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Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Valgus Hindfoot Deformity in CP



- See:
        - Cerebral Palsy:

- Discussion:
    - 64% w/ spastic diplegia & quadriplegia had pes valgus;
    - spastic pes valgus foot is a flexible deformity until adolescence;
    - spastic peroneal muscles pull the forefoot laterally and with it supporting plantar ligaments for the talar head, resulting in plantar flexed talus;
    - left untreated, the natural history may result in midfoot sag and lateral near complete break down in the midfoot.
    - anatomical relationships:
            - plantar flexion of the talus and calcaneus;
            - excessive valgus, external rotation and dorsiflexion of the calcaneus in relationship to the talus;
            - navicular dorsiflexed and abducted on the head of the talus;
            - forefoot is supinated in relationship to the hindfoot;

- Exam:
    - note correctability of the hindfoot in relation to the forefoot;
    - look for equinus contracture (w/ the hindfoot placed in varus);
    - skin changes may occur over the medial aspect of the talar head;

- Non Operative Treatment:
    - patient's w/ spastic deplegia will often not tolerate orthotic management;

- Treatment Methods:
    - Grice Arthrodesis:
            - subtalar extra-articular arthrodesis that was originally devised by Grice for the management of pes valgus due to flaccid paralysis 
                     muscle imbalance (polio);
            - modifications of the Grice procedure have also been widely used for treating hindfoot valgus deformity in CP;
    - Sub-talar Arthrodesis:
    - Triple Arthrodesis:
    - Calcaneal Lengthening:
            - modified Evan's calcaneal lengthening technique;
            - indicated for chronic pain, brace intolerance, and skin changes;
            - surgical approach:
                    - similar to Sub-talar Arthrodesis using modified Ollier incision;
            - care is taken not to damage the calcaneal-cuboid joint;
            - bluntly dissect over the dorsum of the calcaneus, and then dissect medially (just distal to the middle facet;
            - perform similar dissection under the plantar surface of the calcaneus;
            - two curved retractors are inserted dorsally and plantarly inorder to protect the calcaneus during the procedure;
            - insert two Steinman pins on either side of the proposed osteotomy site;
            - the calcaneal osteotomy courses obliquely across the calcaneus between the anterior and middle facets;
                    - begin about 1.5 cm proximal to the calcaneal cuboid joint;
            - insert a lamina spreader to distract the osteotomy site;
            - trapezoidal shaped tricortical graft (10-12 mm in width) is then inserted laterally, inorder to lengthen the lateral column of the foot;
            - ensure that there has not been subluxation of the calcaneal cuboid joint;
            - the graft may then be held in place with Steinman pins;
            - w/ concomitant Equinus contracture, Achilles tendon lengthening may be required



 Valgus and varus deformities of the foot in cerebral palsy.

Calcaneal Lengthening for Valgus Deformity of the Hindfoot. Results in Children who had severe symptomatic flatfoot and skewfoot.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, May 15, 2012 10:17 am