Correction of Complex Foot DeformitiesUsing the lIizarov External Fixator

Mehmet Kocaoglu, MO, Levent Eralp, MO, Ata Can Atalar, MO, and F. ErkaJ Bilen, MO

There are many drawbacks to using conventional approaches to the treatment of complex footdeformities, like the increased risk of neurovascular injury, soft-tissue injury, and the shortening of thefoot. An alternative approach that can eliminate these problems is the IIizarov method. In the currentstudy, a total of 23 deformed feet in 22 patients were treated using the IIizarov method. The etiologicfactors were burn contracture, po liomyelitis, neglected and relapsed clubfoot, trauma, gun shot injury,meningitis, and leg-length discrepancy (LLD). The average age of the patients was 18.2 (5- 50) years.The mean duration of fixator application was 5.1 (2-14) months. We performed corrections without anosteotomy in nine feet and with an osteotomy in 14 feet. Additional bony corrective procedures includedthree tibial and one femoral osteotomies for lengthening and deformity correction, and one tibiotalararthrodesis in five separate extremities. At the time of fixator removal, a plantigrade foot was achievedin 21 of the 23 feet by pressure mat analysis. Compared to preoperative status, gait was subjectivelyimproved in all patients . Follow-up time from surgery averaged 25 months (13 - 38). Pin-tract problemswere observed in all cases. Other complications were toe contractures in two feet, metatarsophalangealsubluxation from flexor tendon contractures in one foot, incomplete osteotomy in one foot, residualdeformity in two feet, and recurrence of deformity in one foot. Our results indicate that the IIizarovmethod is an effective alternative means of correcting complex foot deformities, especially in feet thatpreviously have undergone surgery. (The Journal of Foot & Ankle Surgery 41(1 ):30-39,2002)

Key words: complex foot deformity, ilizarov method, osteotomy

C omplex foo t deformity can be described as a foot withmultiplanar deform ities with or without shortening of thefoot. It can also define those feet with poor soft-tissuecoverage and relapsed or neglected cases , which can be allcomplicated by other problems, such as leg-length discrep­ancy, lower leg deformity, osteomyelitis, and nonunion.Such deformities are caused by trauma, neglected orrelapsed clubfoot, poliomyelitis, osteomyelitis, bum con­tracture, and neuromuscular disease, among others.

Traditionally, correction of complex foot deformitieshas been managed through extensive soft-tissue relea ses,osteotomies, or arthrod esis. Conventional techniques tendto have many disadvantages, including neurovascularinjury, soft-tissue problems, and a shortened foot. More­over, the management of complex foot deformities thathave undergone one or more surgical procedures is diffi­cult (I , 2).

The Ilizarov method was chosen for the correction ofcomplex foot deform ities because it enables correction in

From Department of Orthopaedi cs and Traumatology, Istanbul Uni­versity. Istanbul School of Medicine , istanbul, Turkey. Addres s cone­spondence to: Mehrnet Kocaoglu, MD, Department of Orthopaedics andTraumatology, Istanbul Universit y, Istanbul School of Medicine, 34390Ca ps-Istanbul, Turkey; e-mail: kocaog lum@superonline.com.

Received for publication November 16, 2000; accepted in revisedform for publication September 13, 200 I.The Journal of Foot & Ankle Surgery 1067-2516/02/4101-0030$4.0010Copyright © 2002 by the American College of Foot and Ankle Surgeons

30 THE JOURNAL OF FOOT & ANKLE SURGERY

all three orthogonal planes, at a rate of which may betailored to the type and degree of deformity. It causesminimal surgica l morbidity without the shorte ning of thefoot, and allows the surgeon to manipulate the rate anddirection of the correc tion (3,4). The purpo se of this studywas to evaluate the results of surgical man agement withIlizaro v technique of complex foot deformities, performedat our institution over the last 4 years.

Material and Methods

Twenty-three deformed feet in 22 patients, with anaverage age of 18.2 (5- 50) years, were treated with theIlizarov method (Table I). Historical data were recordedfor each patient. All patients received preoperati ve eva lu­ation of both lower extremities. This evaluation consistedof range-of-motion measurements, neurovascular assess­ment, standing footprint s, two plane and posterior tangen­tial radiographs, orthoroentgenogra phy, computed tomog­raphy (CT) and 3D reconstruction, photography, andDoppler ultrasonography. The talus-first metat arsal angleand calcaneal pitch angle were measured on a lateralweightbearing film (5). A posterior tangential x-ray wasobtained to visualize the body of the calcaneus. Plantarsensation was carefully assessed . Doppler ultrasonograp hywas performed in cases of burn contracture and previoussurgical interventions for vascular evaluation.

