Correction of Severe Foot and AnkleContracture Due to CRPS Using ExternalFixation and Pain Management: Report ofa Pediatric Case

Robert W. Mendicino, DPM, FACFAS,1 Chul Kim, DPM,2 Abraham J. Kabazie, MD,3

and Alan R. Catanzariti, DPM, FACFAS4

Complex regional pain syndrome–induced dystonia is a severe deformity that can affect the lower extremitiesand hinder ambulation. Although a number of conservative treatments have been described for this condition,we are not aware of any publications describing the use of surgical intervention for the treatment of thiscondition. In this report, we describe the case of a pediatric patient with a severe lower extremity deformityin conjunction with chronic pain syndrome. A concerted, interdisciplinary treatment approach was under-taken for the management of this patient, and this included contributions from a foot and ankle surgeon, apain specialist, an internist, a physical therapist, and a psychiatrist. The primary goal of the treatment strategywas to recreate a plantigrade, weight-bearing lower extremity, while controlling pain. To this end, gradualcorrection of deformity was achieved using an external fixator and, by 6 months after the surgery, the patientwas for the first time in years ambulating on the realigned lower extremity. After 3 years of follow-up, shemaintained an activity level that was equal to that which she enjoyed before the injury. Level of ClinicalEvidence: 4 (The Journal of Foot & Ankle Surgery 47(5):434–440, 2008)

Key Words: botulinum, complex regional pain syndrome, CRPS, deformity correction, dystonia,

equinovarus, external fixation

Complex regional pain syndrome (CRPS) Type I, previ-ously known as reflex sympathetic dystrophy (RSD), is achronic pain disorder of the extremities. The clinical signsand symptoms may include (but are not limited to) burningpain, edema, hyperpathia, allodynia, trophic changes, andfunctional impairment. The diagnostic criteria for CRPSTypes I and II are purely clinical, as indicated by Figure 1(1), and can be missed even by experienced clinicians. Themedian age for patients diagnosed with CRPS in the UnitedStates was reported to be 41.8 (range 18–71) years, whereasthe mean age at time of the inciting injury was 37.7 (range

Address correspondence to: Robert W. Mendicino, DPM, FACFAS,The Western Pennsylvania Hospital, Division of Foot and Ankle Surgery,4800 Friendship Avenue, N1, Pittsburgh, PA 15224. E-mail: rmendicino@faiwp.com.

1Chair, Department of Foot & Ankle Surgery, The Western Pennsylva-nia Hospital, Pittsburgh, PA.

2Chief resident, The Western Pennsylvania Hospital, Pittsburgh, PA.3Director, Institute for Pain Management, The Western Pennsylvania

Hospital, Pittsburgh, PA.4Director of Residency Training, Division of Foot and Ankle Surgery,

The Western Pennsylvania Hospital, Pittsburgh, PA.Financial Disclosure: None reported.Conflict of Interest: None reported.Copyright © 2008 by the American College of Foot and Ankle Surgeons

1067-2516/08/4705-0002$34.00/0doi:10.1053/j.jfas.2008.05.010

434 THE JOURNAL OF FOOT & ANKLE SURGERY

FIGURE 1 Differentiation of CRPS Types I and II according to

Merskey and Bogduk1.

sition

14–64) years, and the female to male ratio was 2.3:1 (2–4).One of the debilitating symptoms of CRPS is dystonia. Inthe lower extremities, an equinovarus deformity of the footand ankle is the most common manifestation of CRPS-induced musculoskeletal contracture (5). Because of theprogressive nature of this symptom, immediate treatment isusually necessary to prevent the development of severedeformity. Treatment options for CRPS-induced dystoniainclude serial casting, aggressive physical therapy, sympa-thetic ganglion blocks, and adjunctive botulinum toxin in-jections (6–16). Following a systematic review of the Med-line, Excerpta Medica, and the Cumulative Index of Nursingand Allied Health databases, we were unable to identify areference to the use of gradual correction of the deformityby means of surgical intervention. The patient underwenttendon lengthening, botulinum toxin injections, nerve re-leases, external fixation application, and spinal cord stimu-lator implantation. The purpose of this report is to describethe case of a pediatric patient with CRPS-induced dystonia,who was treated surgically with the use of external fixationin order to gradually correct a severe equinovarus contrac-ture. This article also discusses the importance of a multi-disciplinary approach to this disease process, including peri-

FIGURE 2 Clinical presentation shows the triplanar equinovarus po

operative pain management provided by pain medicine

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specialists, as well as contributions from a physical thera-pist, neurosurgeon, and psychiatrist.

