The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 13, 2019
CASE REPORT

The Combined Lambrinudi and Ankle Arthrodesis with Ring External Fixation in the Long-term Severe Neuromuscular Equinocavovarus Deformity with Ankle and Hindfoot Osteoarthritis: The Cases Presentation and Modified Guideline of Treatment



Prasit Rajbhandari1, 2, Chayanin Angthong1, *, Jiancheng Zang3, Sihe Qin3, Andrea Veljkovic4
1 Department of Orthopaedics, Faculty of Medicine, Thammasat University Pathum Thani, 12120 Thailand
2 Orthopaedics Department, Manmohan Memorial Teaching Hospital, Kathmandu, Nepal
3 Qinsihe Orthopedic Institute Orthopaedics department of Chinese National Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids (NRRA, Beijing, China)
4 Department of Orthopaedic Surgery, University of British Columbia, Vancouver, Canada

Abstract

Background:

Severe equinocavovarus deformity develops from various causes and generally results in major disability that affects patient’s mobility and quality of life. It can be divided into neuromuscular and non-neuromuscular deformities, including two major subtypes: i.e., paralytic and spastic. In addition, ankle osteoarthritis could be caused by prolonged or progressive foot deformity.

Objective:

The present report proposes a modification of the accepted treatment algorithm and Lambrinudi’s surgical technique with ankle and hindfoot arthrodesis to correct theses challenging deformities with the long-term condition.

Results:

Two equinocavovarus cases were included, one in a 54-year old male and the second in a 63-year old female with paralaytic and spastic etiologies respectively. Patient’s deformity correction was acceptable. Each patient demonstrated improved outcomes due to a postoperative plantigrade foot and ankle position. No significant complications were encountered during the course of care and last follow-up. The mean follow-up time was 26 months.

Conclusion:

Severe long term neuromuscular equinocavovarus deformities are a challenging disability in the foot and ankle surgery. The present article proposes a modified guideline of treatment illustrated in two representative case studies of long-term paralytic and spastic equinocavovarus deformities. These conditions can be treated surgically using the stepwise approach as demonstrated in this article with acceptable outcomes.



Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 183
Last Page: 188
Publisher Id: TOORTHJ-13-183
DOI: 10.2174/1874325001913010183

Article History:

Received Date: 20/06/2019
Revision Received Date: 30/07/2019
Acceptance Date: 19/09/2019
Electronic publication date: 30/09/2019
Collection year: 2019

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© 2019 Rajbhandari et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Foot and Ankle Surgery Unit, Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand, Tel: 662-926-9775; Fax: 662-926-9793; E-mail: chatthara@yahoo.com





1. INTRODUCTION

Neuromuscular disorders afflicting foot and ankle are either spastic or paralytic type. Spastic disorders involve upper motor neurons and include head injury, cerebral palsy, stroke, and spinal cord injury. Paralytic disorders involve lower motor neurons and their causes include Charcot-Marie-Tooth disease, peripheral nerve laceration, and poliomyelitis [1Botte MJ, Franko O. Neuromuscular disorder. Thordarson DB, ed Foot & Ankle 2nd Ed Philadelphia, Pa: Wolters Kluwer 2013; 43-80.]. Aggressive manipulation to correct equinus in rigid equinocavovarus may lead to tibial nerve and vessel compression, which is deleterious to neurovascular structures and to the recovery of the wound [2Bernau A. Long-term results following Lambrinudi arthrodesis. J Bone Joint Surg Am 1977; 59(4): 473-9.
[http://dx.doi.org/10.2106/00004623-197759040-00007] [PMID: 863941]
-4Provelengios S, Kyriakos A. The role of pantalar arthrodesis in the treatment of paralytic foot deformities. Surgical technique. J Bone Joint Surg Am 2009; 91: 575-83.
[http://dx.doi.org/10.2106/JBJS.H.00559] [PMID: 19255217]
]. These disorders are problematic because they cause difficulty in ambulation and in performing day to day activities. In addition to difficulty in wearing shoe wear, painful callosities and non-healing ulcer may develop due to long term condition. The deformity becomes progressive and may lead to further deterioration.

