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Objective: To assess the feasibility and results of tibial cortex transverse distraction (TCTD) followed by open correction with internal fixation (OCIF) for foot and ankle deformity with concurrent ulcers.Methods: A retrospective analysis was conducted. Between 2010 and 2019, a two-stage management of TCTD followed by OCIF was performed in 13 patients (13 feet). There were five males and eight females with a mean age of 33.8 AE 14.6 years. Ten patients had a right-side lesion, and three patients had a left-side lesion. The etiology of deformity included seven cases of congenital neurological disease, one case of Charcot-Marie-Tooth disease, one case of trauma sequelae, and three cases of myelomeningocele. Duration of disease, size of ulcers, surgical procedures, healing time, external fixation time, and complications of these patients were recorded. The Texas wound classification and National Pressure Ulcer Advisory Panel (NPUAP) classification were used for assessing the ulcers. The modified Dimeglio score of deformity and American Orthopeadic Foot and Ankle Society (AOFAS) ankle-hindfoot score were applied to evaluate the status before treatment and the results at final follow-up. Results:The TCTD and wound debridement were performed in all patients, and an additional Ilizarov correction technique was added in two patients. All ulcers were healed in 3 months after first-stage treatment. The median patient self-report time of ulcer healing was 2.0 weeks (IQR, 1.8-3.3). The median external fixation time was 138.0 days (IQR, 134.5-141.5) days. After second-stage operative correction, the patients were followed-up for an average of 28.0 AE 2.9 months. At the final follow-up, the modified Dimeglio score of deformity was decreased from 6.7 AE 2.1 to 1 (IQR, 0.0-1.0), and the mean AOFAS score was improved from 42.9 AE 19.1 to 82.6 AE 7.7. Before the treatment, there were eight patients with severe deformity, four patients with moderate deformity, and one patient with mild deformity. Postoperatively, seven patients were classified as mild deformity and six patients had a postural foot. The results of AOFAS ankle-hindfoot score were defined as excellent in three patients, as good in five, and as fair in five. Complications include one case of mild displacement of the osteotomized cortex and one case of pin-tract infection. No delayed union, nonunion, relapse of ulcers, or deformity were observed. Conclusions:The two-stage management of TCTD followed by OCIF could be considered as an alternative treatment for foot and ankle deformities combined with chronic ulcers.

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Background: The management of an ankle malunion involving the posterior malleolus remains challenging, and only a few published studies described the operative treatment of complex posterior malleolar malunion. A transfibular approach allows for direct visualization of the articular reduction of the posterior malleolus, but the reports of its use for correcting posterior malleolar malunion are rare. This study aims to evaluate the results of the intra-articular osteotomy via a transfibular approach for correcting an ankle malunion involving the posterior malleolus. Methods: We conducted a retrospective review of 26 patients with a symptomatic malunited ankle fracture involving posterior malleolus were treated with the intra-articular osteotomy via a transfibular approach in our department. Radiographic assessments were performed using plain radiographs and computed tomographic (CT) scans. Clinical outcomes were assessed using the AOFAS ankle-hindfoot score, visual analog scale (VAS), active range of motion of ankle, and the 36-Item Short-Form Health Survey score. Results: Postoperatively, anatomic correction of articular surface and anatomic reduction of syndesmosis were achieved in all patients as judged by CT scans. No evidence of progression had been found in 18 of 26 patients (69.2%) at final follow-up. The median AOFAS score improved from 42.0 to 81.5 ( P < .001). Median pain VAS score decreased from 6.0 to 1.0 ( P < .001). A favorable clinical outcome was associated with a short time interval from original injury to correction surgery and a lower grade of preoperative arthritis, but not with the posterior malleolar fragment size. However, time interval, the posterior malleolar fragment size, and the grade of preoperative arthritis showed no correlation with the progression of arthritis grade after surgery. Conclusion: An intra-articular osteotomy via a transfibular approach demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced posterior malleolar fragment. Level of Evidence: Level IV, retrospective case series.