot with associated trauma and and was followed by insertion of nonbiodegradable antibiotic-
poorly controlled diabetes mellitus. The patient underwent cemented beads at the medial (L) and plantar (M) aspects of
an initial multiple incision and drainage procedure, plantar the foot. An intraoperative negative pressure wound therapy
cuboidectomy, and obtaining of deep intraoperative bone and device was also applied at the plantar wound (N) while the
soft tissue cultures and bone biopsy (E). Cultures were nega- medial aspect of the foot was closed primarily (O). Please note
tive for osteomyelitis and the patient returned to the operating the utilization of the off-loading and stabilization external fixa-
room 5 days after the first surgery for an entire resection of the tion system for the right foot and ankle (P, Q). The external
navicular and medial cuneiform that were used as autografts fixation device and retained antibiotic beads were removed at
after meticulous dissection of their cartilaginous articulations approximately 8 weeks and the patient was transitioned to a
combined with multiple midtarsal arthrodesis and a plantar non–weight bearing cast immobilization for approximately 8
local advancement flap on the basis of the medial plantar weeks followed by appropriate surgical boot off-loading and
artery (F–I). The entire medial column of the foot was fused accommodative orthotic devices. The patient required an
with the use of a locking plate combined with an off-loading additional incision, drainage and closure procedure at the
and stabilization external fixation system ( J, K). At approxi- plantar aspect of the foot which eventually healed at his last
mately 6 weeks later, the patient returned to the operating 13-month follow-up (R–V).
A,B C
D,E F
(continued)
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G,H I
J,K L
M,N O
(continued)
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350 Chapter 19
Clinical
M,N case III (continued) O
P,Q R
S,T U
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CLINICAL CASE IV
Clinical (A) and radiographic anteroposterior (B) and lateral also received a bilayer matrix wound dressing (L) and was
(C) views showing a severely infected Charcot neuroarthropa- then immobilized with a below-the-knee cast that was changed
thy left foot with a deep abscess. The patient presented with every 2 weeks for approximately 8 weeks. Six months later, the
systemic signs of infection and had a history of open wounds plantar ulceration was still present and the patient underwent
and trauma to the left foot and poorly controlled diabetes mel- further surgical debridement and application of a negative
litus. The patient underwent an initial incision and drainage pressure wound therapy (NPWT). Two months later, the patient
procedure, plantar cuboid exostectomy, and obtaining of deep presented with signs of bone exposure at the cuboid and local
intraoperative bone and soft tissue cultures and bone biopsy cellulitis. At that time, the patient underwent surgical debride-
(D). Cultures were negative for osteomyelitis and the patient ment with NPWT and insertion of nonbiodegradable antibi-
returned to the operating room 5 days after the first surgery otic-cemented beads at the plantar aspect of the foot (M, N).
for an entire medial column arthrodesis (E) and a plantar local The retained antibiotic beads were removed at approximately
advancement flap on the basis of the medial plantar artery (F). 2 months later (O) followed by a revisional plantar cuboid
The entire medial column of the foot was fused with the use exostectomy and delayed primary closure with the assistance of
of a locking plate combined with an off-loading and stabiliza- a NPWT device (P, Q). The patient was transitioned to a non–
tion external fixation system (G–J). At approximately 5 weeks weight bearing cast immobilization for approximately 8 weeks
later, the patient returned to the operating room for removal followed by appropriate surgical boot off-loading and accom-
of the external fixator and hydrosurgical debridement of the modative orthotic devices. The patient was eventually healed at
dehisced flap at the plantar aspect of the foot (K). The patient his last 22-month follow-up (R–W).
A,B C
D,E F
(continued)
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352 Chapter 19
G,H I
J,K L
M,N O
(continued)
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P,Q R,S
T,U V
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354 Chapter 19
Preoperative Considerations osteomyelitis when correlating positive radiographic findings

with clinical presence of a chronic wound and provide treat-
Standardization and consensus regarding treatment may be ment until the imaging studies are complete.
achieved on the basis of evidence-based recommendations. In comparison to traditional radiographs, MRI and CT
In general, the guidelines recommend a careful review of the scans offer greater sensitivity and specificity in distinguishing
patient’s history and the recent circumstances surrounding cortical involvement and early sequestrum. However, CT scans
the presentation of osteomyelitis. The patient’s medical status fail to provide a clear distinction of bone marrow abnormali-
is critical and particular attention is given to the patient’s age, ties in comparison to MRI. The use of gadolinium enhances
peripheral vascular examination, glucose control, tobacco use, the specificity of osteomyelitis with MRI. Nuclear medicine
and cardiovascular and renal function. Special consideration imaging can be helpful when a history of CN confounds the
to the patient’s recuperative potential and multiple anesthesia diagnosis. The most widely used radionuclide studies include
exposures is also necessary. Furthermore, the viability of the technetium 99m methylene diphosphonate bone scan followed
involved extremity must be considered along with a thorough by indium 111-labeled leukocyte scan, technetium 99m hexam-
understanding of anticipated functionality that the patient can ethylpropyleneamine oxime leukocyte scan, gallium 67 scan,
reasonably expect following recovery from all reconstructive and technetium 99m sulfur colloid scan. These studies vary
procedures. in sensitivity and specificity. Ordering the proper bone scan
Classifying the infection as a lower limb-threatening or non– requires detailed knowledge of each specific study.
limb-threatening is essential when considering the surgical plan- Bone biopsy and intraoperative bone cultures remain the
ning. Classic signs of systemic infection, such as persistent fevers, gold standard in the diagnosis and treatment of osteomyelitis.
chills, malaise, and leukocytosis should be addressed if possible Intraoperative bone biopsies with histopathology analysis will
to medically stabilize the patient before surgical reconstruction. help identify the presence or absence of bone infection. Bone
It is important to note that diabetic patients may not exhibit cultures will identify the causative bacterial organisms and
these constitutional signs due to their immunocompromised guide proper antibiotic coverage. Obtaining bone biopsies and
chronic status. Baseline laboratory studies, such as complete cultures will avoid sampling errors, soft tissue contaminants, or
blood cell count with differential, C-reactive protein, erythrocyte false negatives.
sedimentation rate, and blood cultures, will allow the surgeon to
monitor the remission or progression of soft tissue infection and
osteomyelitis. Underlying pathology such as rheumatoid arthri- Detailed Surgical Technique
tis, Charcot joint instability, infected malunions, nonunions, and
hardware failure should be appropriately evaluated before sur- Initial Surgical Debridement
gical treatment to limit potential postoperative complications. The initial surgical step should entail a timely and aggressive
Wound examination should include the location, size, depth, debridement of devitalized soft tissue and bone. While the goal
and exposure of bone or open joints. Probing to bone with ster- of maintaining length and preserving function is important,
ile blunt metal probe may be an indicator of osteomyelitis when the main objective during the initial debridement is the com-
considering the depth and chronicity of the wound. Periph- plete eradication of all infected and nonviable soft tissue and
eral neuropathy associated with deranged glucose metabolism, bone. With this in mind, radical resection of devitalized bone
trauma, structural deformity, and joint instability may increase and soft tissue to the level of clean and healthy margins must
the wound size and hasten the infective process involving sur- be achieved during the initial operative procedure. The surgi-
rounding osseous structures. A thorough vascular assessment is cal site(s) is usually irrigated with 3 L sterile saline solution in
imperative in determining if revascularization procedures are a pulse lavage system, with or without the use of bacitracin or
needed to enhance the healing potential of the lower limb. Neosporin mixed solution. During this process, the operative
Evaluating the bone stock of the patient will validate the use lower limb may be inspected for any remaining evidence of
of autogenous bone grafting versus structural allografts in the sepsis or necrosis. Careful note of the presence or absence of
resected joint areas during final-staged arthrodesis procedures. intraoperative bleeding and perfusion at the tissue margins
Multiple imaging studies including radiographs, nuclear may help determine the need for a vascular consultation.
medicine scintigraphy, magnetic resonance imaging (MRI), After hemostasis has been achieved, the wound is packed with
and computed tomography (CT) are effective diagnostic tools sterile moist to dry dressings. Spanning external fixation may
that can play an indispensible role in the preoperative plan- be required to stabilize segmental defects or off-load weight
ning of suspected osteomyelitis. Radiographs are important bearing sites at risk. Consultation with the infectious disease
for the initial evaluation and identification of osteomyelitis. team with recommendations for broad-spectrum intravenous
Radiographic studies should include foot, ankle, calcaneal, antibiotic coverage is appropriate at this stage, with revisions
and tibial–fibular images to identify the level of deformity, pending definitive intraoperative cultures. The surgical wound
joint instability, and extent of osseous involvement in the foot dressing is typically left in place for a period of 36 to 48 hours,
and lower extremity. Radiographically, osteomyelitis presents after which the patient may undergo a secondary procedure or
as localized or diffuse osteolysis, periostitis, or cortical ero- bedside sterile dressing change may be performed.
sion. These findings, however, are not present until the late
stages of bone infection. Also, osteomyelitis may be obscured
Second-staged Reconstructive Procedure
radiographically in the presence of CN or rheumatoid arthritis.
Advanced imaging facilitates the identification and differentia- The use of circular, hybrid, or off-loading external fixation
tion of osteomyelitis against or in the presence of CN. In the will provide stability at the surgical wound site and associated
interim, it is important to carry a high index of suspicion for osseous segments. If osteomyelitis of the foot and/or ankle
LWBK1121-C19_p341_359.indd 354 04/10/12 3:17 PM

is associated with a resected nonunion, open fracture, or off-loading surgical fixation for further stability and rigidity of
CN characterized by gross instability, a spanning off-loading the entire construct.
external fixator is indicated. External fixation can be utilized
initially after any tarsal bone(s) resection to span the remaining
Third-staged Reconstructive Procedure
joints and stabilize the surrounding osseous structures and soft
tissue envelope. If local and constitutional signs improve, in addition to labora-
Antibiotic-impregnated cement blocks or beads can be uti- tory studies confirming the eradication of infection, the patient
lized to fill in joint spaces and create an aseptic, stable environ- is returned to the operating room for a revision of the margins,
ment to treat residual infection with heat-stable antibiotics. The removal of any retained nonbiodegradable local antibiotic
local application of antibiotics has been used to treat muscu- beads or spacers and the harvesting of a second set of soft tissue
loskeletal infections since the advent of antimicrobial agents. The and bone cultures and biopsy. Infectious disease specialists are
local administration of antibiotics has obvious advantages as an notified regarding the status of the intravenous or oral antibiot-
adjunctive therapy to systemically administered agents. PMMA is ics and the plan for the final definitive treatment. If primary
commonly used as carrier and heat-stable agents; typically vanco- closure is deemed appropriate this may be performed after the
mycin, tobramycin, gentamicin, clindamycin, and cefazolin may removal or exchange of external fixation. Off-loading exter-
be added to form either beads or molded blocks to functions as nal fixation may remain in place to protect plantar or weight
spacers. Since the concentration of antibiotic delivered is a func- bearing surfaces while the soft tissues heal or may be removed
tion of the surface area of the carrier, beads substantially increase before the final reconstruction with circular external fixation.
overall surface area and therefore rates of elution over a single This stage may not always be necessary if the initial bone cul-
spacer. However, spacers have the advantage of providing greater tures and biopsy were negative and after the recommendations
stability in patients who have undergone multiple tarsal bones of the infectious disease team are finalized.
resections. The beads are uniform spheres approximately 1 cm
in diameter and are attached to a cerclage wire or nonabsorb- Final-staged Reconstructive Procedure
able suture to facilitate removal from the wound. Unlike PMMA,
which is not metabolized by the body, calcium sulfate is slowly The goal of definitive reconstruction and lower limb salvage is
resorbed by the host over a period of 2 to 3 months. to provide the patient with a stable, braceable weight bearing
Antibiotic selection is guided by culture-specific sensitivities extremity free from infection. Large osseous defects may be
in a carrier that will elute bacteriostatic or bactericidal dosages grafted if necessary and soft tissue defects are covered. Autog-
over time. The surgical site is then closed by surrounding deep enous bone grafting whether from the iliac crest, tibia, fibula,
tissues or by the utilization of NPWT. This procedure fills in or calcaneus is usually preferable in most cases compared to
joint defects until final arthrodesis is performed with bone allografts. Graft selection must address the size and site of the
grafting if necessary. To achieve this goal, the external fixation osseous defect and any associated deformity. Interpositional
must be placed in a reproducible and predictable fashion. Par- bone wedge grafting, which includes both the iliac crest and fem-
ticular attention is given to wire/pin site placement, alignment, oral head allografts, can be useful in the correction of coronal or
and external fixation construct. sagittal plane malalignment. While autogenous graft is prefera-
Prior to the application of the off-loading external fixa- ble, it is associated with donor site morbidity that can be avoided
tion, the use of a tourniquet if applied is deflated and a new with allograft. In many cases after a total talectomy, a femoral
sterile field is set up in order to prevent contamination during head allograft may be used to restore loss of limb length and
application of the external fixation device. One or two tibia provide a stable osseous block at the fusion site. Debridement
circular ring(s) is placed 10 to 15 cm proximal to the ankle of both the osseous and soft tissue margins must be performed
joint making sure that the circular ring is well aligned within to ensure incorporation of any bone graft material. The need
the lower extremity with adequate space permitting any post- for external fixation may persist, with conversion from an off-
operative edema. The first transosseous wire is inserted from loading device to a compressive role circular external fixation.
a lateral-to-medial direction on the undersurface of the ring A pre-built circular external fixator may be utilized for any
and is perpendicular at 90 degrees to the longitudinal axis foot or ankle resected osteomyelitic joints as it was described
of the leg in the frontal plane, while the second transosseous in Chapter 8. The surgeon may then inspect the preassem-
wire is inserted from a medial-to-lateral direction on the top bled external fixation device and check that the construct is
surface of the ring at a 45- to 60-degree angle to the longi- stable and all components have been tightened. A distance
tudinal axis of the leg. Tensioning for the tibia transosseous of three finger’s breadth between the posterior calf and the
wires ranges between 110 and 130 kg of force. Cutting of the proximal ring of the tibial block must be maintained with the
tibia wires after appropriate bending is then performed. Next, external fixator aligned rectus to the distal lower extremity
a second circular ring is placed located over the midfoot/ and foot. The distal ring of the tibial block should be proximal
forefoot region and secured by the insertion of two smooth or to the ankle joint capsule to avoid violation during wire/pin
olive transosseous wires each at approximately 45- to 60-degree placement. An awareness of lower extremity anatomy and the
angle in opposing fashion. These midfoot/forefoot transos- location of safe zones must be kept in mind while placing the
seous wires are manually tightened and secured to the circular transtibial and foot wires/pins. Compression through the
ring followed by appropriate tightening with the wrenches. ankle may be achieved by translating the foot plate superi-
Next, multiple threaded hinges are incorporated between orly against a stable tibial block. Other techniques, including
the two rings or between the midfoot/forefoot ring and tibial the bent wire technique, may be utilized to compress an
ring(s) and securely fastened into place. A combination of bar- arthrodesis site by translating two adjacent bones toward each
to-clamp apparatus is secured at the bottom and each of the other.
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356 Chapter 19
CLINICAL CASE V
Clinical (A) and radiographic anteroposterior (B), oblique (C), ment and further bone and soft tissue cultures. The patient
and lateral (D) views showing a severely fractured and dislo- eventually underwent multiple debridements with excision of
cated Charcot neuroarthropathy right ankle with instability the peroneal tendon, insertion of nonbiodegradable antibiotic-
and history of edema and pre-ulcerative lesions. The patient cemented beads (L), and negative pressure wound therapy
had a history of type 1 diabetes mellitus, peripheral neuropa- (NPWT) (M). Additional Steinmann pins were used in the previ-
thy, drug abuse, and major depression. The patient underwent ous attempted tibiocalcaneal arthrodesis and an off-loading and
a right total talectomy (E) with autogenous autografting and stabilization external fixation system was used for stability and
tibiocalcaneal arthrodesis with a circular external fixation monitoring of the patient’s wound status (N–R). The patient’s
device (F–K). The circular external fixator was removed at off-loading and stabilizing external fixator was removed within
approximately 9 weeks postoperatively and the patient was 4 weeks and at that time the patient received an additional
placed on a biweekly non–weight bearing cast immobilization surgical debridement and NPWT. The nonbiodegradable anti-
to the right lower extremity. The patient eventually developed biotic-cemented beads were removed at 15 weeks later and the
a deep abscess with severe infection and returned 6 weeks after patient was eventually healed at the last visit approximately
the circular external fixation removal for a surgical debride- 11 months since the original surgery (S–Z).
A,B C
D,E F
(continued)
LWBK1121-C19_p341_359.indd 356 04/10/12 3:18 PM

G,H I
J K
L M
N,O P
(continued)
LWBK1121-C19_p341_359.indd 357 04/10/12 3:18 PM

358 Chapter 19
Q,R S
T,U V
S
W,X Y,Z
LWBK1121-C19_p341_359.indd 358 04/10/12 3:18 PM

Soft tissue coverage, if required, may also proceed at this Conclusion

stage for definitive closure. The soft tissue reconstruction has
to address considerations of the defect location and size, res- The authors have presented a stepwise approach to foot and
toration of function, and durability. External fixation has the ankle osteomyelitis through radical debridement, adequate
advantage of allowing the surgeon easy access to the surgical antibiotic coverage, and joint arthrodesis utilizing external
site during the patient’s convalescence. fixation methods. Advanced training and extensive knowledge
in external fixation in these circumstances is required to obtain
successful outcomes. Proper patient selection and adequate
Postoperative Course preoperative planning will limit postoperative complications
and Complications in patients with multiple comorbidities, extensive infection,
unstable joints, and multiplane deformities.
In the clinical postoperative setting, particular attention is given
to the soft tissue coverage site and external fixation stability.
The presence of superficial cellulitis at the pin/wire site can Recommended Readings
usually be managed with oral antibiotics and local wound care.
Deeper infection and abscess formation requires immediate Beals RK, Bryant RE. The treatment of chronic open osteomyelitis of the tibia in
adults. Clin Orthop Relat Res. 2005;433:212–217.
attention and possible surgical intervention (Clinical Case V).
Capobianco CM, Zgonis T. Abductor hallucis muscle flap and staged medial
Similarly, broken pins/wires must be removed immediately and column arthrodesis for the chronic ulcerated Charcot foot with concominant
replaced. Serial radiographs of the bone graft site are obtained osteomyelitis. Foot Ankle Spec. 2010;3:269–273.
to document consolidation and rule out evidence of persistent Cierney G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomy-
infection. Throughout the postoperative period, the patient elitis. Clin Orthop Relat Res. 2003;414:7–24.
Eralp L, Kocaoglu M, Rashid H. Reconstruction of segmental bone defects due
is evaluated by all medical and surgical teams involved in the to chronic osteomyelitis with use of an external fixator and an intramedullary
patient’s care. Depending on the rate of osseous union, the nail. J Bone Joint Surg Am. 2007;89:183–195.
external fixation is typically kept in place for approximately 10 Jeffries LC, Rodriguez RH, Belczyk R, et al. Negative pressure wound therapy for
to 12 weeks, after which the patient is returned to the operat- the complicated diabetic foot wounds. In: Zgonis T, ed. Surgical Reconstruction
of the Diabetic Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins;
ing room for removal and an additional period of 3 to 4 weeks
2009:119–128.
in a non–weight bearing short-leg cast if feasible. Incomplete Kollig E, Esenwein SA, Muhr G, et al. Fusion of the septic ankle: experience with
osseous bridging or pseudarthrosis is not uncommon in diabetic 15 cases using hybrid external fixation. J Trauma. 2003;55:685–691.
patients with severe osteopenia and peripheral neuropathy and McGarvey WC. The use of external fixation in arthrodesis and salvage of the foot
may require an extended period of non–weight bearing, exter- and ankle. Foot Ankle Clin. 2001;7:147–173.
Paola LD, Ceccacci T, Ninkovic S, et al. Limb salvage in Charcot foot and ankle
nal bone stimulation or revisional surgery, depending on the osteomyelitis: combined use single stage/double stage of arthrodesis and
alignment and surgical site. external fixation. Foot Ankle Int. 2009;30:1065–1070.
Parsons B, Strauss E. Surgical management of chronic osteomyelitis. Am J Surg.
2004;188:57–66.
Ramanujam CL, Zgonis T. Antibiotic-loaded cement beads for Charcot ankle
C l i n ical Tips and Pearls osteomyelitis. Foot Ankle Spec. 2010;3:274–277.
Ramanujam CL, Zgonis T. Primary arthrodesis and sural artery flap coverage
A. Advanced medical imaging can be used to detect the for subtalar joint osteomyelitis in a diabetic patient. Clin Podiatr Med Surg.
presence and extent of osteomyelitis, especially in the 2011;28:421–427.
Salzman CL. Salvage of diffuse ankle osteomyelitis by single-stage resection and
presence of diabetic Charcot neuroarthropathy.
circumferential frame compression arthrodesis. Iowa Orthop J. 2005;25:47–52.
B. Aggressive debridement of infected and devitalized soft Stone PA, Back MR, Armstrong PA, et al. Midfoot amputations expand limb
tissue and bone is critical in the initial surgical treatment. salvage rates for diabetic foot infections. Ann Vasc Surg. 2005;19:805–811.
C. Utilization of antibiotic cement beads/spacers can fill Taylor SM, Kalbaugh CA, Blackhurst DW, et al. Preoperative clinical factors pre-
in largely resected areas and create an aseptic, stable dict postoperative functional outcomes after major lower limb amputation:
an analysis of 553 consecutive patients. J Vasc Surg. 2005;42:227–235.
environment to treat residual infection. Zalavras CG, Patzakis MJ, Holtom P. Local antibiotic therapy in the treatment of
D. Hybrid or off-loading external fixation can span open fractures and osteomyelitis. Clin Orthop Relat Res. 2004;427:86–93.
resected joints, while stabilizing surround osseous struc- Zarutsky E, Rush SM, Schuberth JM. The use of circular wire external fixation in
tures and soft tissue envelope. the treatment of salvage ankle arthrodesis. J Foot Surg. 2005;44:22–31.
E. Negative pressure wound therapy or orthobiologic
dressings may be utilized until final soft tissue recon-
structive closure is initiated.
F. Arthrodesis techniques with bone grafting and exter-
nal fixation are used for final-staged reconstruction in
the foot and ankle.
G. Wire/pin placement with awareness of anatomy and
safe zones will limit the postoperative wire/pin tract
infections and breakage.
H. An additional external fixation foot plate or off-
loading external bars will prevent unwanted weight
bearing and provide off-loading to allow osseous bridg-
ing within resected joints.
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Chapter
20
Crystal L. Ramanujam
Zacharia Facaros
Thomas Zgonis
Surgical Off-loading External