TABLE 1 Etiology, operative procedures, and follow-up of all patients

(I)<fJ

'"o(I)

'"<>::xQlen

co.~

.!::!

~..'3

Foot deformity Additional deformity Etiology Osteotomy typeAdditional corrective

procedures

~ ~%OQl.o's E' E(I) ::> ::>Q:005

(I)

'" E (j)c:;::::..cCD ..... C~ 0 0

tb~5-=

c ~

o 0

!~~f.o.c° E~E -­.§.£

ComplicationsSecondaryprocedures

Result(foot)

§- -, "0 <fJ;;:.Q £;o ~ c= Q) 0o "'- E

LL -

PEV, Pes equinovarus; LLD, leg-length discrepancy; P, plantigrade; RD, residual deformity.

22 16 M R PEV

7 13 F R PEV

87M R PEV

20 18 M L Equinus

216M Bil PEV

24

38

16

30

27

17

24

31

26

19

25

13

35

20

27

30

27

18

36

14

2132

P

P

P

P

P

P

P

P

P

P

P

P

P

P

P

Bursectomy

Flexor tendon Plengthening

Re-osteotomy P

RD

P

Incompleteosteotomy

Recurrence R

PToe contracture + 2nd Flexor tendon RD

MP subluxation lengthening

5

6

5

3 Toe contracture

R:6L:O

8

7

10

14

3

5

5

5

3.5

2

2.5

7

3

5

2

4

8

4

8

8

3

32

2

3

Tibiotalar arthrodesis

Tibial osteotomyAchilles tendon

lengthening

V-osteotomy

Midfoot

Bilateral Achilles tendonlengthening

Supramalleolar Tibial osteotomy

U-osteotomy

Supramalleolar Tibial osteotomy

Supramalleolar

Midfoot Femoral osteotomy

Supramalleolar

Supramalleolar

Midfoot

Midfoot

Midfoot

Polio

Polio

Polio

Clubfoot

Meningitis sequela

Neglected clubfoot Midfoot

Relapsed clubfoot Midfoot

Trauma

LLD

LLD

Bilateral relapsedclubfoot

Trauma

Trauma

Neglected clubfoot

LLD

LLD Polio

Trauma

Clubfoot

LLD Gun shot injury

Trauma

Metatarsus adductus Burn contracture

Metatarsus adductus Burn contracture

Burn contracture

6 M L PEV

7 F L PEV

6 F R PEV

5 M R PEV

6

27 F L Equinus

2 24 M R Pes calcaneus

3 22 F L PEV

4

5

9 6 M L Pes planovalgus

105M R Pes planovalgus

11 50 F R Pes planovalgus

12 15 F R PEV

13 30 F L Equinus

14 37 M L Pes planovalgus

15 16 M L PEV

16 28 M L Pes planovalgus

17 27 M L Forefoot equinus

18 30 M R Pes calcaneovalgus

19

zc:s:OJmJJ

<orC:s:m::::

c....»zc»JJ~

"mOJJJC»JJ-<I'VooI'V

Co)....

Four basic osteotomy patterns were utilized to correctfoot deformities:

I. Supramalleolar osteotomy (Fig. I ) was used in patientswith deformity at the level of a previous anklearthrodesis and deformities at the level of the talusor subtalar joint in the presence of ankle ankylosis.

2. V-osteotomy is a double osteotomy, where the ante­rior part of the osteotomy starts from the neck oftalus and passes through anterior part of the calcaneus.The posterior part is performed between the dorsumof the calcaneal tuberosity and plantar surface of thefoot. These two osteotomies produce a V-shape onthe sagi ttal plane (3, 6). V-osteotomy produces a stiffsubtalar joint; hence we preferred to use it in patientswith stiff subtalar joints and in patients with neuromu s­cular imbalance (Fig. 2).