Case Report

A 14-year-old girl presented to The Foot and AnkleInstitute of Western Pennsylvania on a referral from a painmanagement specialist at the Western Pennsylvania Hospi-tal. The patient developed a progressive equinovarus defor-mity of the left lower extremity after she sustained an anklesprain while diving into third base while playing softball.Within 4 months, she had developed severe equinovarusdeformity and was unable to ambulate with weight on herleft lower extremity. During an approximately 1.5-year pe-riod before presentation to our practice, the patient hadundergone serial casting, physical therapy that includedcontrast baths, and she used an ankle-foot orthosis, underthe guidance of the previous treating physician. She had alsobeen manipulated under general anesthesia and casted in aneffort to reduce the deformity, however this caused such asevere exacerbation of her pain that she had to be admittedinto intensive care and the cast removed. Because of the

of the foot and ankle. A. Posteromedial view. B. Anterolateral view.

severe nature of the pain syndrome and the resultant equi-

7, NUMBER 5, SEPTEMBER/OCTOBER 2008 435

novarus deformity, serious consideration was given to be-low-the-knee amputation. At the time of the referral to ourpractice, the patient was under the care of a physiatrist,neurologist, psychiatrist, pain management specialist, and aphysical therapist. Moreover, she was receiving lumbarsympathetic ganglion blocks under fluoroscopic guidance,and these resulted in limited periods of partial pain relief.

The physical examination revealed a left lower extremitythat was considerably cooler than the contralateral side, andthe skin on the left side demonstrated diminished digital hairgrowth and atrophy. She also exhibited allodynia and hy-peresthesia involving the left foot, ankle, and leg. Muscu-loskeletal examination demonstrated a rigid equinovaruscontracture involving the mid and hindfoot, as well as theankle, with little to no range of motion due to antalgicguarding. Furthermore, the posterior muscle group over-powered the anterior and lateral leg muscles (Figure 2).Radiographic images supported the clinical findings withevidence of an equinovarus deformity of the hindfoot andankle and an adducted position of the forefoot (Figure 3).Additional nerve conduction velocity and electromyo-graphic studies showed no evidence of any other neurolog-

FIGURE 3 Radiographs of the left ankle demonstrate the severity oview. B. Mortise view.

ical conditions.

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Surgical treatment was carefully planned with coopera-tion between the foot and ankle surgeon, pain specialist,internal medicine physician, physical therapist, and the psy-chiatrist. The patient was admitted the day before surgeryand had an indwelling epidural catheter placed, throughwhich ropivacaine and fentanyl were administered under theguidance of the pain medicine service. This was maintainedthroughout the patient’s hospital course. Left lower extrem-ity reconstructive surgery was undertaken the followingday.

Because of the nature of the contracture and associateddysfunction of the anterior and lateral muscle groups, com-mon peroneal nerve and posterior tibial nerve decompres-sions were performed. Additionally, botulinum toxin wasinjected into all of the posterior leg muscles in the region ortheir respective neuromuscular junctions, in an attempt torelieve spasticity and to assist in the subsequent gradualcorrection of the deformity. The gastrosoleus contracturewas the most severe, and the Achilles tendon was length-ened by means of an open technique, although the ankle wasleft in a position of slight equinus in an effort to avoidplacing excessive traction on the musculature of the deep

deformity and multiple joints involved in the contracture. A. Anterior

f the

posterior compartment of the leg. An Ilizarov apparatus

terior

consisting of a distal tibial block, a half ring at the calca-neus, and a 5/8 ring over the forefoot, was then applied.These were held with the appropriate smooth wire fixation,and then tensioned utilizing Ilizarov tensioning principles.The rings were connected with universal hinges and length-ening rods in an unconstrained fashion so that slow, post-operative adjustments could be made to correct the defor-mity (Figure 4).