Fixation and Plastic Reconstruction
Introduction realignment for deformity correction does not preclude the

use of external fixation, rather these situations benefit from
Surgical off-loading external fixation serves as a unique method stable bone and joint alignment established by the device. In
for protection and stabilization of soft tissue and osseous recon- addition, this method can be incorporated to stabilize fractures
struction in the lower extremity. This technique provides a involving the foot and/or ankle while simultaneously providing
means for effective immobilization that is particularly useful off-loading of any plastic flap coverage required in cases of trau-
in plastic reconstruction. The survivability of soft tissue recon- matic soft tissue loss. Most common external fixation constructs
struction can easily be compromised by pressures induced post- for fracture stabilization can be easily modified for off-loading
operatively, most commonly associated with weight bearing and components to prevent further soft tissue compromise caused
premature joint motion. In addition to being well tolerated by excessive contact pressures during the postoperative period.
by the carefully selected patient, off-loading external fixation The indications for specific types of plastic reconstruction
avoids complications often caused by traditional casting and vary on the basis of the clinical scenario and in many cases a
splinting methods while also permitting easy accessibility for combination of techniques can be successfully used. It is useful
wound and/or flap care. Surgical off-loading external fixation to base the surgical approach on the rationale behind the recon-
can be adapted for scenarios requiring simultaneous flap man- structive soft tissue ladder or pyramid, with the least invasive
agement and deformity correction. Plastic reconstruction for options considered first prior to the complicated, more invasive
the foot and ankle includes a wide array of options extending methods. Once infection and/or bone pathology have been
from skin grafts, orthobiologics and negative pressure wound addressed, wounds can initially be considered for primary clo-
therapy (NPWT) to local flaps, pedicle flaps, and free tissue sure. However, wounds left behind following extensive soft tissue
transfer. Utilization of extensive plastic reconstruction with off- and bone resection will most likely require more advanced clo-
loading external fixation should be accomplished through a sure techniques. For larger, deep wounds with exposed tendon
multidisciplinary approach tailored for the individual patient. or bone, NPWT to facilitate proper granulation and prepare the
The authors present a stepwise approach to applying surgical wound for later definitive coverage may be used.
off-loading external fixation for various plastic reconstructive Extensive proximal amputation at the central rays of the
procedures in the foot and ankle. foot for treatment of osteomyelitis and/or necrosis often leads
to creation of a cleft-foot deformity. Although these amputations
are technically easy to perform, the resultant foot may lead
Indications/Contraindications to recurrent wounds, transfer lesions, and instability. Several
options have been described regarding closure of the defects
Surgical off-loading external fixation is indicated for protec- through narrowing of the forefoot via manual compressive
tion of plastic reconstruction that is not amenable to conven- techniques. The use of an off-loading external fixation after
tional casting or splinting. Furthermore, advanced soft tissue central ray resection creates stable compression of the remain-
and osseous procedures at weight bearing or decubitus surfaces ing metatarsals in order to close the defect without tension.
are better off-loaded with external fixation techniques since This technique can also be combined with NPWT, skin grafting,
the limb is fully suspended in a rigid construct. For scenarios or the use of orthobiologic matrices. The use of orthobiologic
in which there is anticipated noncompliance with a non–weight materials such as bioengineered skin substitute tissues may be
bearing status, off-loading external fixation provides an ideal employed if the soft tissue defect is located in an area that is
environment for immobilization and postoperative care. His- unsuitable for a skin flap, and often over exposed neurovascu-
tory of extensive bone resection for osteomyelitis or skeletal lar structures and tendons to prevent desiccation.
360
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Surgical Off-loading External Fixation and Plastic Reconstruction of the Foot and Ankle 361
Split-thickness skin grafting (STSG) provides a quick and reconstruction may be delayed in certain patients with periph-
effective method for closure of well granulated wounds in non– eral vascular disease until optimal circulation for healing can
weight bearing or sometimes if necessary in weight bearing be established. These techniques are not ideal for patients who
areas of the foot. These are especially useful for coverage of are unable to maintain a non–weight bearing status during the
wounds left behind following rotation and insetting of pedicle postoperative period or those who cannot undergo frequent
flaps. Local random flaps, which vary among advancement, monitoring for wound and pin site care.
rotational or transpositional types, are ideal for closure of
small to moderately sized wounds with adequate perfusion.
If a wound has surrounding soft tissue that demonstrates Preoperative Considerations
good elasticity by way of the pinch test, a local random flap
is often an appropriate closure option. These flaps are suit- Appropriate patient selection and surgical timing are vital to
able for coverage of plantar cuboid ulcerations associated the success of plastic reconstruction of the foot and ankle with
with Charcot neuroarthropathy as well as sub-metatarsal head surgical off-loading external fixation. A multidisciplinary team
ulcerations. approach is most successful for the comprehensive manage-
Muscle flaps, which are based on their pattern of blood sup- ment of these patients. An extensive workup, keeping in mind
ply, can provide bulk for larger defects and excellent coverage the presence of infection, vascular status, patient age, associ-
at exposed bone, thereby facilitating local antibiotic delivery. ated comorbidities, level of deformity, as well as knowledge of
The abductor hallucis (ABH) muscle flap is ideal for cover- compliance are crucial to surgical planning. The surgeon also
age of defects on the plantar and medial aspects of the foot needs to consider the patient’s psychosocial status and home
and ankle, possibly extended to the medial malleolus region support system since these can impact surgical expectations,
if necessary. The flexor digitorum brevis (FDB) muscle flap especially regarding the postoperative course.
is favored for plantar central wounds, often allowing for the Once the patient is medically optimized, infectious proc-
donor site to be closed primarily as result of its location. The esses must be addressed through adequate surgical debride-
abductor digiti minimi (ABDM) muscle flap is utilized for tis- ment and appropriate antibiotic therapy. Staging of procedures
sue loss about the lateral aspect of the mid- and rearfoot, often is typically most ideal for the long-term success of plastic
employed to close proximal and plantar lateral defects, and surgical techniques in the lower extremity. The presence of
the extensor digitorum brevis (EDB) muscle flap is favored for peripheral vascular disease must be assessed for improvement
large dorsal and proximal foot and ankle wounds. in healing potential prior to reconstruction. Basic noninva-
Pedicle flaps are indicated when the aforementioned sive vascular testing is completed on a routine basis to ensure
options are not viable. These flaps provide coverage of moder- adequate perfusion to the affected area. Patency and direction
ate to large size defects and are harvested from non–weight of flow at the proposed artery to be included in the pedicle is
bearing surfaces. Neurovascular pedicle flaps such as the tested using a Doppler ultrasound. A formal consultation with
medial plantar artery (MPA) flap or reverse flow sural artery the vascular surgery team is obtained if more extensive workup
neurofasciocutaneous (SAN) flap are ideal for restoring sensa- is warranted. Diagnostic angiography can be performed to
tion on weight bearing surfaces of the foot. The MPA flap is more closely evaluate arterial patency, while vein mapping
useful for defects located to the dorsal-medial or plantar-lateral is specifically done for the reverse flow SAN flap in order to
regions of the midfoot and heel, providing structurally similar determine the location and diameter of the lesser saphenous
tissue to the plantar foot, posterior heel, and ankle defects with vein to delineate skin incision placement and guide surgical
its thick glabrous plantar skin and shock-absorbing fibroadi- dissection.
pose, subcutaneous tissue. The reverse flow SAN flap is pre- Skeletal bone and joint stabilization is often recommended
ferred when attempting to cover extensive tissue loss around when combining plastic reconstruction and off-loading exter-
the heel, ankle, and lower leg. Pedicle flaps in combination nal fixation of the foot and ankle. This technique significantly
with off-loading external fixation are extremely useful since aids in maintaining the foot and lower leg in a well-aligned
these flaps are compromised in areas of movement or variable position, allowing the soft tissue reconstruction to heal in the
tension. Pedicle flaps may also be helpful harvested from the proper orientation in preparation for functional restoration.
opposite extremity and thus creating the cross-leg or cross-foot This phenomenon is important particularly to the plantar
pedicle flap. aspect of the foot, where the replaced soft tissue structures
Free tissue transfer is one of the final options for soft tis- must be able to withstand and endure the absorption and shear
sue coverage in the foot and ankle, ideal for providing stable forces applied during gait. Ordinarily following insetting of the
wound coverage in larger defects and allows for optimal func- flap, any premature movement or disruption before healing
tional outcomes with less donor site morbidity when compared will compromise the area, commonly leading to surgical wound
to pedicle flaps. However, in patients with multiple comor- dehiscence. The off-loading external fixation device allevi-
bidities free tissue transfer may not be indicated since the ates most of this potential adverse effect and when combined
procedures often require longer operating times, prolonged with skeletal bone and joint stabilization it provides adequate
hospital stays, intensive care unit monitoring, and the possible immobilization which is mostly useful for noncompliant or
need for additional surgery to recontour the reconstructed heavier patients who at times will disrupt the external fixation
area. construct inadvertently. Skeletal bone and joint stabilization is
Contraindications for the use of surgical off-loading exter- frequently performed with single or multiple Steinmann pins,
nal fixation include preexisting internal fixation that prohibits sizes of which vary depending on the location and anatomy
proper wire insertion and poor bone quality or pathology that targeted, common sizes ranging from 2.7 to 3.5 mm. The more
precludes pin fixation. Off-loading external fixation and plastic common articulations stabilized tend to be the medial and
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362 Chapter 20
lateral columns of the foot, rearfoot, talocalcaneal and tibio- foam is used on typical full-thickness granular wounds, whereas
talar joints. The necessary external pin is usually inserted in a the second foam is optimal for wounds with undermining or
percutaneous fashion, from the plantar proximal aspect of the exposed avascular structures. After the wound is prepared
foot, oriented in a vertical fashion and oriented proximally and through debridement, the appropriate foam is cut to fit the
superiorly through the aforementioned joints while maintain- wound and placed directly against the wound base. The foam is
ing neutral alignment. C-arm fluoroscopy is commonly utilized then secured in place with the provided adhesive tape followed
to confirm accurate placement and alignment. Multiple exter- by application of the vacuum tube in direct contact with the
nal percutaneous pins are generally used and appropriately cut foam, usually via a small slit cut into the adhesive tape overlying
at the entry point, and exposed portions are protected by pin the foam. Adequate seal can be tested by first connecting the
caps. This percutaneous skeletal bone and joint stabilization vacuum tube to the suction device. Once no leaks are found,
technique is usually recommended before the application of the vacuum tube is then connected directly to the VAC therapy
the surgical off-loading external fixation device. unit preset to 125 mmHg continuous therapy. If the VAC
Characteristics of the particular external fixation system therapy is used over a STSG or any orthobiologic materials, it is
are important factors when considering biomechanical obli- usually left intact for continuous 3 to 5 days at a lower pressure.
gations for the specific pathology. For instance, the desirable Bridging techniques are available for multiple wounds requir-
mechanics for fracture repair can be oriented to allow for ing NPWT or in cases where the vacuum tube cannot be placed
control of interfragmentary movement, whereas for deformity directly over the wound itself.
correction, the individual components and external fixation Prior to the application of the off-loading external fixa-
configurations provide stability and neutralization of forces to tion, the use of a tourniquet if applied is deflated and a new
maintain correction. Prior to reconstructive surgery, significant sterile field is set up and the operative team changes their
soft tissue loss or vascular injury, when present, requires a sta- outer gloves to prevent contamination during application of
ble external fixation construct that will allow for further debri- the external fixation device. One or two tibia circular ring(s)
dement procedures or vascular repair if needed. Furthermore, is placed 10 to 15 cm proximal to the ankle joint making sure
in those instances that require plastic reconstruction, surgi- that the circular ring is well aligned within the lower extrem-
cal off-loading external fixators become applicable to allow ity with adequate space permitting any postoperative edema.
for proper healing time without disruption of the underlying The first transosseous wire is inserted from a lateral-to-medial
correction. direction on the undersurface of the ring and is perpendicular
at 90 degrees to the longitudinal axis of the leg in the frontal
plane, while the second transosseous wire is inserted from a
Detailed Surgical Technique medial-to-lateral direction on the top surface of the ring at
a 45- to 60-degree angle to the longitudinal axis of the leg.
The primary objective is to achieve closure of a wound after These transosseous wires are manually tightened to the periph-
establishing a healthy, noninfected wound bed, well perfused ery of the circular ring via wire fixation nuts and bolts from the
and biomechanically stable with functional anatomy. In order side they were inserted, followed by tensioning and tightening
to do so, concomitant osseous reconstructive procedures may from the opposite sides of the ring. Tensioning for the tibia
be required to correct any underlying deformity that can sup- transosseous wires ranges between 110 and 130 kg of force. At that
port the overlying soft tissue reconstruction. Whether the soft point, cutting of the tibia wires after appropriate bending is
tissue correction is located at the plantar aspect of the foot performed. Next, a second circular ring is placed located over
or more proximally on a non-plantigrade aspect, off-loading the midfoot/forefoot region and secured by the insertion of
external fixation is a useful adjunct to stabilize the overall two smooth or olive transosseous wires each at approximately
reconstruction. Although osseous deformity correction and 45- to 60-degree angle in opposing fashion. These midfoot/
realignment procedures are important for maintenance of forefoot transosseous wires are manually tightened and secured
soft tissue coverage and long-term durability, this chapter will to the circular ring followed by appropriate tightening with the
mostly focus on specific creative soft tissue procedures with wrenches. Next, multiple threaded hinges are incorporated
concomitant off-loading external fixation. between the two rings or between the midfoot/forefoot ring
and the tibial block which may be consisted of two circular rings
and securely fastened into place. Distally threaded rods are
Negative Pressure Wound Therapy
then inserted on the medial and lateral aspects of the device
Prior to the application of the NPWT device, wound bed and are secured posteriorly with carbon fiber bars to off-load
preparation is typically achieved through sharp debridement. the extremity in the appropriate fashion. A final bar-to-clamp
In many cases, the Versajet Hydrosurgery System (Smith & apparatus is secured at the bottom of the off-loading surgical
Nephew, Cambridge, UK) is used to precisely debride the fixation for further stability and rigidity of the entire construct
wound base and avoid excessive tissue loss. Local hemostasis (Figure 20.1).
can be achieved through application of topical thrombin. The Finally, after the application of the external fixation device
most frequently used NPWT device is the VAC system (Kinetic bridging techniques may be useful to connect the VAC system
Concepts, Inc., San Antonio, TX); however, several other so that transosseous wires can be appropriately inserted at ana-
devices are also currently available on the market. The VAC tomic safe zones without sacrificing stability of the VAC dress-
system consists of an open-celled foam, adhesive tape, vacuum ing. NPWT is extremely versatile and can be used adjunctively
tube, and therapy unit with collecting canister. Two types of over several types of plastic soft tissue reconstruction to facili-
foam are available, including the traditional GranuFoam™ tate wound healing in conjunction with off-loading external
(with or without silver) and the Versa White Foam™. The first fixation (Clinical Case I).
LWBK1121-C20_p360_376.indd 362 04/10/12 11:37 AM

A,B C
D,E F
Figure 20.1. One or two tibia circular ring(s) is placed 10 to 15 cm proximal to the ankle joint mak-
ing sure that the circular ring is well aligned within the lower extremity with adequate space permitting
any postoperative edema. The first transosseous wire is inserted from a lateral-to-medial direction on the
undersurface of the ring and is perpendicular at 90 degrees to the longitudinal axis of the leg in the frontal
plane, while the second transosseous wire is inserted from a medial-to-lateral direction on the top surface of
the ring at a 45- to 60-degree angle to the longitudinal axis of the leg (A). These transosseous wires are manu-
ally tightened to the periphery of the circular ring via wire fixation nuts and bolts from the side they were
inserted, followed by tensioning and tightening from the opposite sides of the ring. Tensioning for the tibia
transosseous wires ranges between 110 and 130 kg of force. Next, a second circular ring is placed located
over the midfoot/forefoot region and secured by the insertion of two smooth or olive transosseous wires each
at approximately 45- to 60-degree angle in opposing fashion. These midfoot/forefoot transosseous wires are
manually tightened and secured to the circular ring followed by appropriate tightening with the wrenches
(A). Next, multiple threaded hinges are incorporated between the two rings or between the midfoot/fore-
foot ring and the tibial block which may be consisted of two circular rings and securely fastened into place
(B). Distally carbon fiber bars are then inserted on the medial and lateral aspects of the device (C) and are
secured posteriorly with carbon fiber bars to off-load the extremity in the appropriate fashion (D, E). A final
bar-to-clamp apparatus is secured at the bottom of the off-loading surgical fixation for further stability and
rigidity of the entire construct (F).
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364 Chapter 20
CLINICAL CASE I
Preoperative clinical pictures (A, B) of a chronic Charcot midfoot was followed by the application of negative pressure wound ther-
deformity with a history of recurrent ulcerations and infections. apy directly over the split thickness skin graft recipient area that
The patient’s medical history was also complicated by diabetic was left intact for approximately 5 days (F). Off-loading circular
neuropathy and peripheral vascular disease. The patient was external fixation was used (G, H) to avoid any complications
brought to the operating room for an initial surgical debride- caused by traditional casting and splinting methods while also
ment and to obtain deep soft tissue and bone cultures (C). Three permitting easy accessibility for surgical wound care. The surgical
days after the initial surgery, the patient returned to the operat- off-loading external fixation device was removed approximately
ing room for a midfoot exostectomy with a muscle flap and split 6 weeks postoperatively. Final clinical pictures at approximately
thickness skin graft coverage over the surgical wound (D, E). This 6 months postoperatively (I, J).
A,B C
D,E F
(continued)
LWBK1121-C20_p360_376.indd 364 04/10/12 11:38 AM

G,H I,J
Closure of Forefoot Cleft Wounds ring. The off-loading component of the entire construct is then
applied, integrating a combination of clamps and bars. Two rod-
The affected central ray is resected in traditional fashion by
to-bar and two bar-to-bar clamps are used; however, ring clamps
performing a racquet-type incision circumferentially about the
may also be implemented when a half or full ring is assembled.
digit and extending over the metatarsal. The digit is sharply
One clamp is first attached to the distally oriented threaded
disarticulated at the level of the metatarsophalangeal joint. All
hinge, either medially or laterally, and more specifically, the
nonviable soft tissue is resected, and the metatarsal is carefully
threaded rod positioned anteriorly to the involved hinge. A sec-
dissected from surrounding tissue to the level of healthy bone.
ond clamp is now attached to the opposite threaded rod. Two
The metatarsal is then resected with a sagittal saw and the distal
bars, one for each side, are now clamped into place, oriented in
fragment is sharply removed from the wound. Any underly-
a vertical alignment pointing posteriorly, followed by two addi-
ing necrotic, avascular, or infected tissue is removed. The use
tional clamps now attached to the ends of the previously placed
of a tourniquet if applied is deflated and the surgical site is
vertical bars. A longer bar, oriented in a transverse alignment,
irrigated with sterile normal saline, typically through pulsatile
now connects the vertical bars, through the third and fourth
lavage. Once hemostasis is achieved, all surgeons re-glove and
bar-to-bar clamps required for the kickstand construct. Now,
the extremity is re-draped in order to avoid contamination of
since the wound edges have been carefully re-approximated
the external fixation device.
through narrowing of the forefoot, the wound is closed with
The foot and lower extremity are positioned in neutral
simple interrupted sutures without tension or by using STSG,
alignment on the operating table. The first transosseous wire is
orthobiologic materials, and/or NPWT (Clinical Case II).
inserted from a lateral-to-medial direction on the undersurface
of the ring and is perpendicular at 90 degrees to the longi-
Local Advancement Flap
tudinal axis of the leg in the frontal plane, while the second
transosseous wire is inserted from a medial-to-lateral direction The flap is accurately mapped out according to the exposure
on the top surface of the ring at a 45- to 60-degree angle to needed, blood supply, and attempting to spare adjacent sen-
the longitudinal axis of the leg. These transosseous wires are sory or motor nerves. The entire wound is excised to healthy
manually tightened to the periphery of the circular ring via margins, leaving a circular or rectangular defect. The use of
wire fixation nuts and bolts from the side they were inserted, a tourniquet if applied is deflated and the surgical wound is
followed by tensioning and tightening from the opposite sides irrigated through pulsatile lavage and a new sterile field is set
of the ring. Tensioning for the tibia transosseous wires ranges up about the foot along with changing of all the surgeons’
between 110 and 130 kg of force. A second circular ring is then top gloves. Two incisions are made that extend away from the
positioned at the midfoot region, carefully incorporating the wound, creating a flap with its apex adjacent to the recipient
cleft wound. Medial and lateral olive wires are inserted and fix- site. The length of the incisions should provide acceptable
ated to the midfoot ring with tensioning appropriately to allow mobility while minimizing tension. The flap is meticulously
compression of the metatarsals through the opposing olive undermined in a full-thickness fashion, below the subdermal
wires, therefore producing precise closure of the cleft wound. plexus of vessels in the subcutaneous plane, ultimately releas-
Intraoperative C-arm fluoroscopy is advised during this part ing the binding effect of this tissue. One should then encoun-
of the procedure making sure that the forefoot narrowing is ter multiple thin ligaments that are described as tissue bands
maintained after the application of the distal midfoot circular attaching the dermis of plantar skin to the fascial layer. The
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366 Chapter 20
CLINICAL CASE II
Intraoperative picture (A) of a diabetic cleft foot wound after the surgical procedure. The use of an off-loading external fixation
an extensive partial third ray (metatarsal and toe) amputation. after the central partial third ray resection created stable compres-
Picture (B) shows the application of a negative pressure wound sion of the remaining metatarsals in order to close the defect with-
therapy to the surgical site and before the use of the external fixa- out tension (C–F). The surgical off-loading external fixation was
tion device for surgical narrowing the forefoot area. Please note removed approximately 5 weeks postoperatively and followed by
that the negative pressure wound therapy is secured to the surgical an immediate use of a STSG to the postsurgical wound (G). Final
wound but not connected to the external tubing until the end of clinical outcome at approximately 3 months postoperatively (H).
A,B C
D,E F
(continued)
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G H
surgeon must take caution as to the depth of dissection to Muscle Flaps

