Articles + Research

Sharing What We Know

The IEP team's work goes beyond what happens on mission trips. There's much to learn from our patients and the cases we treat. The team members have worked together to author and publish research and technical articles detailing findings from experiences in Vietnam,  Namibia, and Angola.

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

Authors: Ezequiel Palmanovich, Wing Ip, Huynh Em, Jeffrey Spanko, Meir Nyska, Bruce Lehnert, Alex Tavdi, Nissim Ohana, and David Segal

Background: Rigid talipes equinovarus (TEV) is a complex foot deformity in which the foot is fixed in a plantarflexed, inverted, and adducted position. This pathology has the potential to severely limit basic life activities, which can be devastating for patients in developing countries. The objective of this study was to present the outcomes of patients with mature bones presenting with severe rigid TEV deformity who were operated on during a humanitarian mission to Vietnam using a single lateral approach and a simple and inexpensive fixation technique.

Methods: This is a retrospective analysis of prospectively collected data. We analyzed the outcomes of patients who underwent surgery for a severe rigid TEV that prevented them from walking minimal distances unaided. All feet were fixed in a non-plantigrade position. The surgeries were conducted as part of two International Extremity Project (IEP) missions in Can Tho, Vietnam (2013 and 2018). Pre- and post-operative AOFAS scores were compared using the paired sample t-test.

Results: We operated on 14 feet of 12 patients, 6 (50%) of whom were males, aged 34.42 ± 11.7 (range 12 to 58). Four patients were followed for three months, two patients were followed for 12 months, and eight patients were followed for three years. On the final follow-up visit of each patient, all 14 operated feet were plantigrade with good alignment, and patients reported an improvement in daily activity. After 3 years of follow-up, the mean AOFAS score of eight patients with available data improved by 42.88 ± 3.91 points (95% CI 39.61 to 46.14, P < 0.01). Our patients also reported an improvement in mobility. At the final follow-up examination, no recurrence of the deformity was observed in any of the patients.

Conclusions: Using low-technical surgical modalities, we were able to achieve plantigrade and walkable feet in patients with mature bones who had fixed rigid equinovarus.

Level of evidence: Level IV- Case Series.

Keywords: Fixed rigid equinovarus, Low-technical surgical modalities, One-stage surgery, Humanitarian mission

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

Ezequiel Palmanovich, MD; Wing Ip, DPM; Em Huynh, MD; Jeffrey Spanko, DPM; Meir Nyska, MD; Bruce Lehnert, DPM

Background: Footdrop, or the inability to actively dorsiflex the foot, may result from numerous pathologic conditions, including poliomyelitis and cerebral palsy. Although the gait of patients with footdrop can be improved by performing an extensor hallucis longus (EHL) to tibialis anterior (TA) tendon transfer, the success rate of this procedure is relatively low.

Methods: Seven paralytic patients with footdrop were surgically treated using a new buttonhole-type technique that involves passing a loop of the EHL through a TA split using umbilical tape and suturing at the four corners of the EHL attaching to the TA while the foot is dorsiflexed.

Results: Eight years after surgery, all three patients who were available for follow-up displayed active dorsiflexion, improved mobility, and a palpable TA-EHL tenodesis, with no cockup deformity.

Conclusions: This new approach, which we term Can Tho transfer, improves the mechanical strength of TA-EHL tenodesis.

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

Bruce Lehnert, DPM; Meir Nyska, MD; Wing Ip, DPM; Em Huynh, MD; and Ezequiel Palmanovich, MD

Background: Harvesting of the flexor digitorum longus (FDL) or the flexor hallucis longus (FHL) is a procedure used when tendon transfer is needed. It is commonly used in tibialis posterior reconstruction and Achilles tendon reconstruction. Harvesting of these tendons is sometimes difficult and time-consuming. It is important to obtain sufficient length to make a loop around the navicular bone or anchor it in the calcaneus. We describe a technique in which a loop is passed from proximal identification of the FDL or FHL through the tendon sheath, harvesting it from a minimal plantar approach.

Methods: After using this technique, we evaluated 10 consecutive patients for neurovascular damage.

Results: We found no postoperative neurovascular injuries.

Conclusions: The technique described enables the surgeon to find the FDL/FHL tendon through the medial approach and obtain sufficient length for the procedure by cutting the distal portion of the tendon through an additional plantar incision. Our technical tip for passing the loop facilitates harvest of the tendon easily and safely using the plantar approach.

Level of Evidence: IV, case series.

Keywords: tendon harvesting, flexor digitorium longus, flexor hallucis longus, surgical tip