Journal of Orthopaedic Surgery 2008;16(2):215-9
V osteotomy and Ilizarov technique for
residual idiopathic or neurogenic clubfeet
E Segev, E Ezra, M Yaniv, S Wientroub, Y Hemo
Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel-Aviv Sourasky Medical Center, and the Sackler
Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
ABSTRACT
Purpose. To report the treatment outcomes of V
osteotomy and Ilizarov technique for residual
idiopathic or neurogenic clubfeet.
Methods. 13 patients (14 feet) aged 8 to 18 years
underwent V osteotomy via the calcaneus and talus,
followed by gradual distraction of soft tissue and
bone for foot reconstruction. Eight of the clubfeet
were idiopathic and had undergone previous
surgeries. The remaining 6 were neurogenic and their
pathologies were: Charcot‑Marie‑Tooth disease (n=2),
myelomeningocele (n=2), neurofibromatosis (n=1),
and distal arthrogryposis (n=1). Three of them had
undergone previous surgeries. The Ilizarov frames
were retained for 3 to 6 months and the patients were
followed up for 1.8 to 8.9 years. Range of movement
of the ankle and foot, appearance and position, gait,
pain, function, and patient satisfaction were assessed
according to the modified clubfoot grading system.
The talo-1st metatarsal angle was measured on
anteroposterior radiographs.
Address correspondence and reprint requests to: Dr Eitan Segev, Department of Pediatric Orthopaedics, Dana Children’s
Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv, 64239, Israel. E-mail: esegev@tasmc.health.gov.il
Results. Scores associated with the appearance and
position of the foot, and thus patient satisfaction
were significantly improved, but not for range of
movement, pain, and function. The mean preoperative
and final talo-1st metatarsal angles were 39.7 and 8.7
degrees, respectively (p<0.01). Ten feet achieved the
plantigrade position, one had residual equinus, and 3
had residual adduction and supination.
Conclusion. Patient satisfaction improved
significantly despite no major improvement in pain,
function, and range of movement of the ankle and
foot. This reflects the importance of the appearance
and position of the foot, and justifies the decision to
undergo this long and demanding procedure.
Key words: clubfoot; fixators, external; Ilizarov technique;
osteotomy; recurrence
INTRODUCTION
It is a challenge to treat patients aged >8 years with
residual clubfoot after a series of failed surgeries.
Such feet become stiff and un-amenable to soft-tissue
216 E Segev et al. Journal of Orthopaedic Surgery
(a)
(b) (c)
Figure 1 Patient 7: (a) correction of the right foot and
deformation of the left foot, (b) application of the Ilizarov
frame to the left foot, and (c) the clinical result at the final
follow-up.
correction. Neurogenic clubfeet tend to recur after
soft-tissue release because of muscle imbalance and
pose functional and cosmetic problems. Callosities or
pressure sores may develop on the lateral and dorsal
parts of the foot after prolonged walking. Soft-tissue
distraction is effective for patients aged <8 years, but
may recur in older children.1–4
The conventional triple arthrodesis involves
removal of bony wedges and straightening of the foot,
but tends to stiffen the joints below the ankle, shorten
the foot, and arrest future growth of the small bones.
This procedure’s ability to correct the deformity
is limited and further adjustment is not feasible.
The Ilizarov technique of distraction osteogenesis5
has been used to correct residual clubfeet with
encouraging results.1–4 Double osteotomy (V shape)
via the calcaneus and talus followed by gradual
Figure 2 Patient 12: clinical
and radiographic results before
and after V osteotomy and the
use of Ilizarov technique.
distraction of the soft tissues and bones enables
reshaping of the foot. Reorientation of the foot may
correct the deformities, increase length, and preserve
residual movement in the joints.
We report our 9-year experience in the treatment
of residual idiopathic or neurogenic clubfeet.
MATERIALS AND METHODS
The study was approved by our institutional review
board. Between January 1998 and January 2005, 13
patients (14 feet) aged 8 to 18 years underwent V
osteotomy via the calcaneus and talus, followed by
gradual distraction of soft tissue and bone for clubfoot
reconstruction. Eight of the clubfeet were idiopathic
(Fig. 1) and had undergone previous surgeries (one
foot had had one operation, 3 had had 2, and 4 had
had 3). The remaining 6 were neurogenic and their
pathologies were: Charcot‑Marie‑Tooth disease (n=2),
myelomeningocele (n=2), neurofibromatosis (n=1),
and distal arthrogryposis (n=1, Fig. 2). Three of the
patients had each undergone 2 previous surgeries.
The Ilizarov frames were retained for 3 to 6 months
and the patients followed up for 1.8 to 8.9 years (Table
1).
Under tourniquet control, the posterior tibial
neurovascular bundle was exposed via a medial
Vol. 16 No. 2, August 2008 V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet 217