The patient’s early postoperative course included continu-ous infusion of the epidural block, and daily adjustment of theexternal fixation frame to correct the equinovarus deformity.Immediately following application of the external fixationframe, the pain management specialists continued to adminis-ter anesthesia throught the epidural. With the adequate resolveof the acute post-operative pain, a neurosurgeon implanted aspinal stimulator in an effort to provide long lasting pain relief.Satisfactory correction was gradually achieved over the next 6weeks at the following rate: medial posterior � 8 mm/day,central posterior � 5 mm/day, lateral posterior � 3 mm/day,lateral foot � 2 mm/day, and medial foot � 5 mm/day. The

FIGURE 4 Immediate postoperative views of the left lower extremitand the multiple segments that needed to be addressed during thecontractures distally during the correction. A. Anterior view. B. Pos

lateral foot distraction was performed to prevent crushing

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the cuboid. After the deformity was fully corrected, theframe was left static for an additional 6 weeks, at the end ofwhich the frame was removed in the operating room andadditional botulinum toxin injections were administered toall of the posterior leg muscles. In total, the frame was onfor 3 months. Upon removal of the external fixator, thepatient was casted in the corrected position for an additional2 weeks. The patient began aggressive physical therapy,including ankle range of motion, leg muscle strengthen-ing, and stretching, once the cast was removed. For 6months, she also used an ankle-foot orthosis that blockedplantarflexion and aided in the prevention of recurrentcontracture. The remainder of the postoperative courseproceeded without incident, and after more than 3 yearsof postoperative follow-up, she was ambulating well withno pain in the extremity (Figure 5). She also continued toperform physical therapy modalities in an attempt toprevent recurrent ankle and foot contractures, and shekept biannual visits with her pain specialist for neuro-modulation therapy, and with our service for surveillance

onstrate the frame designed to addres the severity of the deformityection. Note that use of pin fixation of the digits helped to preventview.

y demcorr

of her left lower extremity.

7, NUMBER 5, SEPTEMBER/OCTOBER 2008 437

digits. A. Anterior view. B. Medial view.

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Discussion

Dystonia is a well-documented clinical entity that mayhinder ambulation and, particularly in pediatric patientswith CRPS, may lead to progressive equinovarus deformitydespite adequate pain control. Although a wide range oftreatment options exist for the nonsurgical management ofmusculoskeletal contracture (6–15), including serial cast-ing, physical therapy/manipulation, and injection of botuli-num toxin, these methods may not be adequate for somesevere deformities. Moreover, acute surgical correction ofthese deformities can be problematic because of periopera-tive pain issues that can be very difficult to manage. Gradualcorrection using an external fixation device, combined withadjunctive procedures such as isolated tendon lengtheningand/or botulinum injections, may enable the establishmentof a plantigrade foot in a less acutely traumatic fashion and,as such, may be less stressful to the patient and minimize therisk of exacerbation of the pain syndrome (17–29).

Furthermore, the use of prophylactic neurovascular re-leases can also be useful adjunct procedures to the surgicalcorrection of severe deformity of the lower extremity. Therationale behind this concept hinges on the idea that pro-phylactic removal of any anatomical structures that maylead to strangulation or impingement of neighboring ana-tomical structures will decrease the likelihood of subsequentneurological damage and/or ischemia as the deformity isgradually corrected. This concept is particularly applicableto the posterior tibial nerve and its branches in the tarsaltunnel, and the common peroneal nerve near the head of thefibula, in association with the correction of a wide range oflower extremity deformities (20–23). In the case describedin this report, we implemented this concept by means ofprophylactic release of the neurological components of thetarsal tunnel.