avoid compromise to the underlying neurovascular bundle.
All muscle flaps within the foot are classified as type II intrin-
Once the flap is raised, gentle manipulation into the desired
sic muscles due to the presence of one dominant vessel at its
location is performed, further dissection when necessary for
origin and several minor vessels entering distally. Multiple
increased mobility. Any active bleeders should be coagulated
muscle flaps are available to the reconstructive surgeon
or cauterized accordingly in preparation for insetting of
and three of the most commonly performed are discussed
the flap to the defect. For flaps that are ready for advance-
below.
ment, topical thrombin may be used for further hemostasis
control, particularly in case with larger defects. The flap is
Abductor Hallucis Muscle Flap
now advanced into position, ensuring minimal tension. Deep
sutures should be avoided if possible; however, absorbable The skin incision is placed starting proximal to the first meta-
suture of medium strength is at times needed to maintain tarsal phalangeal joint (MTPJ) along the medial aspect of the
the reconstruction. Nonabsorbable suture is used for skin foot and extends proximally to the plantar aspect of the navicu-
margin approximation, heavier strength when needed for lar tuberosity. When needed, the skin incision can be extended
maximal stability. Areas of redundant skin can be addressed proximally as far as the location of the medial malleolus. It is
through Burrow’s triangle excisions in which the triangle important to note that the skin incision placement should be
is excised perpendicular to the rotating axis. Furthermore, placed just superior to the plantar skin crease junction. Sharp
small Z-plasties may also be added to the base of the flap if and blunt dissection is performed and the commonly con-
additional mobility is required. Once viability of the flap is fronted perforating veins stem from the great saphenous vein,
confirmed, a temporary dressing is applied to protect the flap, ultimately requiring ligation. The fascia overlying the muscle
while re-draping of the extremity is performed to prepare for belly is identified, at which time the muscle’s tendinous inser-
application of the off-loading external fixation. A distal tibial tion located along the medial aspect of the proximal phalanx
ring is placed approximately 10 to 15 cm proximal to the ankle of the hallux is also exposed. Minimal dissection of the tendon
joint and two to three smooth transosseous wires oriented is completed, at which time it is transected after grasping and
45 degrees to each other in the anatomic safe zones of the stabilizing the distal aspect with a hemostat or similar clamp-
lower leg in a similar fashion as described above. There should ing instrument. The transected portion of the tendon is now
be equal space between the ring and the underlying anatomy tagged with a suture, preferably a larger strength nonabsorb-
in a circumferential fashion. The circular ring is then con- able suture. The concept behind tagging is for easier and
nected either to a threaded Steinmann pin or to a transfixa- gentler manipulation in order to prevent compromise by man-
tion pin in the calcaneus. The construct is then elevated from ual handling. Identification of the distal perforating arterial
the bed with a simple bar-to-clamp configuration or through braches is required, branches of the MPA, making certain to
an additional midfoot circular ring as described above. Fur- preserve the proximal perforator, the last of which is generally
ther stability can be achieved by incorporating a large Stein- located 0.5 to 1 cm distal to the plantar aspect of the navicular
mann pin through the midfoot and secured to the off-loading tuberosity. The muscle is gently dissected free from distal to
circular external fixation (Clinical Cases III and IV). proximal, eventually rotated while minimizing tension across
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368 Chapter 20
CLINICAL CASE III
Intraoperative picture (A) of a right plantar lateral ulceration that is secured with nonabsorbable sutures (C). Multiple clini-
of a stable diabetic Charcot foot excised in full-thickness and cal views (D–G) of the surgical off-loading external fixation
in a triangular fashion. (B) shows the marking of the local system consisted of a circular ring in the midfoot area. The
rotational and advancement flap toward the laterally oriented off-loading surgical external fixation device was removed at
base of the excised triangular soft tissue defect. Any tourniquet 5 weeks postoperatively. Final clinical outcome at 4 months
use is deflated before insetting of the flap to the recipient area postoperatively (H).
A,B C
D,E F
G H
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CLINICAL CASE IV
Intraoperative picture (A) of a left plantar lateral ulceration is secured with nonabsorbable sutures (C). Clinical views (D, E)
of a stable diabetic Charcot foot excised in full-thickness and of the surgical off-loading external fixation system consisted
in a triangular fashion. (B) shows the raised local rotational of a circular ring in the midfoot area. The off-loading surgical
and advancement flap toward the laterally oriented base of external fixation device was removed at approximately 5 weeks
the excised triangular soft tissue defect. Any tourniquet use is postoperatively. Final clinical outcome at 4 months postopera-
deflated before insetting of the flap to the recipient area that tively (F).
A,B C,D
E F
the last perforating artery. The muscle is laid into the recipient MTPJs, and its four tendons insert into the middle phalanges.
area, sutured into place with low strength absorbable suture. The lateral plantar artery is the dominant pedicle supply but
At times for complete wound closure, a STSG or orthobiologic the MPA also provides perfusion. The incision is placed through
dressing is applied to augment coverage of the muscle. a midline or “Z” shaped orientation at the plantar aspect of
the foot, being considerate of the obliquely oriented lateral
plantar artery. These perforators when dissecting from a distal-
Flexor Digitorum Brevis Muscle Flap
to-proximal direction are identified, the orientation of vessels
The muscle originates at the medial calcaneal tubercle and the being variable. The binding ligaments are released with further
proximal plantar aponeurosis, the belly of which extends to the blunt dissection and upon appreciation of the plantar fascia, a
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370 Chapter 20
midline incision is performed, exposing the underlying FDB down to the overlying fascia, the tendinous insertion point once
muscle and associated tendons. The tendons are further dis- again identified as with previous muscle flaps, transected and
sected distally, freed, clamped, and transected approximately tagged, at which time, the muscle belly is raised and reflected
1 cm proximal to the plantar aspect of the metatarsal neck proximally, keeping mind of the perforators. The most proximal
areas. Since not all tendons need transection, a decision is made perforator targeted to remain intact is typically located at the
based on the bulk and viability of the individual muscle bellies. base of the fifth metatarsal or potentially up to 1 cm proximal to
The respective tendon(s) is tagged with suture, in which the the base. The tendon is then gently embedded into the recipi-
distal stump of remaining tendon(s) may be sutured to the adja- ent site, sutured in place with lower strength absorbable suture.
cent flexor digitorum longus tendon. The muscle belly is gently Once viability of any of the muscle flaps is confirmed, an
raised while concomitant proximal tension is placed on the autogenous STSG or orthobiologic layer is applied over the
tendinous portion. As with the ABH muscle, distal perforators flap and to also cover any donor sites if necessary, while re-
are ligated accordingly while preserving the proximal branches. draping of the extremity is performed to prepare for applica-
The muscle is then placed into the recipient site, loosely sutured tion of the off-loading external fixation. A distal tibial ring
into place with low strength absorbable suture. is placed approximately 10 to 15 cm proximal to the ankle
joint and two to three smooth transosseous wires oriented 45
degrees to each other in the anatomic safe zones of the lower
Abductor Digiti Minimi Muscle Flap
leg in a similar fashion as described above. There should be
The vascular pedicle is supplied from the lateral plantar artery, equal space between the ring and the underlying anatomy in a
located medially near the lateral calcaneal tuberosity. The mus- circumferential fashion. The circular ring is then connected to
cle is located along the lateral aspect of the foot, the tendon either a threaded Steinmann pin or a transfixation pin in the
of which inserts into the lateral proximal phalanx of the fifth calcaneus. The construct is then elevated from the bed with
digit. The incision is placed along the junction of the dorsal a simple bar-to-clamp configuration or through an additional
and plantar skin crease laterally, extending from the fifth MTPJ midfoot circular ring as described above. Further stability can
to the proximal aspect of the fifth metatarsal base. The incision be achieved by incorporating a large Steinmann pin through
may be further extended proximally when defects to the lateral the midfoot and secured to the off-loading circular external
malleolar region are reconstructed. Dissection initially is carried fixation (Clinical Cases V and VI).
CLINICAL CASE V
Preoperative radiographic (A) and intraoperative (B) pictures of arthrodesis with Steinmann pin fixation and wound coverage
a left foot with a history of calcaneal osteomyelitis after an open with an abductor digiti minimi muscle flap coverage and closure.
reduction and internal fixation. The patient presented after the Please note the harvesting (C), raising (D), and insetting (E) of
internal fixation was removed and with a history of open drain- the muscle flap. Clinical views (F, G) of the surgical off-loading
ing and infected wounds at the lateral aspect of the calcaneal external fixation system consisted of a circular ring in the mid-
wall. The patient underwent an initial incision and drainage foot area. The off-loading surgical external fixation device was
in our institution with further bone and soft tissue cultures. removed at approximately 8 weeks postoperatively. Final clinical
The patient eventually had a delayed primary subtalar joint (H) and radiographic (I) outcomes at 5 months postoperatively.
A B
(continued)
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Clinical
A case V (continued) B
C,D E
F,G H
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372 Chapter 20
CLINICAL CASE VI
Intraoperative picture (A) of a right plantar central recurrent (C) and continuous negative pressure wound therapy (D) for
ulceration of a stable diabetic Charcot foot that had multi- 5 days. Clinical views (E, F) of the surgical off-loading external
ple previous conservative and surgical attempts for wound fixation system consisted of a circular ring in the midfoot area.
closure. The patient returned to the operating room where The off-loading surgical external fixation device was removed
he underwent a revisional initial incision and drainage with at approximately 8 weeks postoperatively (G) and at that time
further bone and soft tissue cultures. He eventually under- the patient also received an autogenous split thickness skin
went a combined flexor digitorum brevis muscle (B) and local graft over the previous granular surgical site created from the
advancement flap (C) for coverage of the exposed bone at orthobiologic coverage (H). Final clinical outcome at approxi-
the plantar aspect of the foot. The donor site as well as the mately 1 year postoperatively (I).
muscle flap was covered with the use of an orthobiologic layer
A,B C,D
E,F G
(continued)
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H I
Medial Plantar Artery Flap as previously mentioned. In addition, towels are placed along
the outside of the external fixation to prevent any rotation
The soft tissue defect should be excised in a triangular shaped or angulation. Once in position, multiple transosseous tibia
fashion, the base of which oriented laterally. A handheld ster- wires are inserted, both tibia rings involving opposing transos-
ile Doppler is used to identify and map out the course of the seous wires, initially driven from lateral-to-medial direction and
artery. This flap is supplied by a combination of dorsalis pedis inferior to the respective rings. The opposing wires are then
collaterals and perforators from the superficial branch of the inserted from a medial-to-lateral direction and superior to the
MPA. When mapping out the skin incision, it is imperative to tibia rings, all four wires oriented, tensioned, and tightened as
create as large of a radius as possible, preserve the medial skin they were described in detail in Chapter 8. Half-pins may be
island, and avoid compromise to the weight bearing aspect of interchanged accordingly, as well as a third transosseous tibia
the forefoot. A semicircular incision is made, extending from wire connecting to each circular tibia ring. The same slotted
the base of the triangle, oriented in a distal–medial direction. fixation bolts and nuts are employed. At all times, neutral align-
Dissection is carried out under loupe magnification, beginning ment of the foot and lower leg is maintained appropriately for
laterally at the apex of the flap and then medially toward the postoperative healing. The next step is incorporation of the
artery. Further blunt dissection once again is executed, releas- two opposing calcaneal olive wires to the external foot plate.
ing the tethering ligaments with care to protect the perforators. The first olive wire is inserted from a lateral-to-medial direc-
Minimal handling of the flap is performed in order to prevent tion, placed firmly in the posterior-superior calcaneal tuberos-
ischemia or necrosis of the flap margins. The direct plantar ity, making sure to engage both cortices. This ensures that the
approach of this pedicle flap affords the surgeon the ability to neurovascular bundle located on the medial aspect is avoided
simultaneously address any underlying osseous deformity via and uncompromised. As the olive wire approaches the skin, it is
ostectomy or arthrodesis as indicated. The MPA flap is gently advised to cease drilling and to perform a minimal percutane-
inset at the recipient site under no tension and secured with ous stab incision, followed by blunt soft tissue dissection using
minimal absorbable suture and after deflation of the tourniquet a curved hemostat, providing a clear uninhibited entry point of
if applied. The donor site is then generally closed with STSG the olive portion into the skin. The wire drilling then resumes
or orthobiologic materials. A temporary dressing is placed to until light resistance is felt and a mallet is now used to complete
protect the soft tissue reconstruction while a new sterile field entrance of the wire, the end result being a parallel wire with
is set up about the extremity and the outer gloves of the entire olive abutment against the lateral calcaneal wall. A second olive
operative team are changed as well as replacement of previously wire is driven in an opposite direction, from medial to lateral,
used instruments in order to avoid cross-contamination. attempting to orient the wire away from the neurovascular
A pre-built static circular external fixation consisting of two bundle, thus, typically driven from a proximal-medial direc-
tibia circular rings (tibial block) connected to an external foot tion into the posterior-inferior aspect, exiting distal-laterally
plate which was constructed prior to the operative procedure is toward the base of the fifth metatarsal. Again, the inserted wire
then applied. The entire construct is placed over the foot and is ceased before the olive portion reached the skin, at which
lower extremity with folded sterile towels placed between the time a small percutaneous stab incision is placed followed by
leg and the external fixation device to maintain proper spacing blunt dissection, and so forth. Two olive wires are now abutting
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374 Chapter 20
the calcaneus for rotational and angular stability. The wires are tion is required. This construct consists of two or three external
connected to the external foot plate by way of posts, fixation TSF foot plates of equal size connected by multiple threaded
bolts, and nuts. It is advised that these wires are not tensioned rods while providing a smoother and more stable posterior
in patients with generalized osteopenia but if one was to do so, external fixation surface for the lower extremity (Clinical
normal force ranges from 70 to 90 kg of force. Next, completion Case VII).
of the entire construct is performed by adding long threaded
rods, half rings, and connection plates to connect and stabilize
the external foot plate to the tibia. Furthermore, a plantar addi-
Postoperative Course
tional off-loading ring may be connected to the external foot and Complications
plate for increased protection.
Based on the multidisciplinary team approach required for
Reverse Flow Sural Artery management of many of these patients, the individual is kept
Neurofasciocutaneous Flap in the hospital, maintained on culture-specific antibiotic ther-
apy, and provided with physical therapy training for appropri-
The reverse flow SAN flap is ideal for coverage of large defects ate non-weight bearing to the involved lower extremity for up
at the heel, ankle, and lower leg. Granulation of extensive soft to the first postoperative week depending on the extent of
tissue loss in these areas may initially be facilitated with NPWT to reconstruction employed. Once discharged from the hospital
provide a viable base for flap application. The wound is typically facility, the patient is then followed at 2-week intervals in the
excised in oval or circular fashion. The level of the most distal surgeon’s outpatient clinic for wound and pin site care with
peroneal arterial perforator also requires recognition, generally serial radiographs monitoring placement of external fixation
located approximately 5 to 7 cm proximal to the distal tip of the and any consolidation of underlying osseous correction. If
lateral malleolus between the fibula and the Achilles tendon. NPWT was chosen for initial placement over the graft or flap,
Harvesting of the flap is begun by tracing the shape of the wound its use is discontinued approximately 5 to 7 days after initial
defect with a surgical marker onto sterile paper wrapping from placement and replaced with sterile dressings. In contrast,
the surgical gloves. The shape is then cut out and retraced onto stent or bolster-type dressings are usually left intact for as long
the proximal posterior leg for appropriate dissection. Under as 2 to 4 weeks postoperatively. External fixation placed as
loupe magnification, the medial sural nerve is identified fol- purely for off-loading reasons can be removed at 6 to 10 weeks
lowed by ligation of the median superficial sural artery and lesser following the initial reconstruction. At the time of external
saphenous vein each with two closely placed medium hemoclips, fixation removal, further surgical performance of revisional
and isolation of the pedicle components is performed after closure techniques if dehiscence has occurred is employed.
transection between the hemoclips. A “Z” shaped incision from For those flaps that had orthobiologic dressings applied over
the pedicle flap to the level of the soft tissue defect is created small defects at the donor site, STSG can then be used for
beginning proximal to distal from the location of the distal per- definitive closure. Additional cast or splint immobilization is
forating peroneal artery with each arm of equal lengths. Further carried out based on the surgeon’s preference, with gradual
blunt dissection with care to avoid traumatic handling of the progression to weight bearing status in accommodative shoe
flap margins is performed. A key component is to avoid under- gear. Ancillary bracing and rehabilitation may be considered
mining of the flap. Dissection is then focused on locating the for patients needing additional support for ambulation.
pedicle components inferiorly, while then completing dissection The most common postoperative complications involved
medially and laterally for full harvesting. The tourniquet if used with surgical off-loading external fixation and plastic recon-
is then released to ensure flap perfusion. The flap is then inset to struction of the foot and ankle are related to poor patient and
the recipient wound bed with placement of absorbable sutures if surgical procedure selection. Complications associated with
necessary due to tissue loss during dissection. Otherwise, nonab- plastic reconstruction of the foot and ankle include surgical
sorbable skin sutures are placed. The superior donor site and/ wound dehiscence, delayed healing, vascular compromise,
or part of the pedicle may then be potentially closed primarily flap necrosis, infection, and re-ulceration. The advantage
or if not possible, further STSG or orthobiologic materials can of surgical off-loading external fixation to support frequent
be implemented. One pertinent step when closing the donor access and monitoring of the wound is invaluable for preven-
site is that deep buried sutures may reduce the primary size of tion, early recognition, and therefore subsequent treatment
the site, aiding in ultimate closure. An appropriate bolster-type of these complications. Complications specific to the use
dressing is applied over skin-grafted areas while the reverse flow of surgical off-loading external fixation are related to the
SAN flap is protected by a temporary dressing for application technical demands of its application. The surgeon needs to
of the off-loading circular external fixation. New sterile draping have ample surgical experience and knowledge of the lower
is performed and the surgical team changes their top gloves to extremity anatomic safe zones and especially the vascular
avoid contamination. components. Inadequate surgical planning and subsequent
Options for this off-loading external fixation device may misplacement of wires and/or pins through vital structures
incorporate full circular rings with an off-loading hybrid supplying the specific soft tissue coverage can lead to flap
“kickstand” version involving clamps and bars, possibly involving failure. Inappropriate wire tensioning can increase risk of
a third half or full ring, or a third option requiring a pre-built any osseous stress fracture. Patients also need to be cautioned
static circular fixation that incorporates an external foot plate. regarding appropriate care during the postoperative period
The stacked Taylor spatial frame (TSF) foot plate technique since the off-loading external fixator has the potential to
can also be utilized for surgical off-loading of this pedicle flap cause injury to the contralateral lower extremity, particularly
or when simultaneous osseous procedures or deformity correc- in the insensate population.
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CLINICAL CASE VII
Intraoperative picture (A) of an open posterior calcaneal wound of equal lengths. The flap is then inset to the recipient wound
with a history of previous recurrent infections that was surgically bed (C) and the superior donor site and/or part of the pedicle
debrided with a minimal partial calcaneal ostectomy. (B) shows are closed with a split thickness skin graft harvested just superior
harvesting of the reverse flow sural artery neurofasciocutaneous to the proximal aspect of the pedicle flap (D). Intraoperative pic-
flap from the posterior aspect of the lower extremity. A modified tures (E, F) of the surgical off-loading external fixation system.
“Z” shaped incision from the pedicle flap to the level of the soft The off-loading surgical external fixation device was removed at
tissue defect is created beginning proximal to distal from the approximately 6 weeks postoperatively. Final clinical outcome at
location of the distal perforating peroneal artery with each arm about 6 months postoperatively (G).
A,B C,D
E,F G
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376 Chapter 20
Conclusion
A. Utilization of extensive plastic reconstruction of the The authors have described the most common applications
foot and ankle with surgical off-loading external fixa- of surgical off-loading external fixation when combined with
tion needs to be accomplished through a multidiscipli- plastic reconstruction for the foot and ankle. Vast knowledge
nary team approach tailored for the individual patient. and experience with an interest in managing these pathologies
B. Basic noninvasive vascular testing is completed on a rou- is required when undertaking the difficult and complex task in
tine basis to ensure adequate perfusion to the affected achieving a successful outcome.
area. Patency and direction of flow at the proposed
artery to be included in the pedicle is tested using a
Doppler ultrasound or further vascular imaging. Recommended Readings
C. When contemplating the circular ring placement for Capobianco CM, Stapleton JJ, Zgonis T. Soft tissue reconstruction pyramid in the
surgical off-loading external fixation, the surgeon diabetic foot. Foot Ankle Spec. 2010;3:241–248.
needs to be aware of the location of internal fixation, Castro-Aragon OE, Rapley JH, Trevino SG. The use of a kickstand modification
for the prevention of heel decubitus ulcers in trauma patients with lower
bone graft, orthobiologics, and soft tissue coverage
extremity external fixation. J Orthop Trauma. 2009;23:145–147.
performed when applicable. Clemens MW, Parikh P, Hall MM, et al. External fixators as an adjunct to wound
D. The technique of skeletal bone and joint stabilization healing. Foot Ankle Clin. 2008;13:145–156.
significantly aids in maintenance of the foot and lower Jebson PJ, DeSilva GL, Kuzon WM Jr, et al. The box frame fixator: a technique
leg in a well-aligned position, allowing the soft tissue for simultaneous fracture and free-tissue transfer management. Plast Reconstr
Surg. 1998;102:262–263.
reconstruction to heal in the proper orientation in Jolly GP, Zgonis T, Blume P. Soft tissue reconstruction of the diabetic foot. Clin
preparation for functional restoration. Podiatr Med Surg. 2003;20:757–781.
E. The surgeon may consider first the least invasive tech- Lowenberg DW, Sadeghi C, Brooks D, et al. Use of circular external fixation
niques for soft tissue reconstruction of the foot and to maintain foot position during free tissue transfer to the foot and ankle.
Microsurgery. 2008;28:623–627.
ankle and progress along the reconstructive pyramid
as needed based on the given clinical scenario.
F. Loupe magnification, Doppler ultrasound probe and
appropriate tourniquet use is crucial to meticulous dis-
section, hemostasis, and maintenance of flap viability
intraoperatively.
G. The concept behind tagging of muscle flaps with suture
during dissection is for easier and gentler manipulation
in order to prevent compromise by manual handling.
H. When applying surgical off-loading external fixation in
conjunction with the reverse flow sural artery neuro-
fasciocutaneous flap, the foot should be held in slight
plantarflexion to reduce tension and stretch on the
pedicle components. Split thickness skin grafting may
also be considered over the pedicle components when
necessary to avoid any skin tension during closure.
I. The most common postoperative complications involved
with surgical off-loading external fixation and plastic
reconstruction of the foot and ankle are related to poor
patient and surgical procedure selection.
J. The advantage of surgical off-loading external fixa-
tion to support frequent access and monitoring of the
wound is invaluable for prevention, early recognition,
and therefore subsequent treatment of any postopera-
tive soft tissue complications.
LWBK1121-C20_p360_376.indd 376 04/10/12 11:39 AM

Chapter Vasilios D. Polyzois
21
Ioannis A. Ignatiadis
Alexandru V. Georgescu
Spyridon G. Pneumaticos
Stepwise Approach to Bone Loss,

