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BY the ANDREAS Department

BERNAU, of Orthopaedic M.D.t, Surgery.

ZURICH, Universirc SWITZERLAND of Zurich.



Long-term method

results of Lambrinudi follow-up in only

following are

triple reported



by the

fifty feet. The average Failures were encountered


eighteen years. feet, and good

the foot in maximum plantar flexion are traced onto a transparent sheet (Fig. 1 -A, left) and an outline of the intended resection is superimposed on it. The components that are to remain are then traced onto a second sheet


results were obtained in twenty. Most of the patients had post-poliomyelitic paralysis. This operation allowed most braced patients to be free of the orthosis. All able but three patients so had An showing the were other able severe to work, disabilities of the and those because literature contraindicaunof is


-4. I_I

to do


poliomyelitis. provided, tions for

extensive review the indications



procedure. drop foot adults, rarely because occurs nowadays in chilis so un-

Paralytic dren and young



common in the developed countries. In countries where poliomyelitis occurs frequently, however, drop foot still poses a therapeutic problem. The conservative methods of
Preoperative (left) and the sketch intended

FIG. with planning postoperative

1-A of the bone foot position wedges (right). to be resected

treatment that have been prescribed include bracing type or another. While the operative treatment used to
tenodesis alone or

of one include type of

combined were


tendon after

transplantation, this




surgery. These operations are no longer recommended. For correction of paralytic drop foot in the absence of other deformities a posterior bone block has also been

thritis of

but resorption of the ankle also.

or fracture of the block joint led to discontinuation In 1927 Lambrinudi

and osteoarof this mode inspired by


Campbell’s 2 bone-block procedure, developed a procedure in which he stabilized the ankle joint by having the posterior tubercle of the talus come in contact with the posterior margin of the articular surface of the tibia, both being covered by cartilage The majority of reports on this





procedure are more than vide long-term follow-up. perience between with 1949 this and 1964.

fifteen years Therefore, in

old, but do not prowe reviewed our expatients operated on


Methods The
cedure standardized is made


Materials and the operative We bone made
Orthopaedic Strasse,

have been procedure to determine

of the operation


described in which



a preoperative

the size of a lateral




wedge with
Foot D-7400 Corresponding
tibioplantar angle FIG.