3. The U-osteotomy starts from neck of the talus, crossesthe subtalar joint, and extends to the superior aspect ofthe tubero sity of the calcaneus. Like the V-osteotomy,a triangular middle bone segment is created withinthe bodies of the talus and calcaneus. This mobilebone segment was stabilized with one or two K-wires,and connected to the lower ring of the base frame, toenable correction of the anterior and posterior segmentin relation to the middle segment. The If-osteotomyalso required a normal relatio nship between hindfootand forefoot (4, 6, 7). If the U-os reotomy is openedmedially or laterally, varus or valgus deformit ies offoot can be corrected. Additionally , the foot height alsocan be increased (Fig. 3).

4. Mid foot osteotomy, which consists of the anterior partof the V-osteotomy and a tarsal osteotomy, is used inpatients with forefoot deformities (Fig . 4).

Other corrective procedures were also carried out.In selected patients, tibial and femoral osteotomies forleg-length discrep ancy, Achilles tendon lengthenin g, tem­porary fixation of the metatarsophalangeal joint with K­wire, bursectomies and ankle arthrodeses were performed(Table I). Tarsal tunnel decompress ion was used in twofeet treated with U- and V-osteotomies.

Surgical Method

In all cases, surgery was carried out under generalanesthesia without neuromuscular blockage or musclerelaxants. Epidural anesthesia was also used in 19 patientsas a postoperative analgesic and as an aid to rehabilitation .A radiolucent operating room table and image intensifierwere used in all cases. Tarsal tunnel decompression wassimultaneously combined with V- and V-osteotomies inorder to protect the posterior tibial nerve.

32 THE JOURNAL OF FOOT & ANKLE SURGERY

The frame consisted of three parts: 1) the base frame ,which is placed on the leg; 2) the heel frame; and 3) theforefoo t frame. The base frame is comprised of two ringsthat fix the tibia with a single K-wire and and a singleSchanz pin from each ring (T-configuration). The squareheel frame made of carbon fiber is preferred to the halfring. Two crossed olive wires, or one K-wire combinedwith a Schantz pin going through the longitudinal axis ofthe calcaneus, on the heel frame and two parallel olivewires going through the first and fifth, and under thesecond, third , and fourth metatarsal heads on the carbonfiber forefoot frame were used. Additionally, one or twowires were used in the mobil e bone segment created withU- and V-osteotomies. A lateral incision and osteotomewere used for the U-osteotom y. The gigli saw was usedfor the anterior part of the V-osteotomy and for othermidfoot osteotomies. Correction was started on the 2ndpostoperative day to prevent prem ature consolidation. Thegoal of the distract ion procedure was to obtain a I mm/da yopening at the osteotomy site.

Fixator duration depended on deformity types andchoice of treatment (e.g., with or without osteotomy) .If osteotomy was performed, the fixator was removedafter obtaining consolidation at the distraction site. Other­wise, the fixator was removed 6 weeks after the deformitycorrect ion. In the latter case, patients were protected witha cast or another form of orthoti c for an additi onal 3-6months to prevent recurrence of deformity.

Postoperati ve patient eva luation consisted of measure­ment of range of motion, radiologic assessment withanter ior-posterior, lateral, and posterior tangential planes,orthoroentgenography in patients whose limbs werelengthened, and standing footprint s.

Results

Of the 22 patients, 14 were male and 8 were female.The etiology of the deformiti es varied to include burncontracture (3), poliomyeliti s (4) , neglected and relapsedclubfoot (7), traum a (5), gun shot injury ( I), equinusdeformity secondary to leg-length discrepancy (2), andmeningitis sequela (1). Six of 23 feet had undergoneprevious surgical intervention. Two of seven clubfeet werecases of neglected foot. The remaining five club feet hadnot responded to prior surgical treatment.

Correction was achieved without osteotomy methodin nine feet (Fig. 5) and with one of these osteotomiesin 14 feet. Osteotomy types and number of cases wereas follows : V- (I) and V-shaped (1), midfoot (7), andsupramalleolar osteotomies (5).

The mean follow-up period from surgery averaged25 (13 - 38) months. The correction period varied from3 to 10 weeks. The mean fixator duration was 5.1(2- 14) month s. Hardware failure did not occur in

FIGURE 1 Patient No. 22 - post-traumatic pes equinovarus deformity treated with supramalleolar osteotomy. A, preoperative appearanceof the patient; B, preoperative radiograph showing the proposed location of the supramalleolar osteotomy; C, at the end of the correctionwith lIizarov frame; 0, 6 months after the fixator removal with plantigrade foot.

