Narrative review of ring fixator management of recurrent club foot deformity

Despite the widespread use of the Ponseti method for treatment of clubfeet, there continue to be a significant number of patients who present with a severe, stiff clubfoot as a result of extensive intra-articular soft tissue release or lack of access to care. In such patients, circular external fixators can be utilized for deformity correction with distraction across soft tissues, joints, and osteotomies. Ilizarov or hexapod circular fixators may be utilized according to surgeon preference. Indications for soft tissue release and osteotomies to aid in correction of clubfoot deformity with Ilizarov and hexapod fixators are not standardized and are guided by patient age, joint congruity, soft tissue suppleness, and osseous deformity. Correction time varies according to clubfoot deformity severity. Following deformity correction, external fixators are left in place for several weeks to stabilize the soft tissues and allow for osteotomy healing. Complications range from relatively minor pin tract infections that resolve with oral antibiotics to tarsal tunnel syndrome, osteomyelitis, or disabling arthritis requiring revision procedures. At Scottish Rite Hospital for Children, we prefer to correct severe residual clubfoot deformity with a hexapod external fixator. Acute correction and gradual correction via distraction are considered for each segmental deformity and utilized to efficiently correct deformity while minimizing soft tissue trauma. The purpose of this article is to summarize the relevant literature related to circular external fixator treatment of recurrent clubfoot deformity and outline our approach to the segmental deformities of the foot and ankle in this patient population.