J Orthopaed Traumatol (2008) 9:11–15 13 Fig. 3 Case 3. Juxta articular hinge used for translation of the tibia at the supramalleolar osteotomy of the rings was done both by Ilizarov wires and half pins (Hybrid). The distal ring was connected to the middle ring at an angle that represented the amount of valgus at the ankle joint. Because the CORA was at the ankle joint and the supramalleolar corrective osteotomy was proximal to it, a translation of the distal tibia was performed with the application of a juxta-articular hinge (Fig. 3). A fibuloto- my was also performed at the mid-diaphyseal area. Correction of the distal valgus was achieved by resect- ing a medially based, supramalleolar closing wedge osteotomy. The wedge angle was equal to the valgus measurement on the long radiographs. After the wedge was removed, the osteotomy was closed with simultane- ous translation (enabled by the juxta-articular hinge) and was fixed by connecting the distal ring to the middle one, resulting in parallel rings. The last step in this procedure was a corticotomy of the proximal tibia. Hinges were also applied by an open laterally based wedge between the first and the second rings in order to progressively correct the knee valgus. In the legs that required length equalization, the elongation was done between the proximal and the middle rings. Results Five legs were treated with a bifocal Ilizarov procedure (Table 1). Knee valgus correction averaged 13.8° (range, 5°–20°). Ankle correction averaged 20.3° (range, 15°–30°). The average period from application to removal of the Ilizarov apparatus was 4.6 months. The leg with the monofocal deformity at the knee was over-corrected with 5° of varus, while that with the monofocal deformity at the ankle was corrected to its neutral position. In all cases, the correction was maintained during the follow-up peri- od. The functional outcome was reported to be satisfying by all patients. Pin tract infection was seen in four legs without any case of osteomyelitis. None of the pins had to be removed or reinserted. Local treatment was sufficient to deal with these superficial infections and there was no need for sys- temic use of antibiotics. In one case, iatrogenic transaction of the common per- oneal nerve was caused by an aberrant location of the nerve and its branches, resulting from a large osteochon- droma at the proximal fibula. There was complete recovery of nerve function after an immediate microsurgical repair. In an additional case, peroneal neuropraxia developed but the patient recovered spontaneously after four months. We attribute this to the distraction at the proximal tibia. In case 6, in whom the knee correction was performed by gradual open lateral wedge, the proximal fibula shift- ed into valgus and pressured the skin. This was corrected by the application of an “olive wire” which pulled the fibula back into normal position (Fig. 4). Reconstruction of the mechanical axis, the goal of this treatment, was accomplished in five of the seven legs (cases 1–5), whereas in case 6 a varus of 5° and 3° was found at the knee and at the ankle, respectively. Equa- a b Fig. 4a, b Case 6 (right leg). a The proximal fibula shifted laterally, in conjuction on the proximal valgus correction of the tibia, causing pressure of the skin, due to the synostosis between the proximal tibia and the fibula by the osteochondroma. b Correction of this condition was achieved by using an olive wire, which pulled the fibula back to normal position