VOLUME 41, NUMBER 1, JANUARYIFEBRUARY 2002 33

FIGURE 2 Schematic drawing of V-osteotomy.

FIGURE 3 Schematic drawing of U-osteotomy.

any of the patients. Psychological intolerance requiringfixator removal was not observed. At the time of fixatorremoval, standing footprints revealed plantigrade footin 21 feet, and leg-length discrepancy was eliminatedin four extremities. Compared to preoperative status,gait was subjectively improved by all patients. Averageankle dorsiflexion and plantarflexion were 13S (10-1 SO)and 47.7° (35-50°) in all patients, except those treatedwith supramalleolar osteotomy. Patients treated withoutosteotomy (n = 7) were assessed radiographically.Talocalcaneal angle improved from 6.8° (0°-1 0°)preoperatively to 25.3° (15°-35°) postoperatively inanteroposterior plane, and from 5.6° (1SO to _10°)preoperatively to 38.7° (30°_50°) postoperatively inlateral plane.

Complications were encountered in several of the feettreated: toe contractures in two patients, metatarsopha­langeal joint subluxation due to flexor tendon contracturesin one, incomplete osteotomy in one foot, reCUlTence ofdeformity in one foot, and residual deformity in two feet.Three secondary procedures were required in three feetin order to treat complications. Toe contractures were

34 THE JOURNAL OF FOOT & ANKLE SURGERY

treated with flexor tendon lengthening, tenotomies, andcast application under general anesthesia at the time offrame removal. Metatarsophalangeal joint subluxation dueto toe contracture was treated by insertion of a K-wirefollowing closed reduction. Re-osteotomy was performedin the one patient with incomplete osteotomy. Minor pin­tract problems on the scale of 1 and 2 according to Paley'sclassification (4) were observed in all cases.

Discussion

The authors defined complex foot deformity as a footwith multiplanar deformities and/or shortening of the foot,poor soft tissues, and cases of relapse or neglect. It may becomplicated by other problems such as leg-length discrep­ancy, lower leg deformity, osteomyelitis, and nonunion.In conventional surgical methods, extensive soft-tissuereleases, osteotomies, and arthrodeses are used in thetreatment of these deformities (3). The surgical goal ismaximum correction with minimal bone resection, andthe establishment of a plantigrade foot. However, casesof neglected feet and feet on which multiple surgicalinterventions have been performed usually require wedgebone resection, which has the drawback of producing amuch-shortened foot. When poor soft tissues are present,conventional open osteotomy is not possible. Scar tissuefrom previous surgery can complicate further surgicalcorrection (8-10). Conventional treatment of complexfoot deformities has many limitations because of theincreased risk of neurovascular injury, soft-tissue injury,shortening of the foot, and destruction of collateralvascular circulation (7, 11).

Symptomatic nonunion is the most common compli­cation of corrective arthrodesis in foot. Rates werereported from 8.1% to 26%. Devascularization of thetalus, especially if large wedges are required, mightproduce avascular necrosis of the talus in 1-6.5%after triple arthrodesis (2). In our osteotomy series, nononunion or avascular necrosis of talus was encoun­tered. In conventional osteotomies, the final correctionis achieved intraoperatively. The Ilizarov method, on theother hand, is amenable to adjustment during the entiretreatment (3, 4, 6, 8).

The goals of foot deformity treatment should be theattainment of foot that is normal in size, pain free,plantigrade, and functional (3). There are two ways inwhich foot deformities can be corrected using the Ilizarovmethod: with and without osteotomy (4, 6, 12). In thenonosteotomy method, deformities are corrected throughjoints rather than the bone substance (13). Soft-tissuedistraction treatment is recommended for patients whohave a congruous joint with no significant fixed bonydeformities and for children younger than 8 years ofage (4, 6, 14, 15). Osteotomy is recommended for the

correction of fixed bony deformity in patients older than8 years and for the correction of neuromuscular imbalancein patients where soft-tissue correction could be obtained,but the correction could not be maintained because tendontransfer is not possible (4, 6). Incidence of deformityrecurrence in our cases is lower than the reported liter­ature (4, 6, 8, 14-16). We observed only one case ofdeformity recurrence. This lower incidence of deformityrecurrence in our cases is most likely related to followingthe principles regarding the use of osteotomy. Herzen­berg also states that recurrence of deformity, while rare inthe osteotomy treatment, is common in the nonosteotomytreatment (16).

