Sharing What We Know: Papers Authored by the IEP Medical Team

In addition to teaching local colleagues new techniques during our mission trips, the medical team uses the experiences in the operating room and patient evaluations to build their own knowledge and skill. Many times, they turn these learnings into articles to present their findings to their peers in the medical community.

Following are the introductions to three articles by the team based on experiences in Vietnam missions. Get more details and article abstracts on the Articles+Research page.

November 2022: Journal of Orthopaedic Surgery and Research

Promising results in a 3-year follow-up for adults undergoing a one-stage surgery for residual talipes equinovarus as part of a humanitarian mission in Vietnam

Talipes equinovarus (TEV) is a triple deformation (equinus, adduction, and supination) leading to an inversion of the foot. This deformity can be either flexible or rigid. Approximately 80% of children with congenital clubfoot are born in developing countries. If left untreated, TEV can cause significant lifelong limitations. While the Ponseti method for treating congenital idiopathic clubfoot has been widely adopted [2], there are still areas in the developing world where this technique is not widely known or available. In many cases even if patients in these countries have been effectively treated during infancy, they are likely to develop rigid TEV because of the lack of follow-up. The most common causes of rigid TEV are neglected congenital clubfoot, poliomyelitis complications, post-traumatic residual deformity or chronic osteomyelitis [1]. Multiple scoring scales have been previously presented aiming to grade the severity of the deformity and to guide treatment [3]. Some have focused on clinical and/ or radiographic parameters [2, 4, 5], while others based their grading on clinical features, structural implications and reducibility [6, 7]. A common general principle is that while milder deformities (either graded by clinical features or reducibility) can lead to a wide range of gait disturbances, the more severe cases result in rigid non-plantigrade feet that are either unshoe-able or un-walk-able [1, 8–11]. To achieve a plantigrade foot, these deformities require surgery [1, 8–11]. Furthermore, corrective surgery to restore foot alignment requires expensive hardware, such as internal or external fixation devices, as well as rigorous follow-up and rehabilitation regimens [1, 8–11] that are often inaccessible.

July/August 2021: Journal of the American Podiatric Medical Association

Can Tho Transfer Technique: Extensor Hallucis Longus to Tibialis Anterior Tenodesis for Footdrop

Footdrop is defined as failure to actively dorsiflex the foot. A variety of pathologic processes, which can be neurologic, systemic, or traumatic, can result in footdrop. The neurologic causes can be either central (eg, poststroke, head injury, multiple sclerosis, cerebral palsy, and poliomyelitis [polio]) or peripheral (eg, nerve injury, compartment syndrome, Charcot-Marie-Tooth disease, and Duchenne and Becker muscular dystrophies).1,2

Another potential cause of footdrop is polio. The poliovirus attacks the anterior horn nerve cells, resulting in flaccid paralysis, which in the chronic phase is most evident in the lower extremities. Patients typically report new episodes of weakness, which occur on average 35 years after the acute polio infection.3 Paralysis leads to chronic deformity, loss of function, muscle imbalances, and resulting gait abnormalities. Generally accepted procedures for patients with neurologic deficit due to polio have been tendon transfers in the foot and ankle to restore balance and function of the paralytic foot.2 Since the advent of the polio vaccine, the polio epidemic has ended; however, the disease is still endemic in three countries, namely, Afghanistan, Pakistan, and Nigeria. Despite this advance, there is no curative treatment for the paralysis that can result from this debilitating and potentially deadly disease.4,5

In patients with cerebral palsy or polio presenting with weakness of the tibialis anterior (TA), gait can be improved by using an extensor hallucis longus (EHL) to TA tendon transfer. However, the success rate of previous EHL to TA tenodesis was reported to be low. Herein we present a newly developed, simple technique to strengthen the tenodesis and improve the rate of success.

2017: Foot & Ankle International

Flexor Digitorum Longus (FDL) or Flexor Hallucis Longus (FHL) Harvesting: Technical Tip and Case Studies

Flat foot in adults is a condition frequently encountered in orthopedics. When the flattening is not acute due to trauma, the main pathology is centered on the tibialis posterior tendon. 6,12 Nonoperative treatment is recommended for the first stage of the disease.1,2,7 For mild and severe flexible deformity (stage II-a, II-b), tendon transfer is indicated as part of medial arch reconstruction.7,9,12,13,16 The tendon most commonly used for transfer is the flexor digitorum longus (FDL),6,16 but the flexor hallucis longus (FHL) is also used. The FHL is only 56% as strong as the tibialis posterior, but it is twice as strong as the FDL. Many surgeons avoid using the FHL as it is rerouted around the neurovascular bundle during the surgery.3 In this article, we describe a safe simple technique for harvesting the FDL/FHL through a plantar approach.

Get more details and article abstracts on the Articles+Research page.