to be removed. The

at the

of the American 5, 1976. Calwer




. The in this


New Orleans, V Orthop#{228}dische

Louisiana, February Universit#{228}tsklinik,

preoperative is 1 20 degrees

and postoperative roentgenograms because of instability of the knee

T#{252}bingen, Germany. VOL. 59-A, NO.
JUNE 1977

patient. 473


TABLE III cellous bone chips. 1 -B). The plane the transverse Any deformity rected During should the and five with by poliomyelitis foot. teroposterior view The ofthe roentgenograms ankle joint and. valgus. of Cases Good Fair Failed deformity may exist. to sixth following an day this. on the basis (Table I). records. After the osteotomies between between and navicular. The joints being with the foot in the correct position wires (Fig. the fore part should be in slight abduction and pronation. 170 1949 the cast and roentgenothen is inadequate. Three edema. of them the pain and in the third. were case a car- Associated or cavus cast is reapplied. the being the patients’ geographical The mean age at operation was cases. The mean length of follow-up was (Table II). I-B). If bone union walking clinic. Six is used for subsidence of the postoperative cast is applied on the fourth anesthetized. Management arthrodesed using three are fixed Kirschner RESULTS IN RELATION AND TO PREOPERATIVE DEFORMITIES COMPLAINTS Results Postoperative No. a posterolateral joint to evert TABLE LENGTH OF II FOLLOW-UP A wedge with calcaneocuboid correct whatever millimeters deep an osteotome there surfaces. and the head of the talus should fit medially as deeply as possible into the navicular. l5-I9yrs. surface An of the oblique foot from mcithe 23 13 14 6 32 10 2 8 9 3 4 12 4 0 8 4 10 1 14 6 1 7 0 1 1 6 0 1 medial third of the talonavicular malleolus. FOLLOW-UP Result No. ed. was caused deformity photographs. From this roentgenograms. 1 -A. relative The foot should to the distal part be increased of the leg. spastic drop fixed pain two with congenital foot. of Cases Good 11 8 1 8 6 6 Fair 19 2 1 13 1 8 Failed 1 6 1 2 4 2 Following above-the-knee with the patient the Kirschner moved. Lambrinudi arthrodeses and 1964. planned bone wedges (Fig. 1 -A) are now resectof the talar osteotomy should be parallel to axis of the ankle joint in plantar flexion.2 years were done.) 13-15 16-19 20-29 No. of Cases Good Fair Failed should occasionally the knee or shortening Technique A pneumatic sion is made over if there tourniquet the dorsal is applied. The axis of the talus should be aimed in the direction of the first metatarsal. have the the good contact in the joints the talus 11 16 23 6 4 10 5 9 8 0 3 5 been done osteotomy calcaneus should be particularly and between The hind part of the foot should be in slight valgus. A slot at least is then cut in the base of the navicular (Fig. were selected for follow-up. Instability Complaint Pain Passively drop Fixed correctable foot equinus varus. and by arthritis had resulted follow-up follow-up All patients had case reports. a view made with the foot in forced plantar flexion as recommended by other investigators In thirty-six cases the shape of the foot at follow-up could be compared with preoperative Results Follow-up was carried THE JOURNAL 17.6 years 18. of the hind part of the foot should be ccrcalcaneal vessels and wedge. Morethan49yrs. 100 degrees right). of deformity 31 16 3 23 II 16 through the cast a below-the-knee months postoperatively are recast the patient grams are below-the-knee In our ned out is discharged wearing made. important The Avoiding damage to the capsule of the ankle joint is to prevent necrosis of the talus. and two feet were (post-poliomyelitis) with in the series. 30-39yrs. six more weeks. AND JOINT The SURGERY OF BONE . out by me personally. The majority (Table the primary club of the feet for without deformity was III). Immediately wires which project weeks postoperatively. In three indication by resection of a corresponding the latter procedure the medial be carefully shielded by retractors. 20-38 yrs. tendons Age at follow-up Lessthan30yrs. included an anof between material in the majority fifty only feet (forty basis for to proximity patients) selection the clinic. This angle is instability of Age at operation lI-l4yrs. and preoperative.474 such a way as to show the shape ofthe foot ANDREAS BERNAU TABLE AGE AT OPERATION postoperatively I AND (Fig. subtend an angle of ofthe leg. In ten patients bilateral operations and in these patients the results were evaluated ofeach foot. In two in the subtalarjoint in painful callosities. There were forty-six feet affected photographs. postoperative. 40-49yrs. and cuboid base is resected from the fore part of the foot Results Follow-up (Yrs. Any remaining gaps in the joints being arthrodesed are filled with can- operation. The sinus tarsi and joint to below the lateral the head ofthe talus are ex- posed .