Various surgical procedures like soft tissue release, osteotomy, arthrodesis, and external fixator application have been described, but little is known about the optimal protocol for surgical treatment of severe equinocavovarus deformity in the hindfoot and ankle osteoarthritis especially in long-term conditions. The purpose of the present study was to develop and modify management guidelines described by Lee et al. (Fig. 1) Lee et al., proposed a guideline for cavovarus correction with ankle sparing treatment. In our study, we adapt their guidelines for the reduction of foot-ankle deformity to achieve more plantigrade position. If the joints cartilage has become deteriorated and arthritic due to long term deformity, we opt for joint arthrodesis. Again, if the joint cartilages are still in viable conditions, we select the ankle sparing treatment as stated by Lee et al., in their guidelines [5Lee WC, Ahn JY, Cho JH, Park CH. Realignment surgery for severe talar tilt secondary to paralytic cavovarus. Foot Ankle Int 2013; 34(11): 1552-9.
[http://dx.doi.org/10.1177/1071100713497001] [PMID: 23832713]
]. The modified guidelines discussed in the present study were also preliminarily applied in the senior authors’ previous study by Manggala et al. [6Manggala Y, Angthong C, Primadhi A, Kungwan S. The deformity correction and fixator-assisted treatment using Ilizarov versus Taylor spatial frame in the foot and ankle. Orthop Rev (Pavia) 2018; 9(4): 7337.
[http://dx.doi.org/10.4081/or.2017.7337] [PMID: 29564076]
], demonstrating the effective outcome of the treatment. Therefore, the present study also aims to describe the modified guidelines in detail and the operative techniques for correcting these challenging equinocavovarus deformities with or without hindfoot and ankle osteoarthritis. All the patients gave consent to the operative procedures and publication of this report.

2. CASE DESCRIPTION

The present study describes two challenging cases with long-term equinocavovarus deformity (Table 1).

2.1. Case I

The first patient was a 54-year-old male who presented with a paralytic right foot and ankle equinocavovarus deformity. The patient complained of the onset of deformity in childhood (Fig. 2). He had normal sensation in the dermatomal distribution of his involved foot and ankle with grade 2 motor power weakness in tibialis anterior and peroneus brevis. The clinical examination revealed lower motor neuron type of palsy. The equinus deformity was 59 degrees plantar flexion, and he was diagnosed provisionally with post-polio syndrome. Preoperative X-rays revealed ankle and subtalar osteoarthritis (Fig. 3 A, B).

Table 1
Summary of treatments in case I and II.


Fig. (1)
Modified guideline followed during the approach, decision-making, and operation for the correction of rigid and reducible severe equinocavovarus deformity with ankle and hindfoot osteoarthritis. The protocol for treatment of paralytic and spastic deformity has been individualized and categorically treated with different approach depending upon the nature of pathophysiology involved.


Fig. (2)
Equinocavovarus deformity as observed clinically before corrective surgery. Old callosity over the dorsolateral surface of the foot indicates pressure area exaggerated by wearing shoes.


Fig. (3)
Pre-operative X-rays of case I (A, B) and case II (C, D) showing the challenging and severe equinocavovarus deformity.


A staged procedure was initially proposed, which was to be performed if equinus was not corrected following soft-tissue release. Due to incomplete correction of equinus by the soft tissue procedure alone, gradual correction of equinus was performed with a Ring External Fixator (REF) at the same time. After 38 days, REF was removed and definitive Lambrinudi and ankle-hindfoot arthrodesis was performed due to the arthritis of ankle-subtalar joints and rigid cavovarus. Triple arthrodesis was performed as described by Lambrinudi [7Lambrinudi C. New operation of drop-foot. Br J Surg 1927; 15: 193-200.
[http://dx.doi.org/10.1002/bjs.1800155804]
] in 1927, with an anteriorly based wedge resection of talus and calcaneus followed by fusion of the talus to the navicular. This was followed by subtalar and calcaneocuboid arthrodesis.

