Utilizing The ‘Steering Wheel Maneuver’ For Deformity Correction In The Foot

The author presents a hybrid technique combining gradual bony and soft tissue distraction with acute deformity correction in multiple planes in a 30-year-old patient.

Foot deformities are attributable to various etiologies. The malalignment can be challenging for patients and can result in painful symptoms in the lower extremity. Non-operative treatment, such as bracing and orthoses, can be helpful but does not alter the deformity. In such instances, one should strongly consider surgical intervention to help improve a patient’s quality of life.

Researchers have described many treatment methods when addressing foot deformities. These include acute and gradual correction methods utilizing external fixation.^1,2 Such methods are technically challenging and require a thorough understanding of external fixation application and deformity correction techniques. Gradual correction, when using the Ilizarov method, adds additional complexity to the procedure since one corrects each plane of the deformity individually, not simultaneously. Advances in external fixation devices that facilitate multiplanar correction, such as the Taylor Spatial Frame (Smith & Nephew), decrease the complexity and length of time it takes to obtain adequate correction. 

Multiplanar corrective devices require a web-based program to determine the correction. In long bones, the visualization of the correction in various planes is generally easier to understand. However, utilizing the program can be challenging for surgeons to conceptualize correction in the foot for various reasons. This can lead to frustration for the surgeon and the patient. 

In the following case, I used a hybrid technique called the “steering wheel maneuver,” which offers an alternative to the traditional Ilizarov and Taylor Spatial Frame. This method combines the benefits of gradual and acute deformity correction using external fixation while removing the complexity one encounters using a web-based program. The steering wheel maneuver was developed at the Rubin Institute for Advanced Orthopedics and authors presented it at the Annual Baltimore Limb Deformity Course in 2013.³ The goal of the procedure is to correct deformity in multiple planes acutely after obtaining gradual bony and soft tissue distraction.  

A Closer Look At The Patient Presentation

A 30-year-old male with no pertinent medical history presented to the clinic with a complaint of painful gait and difficulty in shoes. The patient related a history of multiple foot surgeries as a child due to unilateral clubfoot deformity. He stated his last surgery left him with a painful, stiff foot. The patient felt his foot was not amenable to normal shoe gear or the bracing modifications that his surgeon offered. Accordingly, he was contemplating reconstruction or a below-knee amputation. 

Physical exam findings revealed decreased calf size and muscularity to the left posterior and anterior compartments. He had healed after the last surgery but he had thickened, incisional scars to the medial and lateral borders of the foot. His pulses were palpable with normal sensation to the foot. The patient had a rigid hindfoot with 5 degrees of non-painful ankle dorsiflexion and 15 degrees of plantarflexion. His resting calcaneal position was in valgus. However, he had significant lateral displacement of his calcaneus, which extended beyond the lateral borders of the fibula. The patient had a fixed 30-degree forefoot supinatus deformity with a rigid 45-degree flexion contracture of the first metatarsophalangeal joint (MPJ). The remaining digits were semi-reducible, except the fourth digit, which was in an adductovarus flexion contracture position.

Erect leg radiographs detected a 2 cm limb length discrepancy. His foot radiographs revealed a solid triple arthrodesis with staples and an adducted “stair-stepper” forefoot appearance. The patient had disruption of the lateral Meary’s angle. The first MPJ had prior surgical and adaptive changes in a flexed position. In regard to the patient’s hindfoot alignment, there was a 25-degree valgus deformity with 3.5 cm of lateral displacement.

I explained the surgical options to the patient and recommended proceeding with joint preservation and realignment procedures with external fixation. The plan to correct the foot deformities consisted of double-level osteotomies and selective joint fusion, sparing the ankle joint. After careful consideration, the patient elected to move forward with correction. He chose not to have limb lengthening at the same time so I did not address the limb length discrepancy.

A Step-By-Step Guide To The Hybrid Surgical Technique

The first stage of the operation involved a Gigli saw osteotomy for the midfoot and calcaneus. The external fixation consisted of a tibial block and a butt joint centered with the long axis of tibia. Off the butt joint, I constructed a hindfoot and forefoot block for axial distraction using threaded rods. The patient had an uneventful admission postoperatively.

I started performing axial distraction (anterior block and posterior block) on the fifth postoperative day. The distraction was 1 mm per day for seven days. This comprised the gradual correction phase of the procedure.  

The patient returned to the operating theater after seven days after the final distraction for stage two for the acute correction. At this time, I performed the steering wheel maneuver to correct the forefoot supinatus deformity and the lateral calcaneal displacement. I prepared the first MPJ joint for fusion along with an interphalangeal joint arthrodesis of the fourth digit. Once there was satisfactory alignment, I converted the fixator into a rigid weightbearing device.   

The patient presented routinely for radiographic evaluation and fixator management over 12 weeks. Given the obstruction created by the external fixation on radiographs, I obtained a computed tomography (CT) scan, which confirmed bony union prior to fixator removal at 12 weeks. The patient had two months of physical therapy post-fixator removal and is now ambulating in regular shoe gear with a heel lift. He has not complained of the debilitating pain and discomfort since his corrective procedures.

In Conclusion

The “steering wheel” maneuver is a viable method that combines the benefits of acute and gradual correction when using external fixation for deformity correction. The method decreases the complexity associated with software-based corrections while still allowing accurate realignment. There are numerous applications for this method and one should consider utilization of this technique when performing complex deformity correction.

Dr. Siddiqui is affiliated with the International Center for Limb Lengthening/Rubin Institute for Advanced Orthopedics at Sinai Hospital of Baltimore. He is the Medical Director of Diabetic Limb Preservation at LifeBridge Health in Baltimore and is the Division Chief of Podiatry at Northwest Hospital in Baltimore. Dr. Siddiqui is an Associate of the American College of Foot and Ankle Surgeons.

References

1. Lamm BM, Gourdine-Shaw MC, Thabet AM, Jindal G, Herzenberg JE, Burghardt RD. Distraction osteogenesis for complex foot deformities: Gigli saw midfoot osteotomy with external fixation. J Foot Ankle Surg. 2014;53(5):567-76.
2. Pinzur MS, Gil J, Belmares J. Treatment of osteomyelitis in charcot foot with single-stage resection of infection, correction of deformity, and maintenance with ring fixation. Foot Ankle Int. 2012;33(12):1069-74.
3. Presented at 23^rd Annual Limb Deformity Course, Baltimore, Aug. 30-Sept. 2, 2013.