Forty-one of the fifty feet now can wear ordinary shoes. than one of IV). 4. successful fusion of all joints. could The At walk gait improved postoperatively of writing. on shoes. or moderate severe required Good. 2-B Moderate pain. objecpost6-A. severe fusion of more ankle criteria deformity. demonstrable flat ground. 2-A: A twelve-year-old boy who used long braces following bilateral poliomyelitis. sympof all activity gait callosities arthrosis instability. of activity. 4-C. Fig. 2-C results correlated quite well. the results were in the better correctable deformity deformity. failure of joint or severe arthrosis in the results we adhered The subjective and to these objective joints. pain. no instability. We took this finding when selecting the cases for operation patients were eleven years old. In one are worthy of mdifeet) were completely patient the ankle joint had to be arthrodesed because of painful patient with osteoarthritis. The objective rating of the second graded as fair. Preoperative roentgenogram in maximum plantar flexion. as follows: Ideal: No pain. The medial wire which should fix the talonavicular joint is placed too far inferiorly. callosities present. Above grading grading 20 20 limit (Table I). taken into consideration. Fig. Patterson in patients and associates age at rate of IS into conand our this age beage din- of 47 per cent whose IV Y ARTHODESES FIn Good Patient’s Surgeon’s Fair 27 22 Failed 3 8 Total 50 50 was less than eight years and a failure in older patients. present. high-stepping deformity. eleven caused Exereise were graded the deformity 4-B.LONG-TERM RESULTS FOLLOWING LAMBRINUDI ARTHRODESIS 475 criteria of assessment were decided on prior sessment. Minimum pain some subjective instability. 4-A. age of those with good results was sixin our series were also evenly II). postoperatively. occupations. failure of fusion in the ankle joints. 2-B: Postoperative roentgenogram. but he was dissatisfied his Aids All nine discard them patients who wore short Only two braces were able to toes. He had no significant disability. JUNE 1977 . differentiated IV). no assessed as failures was fifteen years. 59-A. 2-C: Twenty-one years after operation. distributed deformity or calignores. to control to length of follow-up (Table losities. apparatus the foot. patients have by a difference Tolerance had difficulties in buying in foot size (Figs. In assessing a result. The failures respect a correlation The average functional clinical spects graded ity. Seven of the eight feet described objectively as failures of treatment had subjective results graded as fair. and thirty 6-B). Fair: shoes. In the strictly evaluation (Table Fi. The major sources of disability and preoperative deformity as related to results (Table III) show that the majority of failures occurred subsequent to correction the time for more patients were completely strenuous fit for work. Slight to walking or surgical or surgical tomless joints. the subjective and the questions put to the patients to follow-up. a fixed In our drop-foot series. twenty-two of them in physically In the remaining three cases the VOL. good gait in ordinary deformity. grading therefore corresponds in all significant reto those of HallgrImsson and MacKenzie. no callosities. of the patients with the eight feet whose ical results were while the average teen with years. This TABLE RFstJLTS OF and pain functional at Operation In found operation per cent sideration youngest analyzing a failure rate their data. NO. 3-A and shoes 3-B). In the summarized asresult was of the feet than Age shape with in those of the a passively with foot. instability. no limitation of activnormal gait in ordinary shoes. deformity. and required no brace. The cases described as failures vidual mention. Three feet tively as failures of treatment because operatively was unchanged (Figs. activity. of the six patients with severe residual paralysis from poliomyelitis had to continue wearing above-the-knee braces. the patients tended to emphasize the improvement from the preoperative state and objective residual disability frequently was minimized. moderate of one joint or severe limited ordinary in FIG. we were unable to find tween the results and the age at operation. the patient was an architect. which slight the patient limitation of very slight. (two feet) the position was of Fig. fusion successful instability. However. Four were others incapable were of graded walking similarly for because a minimum the of tients. Two patients (three dissatisfied with the results. In from assessing the the functional functional at follow-up clinical clinical were result (Table result.. Failed: severe limitation 2-A FIG. who the results in four groups. eighteen than four hours and in almost of the thirty-seven all pa- patients minutes. walked with canes.