Injection of botulinum toxin is a common adjunct inter-vention used for the treatment of skeletal muscle spasticity(12–16). We used this treatment in an effort to alleviatecontractures of the posterior leg musculature, which ap-peared to be overwhelming the other muscular compart-ments of the leg. Botulinum toxin, however, does not usu-ally cause complete resolution of all spasticity, and this wasthe case in our patient. As such, we felt that an openlengthening of the Achilles tendon would be a beneficialadjunct to the relief of posterior leg contracture in thisparticular patient. To avoid placing a sudden and excessivetensile load on the musculature of the deep posterior com-partment of the leg, a process that could potentially exac-erbate CRPS (27), the Achilles tendon was left in slightequinus. It was felt that the small amount of residual equi-nus would be adequately corrected gradually by means ofadjustment of the external fixation frame.

The external fixation was mounted in the standard block

FIGURE 5 Follow-up clincial non weightbearing views demon-strate the plantigrade position of the foot and the realignment of the

construct with smooth wires. However, the segments were

connected with universal hinges and lengthening rods sothat gradual correction could be obtained over a period of 6weeks, after which the device was maintained static for anadditional 6 weeks. Overall, the frame was left on forapproximately 3 months in the patient we described. Ingeneral, when correcting a contracture, the external fixatoris left on for a total of twice the amount of time it takes tocorrect the deformity. Typically, the first half of this periodof external fixation is used to obtain the desired position ofcorrection, and the second half is used to allow the tissuesto adapt to the new alignment. In certain cases, it may bedesirable to slightly overcorrect the extremity, however thiswas not the case with the patient described in this report. Asan example of this time sequence, if it would take 2 weeksto correct a deformity, then the fixator would be left in placefor a total of 4 weeks. If it takes 10 weeks to obtain thecorrected position, then the fixator would be left in place forand additional 10 weeks (24–28). As a general rule, defor-mity correction without osteotomy and/or arthrodesis con-veys a high rate of recurrence. For this reason, we feel thatpostcorrectional maintenance using appropriate orthosesand bracing, as well as ongoing physical and occupationaltherapy, is just as important as the surgical correction itself.For the patient described in this report, aggressive physicaltherapy was employed for almost a full year followingremoval of the external fixation.

Although the epidural block achieved pain relief through-out the perioperative period, our patient ultimately requiredlong-term management with the use of a spinal cord stim-ulator. The successful use of spinal column stimulation inpatients with CRPS is well documented (30, 31). In the casedescribed in this report, it was not until after the neurosur-geon implanted the spinal column stimulator that the patientwas capable of undergoing manipulation, physical therapy,and rehabilitation. Moreover, as was the case with ourpatient, ongoing physical therapy and the periodic use oflumbar sympathetic ganglion blockade can also be helpfulin the postoperative phase.

The importance of a multidisciplinary approach to thiscomplex clinical problem cannot be overstated. Pain man-agement by pain specialists, surgery by a qualified foot andankle surgeon, aggressive physical therapy, and evaluationof the psychiatric health of the patient, need to be coordi-nated to obtain therapeutic success (29, 32–34). This con-cept is supported by Singh et al (33), who reported anincrease in functional outcome in CRPS patients who hadsimultaneous treatment by the pain management physician,psychologist, physical therapist, and occupational therapist.Additionally, we feel that strong family support is alsoimportant, especially in pediatric patients suffering withdystonia secondary to CRPS. Our experience with the pa-tient described in this report leads us to believe that a

thorough understanding of the complexity of the disorder,

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as well as an appreciation of the treatment plan, on the partof the parents is essential to achieving a successful outcome.

In conclusion, this case demonstrated that CRPS-induceddystonia could be treated using an external fixation devicefor gradual correction. However, perioperative pain man-agement, physical therapy, and the expertise of other med-ical specialists was also important in regard to this patient’ssuccessful outcome. We believe that the successful manage-ment of this type of patient requires constant communica-tion with providers from other medical disciplines, and thatsuch treatment is best undertaken at a tertiary care facilitythat has the capacity to provide the appropriate level ofexpertise.

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