2.1.1. Operative Techniques

2.1.1.1. Double-Stage Operation

First-stage operation: Under spinal anesthesia, the patient was kept in a prone position. Tourniquet was applied. Z-plasty lengthening of the Achilles tendon was completed followed by posterior capsular release to correct equinus. Plantar fasciectomy was completed in order to correct cavus. For bony correction of cavus, a dorsiflexion osteotomy of the first metatarsal was performed along with peroneus longus to brevis transfer to assist in the correction of cavus and adduction of forefoot caused due to peroneus longus overpowering its antagonists.

The equinus deformity to plantigrade position could not be achieved after soft-tissue release; therefore, gradual correction of equinus with a REF (Taylor spatial frame) was the next step in the treatment procedures. The patient was placed in supine position. Two olive wires were placed proximally in the tibial shaft, two in the calcaneus, and two wires were passed through all the metatarsals placed in divergent directions. A hexapod frame was applied and all the wires were tensioned to 110 Newton (Fig. 4 A, B).

Fig. (4)
(A), (B) Gradual correction of equinocavovarus deformity with Taylor spatial frame in rigid deformity of case I. (C) and (D) Progressive union of the Lambrinudi and ankle arthrodesis along with first ray dorsiflexion osteotomy site with presence of significant callus during the 12th week follow up.


Based on online software calculation, deformity correction was done which allowed daily length adjustment from the first postoperative day until all the struts completed the required length for correction. Radiographs were performed once every 2 to 3 weeks to check the correction of deformity.

Second-stage operation: This was performed 5 weeks following the first procedure after pin tract infection was ruled out.

2.1.2. Lambrinudi Arthrodesis

The incision for the Lambrinudi procedure extended from the tip of the fibula up to the base of the lateral cuneiform, passing over the anterior process of calcaneus and lateral aspect of talonavicular joint. Wedge resection of talus and navicular were performed including the anteroinferior aspect of the talar head and proximal surface of the navicular followed by calcaneal debridement. After visualization of cancellous bone, the remaining talar head was then inserted over the inferior edge of the navicular, which reduced the forefoot to the hindfoot. Then calcaneocuboid joint was debrided (Fig. 5 A, B). This was followed by fixation of subtalar and calcaneocuboid joints with screws.

2.1.3. Ankle Arthrodesis

An anterior approach for the ankle was used. Joint debridement was done and talus was anatomically aligned (Fig. 5 C). To assess the alignment of arthrodesis, the angle formed by the long axis of tibia and the body of talus in neutral position compared with that of normal contralateral side in neutral position should be equal [8Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg Am 1987; 69(7): 1052-62.
[http://dx.doi.org/10.2106/00004623-198769070-00014] [PMID: 3654697]
, 9Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am 1980; 62(5): 777-84.
[http://dx.doi.org/10.2106/00004623-198062050-00012] [PMID: 7391101]
]. Attempts were made to adjust the foot into plantigrade position. Finally, tibiotalar fixation was carried out with cannulated screws augmented with the anterior compression plate. The wound was closed in layers.

Fig. (5)
(A), (B) Intraoperative images from an anterolateral perspective show the preparation of bones via wedge resections for triple arthrodesis with the Lambrinudi procedure. (C) Intraoperative image of ankle joint fusion site via the anterior approach. Abbreviations: TA, talus; NA, navicular; CA, calcaneus; TI, tibia.


2.2. Case II

The second patient’s presentation describes spastic equinocavovarus deformity. Equinus deformity of this case was partially reducible and corrected to a lesser equinus position after soft tissue release. This was followed by Lambrinudi and ankle arthrodesis. Again, the construct was further augmented with REF.

The patient was a 63-year-old woman with deformity over left foot and ankle as a complication of encephalitis at the age of 8 years. She had diminished sensation over dermatomal distribution of foot and a grade 0 motor power weakness involving the tibialis anterior and peroneus brevis. The tone of posterior compartment group of muscles was spastic. There was no availability of preoperative clinical picture. Based on lateral X-ray of her foot, the equinus deformity was 43 degrees plantar flexion. X-rays revealed hindfoot and ankle arthritis (Fig. 3 C, D).