occurred We susmore fre- Fig. The functional clinical results as a whole in our Series were rather better in the extremities with a weak gastrocnemius other hand. Note also osteoarthritis of the nay iculocune iform joint. TABLE GASTROCN V EMIUS No. THE JOURNAL OF BONE AND JOINT SURGERY . 4-B: The hyperextensibility of the anterior joint capsule is only visible on a roentgenogram made in maximum plantar flexion. - and Only two disabilities complicaintraoperative are several occurred in the same and healing complications paralyzed fair. the ankle joint seemed normal. This requirement is not supported by our data (Table V). Sometimes patient. gen- Lambrinudi emphasized that a powerful gastrocnemius muscle was a primary prerequisite for his operation. of Cases Paretic Powerful or weak 18 32 Results Good 8 12 Fair 6 16 Failed 4 4 Cotnplications FIG. two the talonavicular patients and in the records. 4-A: Thirty-year-old patient with severe residual postpoliomyelitic paralysis. On the MacKenzie that the best results power in the dorsiflexors are seen in patients and plantar flexors with balanced of the ankle. Fig. overloaded first metatarsal. Sixteen years following Lambrinudi arthrodesis. than in those we agree with with normal strength. the patients’ inability eral debility. 4-C The summarized tions postoperative in Table occurred muscles - complications VI. 3-B patient was fully capable of work Twenty and walked years after operation. 4-C: A lateral roentgenogram of the foot in maximum dorsal flexion shows the increased plantar flexion of the painful. One FIG. Delayed transections in those feet with slight of tendons of the results were postoperative in- wound fection was mentioned pect. however. not Gastroenemius to work was attributable to severe to problems with the feet. the patient complained of ankle instability and stress pain under the head of the first metatarsal. or osteomyelitis. On a roentgenogram of the foot made with the patient standing. Others thought that the muscle should be active although not necessarily powerful. It had no There were no cases of deep pseudarthroses did not cause went unrecogpain. that in only two this complication case histories. club foot FIG.-- quently influence infection The nized by than was mentioned on the final result. without aids. 3-A following several operations in a Contracted twenty-year-old poliomyelitic patient.476 ANDREAS BERNAU - . Fig.

(twenty-six tendo leases achillis. Ankle instability was seen in seven cases.12. It caused serious disability in only two moderate relief by wearing a SO per cent disability residual paralysis. 5-B: Maximum dorsiflexion. But only three auThe as a but researchers the their criteria of assessment. and failed. re- Lambrinudi Orthopaedic vestigators result groups: 9. 5-A: This foot was arthrodesed when the patient was nineteen years old because of equinus of poliomyelitic origin. Fig. additional the majority procedures of which lengthenings Fig. NO.9. symptoms in the ball Five feet were painful at follow-up. Fig.11. 4. One patient high-sided boots. a building-site supervisor who had to change to office work because of ankle pain.12. in our operations Many patients. 5-C: Maximum plantar flexion. were most severe Markeddropfoot I I I frequently led to poor results. of the twenty-two plantar fascia. and so forth. 5-B with high-stepping gait occurred in seven feet. in a given case was assessed in some cent. publications. JUNE many 1977 patients operated on by . In the tables of five inthe results are divided into the three fair. Callosities inthiscondition and usually werepainful. These were localized on the underside of the foot.14 or by his pupils at the Royal National in London. TABLE CoMPLIcATioNs VI Results Total Talonavicular pseudarthrosis Pain Ankle instability Clubfoot Flatfoot Pescavus Good 0 0 1 0 5 0 2 10 6 0 0 Fair Failed Pes equinus Callosities Ankle arthritis Ankle arthritis-+arthrosis Ankle necrosis-arthrosis 2 5 7 2 12 3 13 28 14 1 1 2 4 4 0 7 1 9 12 6 0 1 0 1 2 2 0 2 2 6 2 1 0 FIG. seventeen and twelve osteotomies). published the result was all the communications the His most case on the subject was of notable the in arthrodesis. of MacKenzie. however.14 himself Hospital 1. 5-C Frequently Lambrinudi the success arthrodesis in our cases alone. thirteen years later. Only three Discussion Of Lambrinudi was that good. frequently but seldom caused foot and pes cavus. os- frequently arthrodesis in them A (iditioflal Operations FIG. were successfully treated by use of better footwear. braces.LONG-TERM RESULTS FOLLOWING LAMBRINUDI ARTHRODESIS 477 pseudarthrosis was accompanied by slight drop foot. His result was graded as a failure. This roentgenogram was made with the patient standing. and and 6-B). Deformity of more than 30 degrees foot besides two of the used above-the-knee teoarthritis of the but was caused carried chronic out was only seen patients already in one additional mentioned who . or in the heel and of the big toe. complaints. ankle joint pain in only (Figs. 5-A the others. Roentgenographically could be seen two 6-A feet. patients. it contained 59-A. Change of occupation became necessary for only onepatient. The patient worked as a mechanic and had pain in the foot only during snowy weather. but was also not due to to the were were of the additional operative carried soft-tissue out measures. tendon transfers. comprehensive series thors reason failure failure why rate material who were is therefore unclear 5 to 75 per that VOL. insoles. pension on the obtained The other grounds of drew severe ing The shape of the foot was normal in twenty-one feet and improved Flat foot Residual occurred club at the time of writin the majority of I FIG.