Transport, and Lengthening with
External Fixation
Introduction solely or when performed in combination with other fixation

methods or with traditional flap surgery and advanced plastic
Bone transport is perhaps one of the most unique innovations microsurgical techniques.
of the Ilizarov circular external fixation system. Smaller or
larger bone and soft tissue defects resulting from traumatic or
infectious processes can be treated with bone transport of a seg- Preoperative Considerations
ment or segments of bone within the affected lower extremity.
This technique is based on the distraction histogenesis phe- Careful preoperative planning is necessary to determine the
nomenon, which is characterized by nature’s capability to heal bone segment that will be transported. One end of this segment
a fracture in diastasis and the ability to elongate skin, nerves, is adjacent to the missing bone or to the bone that will be resected
muscles, and vessels under gradual distraction. Bone transport and it will engage the opposite end of the gap when the transport
is usually a salvage procedure in complex conditions where is complete. The other end is where the iatrogenic fracture (cor-
other procedures have failed and has proven effective when ticotomy) will take place to make the bone transport possible.
compared to conventional methods. The first mentioned end of the bone segment is the docking end
Bone transport was identified in the literature for decades and the other end is the trailing end of the transported segment
as an alternative in the management of aseptic or septic of the bone. Behind the trailing end, by gradual distraction, the
and closed or open bone loss of the lower extremity. The same dynamic process of new bone (regenerate bone) formation
terms segmental or internal lengthening are synonymous takes place, as in simple lengthening by intramembranous ossi-
and indicate that although the proximal and distal anatomic fication. As the external fixator drives the docking end toward
structures are intact with normal length of the extremity, a the opposite healthy fragment of bone, many obstacles may be
loss of a fragment of bone (up to subtotal bone loss) possibly present to block the way so that healing procedure starts between
with its soft tissue envelope is in between or is necessary to be these two edges, that is, the docking site.
left behind after surgical debridement. Proximal and distal Some of the most common obstacles associated with the
healthy anatomic structures may also involve different bones bone transport process include the formation of connective
and the technique typically does not interfere with the length tissue within the segmental gap and soft tissue that can be inter-
of the extremity. posed between the facing bone edges as well as the presence
Other alternative techniques to address severe bone and of poor pin placement of the external fixator without correct
soft tissue loss of the lower extremity include and are not preoperative planning. In the event of no postoperative com-
limited to vascularized fibular autografts, intramedullary nails plications, the vascularization process of the facing bony edges
with external fixation in combination with autografting and will start normally and the shape of their surfaces plays a sig-
orthobiologics, structural allografts with autografts and ortho- nificant role for successful bone healing. In many cases, reshap-
biologics, induced membrane techniques as well as free flaps, ing of the facing ends in a flat, cup or cone shape or even
and autografting. autografting may be necessary at the docking site. Additional
In this chapter, the authors will review different applications orthobiologic materials may also be added at the docking site
of the bone transport technique including isolated significant to enhance and promote further bone healing.
bone loss case scenarios or a combination of major bone and Ilizarov termed the above-described technique as bifocal for
soft tissue loss in the lower extremity. Furthermore, the distrac- distraction at one level (corticotomy) and compression at a sec-
tion histogenesis operative technique will be demonstrated ond level (the level of the pseudarthrosis). Depending on the
377
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378 Chapter 21
A B
Figure 21.1. Proximal tibial corticotomy with distal transportation of a bone segment for the manage-
ment of a severe tibial bone loss in the lower extremity (A). Note the use of a uniplane monolateral external
fixator and final outcome (B).
specific location of bone loss, the corticotomy can be proximal uniplane monolateral constructs are attached by only Schanz
with distal transportation of the bone segment (Figure 21.1) pins that transmit forces directly on the soft tissues for distrac-
or distal with proximal transportation of the bone segment tion and transportation together with the bone so distraction
(Figure 21.2). histogenesis is performed instead of a sole distraction osteo-
In addition, in certain case scenarios trifocal techniques (Fig- genesis. This feature of the large Schanz pins is also essential
ure 21.3) can be adapted and very rarely, quadrifocal techniques for the gradual closure of major open wounds and is also ideal
have been used in the literature. Quadrifocal bone transport for allowing possible concomitant plastic surgery procedures
is not routinely recommended due to an increased number of due to the increased space within the external fixation pins
corticotomies that interfere with vascularization as well as the and clamps. Careful preoperative planning of pin insertion is
inevitably small bony segments that undergo transportation. In necessary to avoid any unwanted deviation or inadequate bone
those severe cases of bone loss, a partial fibular transport with segment transportation.
the posterior aspect of the fibula intact may be considered as Circular external fixators are utilized for more complex
an alternative to the bone transport technique. Although this bone transport procedures and are ideal for dynamic proper-
procedure is very challenging, it may also provide a much faster ties that differ from the static circular external fixators. Its
regenerate bone than even a trifocal bone transport (Figure indications are mostly considered for major bone and soft tis-
21.4). sue loss. It usually takes only a small portion of bone segment
There are usually two different external fixation designs for safe attachment of the most proximal and most distal fixed
for the bone transport technique. The safest and most com- circular rings while uniplane monolateral external fixation
mon types include the uniplane monolateral or multiplane needs the presence of at least the entire metaphyses for the
circular external fixation systems. Uniplane monolateral attachment of the fixed clamps.
external fixators are faster and easier to apply and their basic
construct includes two clamps with Schanz pins attached on
the healthy portions of the bone proximally and distally. In
Surgical Technique
most cases, these are fixed on the rail and do not move dur-
ing the bone transport procedure. In between the two clamps
Significant Isolated Bone Loss with
there is another clamp (rarely two when performing trifocal
Adequate Soft Tissue Coverage
technique) with Schanz pins attached on the segment of
bone that is being transported starting its way from the first Although the soft tissue envelope is healthy in these case sce-
fixed clamp toward the second fixed clamp. Careful planning narios and only the bone segment loss needs to be addressed,
and placement of the external fixation pins and/or wires is extra caution is necessary during the bone transport and
required in order to avoid hardware jamming and revisional especially when the large diameter Schanz pins are utilized.
surgery. In many cases, the soft tissues are extremely stretched and
Inappropriate use of pin fixation may result in deviation of under tension and eventually end up in excessive soft tis-
the transported segment and subsequent malformation of the sue mass toward the docking site. This process is based on
bone transport technique. Unlike the circular external fixators, the dermogenesis created behind the trailing end of the
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Stepwise Approach to Bone Loss, Transport, and Lengthening with External Fixation 379
A B
Figure 21.2. Example of a severely infected proximal tibial nonunion and loosened internal
fixation (A). The patient underwent surgical osseous and soft tissue debridement and removal of
hardware. This was followed by a distal tibial corticotomy and proximal transportation of a bone
segment for the management of the severely proximal tibial bone loss (B). Note the use of a
C uniplane monolateral external fixator and final outcome (C).
transported bone segment and needs to be addressed at each The most proximal clamp or ring and the most distal clamp
procedure. Regular skin releases under local anesthesia with or ring will be fixed on the external fixation device, while the
the use of a no. 11 blade are usually necessary during the bone two clamps or rings in the middle will be transporting the
transport procedure. This technique can never be underesti- necessary bone fragments. The proximal clamp or ring will
mated since excess skin tissue at the docking site can create move distally toward the midportion on the lower extremity
major difficulties in bone healing. while the distal one will move proximally in a similar fashion
In a trifocal technique for the management of closed bone toward the midportion of the lower extremity. Regular skin
loss with one proximal and one distal corticotomy, the soft releases throughout this process are necessary to avoid any
tissue issue can cause major obstacles for the completion of postoperative complications (Figure 21.5).
the procedure. When performing these corticotomies, the Finally, both Schanz pins and/or smooth wires can create
docking site will be at a level about the middle of the lower small wounds at the trailing side that usually heal by secondary
extremity. This procedure usually requires four clamps when intention. This is usually the most common site for pin or wire
using a monolateral external fixation system or four to five irritation and/or infection and great attention is given in order
circular rings when using a circular external fixation system. to avoid any further complication and possible removal. Extra
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380 Chapter 21
Most distal Distal

corticotomy corticotomy
Bone loss +
soft tissue gap
A B
C D
E F
Figure 21.3. Example of a trifocal technique in a 60-year-old diabetic patient with traumatic bone and
soft tissue loss of the right proximal tibia (A). Two distal tibial corticotomies were performed with partial
closure of the large wound proximally (B–D). Note the use of a uniplane monolateral external fixator to
facilitate any plastic surgery procedures if needed. Final radiographic and clinical views (E, F) showing
satisfactory regenerate bone distally, safe docking proximally, and complete soft tissue closure by distraction
osteogenesis techniques.
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A,B C
Figure 21.4. Example of a partial fibula transport technique in

a 39-year-old male with a severe posttraumatic bone loss of the mid-
portion and distal third of the right tibia (A). A longitudinal corti-
cotomy of the fibula at the level of the bone loss was performed and
the medial portion of the split fibula was transported medially and
anteriorly with the use of olive wires on a circular external fixator
(B, C). This fixator was changed to a uniplane monolateral external
fixation device during the treatment until consolidation of the regen-
D,E erate bone (D, E).
caution is considered in cases where an intramedullary nailing was to excise the hypertrophic skin edges when the transported
technique is used in combination with the circular external bone segment had reached the docking site. In addition, the
fixator for the bone transport in order to avoid any pin or wire use of autogenous cancellous bone grafting, orthobiologics,
site infection (Figure 21.6). and/or negative pressure wound therapy may also be great
adjuncts at the docking site. This combination of bone trans-
port with autogenous bone grafting has been shown to have
Significant Concomitant Bone and successful healing outcomes without the need of any major
Soft Tissue Loss without Plastic plastic reconstructive procedures. However, the use of free or
Reconstructive Surgery local muscle flaps may also be necessary for recalcitrant non-
In these severe cases of bone and soft tissue loss, the sur- healing wounds (Figure 21.9).
geon has to carefully select the anatomic regions for half-pin
attachment that will stretch and transport the bone, skin, and Significant Concomitant Bone and
related soft tissues. When a circular external fixation is uti- Soft Tissue Loss Treated with Acute
lized, smooth skinny wires are usually preferred for the initial Shortening, Flap Coverage, and
external fixation application since the smooth wires will pierce Bone Lengthening
and cut the underlying skin and soft tissues rather than stretch
them. However, larger diameter Schanz pins are usually utilized The concept of this surgical technique is to provide immediate
in the diaphyseal bone region and when the underlying skin end-to-end bone healing at the docking site and to simultane-
is very fragile. The Schanz pins are inserted as widespread as ously perform a corticotomy and lengthen the bone from an
possible within the circular external fixation device. Caution is anatomic region away from the original bone and soft tissue
also taken to avoid iatrogenic bone fracture from inappropriate loss. In addition, flap coverage by any reconstructive means
half-pin insertion. may also be facilitated with this acute bone segmental shorten-
Figures 21.7 and 21.8 show extreme examples of significant ing technique. However, certain limitations include and are not
bone loss in the lower extremity that was managed with a bone limited to possible vascular compromise of the lower extremity
transport technique and without any plastic reconstructive sur- when there is a necessity for excessive shortening due to ves-
gery. The only soft tissue procedure performed on each case sel kinking and excessive soft tissue mass at the docking site
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382 Chapter 21
A,B C
D,E F
Figure 21.5. Example of a trifocal technique with one

proximal and one distal corticotomy in a 26-year-old female
with a history of a rare tibial aggressive chondrosarcoma
(A). The patient underwent an aggressive radical resection
with an eventual tibial bone loss of approximately 23 cm. A
proximal corticotomy was performed about 5 mm distally to
the tibial tubercle combined with a distal tibial corticotomy
(B–E). The two transporting segments of bone reconnected
and healed at the level of the tibial midshaft with satisfactory
regenerate bone formation at their trailing ends (F–H). Regu-
lar skin releases with a no. 11 blade were paramount to avoid
G,H I a bulky soft tissue mass at the docking site (I).
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A,B C
Figure 21.6. Example of a tibial lengthening over an intramedullary nail with

the use of a circular external fixator (A, B). Pin/wire site infection is one of the most
common complications with this procedure and often occurs at the pins/wires that
transport bone segments. Extra caution is necessary when intramedullary nails are used
in combination with external fixators to avoid deep infection and septic complications.
The external fixator is also used for a shorter period of time compared to traditional
D techniques for limb lengthening (C, D).
A B
Figure 21.7. Clinical presentation of a 58-year-old male with incomplete lower extremity amputation and
major bone and soft tissue loss of the middle and distal third of the tibia (A). A proximal tibial corticotomy and
distal transportation of the bone segment along with the soft tissue envelope was performed (B). (continued)
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384 Chapter 21
C,D E
Figure 21.7. (continued) Note the use of Schanz pins for the procedure that transmit more force on soft
tissues than transosseous wires (C). Autogenous iliac crest bone graft was also used as adjunctive therapy at
the docking site (D). Final clinical outcome without the need of major plastic reconstructive surgery (E).
A,B C
D E
Figure 21.8. Example of a 55-year-old male with a major septic complication of a tibial pseudarthrosis and
after treatment of an open tibial fracture. Major bone and soft tissue loss approximately 21 cm resulted after
surgical debridement of infected and necrotic tissue (A, B). The patient underwent proximal and distal tibial
corticotomies and transportation of the bone segments toward the midportion of the tibia (C–E). (continued)
LWBK1121-C21_p377_390.indd 384 04/10/12 3:23 PM

F G
Figure 21.8 (continued)

Autogenous iliac crest
bone graft was also used as
adjunctive therapy at the
docking site (F, G). Final
radiographic and clinical
outcomes without the need
of major plastic reconstruc-
H I tive surgery (H, I).
A B
C D
Figure 21.9. Example of a 39-year-old male with posttraumatic proximal tibial bone and soft tissue loss
(A). A distal tibial corticotomy and proximal transportation of a bone segment to address the bone loss was
performed (B) combined with a local gastrocnemius flap for simultaneous soft tissue coverage (C, D).
LWBK1121-C21_p377_390.indd 385 04/10/12 3:23 PM

386 Chapter 21
Patella
Distal femur
Exposed & stripped distal femoral bone Resected 14 cm
A B
C,D E
Figure 21.10. Example of an exposed, nonviable right femur that was resected after a major motor
vehicle accident (A, B). The remaining femoral defect was approximately 14 cm and was addressed by acute
shortening to facilitate plastic reconstruction for wound closure (C). This was followed by a proximal femoral
corticotomy and lengthening to address the iatrogenic shortening (D, E).
that will need to be addressed at the time of acute shortening surgery is also warranted to avoid any major postoperative com-
(Figure 21.10). plications. One of the most common reasons for pin/wire tract
infection is the overall instability of the external fixation system
utilized that causes skin irritation, breakdown, and eventual infec-
Significant Bone Loss Treated with
tion. It is highly recommended that four elements of fixation (any
Isolated Bone Cortex Transport
pin/wire combination is acceptable) are maintained on the fixed
In some cases such as focal osteomyelitis, benign bone tumors proximal and distal segments during a bone transport procedure
or traumatic bone loss, debridement of the affected bone may that can even take up to 6 months of duration. In that case, if a
only necessitate part of the cortex and medullary canal without pin/wire becomes septic or loosened it can be safely removed
violating the opposite bone cortex. This represents an example without compromising the external fixation stability during the
of a partial bone transport by preserving the lower extremity’s bone transport process. The transported bone segment can then
stability and by utilizing the remaining cortex for new bone safely migrate by traction of three fixation elements.
formation at the transport site (Figure 21.11). If a trifocal technique is performed for the management
of a tibial defect, a proximal and a distal corticotomy are
performed. In this technique, two segments of bone are trans-
Discussion ported toward the midshaft of the tibia. If the Schanz pins are
attached in close proximity to the docking ends of the opposing
Bone transport surgery is a rewarding surgical experience but bone segments by rancho cubes, these cubes might meet about
usually encounters several minor and/or major complications. the midportion of the tibia before the bone segments engage.
It is imperative that the operating surgeon is well experienced On the other hand, if a circular external fixation is utilized in
in this type of surgery and possesses vast knowledge of external the initial stages of bone transport, multiple hinges are needed;
fixation biomechanics. however, it may be difficult to attach them to the limited space
In the presence of a pin/wire loosening or breakage, the of the circular ring fixation. In addition, other common exam-
patient is usually brought back to the operating room for a ples encountered during this technique may include antecurva-
revisional surgery. If a transported segment is deviating and one tum knee deformity and valgus deviation of the lower extremity
clamp or circular ring has to be removed or changed, revisional as identified by sagittal plane radiographs. If a local or free
LWBK1121-C21_p377_390.indd 386 04/10/12 3:23 PM

A,B C,D
Figure 21.11. Example of an isolated bone cortex transport in a 35-year-old female with a distal tibial
focal osteomyelitis (A). The infected area was resected (B) and a partial bone transport technique was utilized
(C). Note the use of a circular external fixator and obliquely pulling olive wires for the bone cortex transport
and final outcome (D).
tissue transfer is going to be used to cover the concomitant aligned in the lower extremity before the external fixation
soft tissue loss, the uniplane monolateral external fixation for application for the bone transport process. When the bone gap
bone transport is usually recommended due to the increased is exposed, two to three “external screws” are utilized on each
operative space between the proximal and distal segments. side of the gap. The length of the “external” plate depends
Bone transportation using the olive wire technique is not on the size of the bone gap and this technique can also be
typically recommended due to probable segmental instability performed with a one-third tubular plate if the bone defect
and/or migration. Utilization of four to five fixation points ends are in close proximity. This “external” plating technique
on the fixed clamps/wires and three to four fixation points on for better alignment and stability during the bone transport
the migrating clamps/wires are usually recommended in bone process toward the docking site can increase healing rates with
transport cases that are longer than 6 months of duration. better clinical outcomes. However, when it is not used, multiple
The use of hydroxyapatite-coated pins is also recommended hinges and external fixation adjustments might be necessary to
in longer cases of bone transport for increased strength to the align the migrating bone segment during the bone transport.
bone attachment and reducing the risk of pin tract infection. The utilization of a Taylor spatial frame for bone trans-
Careful anatomic placement is paramount in order to avoid port technique requires extensive experience and is usu-
major complications such as bone segment deviation and ally reserved for severe cases of lower extremity deformity
unwanted lower extremity deformity. (Figure 21.13). The most common obstacle in using this system
In some cases, the utilization of “external” dynamic com- is the limited operative space between the telescoping rods and
pression plates is necessary to avoid any unwanted migration inability for accurate placement of half-pins during the bone
of the transported bone segment (Figure 21.12). By using this transport process (Figure 21.14). However, its unique proper-
technique, the “external screws” of the dynamic compression ties and dynamization can provide simultaneous multiple level
plate are inserted at each end of the bone segmental loss and deformity correction and lower extremity alignment.
A B
Figure 21.12. Example of an “external” dynamic compression plate to ensure alignment and stability at
the docking site (A, B). Such plates or sometimes one-third tubular plates may be used to realign the extrem-
ity before performing debridement, application of an external fixator, and transport procedure. In cases
where the “external” plate is attached on necrotic or infected bone, it is removed together with the bone
prior to any transport procedure.
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388 Chapter 21
A,B C
Figure 21.13. Example of a proximal tibial corticotomy and bone transport using the
Taylor spatial frame for the management of severe bone loss combined with deformity.
Residual deformity and alignment can be adjusted gradually with the use of telescoping
D struts (A–D).
A,B C
Figure 21.14. Preoperative radiographic (A–C) and clinical (D, E) views of a severely complex lower
extremity deformity in a young patient with a history of fibular hemimelia. Note that the multilevel deform-
ity consisted of a shortened right lower extremity, procurvatum and valgus deformity of the tibia with lateral
dislocation of the patella, absence of fibula with pathologic ball and socket-type ankle joint in subluxation,
and severe pronation of the hindfoot and midfoot joints. After thorough discussion with the patient about
his lower extremity salvage options, a one-stage reconstruction was performed to address his complex lower
extremity deformity. (continued)
LWBK1121-C21_p377_390.indd 388 04/10/12 3:24 PM

D,E F
G,H I
J,K L,M
Figure 21.14. (continued) The patient underwent realignment of the knee extensor mechanism by
performing a trochleaplasty in order to shape a femoral trochlea which was absent for normal tracking of the
patella in addition to the proximal tibial osteotomy for lengthening and realignment of the lower extremity.
This is an example where the tibial lengthening was achieved with the utilization of a uniplane monolateral
external fixation device (F, G). An intramedullary nail device was also used for arthrodesis of the ankle and
subtalar joints and provided further stability of the distal lower extremity during the lengthening procedure
(H). A supplementary circular external fixator was then applied for additional correction and stability of
the foot to the lower extremity (I, J). The circular external fixator was removed at approximately 3 months
(K). The tibial length was achieved by the uniplane monolateral external fixator for a total gain of 4 cm of
discrepancy and it was removed at approximately 5 months after the original surgery. Final outcome (L, M)
at approximately 1-year follow-up.
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390 Chapter 21
Finally, the management of concomitant major soft tis- Conclusion

sue loss may be addressed either solely by the bone transport
technique or in combination with autogenous cancellous bone Distraction histogenesis has revolutionized clinical solutions
grafting, morphogenic proteins, bone marrow aspirate, and/or for traumatic and infectious bone loss with or without accom-
bone grafting or by the utilization of negative pressure wound panied soft tissue loss. The outcomes of bone transport surgery
therapy. In severe cases, local muscle or free tissue transfers are differ based upon the severity of deformity treated, the sur-
utilized to cover the defects at the docking site. It is imperative geon’s level of experience, and the specific techniques used for
that all osseous and soft tissue structures are free from infection correction. Since these procedures are accompanied by a steep
and that appropriate antibiotic therapy is administered on the learning curve, detailed knowledge of the Ilizarov method of
basis of intraoperative soft tissue and bone cultures. In cases circular external fixation and how to handle likely complica-
where an over traction of the pin fixation can cause skin break- tions are necessary for the experienced surgeon to undertake
down, the distraction osteogenesis process might be temporarily such complicated reconstructions.
delayed and restarted after the skin is intact. The threads of
the half-pins should be covered within the soft tissue envelope
to avoid any potential pin tract irritation and/or infection. In Recommended Readings
addition, the cortices of both bone segments at the docking may Aronson J. Limb-lengthening, skeletal reconstruction, and bone transport with
never be exposed and the periosteum is left intact during the the Ilizarov method. J Bone Joint Surg Am. 1997;79:1243–1258.
surgical debridement of the bone ends. This way the periosteal Bianchi-Maiocchi A, Aronson J, eds. Operative Principles of Ilizarov: Fracture Treat-
blood supply and surrounding neurovascular structures are the ment, Nonunion, Osteomyelitis, Lengthening, Deformity Correction. Baltimore, MD:
Williams & Wilkins; 1991.
driving forces for the healing process at the docking site. Cirpar M, Cetic O, Uslu M, et al. Common complications of segmental bone
transport with Ilizarov technique in defective tibia pseudoarthrosis: a review.
Eur J Orthop Surg Traumatol. 2006;16:380–385.
C l i n i cal Tips and Pearls Codivilla A. The classic: On the means of lengthening, in the lower limbs, the
muscles and tissues which are shortened through deformity. Clin Orthop Relat
A. Careful preoperative planning of pin insertion is nec- Res. 2008;466:2903–2909.
essary to avoid any unwanted deviation or inadequate Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning curve.
Clin Orthop Relat Res. 1994;301:10–18.
bone segment transportation. Green SA. Skeletal defects. A comparison of bone grafting and bone transport for
B. Circular external fixators are utilized for more com- segmental skeletal defects. Clin Orthop Relat Res. 1994;301:111–117.
plex bone transport procedures and are ideal for Guerreschi F, Azzam W, Camagni M, et al. Tetrafocal bone transport of the
dynamic properties that differ from the traditional tibia with circular external fixation: a case report. J Bone Joint Surg Am. 2010;
92:190–195.
static circular external fixators.
Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Jt Dis Orthop Inst.
C. Bone transport surgery mandates extensive surgical 1988;48:1–11.
experience and knowledge of all types of external Paley D. Problems, obstacles and complications of limb lengthening by the Ili-
fixation. zarov technique. Clin Orthop Relat Res. 1990;250:81–104.
D. In severe cases, plastic surgery reconstruction may be Watson JT. Principles of external fixation and bone transport. In: Rockwood CA,
Green DP, Bucholz RW, eds. Rockwood and Green’s Fractures in Adults. 6th ed.
necessary. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:258–296.
E. The utilization of a Taylor spatial frame for bone trans- Watson JT, Kuldjanov D. Bone defects. In: Rozbruch SR, Ilizarov S, eds. Limb
port technique requires extensive experience and is Lengthening and Reconstruction Surgery. New York, NY: Informa Healthcare;
usually reserved for severe cases of lower extremity 2006:185–201.
deformity.
LWBK1121-C21_p377_390.indd 390 04/10/12 3:24 PM

Chapter Mikhail L. Samchukov
22
Alexander M. Cherkashin
Edgardo Rodriguez
John G. Birch
Stepwise Approach to Equinus