2.3. Operative Techniques

Endoscopic gastrocnemius recession was initially performed, but Silfverskiold test was still positive. Therefore, Z-plasty lengthening of Achilles tendon was performed. This was followed by posterior capsular release and plantar fasciectomy. Dorsiflexion osteotomy of the first metatarsal along with peroneus longus to brevis transfer was performed to correct plantar flexion deformity of the first ray. We could obtain plantigrade position of foot after soft-tissue release procedure; therefore, a single-stage operation with definitive correction of deformity was planned.

Lambrinudi procedure was performed using the same technique as in the first patient with an anterolateral approach to the ankle, talonavicular, calcaneocuboid joints, and a sinus tarsi approach for the subtalar joint. Lambrinudi arthrodesis was completed and secured with locking plates and screws. Ankle and subtalar arthrodesis was fixed by retrograde intramedullary nailing (Fig. 6 A, B).

Fig. (6)
(A), (B) Definitive internal fixation with Lambrinudi and ankle arthrodesis, dorsiflexion osteotomy of first metatarsal, augmented with ring Ilizarov fixator which maintained neutral foot alignment and thus prevented recurrence of spastic equinus postoperatively. (C), (D) signs of union with progressive callus formation during the subsequent year follow up.


The senior surgeon preferred the use of an Ilizarov frame to augment arthrodesis and maintain alignment in patients with spastic disorders (Fig. 6 A, B).

Finally, posterior tibial tendon transfer to the lateral cuneiform was performed due to the presence of inversion spasticity. Tendon harvesting was done prior to application of the Ilizarov fixator and the transfer was completed after fixator application. Cavus was not completely corrected in this patient because there was a contracture problem which was due to extensive scar on the plantar surface of the foot as a result of a previous procedure completed at an alternate hospital. The senior surgeon decided to accept plantigrade position and not perform further corrective procedure of midfoot to correct cavus. This avoided potential soft-tissue complications of her sole. The wound was closed in layers.

2.4. Post-Operative Management and Rehabilitation

A posterior splint was applied for the next 2 weeks. Sutures were removed during the second week follow up visit (Fig. 7). Then, a removable short-leg cast was applied in the compliant patient with non-weight bearing for 10 weeks. In noncompliant patients, non-removable short leg casts were required for a period of 10 weeks. Weight bearing as tolerated was resumed if radiological (Figs. 4 C, D and 6 C, D) and clinical union was observed at arthrodesis site (Fig. 8). In case II, Ilizarov frame was removed 6 weeks after operation, when early union signs were observed at arthrodesis sites on radiographic assessment. After cast removal, the patients were taught to practice standing position, weight shift, and small periods of walking followed by increased time of walking distance 12 weeks postoperatively. Balance and proprioceptive exercises were also begun. Scar massage, heat application, and joint mobilization to unfused joints were initiated. Progressive strengthening of hip, knee and ankle along with core strengthening exercises was also encouraged.

Fig. (7)
Deformity correction following Lambrinudi and ankle arthrodesis: (A) lateral and (B) medial views.


Patient’s deformity correction in the present study was not completely perfect. However, each patient demonstrated improved outcomes in terms of acceptable plantigrade foot and ankle alignment with reduced risk of potential future pressure ulcer. The overall results showed improved Thai Visual Analog Scale Foot and Ankle (VAS-FA) (mean preoperative VAS-FA: 37; postoperative VAS-FA: 47.4), and Health-related Quality of Life via Thai Short-Form 36 (SF-36) scores (mean preoperative SF-36: 64.6; postoperative SF-36: 76.5) [10Angthong C, Chernchujit B, Suntharapa T, Harnroongroj T. Visual analogue scale foot and ankle: Validity and reliability of Thai version of the new outcome score in subjective form. J Med Assoc Thai 2011; 94(8): 952-7.
[PMID: 21863677]
, 11Jirarattanaphochai K, Jung S, Sumananont C, Saengnipanthkul S. Reliability of the medical outcomes study short-form survey version 2.0 (Thai version) for the evaluation of low back pain patients. J Med Assoc Thai 2005; 88(10): 1355-61.
[PMID: 16519379]
]. There was a correlation between VAS-FA and SF-36 scores (Pearson Correlation Coefficient (r) = 0.684; P-value = 0.520). Patients in the present report did not report any significant complications during the latest follow-up. The mean follow-up time was 26 months. The similar guideline was also preliminarily applied in the senior authors’ previous study by Manggala et al. [6Manggala Y, Angthong C, Primadhi A, Kungwan S. The deformity correction and fixator-assisted treatment using Ilizarov versus Taylor spatial frame in the foot and ankle. Orthop Rev (Pavia) 2018; 9(4): 7337.
[http://dx.doi.org/10.4081/or.2017.7337] [PMID: 29564076]
], in which residual foot-ankle deformity /injury was corrected in 14 patients. The overall result was satisfied in terms of foot and ankle outcome and quality of life scores. The authors believe that the modified guideline in this report has the potential and advantages in the management of challenging equinocavovarus deformities in the orthopedic practice.