In the constrained foot frame, forces applied to thefoot are directed around the axis of a constructed hinge,positioned to correct a specifically defined deformity.In the nonconstrained system, joints of the ankle andthe foot are used as the fulcrum points for correction.Application of the constrained system in the foot andankle is technically more demanding (3, 11). Although wepreferred the nonconstrained system initially, we decided

to use the constrained system foot frame, based on ourexperience.

Deformity at the level of a previous ankle arthrodesisand deformities at the level of the talus or subtalar jointin the presence of ankle ankylosis are treated best by asupramalleolar osteotomy (4, 6, 7). We used supramalle­olar osteotomy in cases of equinovarus and calcaneovalgusdeformity. V-and U-osteotomies produce a stiff subtalarjoint. So we used them in patients with stiff subtalar jointsand in patients with neuromuscular imbalance. The U­osteotomy requires a normal relationship between hind­foot and forefoot (4, 6, 7). We used the U-osteotomy inpatients with certain types of equinus deformities. If the U­osteotomy is opened medially or laterally, varus or valgusdeformities of foot can be corrected. Foot height also canbe increased with the U-osteotomy. Midfoot osteotomyis used in patients with forefoot deformities (2, 4, 8). Inpatients in whom we wanted to prevent the developmentof stiff subtalar joint, we preferred to perform the midfootosteotomy on the cuboid and navicular or more distal tarsalbones (4, 6, 7, 14).

FIGURE 4 Patient NO.7 - relapsed clubfoot, with shortening and varus deformity of the foot treated with previous midfoot osteotomy. Aand B, Preoperative lateral and AP radiographs.

VOLUME 41, NUMBER 1, JANUARY/FEBRUARY 2002 35

FIGURE 4 (Continued) C and D. AP and lateral radiographs 6 months after corrective surgery with osteotomy and llizarov method . Maturecallus is obvious in the midfoot.

Toe contractures were a common problem, especially inthe medial column lengthening of the foot. Prevention oftoe contractures was achieved through the use of rubberslings or temporary K-wire fixation of the distal inter­phalangeal, proximal interph alangeal, and metatarsopha­langeal joints. Paley recommends connecting a K-wireto the apparatus after inserting the wire across the baseof the distal phalanx, without fixing the metatarsopha­langeal joint (4, 6). We observed metatarsophalangealjoint subluxation in one case of toe contracture that hadbeen treated by the insertion of K-wires as describedby Paley. Therefore, we prefer fixing the metatarsopha­langeal joint with a K-wire to prevent toe contrac­tures, especially in cases where severe deformity ispresented.

Pin-tract problems are related to skin motion atthe interface and are observed mostly in the softtissues around the long bones (4). Minor pin-t ractproblems were observed in all cases studied. All pin­tract problems were of grade 1 or grade 2, accordin gto Paley's classification (4). These superficial infections

36 THE JOURNAL OF FOOT & ANKLE SURGERY

were controlled with local pin-site care. None requiredthe extraction of the K-wire. This is probably due to lesspin-skin motion in the foot compared to the soft tissue ofaround the long bones of the leg. Pin-site problems andtoe contractures are usually related to prolonged fixatorutilization and the severity of deformity.

In cases of pure foot deformit y, the duration of fixatorutilization depend ed on deformity type and choice oftreatment (with or without osteotomy). In cases of footdeformity associated with other extrem ity problems (suchas limb-length discrepancy), the duration of treatmentdepended on secondary procedure s rather than on the footdeformity.

Paley report s the development of acute tarsal tunnelsyndrome after surgery in two patients (4). In cases whereU- and V-osteotomies were carried out, primary tarsaltunnel decompression was performed and no such compli­cation was observed in any of the patients included inthe present study. Early consolidation and/or incompleteosteotomy are more frequent in the foot and can becaused by an inappropriate foot frame (4,6, II). Early, we

observed incomplete osteotomy at the midfoot osteotomysite stemming from the surgical technique employed. Inorder to prevent incomplete osteotomy we used the giglisaw in midfoot osteotomies based on these experiences.

Vascular injury may occur due to surgery or secondaryto deformity correction. The location of the neurovascularstructures may have been altered, especially in severeburn contracture and in some complex foot deformities.