Deformity Correction with
Introduction and (2) acquired or compensatory deformities from polio-

myelitis, trauma, burns, limb lengthening, and contracture
Equinus deformity is generally defined as a limitation of resulting from immobilization after trauma. Multiple factors
dorsiflexion motion at the ankle joint resulting in inability may contribute to ankle equinus including soft tissue (ankle
of the heel to contact the ground surface without some form equinus contracture), adjacent joints, and associated foot and
of anatomical or functional compensation in the lower limb tibial osseous deformities.
and foot. Despite numerous publications on ankle equinus, Typically, conservative treatment is initially used to manage
there is no consensus regarding the degree of ankle dorsiflex- equinus. Depending on the etiology of the equinus, different
ion restriction required to constitute a diagnosis of “equinus conservative modalities including physical therapy, kinesiotap-
deformity,” nor a standardized method of the measurement ing, orthoses, chemodenervation (intramuscular injections of
of ankle equinus. The reported range of normal ankle joint botulinum toxin type A, alcohol, or phenol), nerve neurotomy,
dorsiflexion varies from 3 to 15 degrees in full knee extension and serial casting may be indicated.16,17 If conservative treat-
and from 10 to 20 degrees or even greater at 90 degrees of ment is no longer effective, the patient can undergo surgi-
knee flexion.1–7 As a result, a wide range of reduced ankle dor- cal correction including ankle and/or subtalar joint release,
siflexion has been considered as constituting equinus deform- tendon lengthening, fascial lengthening, or tendon transfers
ity, varying from less than 0 degree to less than 10 degrees of followed by acute deformity correction.
dorsiflexion.8–12 In patients with equinus contracture, tendon Achilles length-
Some authors have suggested using the tibial–sole angle ening (TAL) can be performed via either open Z-lengthening
(TSA), calculated as an angle between the line drawn from the or percutaneous incomplete tenotomies. In open techniques,
plantar aspect of the first metatarsal to the plantar aspect of a posterior longitudinal incision is performed, the tendon is
the calcaneus and the line drawn along the longitudinal axis of cut in a Z-shaped fashion, the foot is dorsiflexed resulting in
the tibia on a weight bearing lateral radiograph.13 Equinus longitudinal shifting of two portions of the tendon that are
deformity is defined based on foot orientation in the sagittal sutured together in the lengthened position followed by wound
plane relative to its normal neutral position (TSA = 90 degrees). closure. With percutaneous techniques such as described by
Equinus deformity is considered to be mild when the foot is in Hoke, two or three incomplete horizontal tenotomies are
a position of plantarflexion less than 20 degrees from neutral, usually performed with a subsequent acute tendon stretch-
moderate when from 20 to 40 degrees, and severe when more ing resulting in its lengthening within the tendon sheath. An
than 40 degrees.14 Other authors recommend using the tibio- alternative to TAL techniques is selective gastrocnemius fascia
talar angle (TTA), the angle between the tibial anatomical axis lengthening using surgical open or endoscopic muscle reces-
and the axis of the talus for deformity assessment. Foot orienta- sion. In this case, the overlying fascia of the gastrocnemius
tion with TTA more than 115 degrees is considered to be true is released allowing anatomical preservation of underlying
ankle equinus.15 muscle fibers of the gastrocnemius and soleus muscles. Several
Although the etiology of ankle equinus is still often poorly surgical procedures have been described for gastrocnemius
understood, a variety of potential causes can be identified recession and gastrocnemius–soleus recession to resolve equi-
including (1) congenital anomalies such as cerebral palsy, nus deformity including Baumann, Baker, Strayer, Vulpius, and
Charcot–Marie–Tooth disease, myelomeningocele, arthro- Stoffel techniques.18–20
gryposis, clubfoot, muscular dystrophy, flatfoot, fibular hem- Despite the benefits of soft tissue lengthening techniques,
imelia, limb length discrepancy, and idiopathic toe walking, such as the ease and rapidity of the surgical procedure and the
391
LWBK1121-C22_p391_408.indd 391 04/10/12 7:36 PM

392 Chapter 22
predictable improvement in ankle dorsiflexion, recurrence of distraction and (2) octahedral variable-strut-length hexapod-
equinus deformity may occur due to weakness of plantarflexion type external fixator. This second type of external fixator
or calcaneal (crouch) gait may develop due to over lengthen- requires the acquisition of numerous anatomic and frame-
ing.21–23 In addition, the open surgical techniques may lead related parameters and intensive preoperative planning using
to (1) significant prominent scar tissue formation provoking associated software to program gradual foot movement during
Achilles tendonosis, (2) sural neuropraxia due to posterior correction.
muscle stretch, and (3) inadvertent complete tenotomy. To One well-known hexapod-type external fixator is the Taylor
prevent those complications, correction of more than 30 Spatial Frame or TSF (Smith & Nephew, Memphis, TN). Sev-
degrees should be avoided.18,20,24 eral TSF configurations have been described for foot deform-
Gradual correction of the foot equinus position using cir- ity correction including standard ring constructs, miter and
cular or semicircular external fixation in combination with butt external fixation constructs.3,26–30 Several Ilizarov-type
Ilizarov distraction histogenesis is an alternative method to circular fixators have been described for management of ankle
acute deformity correction following open or percutaneous equinus. Since deformity is usually corrected via gradual move-
tendon lengthening and muscle recession. In this method, ment through the predetermined axis of rotation, these exter-
the soft tissues are slowly but progressively stretched rather nal fixators include two special biomechanical modules-hinges
than surgically released and stretched acutely, thereby avoid- with the static axis of rotation and angular distractor for
ing traction nerve injuries and extensive scarring while more gradual incremental distraction or compression. Those mod-
adequately adapting to new dimensions following controlled ules can be assembled from multiple individual components
incremental movement of the osseous segments. In addition, such as posts in the original Ilizarov external fixator (Smith
external fixation offers more superior stabilization of the tibia & Nephew, Memphis, TN) and RingFix (SBi, Morrisville, PA)
and foot providing the possibility to combine equinus deform- or provided as preassembled or universal components such as
ity correction with gradual distraction across the ankle joint preassembled inline/outboard hinges and angular distractors
and allowing the patient to ambulate during the treatment. in the Distraction Osteogenesis Ring System (Synthes, West
Chester, PA) and TrueLok Ring Fixation System (Orthofix,
Lewisville, TX). The circular external fixator used in all clini-
Indications cal examples of this chapter is the TrueLok Circular External
Fixation System (Orthofix, Lewisville, TX). Irrespective of
According to Ilizarov, foot deformity correction using circular which external fixator is used, the principles of gradual equi-
external fixation can be divided into closed and open tech- nus deformity correction remain the same for all circular
niques.13,25 Closed techniques involve gradual stretching of soft external fixators.
tissues of the foot without osteotomies and are usually applied
for correction of equinus contracture with relatively congruent
articulating joint surfaces. This involves application of an exter- Preoperative Considerations
nal circular fixator that allows controlled gradual incremental
dorsiflexion movement of the foot either through the natural Preoperative evaluation of ankle equinus deformity consid-
or through the predetermined axis of rotation located in the ered for Ilizarov-type of external fixator application includes
talus. detailed analysis of the deformity and identification of the
Principal indications for closed gradual equinus deformity location of the hinge axis relative to the natural axis of rota-
correction using circular external fixation include: tion of the ankle. For those purposes, the lateral radiograph
of the affected foot and ankle is taken in the standing (weight-
• Severe equinus deformity with TTA more than 115 degrees
bearing) position. Several lines are drawn to analyze associated
without osseous deformities
angles and determine components of the foot involved in
• Less severe equinus deformity with very stiff surrounding soft
ankle equinus deformity (Figure 22.1). These lines include (1)
tissues when gradual correction is indicated to avoid neurov-
the anatomical axis of the tibia, (2) the distal tibia–ankle joint
ascular injury during acute deformity correction
reference line, (3) the line representing the sole of the foot,
• Recurrent equinus deformity after failure of previous soft
connecting the plantar aspect of the head of the first metatar-
tissue releases and open surgical procedures
sal with the plantar aspect of the calcaneus, (4) the axis of the
Open techniques are applicable in cases with compromised talus, (5) the axis of the calcaneus, and (6) the axis of the first
articulating surfaces and/or substantial bone deformities. In metatarsal.
such cases, deformity correction is performed via various types This is followed by measurement of the angles formed by
of osteotomies followed by acute or gradual deformity cor- the drawn lines and their interpretation. Those angles include
rection. In addition, circular external fixation is used in cases (1) TSA between the tibial anatomical axis and the line rep-
with significantly compromised soft tissues when acute equinus resenting the sole of the foot, (2) anterior distal tibial angle
deformity correction is indicated. In these cases, external (ADTA) between the tibial anatomical axis and the distal tibial
fixation may be indicated to avoid infection after an open ankle joint reference line, (3) TTA between the tibial ana-
procedure with internal fixation and improve the stability of tomical axis and the axis of the talus, (4) sole–talar angle (STA)
fixation with simultaneous reduction of compression forces on between the axis of the talus and the line representing the foot
the joints. sole, (5) talar–first metatarsal angle (Meary angle) between
Two major types of circular external fixators have been used the axis of the talus and the axis of the first metatarsal, and (6)
for equinus correction including (1) Ilizarov-type modular calcaneal–first metatarsal angle (cavus angle) between the axis
external apparatus with associated Ilizarov method of gradual of calcaneus and the axis of the talus.13,15
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Stepwise Approach to Equinus Deformity Correction with Circular External Fixation 393
Figure 22.1. Outline of the distal tibia and foot from

a lateral radiograph for preoperative evaluation of ankle
equinus demonstrating anatomical axis of the tibia (1),
distal tibial ankle joint reference line (2), foot sole line
(3), axis of the talus (4), axis of calcaneus (5), and axis
of the first metatarsal (6 ). ADTA, anterior distal tibial
angle; Cavus angle, calcaneal–first metatarsal angle;
Meary angle, talar–first metatarsal angle; STA, sole–talar
angle; TSA, tibial–sole angle; TTA, tibiotalar angle.
Angle analysis starts from the TSA. If the TSA is increased techniques or through the different forms of V-osteotomy and
(normal TSA at neutral foot orientation is 90 degrees), the foot Y-osteotomy.
position can be interpreted as an equinus. Analysis of the other
angles helps to identify whether the anatomical bony abnor-
mality or functional imbalance are responsible for that equinus Detailed Surgical Techniques
position and to localize this abnormality/imbalance. Result of
this analysis will also influence decision making to determine Surgical technique and external fixator assembly mainly depend
appropriate treatment tactics to correct foot equinus. on the method of equinus deformity correction selected: (1)
For example, if the ADTA is increased (normal ADTA is Closed method of gradual deformity correction either through
80 degrees, apex posteriorly), the equinus results from tibial the predetermined axis of rotation (two hinges with angular
sagittal plane deformity (procurvatum) and should be cor- distractor) or through the natural axis of foot plantar/dor-
rected via supramalleolar osteotomy. In cases with increased siflexion at the talus (floating talus technique), or (2) open
TTA (normal TTA is 115 degrees), the equinus is located at method of foot deformity correction using supramalleolar oste-
the level of the ankle joint and can be interpreted as a true ankle otomy, focal dome osteotomy, V-osteotomy, and Y-osteotomy
equinus. If the increase in TTA is proportional to the increase followed by acute or gradual deformity correction.
in TSA, the ankle equinus is solely responsible for foot equi-
nus position. In patients with relatively congruent articulating
Closed Method of Equinus
joint surfaces, correction of equinus can be achieved using
closed Ilizarov technique with hinges and angular distractor.
In situations with compromised articulating surfaces, correc- The external fixator for closed gradual deformity correction
tion of equinus can be achieved using subtalar focal dome can be assembled as either constrained or unconstrained
osteotomy followed by acute/gradual rotation of the foot into hinge system.25,31,32 A constrained hinge system uses a static
dorsiflexion. predetermined axis of rotation of the foot during equinus
In cases where increase in the TTA is not proportional to deformity correction, which is the common axis of rotation of
a TSA increase (usually TSA > TTA), other foot deformities both hinges on the external fixator. Foot rotation is achieved
are present and combined with ankle equinus. Ankle equinus by acute manipulation or pre-calculated gradual incremental
may be combined with a calcaneal deformity manifested by daily adjustments (distraction/compression) of the angular
decreased height of the calcaneus and reflected as decrease distractor.
in the STA (normal STA is 24.5 degrees). Ankle equinus may An unconstrained hinge system uses the natural (ana-
also be combined with an anterior cavus deformity reflected tomical) center of rotation of the ankle joint as the axis of foot
as a decreased Meary angle (normal talar–first metatarsal rotation during the equinus deformity correction. Due to the
angle is 5 degrees). Finally, when the TSA is increased but multiaxial nature of the ankle joint and fluctuating orientation
the TTA and STA are normal, the equinus foot position may of the rotation center,33–38 the external fixator assembly has
result from cavus deformity represented by a decreased cavus no hinges attached to the external fixator in relation to the
angle (normal calcaneal–first metatarsal angle is 130 degrees). center of rotation. In this case, foot rotation is usually achieved
Depending on the severity of equinus in such cases, deform- by gradual anterior compression, posterior distraction, or a
ity correction can be achieved by one of the Ilizarov closed combination of both.
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394 Chapter 22
Constrained Gradual Equinus Deformity Correction limb. The minimal acceptable separation between the distal and
through the Predetermined Axis of Rotation using proximal rings of the block should be approximately 100 mm.
Hinges and an Angular Distractor Initially (e.g., during the preoperative or intraoperative external
fixation preassembly), two rings are connected to each other
The external fixator for closed gradual deformity correction only anteriorly and posteriorly by two threaded rods that are uti-
through the predetermined axis of rotation consists of two sec- lized for external fixation alignment during the surgery. Medial
tions (tibial double-ring block and foot support) interconnected and lateral threaded rods are attached at the end of the surgery
by two hinges (laterally and medially) and an angular distractor to increase the external fixator’s rigidity and overall stability of
posteriorly. The tibial double-ring block is composed of two fixation. In cases when equinus deformity correction is com-
rings (usually of the same diameter) placed parallel to each bined with tibial lengthening (Figure 22.2), an additional ring
other and connected by four threaded rods. The distal ring of is attached to the external fixator proximally to the double-ring
the double-ring block is placed at the supramalleolar level while block. This ring is used to provide stable fixation of the proximal
the proximal ring is located at the medial/proximal third of the tibial segment after proximal tibial osteotomy for lengthening.
A,B C
D,E F
Figure 22.2. Severe equinus deformity in a 15-year-old girl secondary to linear scleroderma associated with
4 cm of tibial shortening: (A) clinical photograph demonstrating foot equinus with no ankle motion, waxy
texture of the skin on the tibia and dorsum of the foot with areas of hyperpigmentation; (B) lateral radiograph
illustrating foot equinus with congruent articulating surfaces at the ankle joint; (C) intraoperative photograph
showing foot stabilization with oblique wires; (D) intraoperative photograph demonstrating alignment of
hinge axes by bending the distal tibial ring during external fixation assembly; (E) intraoperative radiograph
illustrating hinge rotation axis aligned with the center of the talar dome; (F) clinical photograph of the final
external fixation assembly showing its orientation relative to the tibial and foot axes; (G–I) postoperative radio-
graphs and photograph demonstrating foot position before gradual equinus deformity correction;
(J, K) postoperative radiographs demonstrating foot position after gradual equinus deformity correction;
(L, M) anteroposterior and lateral radiographs after foot support removal during the consolidation period
showing active mineralization of the 3 cm distraction regenerate; (N) clinical photograph after foot support
removal illustrating plantigrade position of the foot; (O–Q) radiographs and clinical photograph at 2-year
follow-up. (continued)
LWBK1121-C22_p391_408.indd 394 04/10/12 7:36 PM

G,H I
J,K L,M
N,O P,Q
LWBK1121-C22_p391_408.indd 395 04/10/12 7:36 PM

396 Chapter 22
Typical fixation of the double-ring block to the tibia for

equinus deformity correction is achieved by two 1.8 mm
diameter cross wires at the distal ring and one 5 mm diameter
medial-face half-pin at the proximal ring. In order to protect
the syndesmosis, one of the cross wires is an olive-stopper
fibular-tibial wire inserted from posterolateral in an antero-
medial direction, with the olive-stopper resting on the fibula.
Depending on individual characteristics of the patient such as
increased weight, large muscle mass, increased physical activity,
involvement in athletics, and poor bone quality, stabilization of
the tibial double-ring block can be supplemented by inserting a
third wire at the distal ring and by either replacing the half-pin
at the proximal ring with two wires, adding a second half-pin,
or combining the first half-pin with a medial-face wire.
For foot support assembly, a foot plate with a double row of
holes can be used in conjunction with a same diameter half ring
connected to the foot plate anteriorly. Alternatively, a foot sup-
port can be constructed from a horseshoe-shaped foot plate with
a single row of holes, two foot plate extensions to accommodate
different lengths of the foot, and an anteriorly placed half ring.
Typical fixation of a foot support to bone is achieved by Figure 22.3. Intraoperative radiograph demonstrating an anterior
two 1.8 mm diameter calcaneal opposing olive-stopper wires shifting of the common hinge axis of rotation relative to projected
(inserted inferior to the peroneal tendon laterally and inferior/ ankle rotation center to produce joint distraction during gradual
posterior to the tarsal tunnel medially) and one 1.8 mm equinus deformity correction.
diameter medial olive-stopper wire inserted through the bases
of at least the first and fifth metatarsals. Depending on the Depending on the anatomical structure of the ankle joint
individual metatarsal relationships, a forefoot fixation wire can and level of congruency between the articulating surfaces of
penetrate the first, second, and fifth; first, fourth, and fifth; or the tibia and talus, the common axis of external fixation hinge
all five metatarsals. Forefoot stabilization can be increased by rotation can be oriented to the projection of the ankle joint
placing a second metatarsal lateral olive-stopper wire. In this center of rotation (Figure 22.2E). In order to compensate for
case, the first forefoot wire is inserted through the first, second, the obliquity and “fluctuation” of the intermalleolar axis and
and third metatarsals while the second wire penetrates the fifth therefore prevent joint compression when using uniplanar
and fourth metatarsals. The second forefoot wire is inserted at hinges, initial distraction along the threaded rods of the hinges
the base of the metatarsals and at a slightly oblique direction should be performed until a 3 to 5 mm gap is created at the
from inferior to superior and from posterior to anterior follow- ankle joint. Alternatively, the common axis of hinge rotation
ing the orientation of the metatarsals.13 can be shifted anteriorly (approximately 8 to 10 mm) relatively
Fixation of the hindfoot can also be increased by placing a to the projection of the ankle rotation center (Figure 22.3).
third horizontal calcaneal wire and/or a midfoot wire through Shifting of the hinge axis anteriorly produces ankle joint dis-
the cuboid and cuneiforms. Alternatively, two 5 mm diameter traction during gradual equinus deformity correction, thereby
half-pins can be inserted posteriorly (the first half-pin from pos- stretching the joint capsule and posterior soft tissues. In addi-
terolateral to anteromedial, and the second half-pin from poster- tion, the axis of hinge rotation can also be shifted distally
omedial to anterolateral) for calcaneal fixation of the hindfoot. (approximately 5 to 8 mm) relative to the anatomical center of
Finally, two calcaneal-midfoot olive-stopper wires inserted in the ankle rotation to prevent potential anterior foot subluxation at
calcaneus from the posterolateral and posteromedial toward the end of gradual equinus deformity correction or to reduce
anteromedially and anterolaterally, respectively, can be used for preexisting subluxation.
foot stabilization (Figure 22.2C). Those wires exit at the base of For more precise location of the common axis of hinges
the metatarsals crossing the entire foot in the horizontal plane. rotation relative to the axis of ankle joint rotation, the sec-
In order to increase the stability of fixation further, they can be ond is identified during surgery on the lateral radiograph. A
supplemented by two or three parallel wires placed horizontally temporary wire is inserted through the talus representing the
through the calcaneus, midfoot, and/or metatarsals (Figure common axis of hinges rotation. Cannulated hinges are then
22.2G). In some cases of rigid equinus deformity, digital wires placed over the ends of this wire and the tibial portion of the
can be inserted through the interphalangeal joints to prevent external fixator and the foot support are both aligned relative
digital contractures during deformity correction. to the orientation of the temporary talar wire (Figure 22.4).
After fixation, the distal ring of the tibial double-ring block The temporary wire is removed after completion of external
and the foot support should be interconnected by two unipla- fixation stabilization at the end of the surgery allowing gradual
nar hinges (one laterally and one medially) with a common rotation of the foot portion of the external fixator relative to
axis of rotation and one angular distractor placed posteriorly the tibial portion of the external fixator around the predeter-
(Figure 22.2F). Ideally, the angle between the double-ring mined axis of rotation. In order to avoid compression of joint
block and the foot support should mimic the TSA with the axis surfaces during equinus deformity correction, 3 to 5 mm of
of the hinges positioned at the proper orientation relative to initial joint distraction can also be acutely performed as a final
the axis of foot dorsiflexion/plantarflexion. stage of surgery.
LWBK1121-C22_p391_408.indd 396 04/10/12 7:36 PM