osteoarthritis: found this sequela of his 100 cases. By comparative measurement of lateral roentgenograms of the foot in maximum plantar flexion. or requires an arof the ankle joint or even of the knee joint. The greatest amount of recurrence of drop foot was 10 to 20 degrees. In his first publication. as judged comparative the postIn roentgenograms approximately greatest amount Contraindications a fifth of ofrecurrence patients ofdrop in our series. posed to drop the question foot was a progreswould arise discussed in the the only joint Tschui who FIG. Joint Severe congruity knee is thus instability worsened. One year following operation there was severe osteoarthritis. Among the series reviewed. therefore our series. into account We think by us in treating that this explains reported cent) and highest rates of Patterson (17 of pseudarthrosis and associates per cent). Deformity. MacKenzie a wedge a lateral instability cent .’ of the ankle it had a prolonged the difficulties nation deformity. THE JOURNAL OF BONE AND JOINT SURGERY . Our series showed a 16 per cent failure rate. of the ankle for a failed joint can in exceptionally negative to the operation. In our in the talonavicularjoint one of the adverse factors equinus deformity: as early as two to six series only two pseudoccurred. of the cation cent A patient with residual postoperative inhas to continue wearing a brace. preoperative than trophic eleven changes: osteoarthritis ‘ears. and in neither apply. this complication was mentioned by Lateral foot of the ankle supination. he established that no recurrence of drop foot could be shown in two-thirds of all the feet in his series. tients operative and that was by found in only in maximum 12 per cent preoperative plantar of the paand flexion. wear a brace Painful Age Severe less postoperatively. the great majority of cases of non-union occurred in the talonavicular joint. The of ankle 12 of resecting skin incision.478 ANDREAS BERNAU provided long-term follow-up on patients (more than ten years) and the failure rate in those series ranged from 8 to 35 per cent. be painful said osteoarthritis occurred to have only in our series. instabilTh’: why the incidence of yarns deformity was not increased in our own series (Table VI) but. and in twelve of them pain was However. we have established to the Ankle and those described a list of contraindica- by procedure. in ankles operated on without Kirschner-wire fixation. in the literature and in our joint made ranged was the fore from 14 per part to 25 per instability on series can with in fifteen present. in contrast. of the ankle joint. In three of eight feet it was responsible result. joint instability: This will be made worse by the procedure because the narrow posterior part of the articular surface of the talus will be made to articulate more loosely between the malleoli than the wider anterior seg- ment. and in patients weeks who used a walking cast following operation. This recommendation the majority was taken of our patients. nance of residual valgus deformity in our plained base by the difficulty through Painful the predomiseries is exwith a medial stability throdesis frequency 9 per cent. MacKenzie found an increased frequency of pseudarthrosis in patients who were more than twenty years old at operation. She wore ordinary shoes but reported difficulty in buying shoes because ofthe three-centimeter shortening of the foot operated on. as to whether ankle author arthroses did any Increased Lambrinudi sive tendency postoperatively. this housewife and office clerk was fully capable of work. The in the series in that Pseudarthrosis: rected. The postoperative roentgenogram shows anterior subluxation and avascular necrosis of the retained segment of talus. (33 of MacKenzie While only one pseudarthrosis in the talocalcaneal joint was mentioned in those reports.14 mentioned encountered in attempting to correct supiPainful callosities on the lateral border frequently unless this deformity is cor- but once it did occur on the result. the foot was 35 degrees. be visualized preoperatively a roentgenogram held in forced and is a contraindi- only two other authors In two feet painful osteoarthritis necessitated arthrodesis joint. of the foot occur The majority of authors 912. and ten years later an arthrodesis of the ankle was needed. such that the patient has to 6-B Twenty-four years following the Lambrinudi arthrodesis and fourteen years after arthrodesis of the severely painful ankle joint. 6-A This patient had a poliomyelitic equinus foot and was operated on at the age of twelve years. influence were per Severe. FIG. this question. The head of the talus should be fitted as far medially as possible into the groove in the navicular in order to prevent postoperative supination deformity. other tions In analyzing our own failures authors.