FIGURE 5 Patient No. 21 - bilateral relapsed clubfoot, treated with nonosteotomy method. A, preoperative standing appearance of thepatient; B, the right side was operated on first; C. cast application was performed after fixator removal with resultant plantigrade foot.

VOLUME 41, NUMBER 1, JANUARYIFEBRUARY 2002 37

FIGURE 5 (Continued) 0 , left side operated on 6 months following fixator removal; E, 1 year after fixator removal of left side, pat ient canstand and walk with a bilat eral plantigrade foot.

We performed Doppler ultrasonograph y in case s ofprior surgical inter vention s. We did not observe majorneuro vascular injury in any of the cases included in thisstudy.

A stiff equinovarus foot that is corrected into a planti­grade position is still a stiff planti grade foot. Frequently,patients do not take this into consideration and maybecome disappointed after treatm ent. While aestheticallymore pleasing and function ally plantigrade, the foot stilldoes not perform normally. Therefore , before startingtreatment of any complex foot deformity, it is impor­tant that the patient recei ves a realistic explanation of ju stwhat the foot deformity correc tion will accomplish, whatthe foot will be like in the corrected position , and thefunctional limitations (3) .

Conclusion

Treatment of foot deformities by the I1izarov method istechnically difficult. Nonetheless, this method is particu­larly advantageous in treating complex foot deformities.Based on our findings , the Ilizarov method can success­fully correct complex foot deformities.

38 THE JOURNAL OF FOOT & ANKLE SURGERY

References

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2. Ouzounian, T. J., Kleiger, B. Arthrodesis of foot and ankle, ch. 95.In Disorders of the Foot and Ankle, 2nd ed., vol. 3, pp. 2614 - 2646,edited by M. H. Jahss, W. B. Saunders, Philadelphia. 1992.

3. Paley, D. Principles of foot deformity corrections. In OperativeFoot Surgery , pp. 476-514, edited by 1. S. Gould . W. B. Saun ders.Philadelphia . 1994.

4. Paley, D. The correction of complex foot deformities usingIlizarov' s distraction osteotomies. C1in. Orthop. 293:97- I 1I. 1993.

5. Rosman, M., Brown. K. Preoperat ive lIizarov frame constructionsfor correction of ankle and foot defo rmities. J. Pediatr. Orthop.11:238- 240. 1991.

6. Paley. D. Problems, obstacles and complication of limb lengtheningby the Ilizarov technique. Clin . Orthop. 250:8 1- 104, 1990.

7. Bradish, C. F., Noor , S. The llizarov method in the management ofrelapsed clubfee t. J. Bone Joint Surg. 82-B :387 -39 1,2000.

8. Desgrippes Ysouelot. Poo Benshel. H. Use of the lIizarov externalfixator in multioperated, recurrent clubfoot. 1. Pediatr. Orthop.I(B):181, 1992.

9. Calhoun, J. H., Evans, E. B., Hernd on. D. N. Techn iques for themanagement of bum contractures with the llizarov fixator. Clin.Orthop. 280:117 - 124. 1992.

10. Franke, J., Grill, F., Hein, G.. Simo n, M. Correct ion of clubfootrelapse using Ilizaro v's appara tus in children 8 -15 years old. Arch.Orthop. Trauma Surg. 110:33- 37. 1990 .

II. Grand, A. D., Atar, D., Lehman, W. B. The Ilizarov technique in

correction of complex foot deformities. Clin. Orthop. 280:94-103,1992.

12. Grill, F., Franke, 1. The Ilizarov distractor for the correction ofrelapsed or neglected clubfoot. J. Bone Joint Surg. 69-B:593-597,1987.

13. Reinker, K. A., Carpenter, C. T. Ilizarov applications in the paedi­atric foot. J. Pediatr. Orthop. 17:796-802, 1997.

14. Oganesian, O. V., Istomina, I. S., Kuzmin, V. I. Treatment of

equinocavovarus deformity in adults with the use of hinged distrac­tion apparatus. 1. Bone Joint Surg. 78-A:546-556, 1996.

15. Oganesian, O. V., Istomina, I. S. Talipes equinocavovarus deformi­ties corrected with the aid of a hinged-distraction apparatus. Clin.Orthop. 266:42 - 50, 1991.

16. Herzenberg, 1. E., Paley, D. Ilizarov applications in foot and anklesurgery. Adv. Orthop. Surg. 16:162-174, 1992.

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