Assembly and attachment of the foot support is also deter-

mined by the severity and anatomical nature of the equinus.
For example, in cases with foot equinus due to moderate
plantarflexion contracture or hindfoot deformity with pre-
served gap between the articulating surfaces of the ankle joint
and the minimal resistance of posterior soft tissues, forefoot
fixation only may be adequate to achieve gradual dorsiflexion.
For forefoot fixation in such cases, at least one 1.8 mm diam-
eter medial olive-stopper wire is inserted through the first and
fifth metatarsals, tensioned and secured to a half ring or foot
plate. Similar to that for constrained external fixators, forefoot
stabilization can be increased by placing a second metatarsal
lateral olive-stopper wire. The anterior foot support is con-
nected to the tibial ring or double-ring block by two threaded
distraction rods with hinges anteriorly. Correction of the equi-
nus deformity is achieved by gradual incremental shortening
of those threaded rods using a pre-calculated rate and rhythm
of correction.
Alternatively, simple calcaneal fixation may be used to
achieve gradual dorsiflexion. A pair of crossed olive-stopper
Figure 22.4. Intraoperative photograph showing external fixation wires is inserted through the calcaneal tuberosity in a direc-
assembly using a temporary talar wire and cannulated hinges. tion from posteromedial and posterolateral to anterolateral
and anteromedial, respectively, tensioned and secured to a
foot plate. The foot plate is connected to the tibial ring or
Unconstrained Gradual Equinus Deformity Correction
double-ring block by two threaded or telescopic distraction
through the Natural Axis of Ankle Joint Rotation
rods with hinges posteriorly. Correction of the equinus is
using the “Floating Talus” Technique
achieved by gradual incremental elongation of those poste-
Gradual dorsiflexion of the foot through the predetermined rior rods also using a pre-calculated rate and rhythm of cor-
axis of rotation using two hinges and an angular distractor is rection.
the predominant method for closed equinus deformity correc- In cases with more severe isolated foot equinus when both
tion. One of the important requirements for this technique hindfoot and forefoot are involved in the deformity (e.g.,
is a relatively preserved shape of the talus allowing uniplanar ankle equinus with forefoot cavus deformity) but the degree
movement around a single axis of rotation. In cases with of hindfoot equinus deformity is different of that in the
complex deformity of the talus not allowing uniplanar foot forefoot, and cases with combined foot deformity (e.g., ankle
movement around a single axis of rotation, very severe equinus equinus and forefoot supination) when equinus deformity
foot deformity with profoundly increased TTA (more than correction will be followed by correction of deformities in
140 degrees) and foot subluxation at the ankle, and situations the other planes, hindfoot and forefoot require separate sta-
where both hindfoot and forefoot deformities are involved in bilization. Following stabilization, both forefoot and hindfoot
equinus position of the foot at the ankle, correction of deform- support assemblies can be then connected to the tibial block
ity can be achieved using unconstrained external fixators or for independent correction of the associated deformities
the so-called “floating talus” technique (FTT). This technique (Figure 22.5).
allows gradual dorsiflexion of the foot without hinges through For this purpose, a calcaneal half ring or foot plate is attached
an anatomical (natural hinge) axis of rotation located at the to a tibial fixation module (e.g., double-ring block) posteriorly
talus.13,14,22,25,31,32,39 Another indication for this technique is in by two distraction threaded rods with hinges to allow posterior
cases with foot equinus that requires ankle arthrodesis after translation of the calcaneal external support as the calcaneus
deformity correction. Several variations of FTT have been moves plantarward. A metatarsal half ring or foot plate is also
developed to correct ankle equinus. attached to the tibial fixation module by compression threaded
Similar to constrained external fixators with unilateral rods with hinges to allow anterior translation of the metatarsal
hinges, the standard apparatus for FTT includes a tibial fixa- external support during correction. Deformity correction in
tion module and a foot support assembly interconnected by this case is achieved by gradual lengthening of the posterior
traction units to effect gradual dorsiflexion of the foot. For distraction rods to push the calcaneus distally and keep the
correction of moderate equinus contractures, a single ring can tibiotalar joint distracted, with simultaneous shortening of the
be mounted at the junction of the middle and distal thirds of anterior compression rods to pull the forefoot proximally.
the tibia utilizing two 1.8 mm diameter crossed olive-stopper Finally, when both hindfoot and forefoot are involved in
wires positioned in the transverse plane. To enhance three- the equinus and the degree of hindfoot deformity is the same
dimensional stability of tibial fixation, either additional hori- as that in the forefoot, the entire foot is stabilized within the
zontal drop-wire or medial-face half-pin may be inserted and foot support and the hindfoot and forefoot are moved together
attached at the distance below the ring. For correction of more during deformity correction as a single block. The standard
severe equinus deformity, a standard tibial double-ring block apparatus in these cases includes tibial double-ring block and
is used, which is attached to the tibia using wires and half-pins foot support assembly attached to the distal tibia and the foot
similar to that described for constrained external fixators. with cross wires and half-pins similar to that for a constrained
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398 Chapter 22
A,B C
D,E F
Figure 22.5. Correction of severe rigid equinus deformity associated with

varus and cavus deformity of the foot secondary to a cardiovascular accident,
followed by hip adductor and hamstring release and failed tendo-Achilles lengthen-
ing: (A) clinical photograph demonstrating severe equinus of the foot associated
with varus and cavus deformities; (B) lateral radiograph illustrating foot equinus
with associated deformities and anterior subluxation; (C) intraoperative photo-
graph showing stabilization of the hindfoot and forefoot to foot supports for inde-
pendent deformity correction; (D–F) lateral radiographs demonstrating dynamics
of simultaneous equinus and cavus deformity correction; (G) lateral radiograph
G after deformity correction.
external fixator. In contrast to the above-described constrained ments should be considered for successful application of this
external fixation technique, the tibial double-ring block and foot FTT. These requirements include the following:
support are interconnected only by posterior and anterior angu-
lar distractors with no hinges attached in the projection of talus • Presence of at least 5 to 10 degrees of true arc movement of
medially and laterally. Deformity correction is achieved by simul- the talus at the ankle joint
taneous gradual distraction on the posterior angular distractor • Foot rotation within the range of ankle motion should be in
and gradual compression on the anterior angular distractor. the same (sagittal) plane
Since foot rotation is performed around a not-well-deter- • Hindfoot and forefoot should move within the range of
mined and “fluctuating” axis of rotation located in the talus, ankle motion as one unit
a gap of approximately 5 mm should be created by distraction • Additional deformities of the hindfoot and forefoot should
before the initiation of deformity correction, and constantly be located in the same plane
maintained during deformity correction to avoid ankle joint • Presence of some space at the posterior portion of the ankle
compression. Several other clinical and radiographic require- joint on the lateral radiograph
LWBK1121-C22_p391_408.indd 398 04/10/12 7:36 PM

In cases that require ankle fusion after foot equinus correc-

tion, a tibial double-ring block is connected to a foot support by
only one angular distractor placed anteriorly. Equinus deform-
ity correction is achieved by gradual compression of the ante-
rior angular distractor. Initially, a distraction rate of 0.5 mm per
day is used for the first 1 to 2 weeks. If the patient experiences
no pain, deformity correction is continued at a normal distrac-
tion rate of approximately 1 mm per day.
Open Method of Equinus

The major indications for open equinus deformity correction
include situations with compromised articular surfaces of the
ankle and substantial bone deformities. Closed repositioning
of the talus within the ankle mortise in these cases may produce
a significant incongruity of the articulating surfaces resulting in
further limitation of joint range of motion, the development
of associated deformities, and pain. Instead, the articulating
surfaces are kept intact and equinus deformity may be cor-
rected by osteotomy performed above or below the ankle joint.
Although different types of osteotomies have been described
for equinus deformity correction, the most common are
(1) supramalleolar osteotomy, (2) focal dome osteotomy, and
(3) V-osteotomy or Y-osteotomy.
Open Equinus Deformity Correction

through Supramalleolar Osteotomy Figure 22.6. Outline of the distal tibia and foot from a lateral
Primary indications for supramalleolar osteotomy include cases radiograph with preoperative planning of equinus deformity correction
with foot equinus when the increase in TSA is proportional to demonstrating anatomical axes of the proximal (1) and distal (2) tibia
in the sagittal plane, apex of the deformity (3), bisector line through
the increase in TTA and the amount of this increase is equal
the apex of the deformity (4), projection of the common hinge rota-
to the increase in ADTA. In this situation, the equinus position axis (5), osteotomy level (6), and location of external supports.
tion of the foot results from the sagittal plane procurvatum
deformity of the distal tibia and requires acute or gradual
correction at the apex of the deformity. Preoperative plan-
ning is essential for the correction of distal tibial procurvatum • Type and location of the foot external support and its inter-
deformity to (1) identify the location of the hinge rotation connection with the external support of the distal tibial seg-
axis, (2) determine the level of the osteotomy and its spatial ment is made
relation to the apex of the deformity, (3) design the appropri- • Calculation of the daily amount of angular distractor adjust-
ate external fixation assembly to provide adequate fixation of ment required to produce the desired rate of bone distrac-
bone segments, and (4) calculate the optimal rate of distraction at the osteotomy level is performed
tion. For analysis of the deformity and preoperative planning,
It should be noted that placement of the hinge rotation
a lateral radiograph of the tibia and foot in maximal plantar-
axis at the anterior tibial cortex results in a triangular shape
flexion is used.40 Parameters necessary for the planning of
of the distraction regenerate with minimal bone lengthening.
deformity correction are identified by the following steps
Shifting of the axis away from the anterior cortex produces
(Figure 22.6):
a trapezoidal shape of the distraction regenerate with a pro-
• Anatomical axes of the proximal and distal tibia in the sagit- portional increase in the amount of bone lengthening. Tibial
tal plane are located osteotomy performed at the apex of the deformity results in
• Apex of the deformity is identified as the intersection no horizontal translation of the contacting bone surfaces at the
between the anatomical axes osteotomy level. Shifting the osteotomy level above the apex of
• The bisector line of the angle at the apex of the deformity the deformity results in posterior translation of the contacting
is constructed, and the appropriate center of rotation of surface of the distal segment at the level of the osteotomy.
angulation (CORA) along the bisector line that will provide A secondary indication for supramalleolar osteotomy includes
restoration of the alignment and produce required amount patients with equinus deformity and a fused ankle. In these
of lengthening is chosen cases, procurvatum of the distal tibia is not necessarily present
• The level of the osteotomy relative to the apex of the but the equinus deformity correction is achieved via a similar
deformity resulting in an acceptable amount of horizontal corrective osteotomy performed either at or just above the level
translation of the contacting bone surfaces at the level of the of the fused joint. Due to the very distal level of the osteotomy,
osteotomy is selected the hinge axis of rotation is placed at the center of the talus and
• Type and location of the external supports for fixation of the initial distraction should be performed to prevent compression
proximal and distal tibial segments are determined of the bone segments at the level of the osteotomy (Figure 22.7).
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400 Chapter 22
A B
C D
E F
Figure 22.7. Correction of fixed rigid equinovarus deformity in a 16-year-old boy after a severe motor vehicle occupant injury of the lower
extremity resulting in ankle and subtalar arthrodesis, significant scarring over the anterior aspect of the ankle and hypertrophic callus on the
lateral aspect of the forefoot: (A) clinical photograph demonstrating foot equinus with no ankle motion and significant scarring over the anterior
and lateral aspects of the ankle; (B) lateral radiograph illustrating ankylosed ankle joint and foot equinus; (C) intraoperative radiograph showing
supramalleolar osteotomy; (D) intraoperative photograph demonstrating assembly of calcaneal foot support and alignment of polyaxial hinges
along a temporary talar wire; (E) intraoperative radiograph illustrating alignment of the polyaxial hinges rotation axis; (F) clinical photograph
with final external fixation assembly showing its orientation relative to the tibia and foot; (G–I) postoperative radiographs and photograph
demonstrating foot position during gradual equinus deformity correction; (J–L) postoperative photographs and radiograph demonstrating foot
position after acute varus deformity correction with tibial double-ring block and foot support connected by four threaded rods with universal
lockable hinges; (M, N) lateral radiograph and clinical photograph at 2-year follow-up. (continued)
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G,H I
J,K L
M N
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402 Chapter 22
The external fixation assembly for equinus deformity cor- the ADTA is normal and equinus is located predominately at
rection via supramalleolar osteotomy usually includes a double- the level of the ankle joint with a proportional increase in both
ring block for stabilization of the proximal tibial segment and TSA and TTA (Figure 22.8).
a single ring for stabilization of the distal tibial segment. The For ease of access to the talar neck and subtalar area, the
proximal double-ring block and distal tibial ring are connected osteotomy is performed first, followed by wound closure and
by a pair of hinges anteriorly and an angular distractor poste- external fixation application. The focal dome osteotomy is
riorly. usually done under general anesthesia in the supine position.
The proximal double-ring block is placed parallel to the ana- A tourniquet is used during the osteotomy and deflated after
tomical axis of the proximal tibia (proximal ring of the block a compression dressing is applied. A curved incision going
at the level of the fibular head and distal ring of the block at around the lateral malleolus is used for the approach. The
approximately 5 cm above the osteotomy) and secured to the osteotomy is performed through holes drilled along a curved
bone by two pairs of 1.8 mm diameter cross wires, three 5 mm line of intended osteotomy, intersecting the neck of the talus
diameter half-pins, or a combination of wires and half-pins. For and continued to the adjacent upper portion of the calcaneus
half-pin stabilization of the proximal tibial segment, two half- (Figure 22.8D). The predrilled holes are connected by either
pins are inserted at the level of proximal ring of the block (one a wide curved (preferably) or narrow straight osteotome fol-
half-pin is inserted from anteromedial to posterolateral through lowed either by acute deformity correction around the body of
the tibia and the head of the fibula while the other half-pin is the talus and temporary stabilization by two cross wires or by
inserted at a 90- to 120-degree angle from anterolateral to poster- just temporary stabilization during external fixation applica-
omedial through the tibia only) and a third half-pin is inserted at tion for gradual deformity correction.13,25
the level of the distal ring of the block as a medial-face half-pin. External fixation assembly is similar to that used for con-
The distal tibial ring is placed perpendicular to the anatomi- strained closed deformity correction, composed of a double-
cal axis of the distal tibia approximately 1.5 to 2 cm above the ring tibial block and foot support assembly connected by a pair
joint (or 0.5 to 1 cm above the physis if it is open) and secured of hinges and one angular distractor. The double-ring block
to the bone by two 1.8 mm diameter cross wires. One wire is attached to the tibia using two 1.8 mm diameter cross wires
should be an olive-stopper wire inserted from posterolateral to distally (lateral olive fibular-tibial wire to prevent subluxation
anteromedial through the fibula and tibia while the other wire of the talus in the ankle mortise during the correction proc-
is a smooth wire inserted from anterolateral to posteromedial ess and a smooth tibial wire) and at least one 5 mm diameter
through the tibia only at a 45- to 60-degree angle relative to the medial-face half-pin proximally.
first wire. Stability of the distal tibial segment fixation can be The foot support is constructed from a foot plate, two foot
enhanced by insertion of a third (drop) wire or placement of plate extensions, and anteriorly placed half ring. Calcaneal fix-
an additional half-pin. ation of foot support assembly is achieved by either two 1.8 mm
If distal ring stabilization cannot provide adequate fixation diameter opposing olive-stopper wires or two 5 mm diameter
of the distal tibial segment (very short length of the distal posterior half-pins slightly angulated toward the midline. The
tibial segment, significant osteopenia, anatomical abnormali- forefoot is stabilized to the anterior portion of the foot support
ties not allowing the insertion of cross wires at the appropriate assembly by at least one medial 1.8 mm diameter olive-stopper
angle, etc.), foot stabilization should be included to prevent wire inserted through at least the first and fifth metatarsals.
loss of bone fixation during deformity correction. The typi- Since correction of the equinus deformity is achieved via
cal foot support assembly in these cases includes a foot plate foot rotation around the talus, the body of the talus should also
connected to two foot plate extensions blocked anteriorly by a be stabilized and attached to the tibial portion of the external
half ring. The foot support is attached to the distal ring by four fixator creating a single stabilization module. Fixation of the
threaded rods and secured by two 1.8 mm diameter opposing body of the talus is accomplished by a single or two opposing
olive-stopper wires or two 5 mm diameter posterior half-pins 1.8 mm diameter crossed olive-stopper wires connected to the
inserted in the calcaneus with at least one 1.8 mm diameter tibial double-ring block via cubes with the wire fixation bolts or
medial olive-stopper wire inserted through at least the first and threaded rods with slotted washers. Alternatively, talar wire(s)
fifth metatarsals. can be secured by wire fixation bolts to an additional half ring
Deformity correction is initiated 5 to 6 days after the surgery or foot plate placed below the tibial double-ring block and
by incremental elongation of the posterior angular distractor. attached to the block by threaded rods with universal hinges
The amount of daily elongation can be calculated as a ratio (Figure 22.8E).
between the length of two lines both drawn from the axis of If equinus deformity can be corrected acutely, the double-
hinge rotation but one line orthogonally to projection of the ring block and foot support assembly are connected by four
angular distraction and second line orthogonally to the mid- threaded rods followed by slight acute compression. In cases
dle of the bone segments at the level of the osteotomy.40 After where gradual deformity correction is performed, the tibial
completion of deformity correction, the hinges and angular double-ring block/talar support assembly should be connected
distractor are replaced with four threaded rods to increase the to the foot support by two uniplanar hinges and one posterior
overall stability of external fixation. angular distractor (Figure 22.8F). The appropriate location of
the hinge rotation axis depends on a variety of factors, includ-
ing the severity of equinus, anatomical structure and level of
congruency between the articulating surfaces of the tibia and
through Focal Dome Osteotomy
talus, preoperative range of motion of the ankle joint, and the
A focal dome-shaped or U-osteotomy is applicable in cases with amount of posterior foot height discrepancy. For cases that
moderate equinus deformity (usually up to 30 degrees) when require only equinus deformity correction without a need to
LWBK1121-C22_p391_408.indd 402 04/10/12 7:37 PM

A B
C D
E F
Figure 22.8. Rigid recurrent equinus deformity correction in an 18-year-old boy with multiple congenital
anomalies of the left lower extremity with relative fibular overgrowth, and secondary cavus deformity, status
post partial percutaneous tendo-Achilles lengthening, closed equinus and cavus deformities correction, and
tibial lengthening: (A, B) preoperative clinical photograph and lateral radiograph demonstrating foot equinus
with incongruity of the articulating surfaces of the ankle; (C) preoperative planning of a U-osteotomy for
gradual equinus deformity correction; (D) intraoperative photograph showing the U-osteotomy; (E, F) intra-
operative photographs illustrating stabilization of the talar wire in an additional half ring and final external
fixation assembly for equinus deformity correction; (G) intraoperative radiograph demonstrating orientation
of the hinge rotation axis relative to the U-osteotomy; (H) postoperative photograph showing foot position
after gradual equinus deformity correction with tibial double-ring block and foot support connected by four
threaded rods with universal lockable hinges; (I, J) lateral radiograph and clinical photograph at 1-year
follow-up. (continued)
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404 Chapter 22
G H
I J
increase the posterior foot height, for example, the common of the calcaneus in line with the sinus tarsi. The posterior arm
axis of hinge rotation should be in line with the ankle axis of (calcaneal osteotomy) lies behind the peroneal tendons and is
rotation at the center of the dome of the talus. In cases that directed to exit on the dorsal surface of the calcaneus behind
require equinus deformity correction and increased posterior the posterior facet of the subtalar joint. The anterior arm runs
foot height, the common axis of hinge rotation should be in an anterodorsal direction through the calcaneus between
shifted more anteriorly and placed at the anterior corner of the the anterior and medial facets of the subtalar joint, exiting
osteotomy at the neck of the talus (Figure 22.8G). The surgery through the neck of the talus. It is important to confirm that
is completed by attaching the angular distractor connected to osteotomies are complete. This can be ascertained by visualiza-
the posterior midline holes on the distal tibial ring and foot tion of the bone cuts on the x-ray, by twisting the osteotome
plate for pre-calculated gradual distraction. inside the osteotomy, or by palpation of the edges of the oste-
otomy. The ability to translate the fragments on either side of
the osteotomy assures its completion.15,41–43
The external fixation is constructed of a proximal double-
through V-Osteotomy
ring block and two foot supports each connected to the distal
A V-osteotomy is actually a combination of two osteotomies: ring of the tibial block by a pair of hinges and an angular dis-
(1) a posterior oblique calcaneal osteotomy and (2) an ante- tractor (Figure 22.9C). The double-ring block is attached to the
rior calcaneal-talar neck osteotomy. This osteotomy is useful in tibia similar to that for a focal dome osteotomy using two cross
cases with severe equinus deformity (usually more than 30 to wires distally and at least one medial-face half-pin proximally.
35 degrees) associated with other deformities of the anterior One or two 1.8 mm diameter cross opposing olive-stopper wires
and posterior portion of the foot (Figure 22.9). are inserted into the body of the talus, tensioned, and con-
Similar to a focal dome osteotomy, a V-osteotomy is also nected to the tibial double-ring block.
performed under general anesthesia in the supine position. A foot plate is used for posterior foot support that is placed
The V-osteotomy can be performed either through a lateral over and fixed to the calcaneus with two 1.8 mm diameter
Ollier’s incision or a less invasive approach through the pero- cross olive-stopper wires or two posterior 5 mm diameter
neal tendons. Both “arms” of the V-osteotomy intersect at an half-pins. The calcaneal foot support should be positioned
acute angle of about 60 to 70 degrees on the plantar surface parallel to the sole of the foot and tilted to match any
LWBK1121-C22_p391_408.indd 404 04/10/12 7:37 PM

A B
C D
Figure 22.9. Severe recurrent rigid equinus deformity correction in an 11-year-old girl with arthrogrypo-
sis, status post multiple operations of the lower extremities including repeated bilateral clubfoot releases,
right midfoot osteotomy with acute deformity correction and left foot V-osteotomy with gradual deformity
correction: (A, B) preoperative clinical photograph and lateral radiograph demonstrating severe foot equinus
with incongruity of the articulating surfaces of the ankle; (C) intraoperative photograph illustrating the
external fixation assembly with anterior and posterior foot supports each connected to the tibial double-ring
block by a pair of hinges and an angular distractor for independent equinus deformity correction; (D) post-
operative lateral radiograph before equinus deformity correction showing orientation of the hinge rotation
axes relative to the V-osteotomy with half-pin stabilization of the body of the talus; (E, F) lateral radiograph
and clinical photograph demonstrating foot position at the completion of equinus deformity correction;
(G, H) lateral radiograph and clinical photograph at 6-year follow-up. (continued)
hindfoot deformity in the coronal plane (valgus or varus). the predetermined gradual distraction to push the posterior
This posterior foot support is connected to the distal tibial portion of the calcaneus distally.
ring of the block using a pair of hinges with the common axis The anterior foot support is constructed from either one or
of rotation located at the lower end of the calcaneal osteot- two half rings or foot plates positioned over the dorsum of the
omy, which is in line with the sinus tarsi at the plantar aspect of foot perpendicular to the longitudinal axis of the metatarsals
the calcaneus (Figure 22.9D). An angular distractor is attached (forefoot) and also connected to the distal tibial ring using a
to the posterior midline holes on the ring and foot plate for pair of hinges with the common axis of rotation in line with the
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406 Chapter 22
E F
G H
end of the anterior arm of the V-osteotomy at the dorsal surface two to three increments to gradually rotate the foot around the
of the foot at the neck of the talus (Figure 22.9D). Forefoot sta- predetermined axis of rotation. Depending on the location of
bilization is achieved by a pair of metatarsal olive wires inserted the axis of rotation relative to the natural rotation center of
in such a way that one of these wires passes through the first the ankle joint, equinus deformity correction can be achieved
metatarsal and another one passes through the fifth metatarsal. simultaneously by gradual incremental distraction of the ankle
An angular distractor is attached to the anterior midline holes joint. If necessary, the gap between the articulating surfaces of
on the ring and foot plate for the predetermined gradual com- the ankle can be increased or reduced by acute or gradual dis-
pression to dorsiflex the anterior portion of the foot. traction or compression of the threaded rods connecting the
hinges to the tibial double-ring block.
When deformity correction is achieved around the natural
Postoperative Protocol During axis of ankle joint rotation (unconstrained external fixators),
Equinus Deformity Correction initial distraction of the ankle joint (approximately 3 to 5 mm)
must be performed prior to initiation of equinus deformity
For closed constrained and unconstrained external fixa- correction to prevent joint compression. Usually, either pos-
tion methods, deformity correction should be initiated 1 to terior distraction or anterior compression is performed at an
3 days after surgery, as soon as the patient is comfortable and approximate rate and rhythm of 0.5 mm, four times daily. In
can tolerate incremental external fixation adjustments. When the majority of cases with simultaneous posterior distraction
deformity correction is performed around a predetermined and anterior compression, both distraction and compression
axis of rotation (constrained external fixators), the daily rate are done at the same rate of 1 to 3 mm per day. Sometimes,
of distraction of the posteriorly located angular distractor var- compression of the anterior rods should be at a higher rate
ies depending on the soft tissue condition and distance from than distraction of the posterior rods due to a difference in
the angular distractor to the axis of hinges, usually ranging length of the associated lever arms. In order to avoid ante-
from 1 to 3 mm per day. Angular distraction is performed in rior foot subluxation during equinus deformity correction,
LWBK1121-C22_p391_408.indd 406 04/10/12 7:37 PM