13. .. Lambrinudi C. P. F. Jan. and Calcaneous Deformities 22: f. Bone and Joint Surg. 1937. for Drop Foot. were for better treated the by the LamHoke triple ararthrodesis example. Unfall-Chir.: Zur Fuss-Arthrodese-Arthrorhise-Operation nach Lambrinudi. 1951. 59-A. A Study of the Indications. 1962. 1927. 1933. N. Studies Operation Operation paralytischen Spitzfusses. In a number of other cases a similar course was expected. (twenty-one sciatic associated with battle cases below-the-knee and lateral peronealinjuries) is of particuamputation had to in those of other authors. . Roy. F. 11 . J. Orthop.11 that arthrodesis also is indicated in spastic and feet of all types due to hemiplegia or iso- lated lesions of the peroneus muscle.10. cases of pes cavus than. f. . 41-B: 738-748.: L’op#{233}ration de Lambrinudi dana Ic traitement du pied #{233}quinaralytique. Arch. 78.. 2. P. PAUL: A Modified Lambrinudi Operation CAMPBELL: Cited in Lambrinudi . Med.6 poliomyelitis. J. nach Lambrinudi. 1955. Bone and Joint Surg. orthop. .: Lambrinudi’s Arthrodesis. British A Method ofCorrecting Equinus Joint. M. 25: 283-292... chir. . Surg. of the Foot. . . Oct. the Lambnnudi flaccid equinus However. BENYI. V . p. 1951.6. Proc. NO. PUTTI: and Nov. The great majorlty of patlents lfl our series. J. Surg..: Results. I. G. L. . at the Sub-Astragaloid Scandinavica. . br assistance n translating this paper. 9. 14. H.. B#{233}nyi described his own version of the operative technique for severe cases of congenital club foot. PATTERSON. f. PARRISH. JUNE 1977 . In two be carried out following a Lambrinudi arthrodesis because of the severe trophic changes caused by the sciatic denervation. 937-941. either of the dorsiflexors of the foot or of the peroneal muscles. May 1960. 4. orthop. trophic The changes We do not muscles procedure therefore is contraindicated or active if are present. J. on Reconstructive and Stabilizing Operations for Drop-Foot. A. 12. 1940.. on the Skeleton of the Foot. British J. VOL.LONG-TERM RESULTS FOLLOWING LAMBRINUDI ARTHRODESIS 479 had an equinus foot as a result of that of Meary nerve pareses lar interest. Muller pointed out that certain brinudi throdesis. 32-A: in M#{252}ller#{176}.. 1950.: New on Drop-Foot.: 7.: C. F.: Lambrinudi’s Operation for Drop-Foot. HART. Zeitschr. J. References I.. 5. Bone and Joint Surg. Techniques End TSCHUI. . DETZEL. MEARY. 10.: Stabilizing Operations Used. E. p MULLER. we agree with others 4. regard a paretic 4. 1959. Bern. Bone and Joint Surg. L. Arch. LAMBRINUDI.. R. and HATHAWAY. Supplementum 6. 42-B: 333-335. 44: 579-585. Soc. 54: 215-223. Acta Chir. Cited F. M. 85: 133-146. and SN0RRI: SEDDON. MACKENZIE. Resultate der Fuss-Arthrodese-Arthrorhise-Operation 1-26. gastrocnemius peroneal Indications as contraindications to this procedure. 4. 8. Rev. as well as NOTE: The author would like to thank Dr. Casey. 193. HALLGRIMSSON. JR. 37: 66-83. 1943. R. orthop. HANS: Die operative Behandlung des FITZGERALD. J. 15: 193-200. Unfall-Chir. 26: 788- 791. 3. LAMBRINUDI.