Table 1
Demographic and clinical data of the patients

Patient Diagnosis Previous surgery Age at Time in Follow‑ Complications

No. surgery frame up
(years) (months) (years)
1 Idiopathic Lateral posteromedial 9.8 3 8.9 Pin tract infection
clubfoot release x2
2 Charcot-Marie- Lateral posteromedial 14 3.5 8.0 Pin tract infection, toe flexion
Tooth disease release x2 contracture
3 Idiopathic Lateral posteromedial 8 3.5 7.0 Pin tract infection
clubfoot release
4 Neurofibroma- - 15.8 3.5 5.0 Pin tract infection
tosis
5 Myelomenin- - 18 3.5 4.1 Great toe necrosis, toe flexion
gocele contracture
6 Idiopathic Lateral posteromedial 13.9 3.5 3.9 Pin tract infection
clubfoot release x2, Evans procedure
7 Idiopathic Lateral posteromedial 9.9 3.5 3.0 Residual equinus contracture,
clubfoot release x2, Evans procedure pin tract infection
7 Idiopathic Lateral posteromedial 11.2 3.5 1.9 Pin tract infection, toe flexion
clubfoot release x2, Evans procedure contracture
8 Myelomenin- Lateral posteromedial 15.5 6.0 2.9 Residual supination, pin tract
gocele release x2, tibialis anterior infection
tendon transfer
9 Idiopathic Lateral posteromedial 9.1 3.5 2.3 Lateral wound dehiscence, toe
clubfoot release x2 flexion contracture, residual
supination
10 Idiopathic Lateral posteromedial 14.1 3.0 1.9 Lateral wound dehiscence,
clubfoot release x2, Evans procedure toe flexion contracture
11 Charcot-Marie- - 12.7 4.0 1.9 Pin tract infection. Toe flexion
Tooth disease contracture
12 Distal Lateral posteromedial 13.5 3.5 1.9 Pin tract infection
arthrogryposis release, Grice procedure
13 Idiopathic Lateral posteromedial 12.2 3.0 1.8 Pin tract infection, toe flexion
clubfoot release x2 contracture, residual supination

approach and protected. The tarsal tunnel was then
released. The peronei tendons were elevated from
the calcaneus via a lateral approach, and the cuboid
and talus were exposed. The hind foot and forefoot
were separated from the middle stationary fragment
using a V osteotomy. A wedge‑shaped piece of bone
was removed from the lateral aspect of the osteotomy
to prevent impingement of the bone fragments. The
modular 2‑ring Ilizarov frame was then attached to
the tibia. The hindfoot and forefoot deformities were
corrected gradually in relation to the stationary middle
fragment by proper orientation of the distractors
and hinges5 (Fig. 3). The frame was kept until bony
consolidation. A cast was applied for 4 to 6 weeks
after frame removal, followed by rehabilitation.
Preoperatively and at final follow-up, range of
movement of the ankle and foot, appearance and
position, gait, pain, function, and patient satisfaction
were assessed using the modified clubfoot outcome
grading system,6 with a best possible score of 150.
The talo-1st metatarsal angle was measured on
anteroposterior radiographs. Preoperative and final
follow-up results were compared using the Wilcoxon
signed rank test, with adjustment for ties. A p value
of <0.05 was considered statistically significant.
RESULTS
There was no significant difference in the functional
and radiographic results between patients with
idiopathic or neurogenic defects. Scores associated
with appearance and position of the foot, and thus
patient satisfaction were significantly improved, but
not for range of movement, pain, and function (Table
2). In the respective preoperative and final follow-up,
mean scores of ankle dorsiflexion were 4.3 and 4.6
(p=0.317), subtalar motion were 2.1 and 0.7 (p=0.102),
heel position were 0.0 and 6.4 (p=0.002), forefoot
adduction were 0.0 and 6.8 (p=0.002), supination
218 E Segev et al. Journal of Orthopaedic Surgery

Figure 3 Medial and lateral views of a foot model showing the V osteotomy and Ilizarov technique.

Table 2
Functional results, appearance, and patient satisfaction according to the modified clubfoot outcome grading system6

Patient Ankle Subtalar Heel position Forefoot Supination Cavus Gait Pain Function Patient Total
No. dorsiflexion motion adduction satisfaction

Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final Preop Final

1 10 10 10 0 0 10 0 10 0 0 0 0 15 20 20 20 15 15 0 15 70 100
2 5 5 0 0 0 10 0 10 0 10 0 10 15 20 20 20 15 5 0 25 55 115
3 0 5 0 0 0 10 0 10 0 10 0 10 10 15 25 25 15 15 0 15 50 115
4 10 10 0 0 0 10 0 10 0 0 0 0 15 15 15 15 15 15 0 15 55 90
5 10 10 10 0 0 10 0 10 0 0 0 0 15 15 25 15 15 15 15 25 90 100
6 10 10 0 0 0 0 0 0 0 0 0 10 15 15 15 15 5 15 15 15 60 80
7 right 0 0 0 0 0 0 0 10 0 10 0 10 10 15 15 15 15 15 0 15 40 90
7 left 0 0 0 0 0 10 0 10 0 10 0 10 10 20 25 25 15 15 0 15 50 115
8 0 0 10 10 0 5 0 5 0 10 0 10 10 10 15 15 20 20 0 15 55 100
9 5 5 0 0 0 0 0 0 0 0 0 10 10 10 25 25 20 20 0 15 60 85
10 0 0 0 0 0 5 0 5 0 10 0 10 15 20 15 25 5 15 0 25 35 115
11 0 0 0 0 0 5 0 5 0 10 0 10 10 15 5 15 5 15 0 15 20 90
12 5 5 0 0 0 5 0 5 0 10 0 10 15 20 15 15 5 15 15 25 55 110
13 5 5 0 0 0 10 0 5 0 0 0 10 10 15 5 15 15 5 0 15 35 80
Mean 4.3 4.6 2.1 0.7 0 6.4 0 6.8 0 5.7 0 7.9 12.5 16.1 17.1 18.6 12.9 14.3 3.2 17.9 52.1 98.9
p Value 0.317 0.102 0.002 0.002 0.005 0.001 0.004 0.317 0.414 0.001 0.001

Table 3 were 0.0 and 5.7 (p=0.005), cavus were 0.0 and 7.9
Radiographic results (p=0.001), gait were 12.5 and 16.1 (p=0.004), pain
were 17.1 and 18.6 (p=0.317), function were 12.9 and
Patient Anteroposterior talo-1st metatarsal angle 14.3 (p=0.414), and patient satisfaction were 3.2 and
No. 17.9 (p=0.001). The mean preoperative and final talo-
Preop Final
1st metatarsal angles were 39.7º and 8.8º, respectively
1 34º 15º (p<0.01, Table 3).
2 50º 20º Patient 7 had residual equinus contracture of
3 53º 5º
4 30º 5º the left foot after removal of the cast (Fig. 1). After
5 38º 8º intensive physiotherapy had failed, the contracture
6 75º 16º was corrected to the plantigrade position with re-
7 right 24º 0º application of the Taylor spatial frame. Three patients
7 left 40º 6º
had residual adduction and supination of the forefoot
8 35º 5º
9 50º 17º after frame removal, because the talonavicular
10 30º 10º joint (not the talar neck) was separated and bony
11 32º 10º stabilisation was not achieved. It is important
12 30º 6º that the V osteotomy is through the talar neck for
13 35º 0º
bony consolidation. Seven patients developed toe
Mean* 39.7º 8.8º
contractures and underwent flexor tenotomies. In
* p<0.01 one, the toes were stabilised with Kirschner wires and
Vol. 16 No. 2, August 2008 V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet 219

an Ilizarov half‑ring with the frame on the foot. In the
other 6 the foot was stabilised with a cast after frame
removal. Four patients had dehiscence of the lateral
surgical wound secondary to severe scarring and
compromised blood supply. The wound dehiscence
resolved after topical treatment with eusol and
granuflex. 11 patients developed pin tract infection,
which resolved with oral or intravenous antibiotics.
Patient 5 had necrosis of the great toe which resolved
with eusol and granuflex.
DISCUSSION
The Ilizarov technique enables correction through
soft-tissue distraction1,7–9 or combination of soft-
tissue distraction and bony manipulation.2,3,10 Soft-
tissue distraction is appropriate for feet with mild
secondary bony changes and for younger patients.5,11
Our patients were older and had scar and muscle
imbalance around the foot secondary to previous
surgeries. These feet had severe bony and joint
changes, and soft-tissue distraction alone could have
resulted in incongruent joints and recurrence.
It is important to establish the vascular anatomy
prior to distraction. This can be achieved using
ultrasound Doppler scanning or angiography. Tarsal
tunnel was routinely released to minimise the risk of
vascular injury and the V osteotomy was performed
via a lateral incision under direct vision.
Patients report being satisfied with the appearance
and plantigrade position of the foot, the ability to walk
and to wear normal shoes.1,4,7 They also attain a more
balanced load on pedobarography.12 The results from
patient‑based responses are more favourable than
clinical assessments by the surgeon.13,14 Encouraging
results are reported mainly from the cosmetic
perspective and satisfaction, not function.13,14
In our study, patient satisfaction improved
significantly, despite no major improvement in range
of movement of the ankle and foot, pain, and function.
This reflects the importance of the appearance and
position of the foot, and justifies the decision to
undergo this long and demanding procedure.

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