3. DISCUSSION

Multiplanar equinocavovarus foot and ankle deformities in neuromuscular disorders are associated with or without severe joint stiffness, osteoarthritis, and soft-tissue contracture and pose a significant challenge to the use of conventional correction methods especially in the long-term condition.

Fig. (8)
Weight bearing images of case II following deformity correction showing supple, painless, plantigrade foot.


In the first patient, REF was used to provide gradual correction of irreducible equinus before definitive Lambrinudi and ankle arthrodesis. Because of long term deformity in the first patient, the soft tissues around the ankle became stagnated due to which it was difficult to achieve optimal overall correction and we accepted the plantigrade position. In the second patient, REF was used to prevent the recurrence of equinus and maintain alignment. The second case had significant spasticity of all posterior compartment muscles resulting in long-term deformity. Despite soft tissue release, there was continuous spasticity of the remaining posterior muscles [3Graves SC, Mann RA, Graves KO. Triple arthrodesis in older adults. Results after long-term follow-up. J Bone Joint Surg Am 1993; 75(3): 355-62.
[http://dx.doi.org/10.2106/00004623-199303000-00006] [PMID: 8444913]
]. Thus, there was a risk of recurrent equinus in the splint postoperatively even after performing Lambrinudi and triple arthrodesis. Hence, REF construct was augmented to nullify the effect of muscle spasticity and maintain the alignment of foot, thus providing additional compression with lower complications [6Manggala Y, Angthong C, Primadhi A, Kungwan S. The deformity correction and fixator-assisted treatment using Ilizarov versus Taylor spatial frame in the foot and ankle. Orthop Rev (Pavia) 2018; 9(4): 7337.
[http://dx.doi.org/10.4081/or.2017.7337] [PMID: 29564076]
, 12Reitenbach E, Rödl R, Gosheger G, Vogt B, Schiedel F. Deformity correction and extremity lengthening in the lower leg: Comparison of clinical outcomes with two external surgical procedures. Springerplus 2016; 5(1): 2003.
[http://dx.doi.org/10.1186/s40064-016-3666-3] [PMID: 27933259]
].

