SLR - May 2013 - Jennifer C. Van
Reference: Shu H, Ma B, Kan S, Wang H, Shao H, Watson JT. Treatment of posttraumatic equinus deformity and concomitant soft tissue defects of the heel. J Trauma. 2011 Dec;71(6):1699-704.
Scientific Literature Review
Reviewed by: Jennifer C. Van, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Equinus deformity is defined as limited, less than 10 degrees, ankle dorsiflexion with the knee extended. Numerous etiologies exist for this condition, including traumatic injury. Posttraumatic contractures of the foot and ankle combined with soft tissue defects of the heel are challenging problems. With the increasing success of limb salvage, posttraumatic equinus contractures are seen with increased frequency. Patients with posttraumatic equinus deformity are often accompanied by unstable scarring of the Achilles or even full-thickness ulcers of the heel. This article reports the outcome of simultaneous equinus foot deformity correction by using a hinged Ilizarov technique combined reversed sural fasciocutaneous island flap transfer for the soft tissue coverage of the heel.
Methods: Between June 2006 and May 2010, seven cases of posttraumatic equinus deformity with associated unstable scar or ulcer of the heels were treated using a hinged Ilizarov apparatus and reversed sural fasciocutaneous island flap transfer. An Achilles tendon lengthening was also performed on all patients.
Inclusion criteria were the following: (1) severe posttraumatic equinus deformity with concomitant soft tissue compromise lasting more than six months, (2) equinus deformity more than 35 degrees, and (3) absence of severe degenerative changes of the ankle.
A hinged Ilizarov apparatus was applied for gradual correction of equinus deformity in all patients. Patients underwent either single- or two-staged procedures based on the degree of scarring located on the planned flap pedicle recipient site.
Debridement of the heel, open Z-Achilles tendon lengthening, reverse sural fasciocutaneous island flap transfer, and hinged Ilizarov application were done simultaneously in five patients as a single-stage procedure. The remaining two patients underwent two-staged procedures secondary to extensive scarring. With these patients, the delayed sural island flap procedure was done first. Two weeks later, the debridement of the heel, Achilles tendon lengthening, delayed flap transfer, and the hinged Ilizarov apparatus were performed at the same time as a second-stage surgery.
Ulcers or unstable scarring of the heel were debrided. Next, an open Z-Achilles tendon lengthening was performed in all patients. Afterwards, a reversed sural fasciocutaneous flap transfer was utilized for soft tissue coverage of the heel. Ilizarov external fixator was then applied. Two weeks after flap transfer, adjustments of the Ilizarov fixator were initiated to gradually correct the equinus deformity.
Total correction time for equinus deformity ranged from three weeks to five weeks of active correction. Once neutral correction was achieved, the fixation was maintained for an additional six weeks to ensure overall correction. All patients participated in active to assistive ROM exercises after Ilizarov apparatus removal.
Results: Postoperative evaluations included (1) degree of active dorsiflexion of ankle, (2) total active ROM, (3) walking ability, and (4) flap durability. The mean postoperative equinus contracture was -45 degrees (range, -35 degrees to -65 degrees). Active dorsiflexion of ankle beyond neutral was graded as good, neutral dorsiflexion was graded as fair, and below neutral dorsiflexion was graded as poor. Results were good in three patients and fair in four patients. Total active ankle ROM greater than 10 degrees was defined as good, five degrees to 10 degrees was graded as fair, and less than five degrees was graded as poor. Five patients had good and two patients had fair results.
For walking ability, the results were good in six patients and fair in one. Postoperative satisfaction of patients was good in all seven patients. All flaps provided stable, durable skin coverage with acceptable cosmesis. Three patients developed complications. Marginal necrosis of the sural flap (less than 10 percent total flap area) occurred in one patient, which was treated conservatively. Two cases of pin site infection occurred and were also successfully treated conservatively. All seven patients could walk with full weight-bearing and without long-term complications; mean follow up was 21 months (range, 12-40 months).
Conclusions: This study showed that posttraumatic equinus deformity accompanied by soft tissue defect of the heel can be treated effectively with Achilles tendon lengthening, reversed sural fasciocutaneous island flap transfer, and a hinged Ilizarov technique.