distraction of the hindfoot must be done in a posteriorly external fixation is stabilized. In order to increase the stability
inclined direction and a 1.5:1 or even 2:1 ratio of anterior com- of fixation during the consolidation period, hinges and angular
pression to posterior distraction should be applied.13 distractors may be replaced with regular threaded rods con-
The dynamics of deformity correction and maintenance necting the external fixation modules directly or in combina-
of the gap between the tibia and the talus are monitored on tion with conical washers or universal hinges.
lateral radiographs of the foot and ankle taken biweekly after The consolidation period usually lasts 1.5 to 2 months. Dur-
beginning of distraction. In cases of unplanned changes in ing this period, the patient should walk with gradually increas-
the gap between the articulating surfaces (more or less than ing loads on the foot. After external fixation removal, plaster
5 mm), appropriate adjustment to the treatment protocol cast immobilization is used for additional 1 to 2 months. After
such as additional compression or distraction along the hinge cast removal, physical therapy is instituted to gradually increase
threaded connecting rods should be carried out, either acutely range of motion and weight bearing.
or gradually.
Correction of equinus deformity should be continued until
the foot is in a plantigrade position (TSA = 90 degrees). Due
to the commonly seen “rebound” of the soft tissues after exter-
nal fixation removal, slight overstretching (i.e., beyond the
Clinical Tips and Pear l s
intended end point of equinus deformity correction) is usually A. Preassembled circular external fixator for equinus
desirable. Therefore, at least 10 degrees of overcorrection into deformity correction should allow for easy intraoperative
dorsiflexion (in some cases up to 15 to 20 degrees) is required external fixation adjustment including repositioning of
for proper foot function and normal gait restoration after hinge rotation axis proximally/distally and anteriorly/
treatment. posteriorly relative to the distal tibial ring, distracting of
As soon as the desired amount of overcorrection has been the ankle joint acutely/gradually, and relocating of the
achieved, the apparatus is stabilized in this position for approx- foot support assembly proximally/distally and anteriorly/
imately 6 weeks. At the end of the stabilization period and posteriorly relative to the hinge rotation axis
2 weeks before external fixation removal, the angular distractor B. To preserve three dimensional external fixation align-
should be replaced by anterior (or posterior) threaded con- ment during its application, either the most proximal
nection rods that can be easily removed and replaced to lock and the most distal wires are inserted first as the refer-
and unlock movement at the ankle joint. At that time regular ence wires or the temporary wire placed through the
uniplanar hinges can be replaced by multiplanar hinges allow- axis of rotation is used followed by tibial and metatar-
ing plantarflexion/dorsiflexion movement along the oblique sal/calcaneal wires
natural axis of rotation of the ankle joint. During the day, this C. To create an equal amount of calcaneal and metatarsal
connection rod should be removed allowing physical therapy wire tensioning in static foot support and prevent foot
to increase movement at the ankle joint. At night, the con- support deformation during wire tensioning, the most
nection rod should be replaced to lock the ankle and prevent distal (metatarsal) wire(s) should be tensioned first fol-
recurrence of the deformity. The external fixator is removed lowed by simultaneous tensioning of the calcaneal wires
when no tendency for recurrence is observed after unlocking D. To avoid external fixation interference and provide
the ankle movement and active dorsiflexion is restored. superior access to soft tissues and bones, it is recom-
After external fixation removal, a short-leg walking cast is mended to perform foot osteotomy prior to external
typically applied for an additional 4 to 6 weeks. In some cases, fixation application with a temporary stabilization of
this is followed by an ankle-foot orthosis constructed to keep osteotomized bone segment using Steinmann pins or
the foot at 10 degrees of dorsiflexion at night. Finally, some cross transosseous wires
patients require a special shoe with an anterior wedge in order E. To increase the overall external fixation rigidity and
to maintain foot position during daily activities for an addi- improve ankle joint visualization on anteroposterior
tional 2 to 4 months. radiographs, the additional horseshoe-shaped foot
For open methods, Ilizarov’s general principles of new bone plate is recommended to complete the foot support
formation under the influence of tension stress (distraction assembly anteriorly instead of a regular half ring
osteogenesis) should be applied for gradual equinus deformity F. To provide the most flexible and controllable stabiliza-
correction.25 After completion of the osteotomy and soft tissue tion of the talus during equinus deformity correction,
closure, the external fixator is stabilized in the neutral position the talar wire(s) should be attached to the independ-
for a latency period. Correction is started on the third or fourth ent external support such as half ring or foot plate,
day after the surgery to prevent premature consolidation. which is interconnected with the double-ring tibial
The threaded rod of the posterior angular distractor should block and foot support assembly
be lengthened (distracted) at the predetermined rate while G. In order to reduce skin movement and minimize soft
the threaded rod of the anterior angular distractor should be tissue irritation around wires and half-pins, a compres-
shortened (compressed) at the same rate. sive dressing should be applied around the foot and
During the deformity correction period, the patient should ankle immediately after the surgery
be checked every 2 weeks. Each patient visit should include H. To preserve achieved dorsiflexion and prevent equi-
detailed clinical examination and radiographic assessment nus deformity recurrence, the shoe with anteriorly
of the dynamics of bone segment movement and new bone opened wedge lift is recommended after external fixa-
formation in the distraction gaps. After achieving the desired tion removal for continuous soft tissue stretching
foot position, distraction/compression is discontinued and the
LWBK1121-C22_p391_408.indd 407 04/10/12 7:37 PM

408 Chapter 22
Conclusion 21. Biedermann R, Kaufmann G, Lair J, et al. High recurrence after calf length-
ening with the Ilizarov apparatus for treatment of spastic equinus foot
deformity. J Pediatr Orthop B. 2007;16:125–128.
The authors have presented various fixation methods for 22. Carmichael KD, Maxwell SC, Calhoun JH. Recurrence rates of burn con-
addressing lower extremity equinus deformities with external tracture ankle equinus and other foot deformities in children treated with
fixation. Vast knowledge and experience with circular external Ilizarov fixation. J Pediatr Orthop. 2005;25:523–528.
23. Emara KM, Allam MF, ElSayad MN, et al. Recurrence after correction of
fixation is necessary to maximize favorable outcomes.
acquired ankle equinus deformity in children using Ilizarov technique. Strate-
gies Trauma Limb Reconstr. 2008;3:105–108.
24. Jaddue DAK, Abbas MA, Dayed-Noor AS. Open versus percutaneous tendo-
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Chapter
23 Paul S. Cooper
External Fixation Postoperative

Care and Rehabilitation
Introduction refrain from smoking due to the higher rate of soft tissue and
osseous complications following application of the external
Complications seen in the postoperative period with the use fixation device.
of external fixation in the lower extremity are numerous and
range from mild to severe. While the most common complica-
tion is soft tissue irritation and/or infection around the wire/ Hospital Discharge
pin site, this is not the most drastic. More severe complications
involve contractures, axial deviation of the lower extremity, Following patient discharge, the first return visit to the out-
severe swelling, nerve injury, potential refracture, loss of cor- patient clinic may occur within 10 to 14 days. During this visit
rection, or deep vein thrombosis with possible extension to a and subsequent visits, standard foot, ankle, and lower extrem-
pulmonary embolus. ity radiographs should be obtained for evaluation of the index
procedure. In cases where either lower limb lengthening or
compression arthrodesis occurs, radiographs of the adjacent
Immediate Postoperative Period uninvolved joints should similarly be included in the series to
evaluate for potential joint incongruency. Patients may follow
Primary issues in the immediate postoperative period while up every 1 to 2 weeks as needed during the active external fixa-
still in the hospital setting include wound and wire/pin care, tion adjustment phase. In cases where a static circular external
appropriate antibiosis, pain management, and anticoagulation fixator was utilized and no postoperative corrections through
considerations. Generally, the postoperative dressings applied the external fixator are occurring, visits may be spaced to
for both the incisions and wires/pins remain unchanged until every 3 to 4 weeks. In cases of arthrodesis or lower extremity
the first follow-up visit in the clinical setting. Patients with active
wounds may have a negative pressure wound therapy (NPWT)
applied intraoperatively. Typically, a NPWT device may lose the
suction seal due to the wire/pin density around the wound and
should be checked daily for integrity (Figure 23.1). The risk
for deep vein thrombosis stems from a lack of muscle action in
the lower extremity, especially when the external fixator spans
one or more major joints. Children and most healthy adults do
not usually require anticoagulation while in the external fixa-
tion device. High-risk candidates for anticoagulation therapy
postoperatively include those with coagulopathy disorders,
prior deep vein thrombosis or pulmonary emboli, and certain
neoplastic disorders. Elastic wraps may be also used on the
lower extremity involved to add some degree of compression
and keep any potential edema formation in check. On rare
occasions when the patient’s swelling places the lower extrem-
ity at risk for impingement on the external fixation rings, a trial
course of diuretics may be also indicated (Figure 23.2). While
in the hospital setting, the patient should have daily physical Figure 23.1. An example of a negative pressure wound therapy
therapy to work on uninvolved adjacent joint motion and inde- (NPWT) system in conjunction with the external fixation device. This
pendence with non–weight bearing gait training using a walker, technique can be quiet challenging with the frequency of NPWT
crutches, or other assistant devices. In addition, patients should dressing changes.
409
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410 Chapter 23
Figure 23.4. Example of half-pin tract inflammation without

infection.
Figure 23.2. Example of excessive postoperative swelling con-
stricting the soft tissues in the midcalf region. The patient returned to
the operating room for circular ring exchange. and water, or Betadine-soaked non-adherent dressings. Irritants
such as alcohol or peroxide should be avoided for risk of inflam-
ing surrounding soft tissue. A bacterial ointment may be applied
lengthening, an external bone stimulator may be applied to at the wire/pin interface followed by application of the dressing.
help facilitate the healing process. Several units have been Commercially available wire/pin sponges are now available that
made to be attached directly to the external fixator through an have silver-impregnated antibacterial properties which can be
adaptor if needed during the postoperative period. applied with a wire/pin clamp to minimize soft tissue excur-
sion (see Chapter 5). Alternatively, a cut 2 × 2 in. or 4 × 4 in. in
multiple layers combined with a Kerlix wrap allows minimal
Postoperative Clinic Visits soft tissue excursion around the wires/pins, thus reducing risk
for irritation or infection (see Chapter 5). Crusting around the
Wire/pin tract issues are the greatest potential complication and wires/pins may develop and by itself is not a sign or increased
challenge following application of external fixators. Wire/pin risk for infection. The wire/pin crusts can be removed safely
vulnerability for irritation or infection is dependent on location, thus reducing the potential for trapping bacteria underneath
position of the transosseous wire or half-pin, the degree of soft the soft tissue crust (Figure 23.3). Wire/pins may be noted to
tissue overlying the wire/pin site, external fixation stability, and demonstrate some redness in a zone around the wire/pin which
risk for trauma during the postoperative period. In the immedi- blanches under pressure. This case is more related to wire/pin
ate perioperative period, petroleum gauze wrapped around the inflammation and a nonsteroidal anti-inflammatory may help
pin sites combined with wire/pin sponges or Betadine-soaked with addressing discomfort associated with inflammation signs
adaptic dressings applied at the time of surgery meet the mini- (Figure 23.4). Wire/pin irritation may increase as additional
mum needs. In the postoperative period, the initial wire/pin wire/pin tension develops in cases of compression or distraction
dressing needs to be inspected and cleaned and wire/pin sites osteogenesis. In these cases, the corresponding skin in front of
may be addressed with normal saline alone, antibacterial soap the wire/pin may need to be released with a no. 11 blade (Figure
23.5). This technique can be performed under local anesthesia
in the clinical setting when warranted.
True purulent drainage is a sign of infection which may
also manifest as non-blanching redness, increased pain and
tenderness on palpation, warmth, fluctuance, and a systemic
rise in temperature (Figure 23.6A and B). Early management
of a wire/pin infection includes increasing wire/pin care
from once a day to twice daily, reduction in range of motion
or weight bearing status in physical therapy, administration of
topical in addition to oral antibiotics for a 7- to 10-day course.
Typically, with mild wire/pin tract infection, resolution will be
noted as soon as 1 to 2 days initiating the course of treatment.
In cases of recalcitrant wire/pin infection, the wire/pin may
be also removed in the clinical setting if needed. For a more
extensive cellulitis or deeper infection, or if multiple wire/pin
removal compromises external fixation stability, the patient
should return to the operating room for adequate manage-
Figure 23.3. Example of a soft tissue crusting without drainage ment. The procedure consists of wire/pin removal, incision
from a calcaneal half-pin. and drainage and curettage of wire/pin tracts, and adjustment
LWBK1121-C23_p409_414.indd 410 04/10/12 11:39 AM

External Fixation Postoperative Care and Rehabilitation 411
Figure 23.5. Releasing stab wound with a no. 11 blade created

due to tension from transport segment on the surrounding skin.
of the external fixation device with new wires/pins away from

the site of infection. A systemic course of intravenous antibiot-
ics may be also necessary until the cellulitis resolves.
Postoperative Weight
Bearing Status
Initial weight bearing is limited until the wound is healed at
the 2- to 4-week postoperative period. Progressive weight bear- B
ing with crutches or other assistant devices may be initiated
Figure 23.6. Evidence of wire (A) and half-pin (B) drainage with
under a physical therapist’s supervision and may increase over fluctuance necessitating removal and surgical debridement.
the postoperative period to full weight bearing if axial load is
deemed beneficial (Figure 23.7A and B). Conditions where
Figure 23.7. Gait training in the postop-

erative period (A, B) is helped by the addition
of a rocker attachment to the bottom of the
foot ring. A B
LWBK1121-C23_p409_414.indd 411 04/10/12 11:39 AM

412 Chapter 23
weight bearing is stimulatory include bone consolidation in removal of external fixation. Plain radiographs are also used to
long bone nonunions, ankle and subtalar joint arthrodesis. monitor for bone trabeculation across an arthrodesis site and
Physical therapy is also involved early on to focus on active and the absence of cortical irregularity. In cases with corticotomy
passive range of motion of uninvolved joints. Motion at the and bone transport, the regenerate bone needs to have defined
knee and ankle if free should be initiated almost immediately. cortices and sufficient bone density prior to external fixation
The resultant pumping action increases flow into the lower removal. When there is difficulty in visualization on plain
extremity which decreases risk for deep vein thrombosis as well radiographs or clinical uncertainty, a computed tomography
as improving the venous and lymph system to aid in outflow, scan can be used for confirmation. Generally, in uncompli-
minimizing swelling while in the external fixator. Nonimpact cated arthrodesis a minimum of a 10-week period is required
activities patients may pursue while in the external fixator whereas with lower extremity bone transport, the time period
include and are not limited to bicycling, upper body strength- is considered 2 to 3 times that of the period of lengthening
ening and pool therapy conditional on clean wires/pins, and and/or evidence for sufficient bone matrix in the transport
healed incisions. In cases where distraction osteogenesis cre- segment.
ates added tension across uninvolved joints, the frequency and Reasons for early return to the operating room involve
extent of therapy on the adjacent joints should be increased external fixation device adjustments due to a loss of alignment
to minimize contractures. Patients should also be set up with a that cannot be reduced with outpatient adjustments (Figure
daily home exercise program that can be performed between 23.9A and B). Additional indications include swelling severe
outpatient clinic visits with the physical therapist. In contrary, enough to create pressure ulcers on the lower extremity in
weight bearing status may not be feasible in morbidly obese the existing external fixator and loss of fixation in a segment
patients with active Charcot neuroarthropathy plantar foot due to wire/pin breakage or necessitating a number of wires/
wounds and external fixation. In these cases, upper extrem- pins exchange due to infection.
ity strengthening and active and passive range of motion of External fixation removal while possible in the clinical set-
uninvolved joints is maintained throughout the postoperative ting is generally recommended in the operating room for addi-
period. tional wire/pin debridement or staged procedures if necessary.
Intraoperative C-arm fluoroscopy can be used for confirmation
of consolidation across the index surgical site upon external
External Fixation Duration fixation removal. All pin/wire sites are curetted at the time if
and Removal needed and petroleum non-adherent dressings are applied to
the sites followed by application of a compression dressing and
Decision for the timing of external fixator removal is based on posterior splint or cast. The patient is advised to be non–weight
a multitude of factors. Over time, as the patient is able to weight bearing until the first postoperative clinic visit at 2- to 3-week
bear a greater amount and duration, symptoms through the period at which time a walking cast is applied for an additional
surgical site become less. The external fixation device may be 6 to 8 weeks with progressive weight bearing initiated. In most
loosened in the clinical setting at the zone of the primary pro- foot and ankle cases, the patient will be transferred following
cedure and gently torque between rings to assess for motion the period in the walking cast into a walker boot and initiate
and any discomfort (Figure 23.8A and B). In cases where there physical therapy with pedorthic consultation for lower extremity
is no discomfort and full stability, clinical parameters warrant bracing or orthosis.
A B
Figure 23.8. Adjustments in the postoperative period include tightening loose bolts (A) with strut adjust-
ments (B) without any patient discomfort.
LWBK1121-C23_p409_414.indd 412 04/10/12 11:40 AM

External Fixation Postoperative Care and Rehabilitation 413
A B
Figure 23.9. Example for returning to the operating room in the postoperative period. In this case, a
staged external fixation conversion which initially allowed for free flap access (A) is now converted to com-
pression configuration to aid in ankle arthrodesis (B).
Conclusion
A. Primary issues in the immediate postoperative period External fixation represents an effective and versatile treatment
include wound and wire/pin care, appropriate antibiosis, method yet requires diligent care in the postoperative period.
pain management, and anticoagulation considerations. Ideal management of these cases can be facilitated through
B. Wire/pin vulnerability for irritation or infection is appropriate consultation with physical therapy, nursing, and
dependent on location, position of the transosseous wire pedorthics. The unique external fixation elements coupled
or half-pin, the degree of soft tissue overlying the wire/ with complex pathology involved calls for careful consideration
pin site, external fixation stability, and risk for trauma. of patient compliance and knowledge of proper precautions to
C. Progressive weight bearing with crutches or other assist- reduce risk of postoperative complications.
ant devices may be initiated under a physical therapist’s
supervision and may increase over the postoperative
period to full weight bearing if axial load is deemed Recommended Readings
beneficial. Physical therapy is also involved early on to National Association of Orthopaedic Nurses. An Introduction to Orthopaedic Nurs-
focus on active and passive range of motion of unin- ing. 2nd ed. New Jersey, NJ: Anthony J. Jannetti, Inc.; 1999.
Schoen DC. Adult Orthopaedic Nursing. Philadelphia, PA: Lippincott Williams &
volved joints.
Wilkins; 2000.
Schwartsman V. What one should know about the Ilizarov method. The ILIZAROV
Method, http://www.lasvegasortho.com/ilizarov.htm, August 2000.
Smeltzer SC, Bare BG. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
Philadelphia, PA: Lippincott Williams & Wilkins; 1992.
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LWBK1121-C23_p409_414.indd 414 04/10/12 11:40 AM
Index
Note: Page numbers followed by f indicates figure.
A Ankle bone block impingement syndrome, 123 implant size and external fixation material
Abductor digiti minimi (ABDM) muscle flap, Ankle delta–spanning external fixation system, considerations, 36, 38
361, 370–373 198–201, 199f, 200f olive transosseous wires, 36
Abductor hallucis (ABH) muscle flap, 361, Ankle equinus, 391. See also Equinus deformity steerage pins, 36
367, 369 Ankle-foot orthosis (AFO), 407 Biplanar design, 7
Achilles deformities, 123 Ankle joint, acute CN fracture/dislocation at, Biplane ankle external fixator technique,
Achilles tendon, 24, 265 294f 75–78, 75f–79f
lengthening, 180 Ankle joint dorsiflexion, 265 clinical case II, 78
Allogenic structural grafting, 149 Ankle/pilon trauma clinical case III, 80
Allograft tissue, 90 external fixation for delta variant of, 81, 81f
Ankle arthrodesis fracture reduction, 191–198 Bone biopsy, in osteomyelitis, 354 Bone
circular external fixation for, 237–245 indications/contraindications for, 187 cultures, in osteomyelitis, 354
ankle joint compression, 244f internal fixation with, 188–191 Bone transport, 377–390
basic circular external fixation postoperative course and complications, bifocal, 377–378, 378f, 379f
components, 237–238, 238f 201–205, 202f clinical tips and pearls, 390
clinical case on, 245, 245f preoperative considerations for, 188–191 preoperative considerations, 377–378
forefoot stabilization, 242, 243f surgical technique for, 198–201 quadrifocal, 378, 381
pre-built circular external fixator for, Ankle procedures surgical technique, 378–390
238, 239f external fixation for, 237–263 bone loss treated with acute shortening,
reference wire, insertion of, 240, 241f, circular flap coverage, and bone lengthening,
242f for ankle arthrodesis, 237–245 (See also 381, 386, 386f
removal of Steinmann pins, 242, 244f Ankle arthrodesis) bone loss treated with isolated bone
removal of sterile towels, 242f for ankle joint arthrodiastasis, 251–257 cortex transport, 386, 387f
second transosseous talar wire placement, for supramalleolar osteotomy, 257–263 bone loss with adequate soft tissue
243f clinical tips and pearls, 263 coverage, 378, 379, 381, 383f
Steinmann pins, for temporary fixation, indications/contraindications for, 237 bone loss without plastic reconstructive
240f surgical technique, 237–245, 247–252, surgery, 382, 384f, 385f
sterile towels, use of, 240f 254–263 external dynamic compression plates, use
talar preparation, 240f uniplane monolateral, for ankle of, 387, 387f
with telescoping rods, 245, 247f arthrodesis, 245–251 Taylor spatial frame, use of, 392, 388f,
tibia, preparation of, 239f Ankle-spanning external fixator, 177 389f
tibia stabilization, 242, 243f Anterior distal tibial angle (ADTA), 392, 393, trifocal, 378, 380f
transosseous wire insertion into 393f Brachymetatarsia, 207–210, 209f, 210f
calcaneus, 245f Antibiotic-impregnated cement blocks, 355 Burrow’s triangle excisions, 367
with virtual axis hinges, 245, 247f Arbeitsgemeinschaft für Osteosynthesefragen
uniplane monolateral for, 245–251 (AO) Foundation, 35
ankle hinge joint, tightening of, 249, 251f Arched wire, 36 C
basic external fixation components, 247f docking technique, 59 Calcaneal–first metatarsal angle (cavus angle),
compression–distraction unit, use of, 249, Arthrodesis, uniplane monolateral foot 392, 393f
251f external fixator technique for, 85–87 Calcaneal fracture, 162, 163
distal clamp for calcaneal half-pin Autogenous structural grafting, 149 management, 174–177
insertion, 245, 248f Avascular necrosis, of talus, 164 Calcaneal pin, usage of, 78
final construct in compression mode, Axial wires, usage of, 14, 14f Calcaneal ring, 225
251f Calcaneal skinny wire, 15
half-pin insertion into proximal tibia, Calcaneal tuberosity, 177
249, 249f, 250f B Calcaneal varus, 177
hinge clamp articulations, locking of, Below-the knee amputation (BKA), in diabetic Calcaneus, safe lower extremity anatomic zones
249, 250f patient, 294 for, 26–27, 26f, 27f
placement of proximal half-pins, 249, Bent wire technique, 36, 177, 324 C-arm fluoroscopy, 129, 324, 362
249f Bicortical fixation, 18, 71 usage of, 50
talar neck half-pin, insertion of, 245, 248f Bilateral constructs, 38 Center of rotation and angulation (CORA),
Ankle arthrodiastasis, 237 Biomechanics, of external fixation, 33–39 124–125
circular external fixation for, 251–257, 258f bent wire technique, 36 Charcot ankle arthrodesis, 296–300, 303–306
anterior motor construct, 256f dynamization, principles of, 33–34 alignment of lower extremity with tibial
anterior strut use as motor, 257f external fixation wire/pin and bone block and foot plate fixation, 298f
arthrodiastasis technique, 252, 252f–253f, interface, 35–36, 35f, 36f clinical cases, 303–306
259, 259f external fixator construct stability, optimizing, final circular external fixation construct
clinical case on, 252, 252f–253f, 257, 259f 38–39, 39f for, 302f
external fixator for, 251–252, 252f fracture healing, cyclic microshear on, 34 half-pin insertions, 299f
finished construct in medial view, 257f hybrid wire/pin external fixation prebuilt static circular external fixation
medial hinge construct, 254f–255f configurations, 38 construct, 298f
415
LWBK1121-IND_p415_420.indd 415 05/10/12 7:41 PM