Nineteen patients were studied by Elsner et al. [13Elsner A, Barg A, Stufkens SA, Hintermann B. Lambrinudi arthrodesis with posterior tibialis transfer in adult drop-foot. Foot Ankle Int 2010; 31(1): 30-7.
[http://dx.doi.org/10.3113/FAI.2010.0030] [PMID: 20067720]
] who underwent Lambrinudi procedure and demonstrated subsequent significant improvement in their American Orthopaedic Foot & Ankle Society and Short Form-36 scores. Bernua et al. [2Bernau A. Long-term results following Lambrinudi arthrodesis. J Bone Joint Surg Am 1977; 59(4): 473-9.
[http://dx.doi.org/10.2106/00004623-197759040-00007] [PMID: 863941]
], demonstrated similar findings in 50 feet following Lambrinudi procedure, where 42 patients had experienced good outcome. Tang et al. [14Tang SC, Leong JC, Hsu LC. Lambrinudi triple arthrodesis for correction of severe rigid drop-foot. J Bone Joint Surg Br 1984; 66(1): 66-70.
[http://dx.doi.org/10.1302/0301-620X.66B1.6693480] [PMID: 6693480]
], suggested that Lambrinudi procedure is a useful method for treating severe rigid equinus deformities. Saltzman et al. [15Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV. Triple arthrodesis: Twenty-five and forty-four-year average follow-up of the same patients. J Bone Joint Surg Am 1999; 81(10): 1391-402.
[http://dx.doi.org/10.2106/00004623-199910000-00004] [PMID: 10535589]
], studied 55 patients with neuromuscular disorder where triple arthrodesis was performed. Ninety-five percent of these patients were satisfied with the operation results. Provelengios et al. [4Provelengios S, Kyriakos A. The role of pantalar arthrodesis in the treatment of paralytic foot deformities. Surgical technique. J Bone Joint Surg Am 2009; 91: 575-83.
[http://dx.doi.org/10.2106/JBJS.H.00559] [PMID: 19255217]
], studied 24 patients who underwent a one-stage pantalar arthrodesis at an average duration of follow-up at 37.2 years, with good results. Consistent with the outcomes of above-mentioned studies, the author’s previous study demonstrated satisfactory outcomes of surgical treatment using the present study’s modified guidelines of treatment [6Manggala Y, Angthong C, Primadhi A, Kungwan S. The deformity correction and fixator-assisted treatment using Ilizarov versus Taylor spatial frame in the foot and ankle. Orthop Rev (Pavia) 2018; 9(4): 7337.
[http://dx.doi.org/10.4081/or.2017.7337] [PMID: 29564076]
]. In addition, the present guideline highlights the benefit of combined technique with osteotomy, arthrodesis, and REF to correct challenging equinocavovarus conditions, specifically long-lasting ones. Regarding potential complications, pseudarthrosis has been reported in up to 28% of patients following pantalar arthrodesis with ankle and talonavicular joints being the most common areas of non-union [16Angus PD, Cowell HR. Triple arthrodesis. A critical long-term review. J Bone Joint Surg Br 1986; 68(2): 260-5.
[http://dx.doi.org/10.1302/0301-620X.68B2.3958012] [PMID: 3958012]
-18Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthrosis of the ankle and hindfoot. J Bone Joint Surg Am 1992; 74(7): 1042-9.
[http://dx.doi.org/10.2106/00004623-199274070-00011] [PMID: 1355770]
]. These potential complications were addressed and likely prevented by using the combined technique of Lambrinudi, and ankle arthrodesis with augmentation and further stabilization of arthrodesis using REF. REF likely provided additional compression and potentially reduced the probability of pseudarthrosis. Although the final results of the patient’s deformities correction in the present study were not completely perfect, each patient demonstrated improved outcomes in terms of plantigrade foot and ankle position that likely reduced the risk of future pressure ulcers. In addition to these evidence, the similar guideline was also preliminarily used in the senior author’s previous study by Manggala et al. [6Manggala Y, Angthong C, Primadhi A, Kungwan S. The deformity correction and fixator-assisted treatment using Ilizarov versus Taylor spatial frame in the foot and ankle. Orthop Rev (Pavia) 2018; 9(4): 7337.
[http://dx.doi.org/10.4081/or.2017.7337] [PMID: 29564076]
], in which residual foot-ankle deformity/injury was corrected in 14 patients. The overall result was satisfactory. Thus, the modified guideline algorithm and surgical technique in the present study may be utilized as a recommended protocol in the future to achieve satisfactory results. The well-aligned corrections of deformities potentially reduce the risks of complications such as pseudarthrodesis and soft-tissue compromise.

