Surgical

Achilles tendon lengthening

This procedure lengthens a tight Achilles tendon, which can prevent the foot from bending upward at the ankle, allowing increased motion at the ankle joint. It may be used in combination with another procedure (for example, to apply internal or external fixation), to correct lower limb deformity.

There are three methods in general use; all require some form of surgery under anesthetic. Each technique has benefits depending on the circumstances and the severity of the condition, and you should discuss them with your surgeon.

Recovery time is about six to eight weeks. A very tight Achilles tendon may require more-complex lengthening surgery, which is more invasive and takes longer to heal. After surger, patients may be placed into a protective cast, splint or walking boot, followed by physical therapy.

Ankle fusion (arthrodesis)

Ankle arthrodesis is a procedure that may be needed in the case of severe ankle arthritis. There are 50,000 new cases of ankle arthritis in the U.S. every year, and about 100,000 patients undergo ankle arthrodesis annually (often for pes planus, ankle arthritis or a combination of the two).1

When non-surgical treatments have failed, ankle arthrodesis may be performed to fuse the bones of the lower leg — the tibia, fibula and talus — into one bone. This can relieve pain, and maintain or improve function by eliminating motion in the arthritic ankle.

Approximately six weeks after fusion, the ankle should be well on its way to uniting, and be fully united by 12 to 14 weeks. The bone will get stronger over time. Ankle arthrodesis may be combined with a procedure to attach internal or external fixation, depending on the severity of the ankle’s condition.

Guided Growth Technique

Special internal plates, such as the Guided Growth eight-Plate and Quad-Plate systems, can be used to correct both congenital and acquired (such as from an injury) deformities, so long as the bone’s growth plates are not fused. These Guided Growth plates have a hole in the center, for a temporary guide pin to be implanted to ensure accurate application. The plates are attached to the surface of the bone over the growth plate by two or four screws, which are not locked to the plate but, rather, are allowed to swivel and move away from each other as bone growth occurs.

The implant acts like a flexible hinge, letting growth on the opposite side of the growth plate gradually straighten the limb. The procedure is minimally invasive and outpatient, with no cast required. Patients can weight-bear and return to their normal activities as they feel able.

Acute deformity correction with internal devices

Specific bone deformities can be corrected over the short term using internal devices, such as nails or plates. This is suitable for mild deformities (Blount’s disease or other angulation). The bone is corrected in these procedures by carefully cutting out a wedge of bone (osteotomy) then closing the gap using the internal device.

Bone lengthening

Lengthening with no associated deformities can be carried out with specific internal devices, such as lengthening nails activated by the patient movement or specific magnetic remote controls. In these procedures, an osteotomy (cutting the bone) is done, and a lengthening nail is put in. After consolidation, the device must be removed. However, in the majority of cases, bone lengthening is carried out by using external fixation (see next section).

External fixation

An external fixation device is worn outside the body. This device, which is called a fixator, is connected to the bone with bone screws (commonly called pins). The pins pass through the skin, and sometimes muscles, to connect the external fixator to the bone, in order to hold the bone in place and to anchor the fixator securely. Sometimes wires are used with or instead of pins to hold the bone pieces in place.

External fixation is used for temporary stabilization, fracture treatment and treatment of deformities that have arisen after healing from trauma injuries.

Limb lengthening and deformity correction

Limb lengthening and limb correction are gradual techniques that can help to correct the results of irregular bone growth that occurred in childhood, or help to repair the damage from an accident, bone loss or a non-union (a fracture that has not healed properly). The bone is corrected in these procedures by carefully cutting the bone (osteotomy) and then slowly lengthening or correcting the limb. It is very important that this type of specialist surgery is carried out and supervised by an experienced limb reconstruction surgeon.

The surgeon uses the external fixator to place the bone in correct position and alignment until bone healing occurs and deformity correction is achieved. This takes approximately six weeks for a simple fracture, and up to one year or longer for a more complicated procedure. A limb reconstruction surgeon may ask a patient to turn one or more pieces to gradually lengthen the bone. When lengthening is complete, the fixation must stay on until the bone has healed.

External fixation is a minimally invasive and flexible treatment that can be tailored for the patient. With an advanced external fixator, such as TL-HEX, different adjustments can be performed without changing the bone screws or wires.

  1. Gallagher B. Treatment for end-stage ankle arthritis re-evaluated. Nashville, TN: Vanderbilt University Medical Center. http://www.mc.vanderbilt.edu/documents/orthopaedics/files/Gallagher%20-%20f-a%20NMN.pdf [Accessed December 2015].