416 Index
Charcot ankle arthrodesis (continued) Closing-wedge osteotomy, 123 device, Hippocrates rudimentary, 1f
Steinmann pins, removal of, 301f CN. See Charcot neuroarthropathy (CN) for elective and reconstructive ankle
talar olive wire, insertion of, 300f Compartment syndrome, 148 procedures, 237–263
temporary ankle transfixation with Compression–distraction nuts, 238, 239f clinical cases, 245, 245f–246f, 252,
Steinmann pins, 297f Compression mode, for joint arthrodesis, 35 252f–253f, 259, 259f
tibiotalar articular surfaces resection, 297f Coronal plane deformities, of forefoot, 124 clinical tips and pearls, 263
transfibular approach with resection of distal Corticotomy, 210 indications/contraindications for, 237
fibula, 296, 296f Cyclic microshear effects, on fracture healing, surgical technique, 237–245, 247–252,
transosseous wire insertion, 299f 34, 34f 254–263
variable hinge construct, 298f for elective and reconstructive arthrodesis of
Charcot deformities, at Lisfranc’s level, 264 midfoot/hindfoot, 224–236
Charcot neuroarthropathy (CN), 27, 92 , 119, D candidates for, 224
264, 293 DeBastiani’s external fixator, 33 circular, 225
difficulties in management of, 108 Delta-spanning external fixator, 191 clinical cases on
hindfoot/ankle deformities, 293–317 Diabetic forefoot wound closure, 219–222, 222f ankle valgus collapse from previous
clinical tips and pearls, 317 Diabetic patients, external fixation in, 225 attempted ankle arthrodesis, 231,
goals of operative management of, 293 Diagnostic angiography, 361 231f
preoperative considerations, 293–295 Diaphyseal junction, 22 avascular necrosis of talus, 226,
surgical algorithm for approaching of, 294t Digitorum brevis muscle, 90 226f–227f
surgical intervention for, 293 Distal tibia diaphyseal, 23. See also Tibia avascular necrosis with collapse of
surgical technique, 296–317 Distal tibia metaphysis, 23, 23f. See also Tibia talus after triple arthrodesis, 232,
Charcot ankle arthrodesis, 296–300, Distraction arthroplasty, uniplane monolateral 232f–233f
303–306 foot external fixator technique for, 90 CN fracture and dislocation at Lisfranc’s
Charcot tibiocalcaneal arthrodesis, Distraction mode, 35 joint, 235, 235f–236f
300–301, 306f–310f, 310–315 Distraction Osteogenesis Ring System, 392 foot collapse and subluxation at
correction of Charcot peritalar Doppler probe, handheld, 265 talonavicular joint, 229, 229f–230f
subluxation, 301–303, 314f–315f, Doppler ultrasound, 361 pes planovalgus deformity with joint
315–317 Dorsalis pedis artery, 27 pain, 228, 228f–229f
midfoot deformities, 264–292 Drop wire, role of, 16, 16f posttraumatic arthritis at both ankle
clinical presentation of, 265 Dynamization, principles of, 33–34, 33f, 34f and subtalar joints, 233, 233f–234f
clinical tips and pearls, 292 clinical tips and pearls, 236
preoperative considerations, 264–265 compression arthrodesis of joints in,
primary objective in, 264 E 225–226, 230
procedure selection for, 264 Edema in diabetic patients, 225
surgical algorithm for approaching, 265t chronic, 106 indications/contraindications for,
surgical technique, 265–291 posttraumatic, 106 224–225
combined internal and external Eichenholtz classification, of CN deformities, postoperative course, 230, 236
fixation, 277, 286–290 293 preoperative considerations, 225
compression through bent wire Elasticity values, approximate modulus of, 36t in rheumatoid patients, 225
technique, 274, 277, 281–286 Equinus deformity surgical technique, 225–230
compression through olive wire correction with circular external fixation, equipment, operating room preparation
docking, 266–275 391–407 and, 50–53
compression through struts, 273, 276f, clinical tips and pearls, 407 for forefoot elective and reconstructive
277–280 closed method of, 393–399 surgery
uniplane monolateral external indications for, 392 surgical technique, 207–222
fixation, 290–291 open method of, 399–406 for forefoot trauma
peritalar variant, 295f through focal dome osteotomy, indications/contraindications, 148
stage 1, 293 402–404, 403f–404f postoperative course and complications,
stage 2, 293 through supramalleolar osteotomy, 160
stage 3, 293 399–402, 399f–401f preoperative considerations, 148–149
talar variant, 295f through V-osteotomy, 404–406, surgical technique, 149–160, 159f, 160f
Charnley’s external fixator, 35 405f–406f history and evolution of, 1–10
Cierny–Mader classification system, lower postoperative protocol during, 406–407 hybrid, 9, 9f
extremity salvage and, 347 preoperative considerations, 392–393, 393f ankle, 81–85
Circular constructs, 38 surgical technique, 393–406 for midfoot and hindfoot trauma
Circular external fixation definition of, 391 indications/contraindications for,
components Extensor digitorum brevis (EDB) muscle flap, 162–163, 163f
circular, half rings and foot plates, 41, 361 postoperative course and complications
41f, 42f External fixation of, 180–185
hinges, 48, 48f for acute ankle/pilon trauma preoperative considerations, 163–169
nuts and bolts, 45, 46f indications/contraindications of, 187 surgical technique, 169–180, 172f,
plates, 47–48, 48f postoperative course and complications, 175f–176f
posts, 45, 46f 201–205, 202f modes of, 34–35
tensiometer, 45, 47f preoperative considerations for, 187–198 for osteomyelitis in foot and ankle, 341–359
threaded rods, telescoping rods, and surgical technique for, 198–201 postoperative care and rehabilitation,
struts, 41–44, 42f–44f advantages of, 33 409–413 (See also Postoperative period,
washers, 47, 47f biomechanical modes of, 35 care in)
wires and half-pins, 44, 44f, 45f biomechanics of, 33–39 purpose of, 6
wrenches, 45–47, 47f biplane ankle, 75–81, 75f–79f safe lower extremity anatomic zones for,
for tibial pilon fractures, 201 Charcot neuroarthropathy midfoot 12–32, 12f–14f
Circular external fixation constructs, 224 deformities and, 264–292 anatomic landmarks, 21
Clawtoe correction and proximal phalangeal circular, 9 calcaneus, 26–27
lengthening, 211–219 classification/types of, 5–10 cross-sectional anatomy, 21–22
Cleft-foot deformity, 360 components, circular, 41–48 half-pin application, 18–21
LWBK1121-IND_p415_420.indd 416 05/10/12 7:41 PM

Index 417
midfoot and forefoot, 27–30 clinical tips and pearls, 340 Hindfoot/ankle, osteotomy and arthrodesis
talus, 23–26 indications/contraindications for, 318–319 procedures, 319–320
terminology, 14–17 postoperative course, 339–340 Hinges, role of, 48, 48f
tibia, 22–23 preoperative considerations in, 319 Hinge system
transosseous wire application, 17–18 surgical technique for, 319–340 constrained, 393
static circular, 92–117 infected nonunions of foot and ankle, unconstrained, 393
indications/contraindications, 92–106 326–328 Hippocrates rudimentary external fixation
postoperative course and complications, pediatric foot and ankle malunions/ device, 1f
115–117 nonunions, 328, 331, 336 Hoffman’s external fixation application
preoperative considerations, 106–108 realignment hindfoot/ankle osteotomies technique, 4
surgical technique, 108–115, 109f and arthrodesis procedures, 319–320 Hohmann retractors, 210
timeline of, 1–5 realignment midfoot osteotomies Hybrid ankle external fixator technique,
unilateral, 3 and arthrodesis procedures, 320, 81–82, 82f–84f
uniplane monolateral ankle, 71–75, 71f–74f 324, 326 clinical case IV, 85
uniplane monolateral foot Foot and ankle osteomyelitis, external fixation Hybrid clamps and bars, use of, 365
for arthrodesis, 85–89 for, 341–359 Hybrid external fixators, 9, 9f
for distraction arthroplasty, 90 clinical cases Hybrid/modified circular external fixation
usage of, 1 fractured and dislocated CN right ankle constructs, 326–327
with instability, 356, 356f–358f Hybrid wire/pin external fixation
infected CN foot with deep abscess, 348, configurations, 38
F 348f–350f, 351, 351f–353f
Fibular wire, 110 infected diabetic CN foot with abscess
usage of, 14, 15f and osteomyelitis, 342, 342f–344f, I
Finite element analysis, 34 345, 345f–347f Ilizarov external fixator, 292
Flexor digitorum brevis (FDB) muscle flap, clinical tips and pearls, 359 Ilizarov technique, 320
361, 369–370 indications/contraindications for, 341–351 Ilizarov-type circular fixators, 392
Floating talus technique (FTT), 397–398 postoperative course and complications, Infection, signs for,354
Foot and ankle 359 Intercuneiform half-pin, usage of, 200
circular external fixation of, 50–53, 51f–53f preoperative considerations, 354
Taylor spatial frame for surgical technique for, 354
deformity planning, 122–125 final-staged reconstructive procedure, 355 K
indications/contraindications, 119–121 initial surgical debridement, 354 Kirschner (K)-wire, 4, 174, 201
postoperative course and complications, second-staged reconstructive procedure, Known-to-unknown concept, defined, 18
141–147 354–355
preoperative considerations, 122–125 third-staged reconstructive procedure,
for rearfoot/ankle arthrodesis and 355 L
arthrodiastasis, 131 Forefoot cleft wounds, closure of, 365 Lambotte’s fixator, 4
for supramalleolar deformity correction, clinical cases, 366, 366f–367f Ligamentotaxis, 191
125–130 Forefoot elective and reconstructive surgery principle of, 191
surgical technique, 125–141 with external fixation Lisfranc’s fractures, 148, 149
for unstable Charcot midfoot deformities, surgical technique, 207–222 Local advancement flap, 365, 367
133–141 uniplane monolateral external fixators, clinical cases, 368, 368f, 369, 369f
Foot and ankle malunion/nonunion deformities, 207f Local random flaps, 361
circular external fixation for, 318–340 Forefoot ring, 225 Lymphedema, 106
clinical cases Forefoot trauma
distal lower extremity fracture after ORIF, indications/contraindications of, 148
328, 328f–330f postoperative course and complications, M
distal tibial deformity correction for 160 Malunions/nonunions, in foot and ankle, in
malunited ankle fusion, 336, 336f preoperative considerations of, 148–149 pediatric patients, 328–339
foot plate connected to bottom of foot surgical technique Mayo stand, usage of, 51
external fixation support, 339, 339f circular external fixation, 157–160 Medial plantar artery (MPA) flap, 361,
left ankle valgus deformity, ankle instability, forefoot stabilization, 149–157, 157f 373–374
and tibial shortening, 334, 334f–336f, Fracture healing, cyclic microshear on, 34, 34f clinical case, 375, 375f
336 Fracture reduction, external fixation for, Metaphyseal junction, 23
malunion of distal tibia and fibula fracture 191–198 Metatarsal bone defect, 149
with angle deformity, 325, 325f Free tissue transfer, 361 Metatarsal fractures, 148
medial column nonunion and malunion FTT. See Floating talus technique (FTT) Metatarsophalangeal joint (MTPJ), 149 , 207
with posttraumatic deformity, 327, arthrodesis and arthrodiastasis, 210–211,
327f 212f, 213f
open right distal tibial and fibular G Midfoot and hindfoot trauma
fractures, 330, 330f–331f Gastrocnemius recession procedure, 265–266 external fixation for
osteomyelitis sequelae of malunited Gauze, saline-soaked, 110 indications/contraindications for,
arthrodesis with proximal tibia valgus Gigli wire saw, 210 162–163, 163f
deformity and shortening, 332, GranuFoam, 362 postoperative course and complications
332f–334f Growth plate disturbance, 328, 330, 330f–331f of, 180–185
paralytic malunion, 326, 326f preoperative considerations, 163–169
posttraumatic arthritis from malunion of surgical technique, 169–180, 172f,
talus fracture, 320, 320f–321f H 175f–176f
posttraumatic right ankle valgus deformity, Half-pins, 35, 224, 225 Midfoot osteotomies and arthrodesis
337, 337f–339f application, 18–21, 19f–21f procedures, 320, 324, 326
talar neck and body fracture with drawback of, 18 Midfoot wedge resection, 324
malunion, 321, 321f–323f insertion and fixation, 62–69, 65f–69f Midshaft tibia, 22–23. See also Tibia
talar varus malunion with avascular Hawkins Grade 3 and 4, 162 Mini fluoroscopy, usage of, 50
necrosis, 323, 323f–324f Hexapod-type external fixator, 392 Monolateral constructs, 38
LWBK1121-IND_p415_420.indd 417 05/10/12 7:41 PM

418 Index
Monolateral external fixator, 71, 90 closure of forefoot cleft wounds, 365, 366, Standard half-pin insertion technique, 62
Muscle flaps, 361, 367–373. See also specific types 366f–367f Static circular external fixation, 92–117
abductor digiti minimi muscle flap, 370–373 local advancement flap, 365, 367, 368, application of, 110
abductor hallucis muscle flap, 367, 369 368f, 369, 369f Charcot neuroarthropathy, difficulties in
flexor digitorum brevis muscle flap, 369–370 medial plantar artery flap, 373–374 management of, 108
muscle flaps, 367–373 determining size of, 106–108
negative pressure wound therapy, evaluating and addressing psychosocial
N 362–365 issues, 108
Negative pressure wound therapy (NPWT), reverse flow SAN flap, 374, 375, 375f indications/contraindications of, 92–106
341, 345, 355, 360, 362, 363f, 409 Plates, role of, 47–48, 48f postoperative course and complications,
clinical case on, 364, 364f–365f Polymethyl methacrylate (PMMA), 341, 355 115–117
Neurovascular pedicle flaps, 361 Popliteus muscle, 21 preoperative considerations of, 106–108
Neurovascular structure, 23 Postoperative period, care in, 409–413 surgical technique, 108–115, 109f
Nonabsorbable nylon, 367 clinical tips and pearls, 413 Steerage pins, 36, 37f
NPWT. See Negative pressure wound therapy complications and, 409 Steinmann pin, 3, 115, 177, 225
(NPWT) external fixation duration and removal, 412, usage of, 51, 141
Nuclear medicine imaging, in osteomyelitis, 354 413f Stirrups wire, usage of, 16, 16f
Nuts and bolts, role of, 45, 46f hospital discharge and, 409–410 Supramalleolar deformity correction, Taylor
immediate postoperative period and, 409 spatial frame for, 125–130
postoperative clinic visits, 410–411, 411f Supramalleolar osteotomy (SMO), 237, 257
O and weight bearing status, 411–412 circular external fixation for, 257–263
Off-loading external fixation, and plastic Prebent transosseous wire technique, 224–226 dome osteotomy, 259–260, 260f
reconstruction. See also Plastic Prolene suture, 367 drop half-pin for added stability, 260, 261f
reconstruction of foot and ankle, with Proximal interphalangeal joint (PIPJ), 211 five-eighth ring, use of, 260, 261f
surgical off-loading external fixation Proximal tibia metaphyseal, 22. See also Tibia olive transosseous wire into talus, 260,
Off-loading external fixation device, 374, 375, 262, 262f
375f osteotome, use of, 260, 261f
Olecranon fractures treatment, external Q pre-built circular external fixator, 259,
fixation device for, 1 Quadrifocal bone transport, 378, 381f 259f
Olive transosseous wires, 36 proximal tibial reference wire, insertion
Olive wires, 13, 225 of, 260, 261f
docking technique, 59 R removal of Steinmann pin, 262, 262f
in fixation of calcaneus, 27 Rancho cube, usage of, 21 struts, adjustment of, 262, 263f
usage of, 110 Rearfoot/ankle arthrodesis and arthrodiastasis transosseous wire, insertion of, 260, 261f
Open reduction and internal fixation (ORIF), Taylor spatial frame for, 131 Sural artery neurofasciocutaneous (SAN) flap,
148, 162, 187, 318 Reference wire, usage of, 18 reverse flow, 361, 374
Operating room Rheumatoid patients, external fixation in, 225 clinical case, 375, 375f
external fixator application in, 50–53, RingFix, 392 Surgical off-loading external fixation, 360
50f–53f Rocker bottom deformity, 264, 266f and plastic reconstruction of foot and ankle,
preparation for circular external fixation, 360–376 (See also Plastic reconstruction
50–53, 51f–53f of foot and ankle, with surgical off-
Osseous defects, infected, management of, S loading external fixation)
326–328 Safe lower extremity anatomic zones, for
Osteomyelitis of foot and ankle, 341 external fixation, 12–14, 12f–14f
management of, 341–359 anatomic landmarks, 21 T
primary intraoperative goal in treatment calcaneus, 26–27 TAL. See Tendon Achilles lengthening (TAL)
of, 341 cross-sectional anatomy, 21–22 Talar dislocation, lateral, 169
Osteoporosis, external fixation in, 224 half-pin application, 18–21 Talar–first metatarsal angle (Meary angle),
midfoot and forefoot, 27–30 392, 393f
pin-to-bar type, 12, 12f Talar neck fractures, 162
P talus, 23–26 Talus
Papineau technique, 149 terminology, 14–17 partial or total enucleations of, 169
Parkhill’s original bone clamp, 7 tibia, 22–23 safe lower extremity anatomic zones for,
Pediatric foot and ankle malunions/ transosseous wire application, 17–18 23–26, 24f–26f
nonunions, 328–339 Salvage arthrodesis, 180 Tarsometatarsal joint, 149
Pedicle flaps, 361 Schanz pins, 9, 378 Taylor spatial frame (TSF), 119, 320, 392
Peripheral vascular disease (PVD), 265 Segmental bone loss in midfoot and hindfoot, for foot and ankle
Peritalar dislocation, 314f external fixation for, 224 225 deformity planning, 122–125
Peritalar joint, 162 Skeletal bone and joint stabilization, 361–362 indications/contraindications, 119–121
stabilization, 177 Skinny wire postoperative course and complications,
Peroneal nerve, 27 calcaneal, 15 141–147
Pes planovalgus, 15 tensioned, 15 preoperative considerations, 122–125
Pinch test, 361 transosseous, 24 for rearfoot/ankle arthrodesis and
Pin sponges, 410 SMO. See Supramalleolar osteotomy (SMO) arthrodiastasis, 131
Plantar calcaneal tuberosity, 110 Smoking cessation, for surgery, 225 for supramalleolar deformity correction,
Plantarflex, 220 Soft tissue loss, management of, 377–390. 125–130
Plastic reconstruction of foot and ankle, with See also Bone transport surgical technique, 125–141
surgical off-loading external fixation, Sole–talar angle (STA), 392, 393f for unstable Charcot midfoot deformities,
360–376 Spacers, 355 133–141
clinical tips and pearls, 376 Spanning external fixator, principles of, 187 Tendon Achilles lengthening (TAL), 265–266,
indications/contraindications, 360–361 Split-thickness skin grafting (STSG), 361 391
postoperative course and complications, 374 Stacked Taylor spatial frame foot plate Tensiometer, role of, 45, 47f
preoperative considerations, 361–362 technique, 374 Thin tensioned wires, 35
surgical technique, 362–375 Stader splint, 4 Threaded rods, 238, 238f
LWBK1121-IND_p415_420.indd 418 05/10/12 7:41 PM

Index 419
Tibia insertion and fixation, 55–62, 55f–65f V

external fixation block, 198, 201 usage of, 110, 111f–115f VAC system, 362
safe lower extremity anatomic zones for, Trifocal bone transport, 378, 381f Vein mapping, 361
22–23 TrueLok Circular External Fixation System, Versajet Hydrosurgery System, 362
distal tibia diaphyseal, 23 331, 392. See also Equinus deformity Versa White Foam, 362
distal tibia metaphysis, 23 TrueLok Ring Fixation System, 392 V-osteotomy, 404–406, 405f–406f
midshaft tibia, 22–23 TSF. See Taylor spatial frame (TSF)
proximal tibia metaphyseal, 22 Tube-to-bar external fixator, 7
Tibia block, 327–328, 355 W
Tibial double-ring block, 394 Washers, role of, 47, 47f
Tibial fractures, 18 U Wedge osteotomies, 257
Tibial pilon fractures, circular external fixation Uniplanar design, 7 Wire/pin crusts, 410
for, 201 Uniplane monolateral ankle external fixator Wire/pin vulnerability, for irritation or
Tibial–sole angle (TSA), 391, 392, 392f technique, 71–74, 71f–74f infection, 410–411, 410f, 411f
Tibial wire, usage of, 14–15, 15f clinical case I, 75 Wires and half-pins, role of, 44, 44f, 45f
Tibiotalar angle (TTA), 391, 392, 393, 393f Uniplane monolateral external fixators, 378 Wires first method, 15, 15f
Tillaux–Chaput tibia fracture, 201 Uniplane monolateral foot external fixator Wolff’s law, 33
Total talar extrusion, 177–180 technique Wrenches, role of, 45–47, 47f
Transcalcaneal pin, 157 for arthrodesis, 85–87, 86f–87f, 89f–90f
Transfixion pins, 35 clinical case V, 88–89
Transosseous wire, 55, 225 for distraction arthroplasty, 90, 91f
application, principles and techniques for, Unstable Charcot midfoot deformities, Taylor
17–18, 17f, 18f spatial frame for, 133–141
LWBK1121-IND_p415_420.indd 419 05/10/12 7:41 PM

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External Fixators

of the Foot and Ankle

LWBK1121-FM_pi-xii.indd 1 05/10/12 1:09 PM

Vasilios D. Polyzois, MD, PhD

Thomas Zgonis, DPM, FACFAS

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Copyright © 2013 Lippincott Williams & Wilkins

Two Commerce Square

530 Walnut Street

Library of Congress Cataloging-in-Publication Data

External fixators of the foot and ankle/editors, Thomas Zgonis, Paul

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Bradley P. Abicht, DPM Alexandru V. Georgescu, MD, PhD

Claire M. Capobianco, DPM James E. Orsak, BSME

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Edgardo Rodriguez, DPM John J. Stapleton, DPM, FACFAS

Roberto H. Rodriguez, DPM, FACFAS J. Tracy Watson, MD

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1 History and Evolution of External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Safe Lower Extremity Anatomic Zones for External Fixation. . . . . . . . . . . . . 12

3 Biomechanics of External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

4 Circular External Fixation Components and

5 Operating Room Preparation and External Fixation Equipment . . . . . . . . . . 50

6 Stepwise Approach to Transosseous Wire and

7 Stepwise Approach to Uniplane, Biplane,

8 Stepwise Approach to Static Circular External Fixation. . . . . . . . . . . . . . . . . 92

9 Stepwise Approach to Taylor Spatial

10 Stepwise Approach to Forefoot Trauma and External Fixation . . . . . . . . . . 148

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11 Stepwise Approach to Midfoot/

12 Stepwise Approach to Ankle/

13 Stepwise Approach to Forefoot Elective and

14 Stepwise Approach to Midfoot and

15 Stepwise Approach to Ankle Elective and

16 Stepwise Approach to Charcot Midfoot

17 Stepwise Approach to Charcot Hindfoot/

18 Stepwise Approach to Adult and Pediatric Foot and

19 Stepwise Approach to Foot and Ankle

20 Surgical Off-loading External Fixation and

21 Stepwise Approach to Bone Loss, Transport, and

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22 Stepwise Approach to Equinus Deformity

23 External Fixation Postoperative Care and Rehabilitation. . . . . . . . . . . . . . . 409

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History and Evolution

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Figure 1.3. Clayton Parkhill

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Figure 1.4. Albin Lambotte (1866–1955)

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of the pin with a hammer. Later, in 1916, he perfected the

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Ilizarov performed a corticotomy of the fibula and distracted

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Figure 1.7. Pinless external fixation components

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Figure 1.11. anteroposterior

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