CONCLUSION

Severe long term neuromuscular equinocavovarus deformities are a challenging disability in foot and ankle surgery. The present article proposes a modified guideline of treatment illustrated in two representative case studies of long-term paralytic and spastic equinocavovarus deformities. Both the patients in the study demonstrated acceptable plantigrade foot and improved ankle alignment during the latest follow up. There was an improvement in the various qualitative and quantitative parameters which are listed above. These conditions can be treated surgically using the stepwise approach as demonstrated in this article with acceptable outcomes.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

All thepatients gave consent to the operative procedures and publication of this report.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Botte MJ, Franko O. Neuromuscular disorder. Thordarson DB, ed Foot & Ankle 2nd Ed Philadelphia, Pa: Wolters Kluwer 2013; 43-80.
[2] Bernau A. Long-term results following Lambrinudi arthrodesis. J Bone Joint Surg Am 1977; 59(4): 473-9.
[http://dx.doi.org/10.2106/00004623-197759040-00007] [PMID: 863941]
[3] Graves SC, Mann RA, Graves KO. Triple arthrodesis in older adults. Results after long-term follow-up. J Bone Joint Surg Am 1993; 75(3): 355-62.
[http://dx.doi.org/10.2106/00004623-199303000-00006] [PMID: 8444913]
[4] Provelengios S, Kyriakos A. The role of pantalar arthrodesis in the treatment of paralytic foot deformities. Surgical technique. J Bone Joint Surg Am 2009; 91: 575-83.
[http://dx.doi.org/10.2106/JBJS.H.00559] [PMID: 19255217]
[5] Lee WC, Ahn JY, Cho JH, Park CH. Realignment surgery for severe talar tilt secondary to paralytic cavovarus. Foot Ankle Int 2013; 34(11): 1552-9.
[http://dx.doi.org/10.1177/1071100713497001] [PMID: 23832713]
[6] Manggala Y, Angthong C, Primadhi A, Kungwan S. The deformity correction and fixator-assisted treatment using Ilizarov versus Taylor spatial frame in the foot and ankle. Orthop Rev (Pavia) 2018; 9(4): 7337.
[http://dx.doi.org/10.4081/or.2017.7337] [PMID: 29564076]
[7] Lambrinudi C. New operation of drop-foot. Br J Surg 1927; 15: 193-200.
[http://dx.doi.org/10.1002/bjs.1800155804]
[8] Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg Am 1987; 69(7): 1052-62.
[http://dx.doi.org/10.2106/00004623-198769070-00014] [PMID: 3654697]
[9] Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am 1980; 62(5): 777-84.
[http://dx.doi.org/10.2106/00004623-198062050-00012] [PMID: 7391101]
[10] Angthong C, Chernchujit B, Suntharapa T, Harnroongroj T. Visual analogue scale foot and ankle: Validity and reliability of Thai version of the new outcome score in subjective form. J Med Assoc Thai 2011; 94(8): 952-7.
[PMID: 21863677]
[11] Jirarattanaphochai K, Jung S, Sumananont C, Saengnipanthkul S. Reliability of the medical outcomes study short-form survey version 2.0 (Thai version) for the evaluation of low back pain patients. J Med Assoc Thai 2005; 88(10): 1355-61.
[PMID: 16519379]
[12] Reitenbach E, Rödl R, Gosheger G, Vogt B, Schiedel F. Deformity correction and extremity lengthening in the lower leg: Comparison of clinical outcomes with two external surgical procedures. Springerplus 2016; 5(1): 2003.
[http://dx.doi.org/10.1186/s40064-016-3666-3] [PMID: 27933259]
[13] Elsner A, Barg A, Stufkens SA, Hintermann B. Lambrinudi arthrodesis with posterior tibialis transfer in adult drop-foot. Foot Ankle Int 2010; 31(1): 30-7.
[http://dx.doi.org/10.3113/FAI.2010.0030] [PMID: 20067720]
[14] Tang SC, Leong JC, Hsu LC. Lambrinudi triple arthrodesis for correction of severe rigid drop-foot. J Bone Joint Surg Br 1984; 66(1): 66-70.
[http://dx.doi.org/10.1302/0301-620X.66B1.6693480] [PMID: 6693480]
[15] Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV. Triple arthrodesis: Twenty-five and forty-four-year average follow-up of the same patients. J Bone Joint Surg Am 1999; 81(10): 1391-402.
[http://dx.doi.org/10.2106/00004623-199910000-00004] [PMID: 10535589]
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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