- 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;
Bennet G, Rang MM, Jones D: Valgus and varus deformities of the foot in cerebral palsy.
Dev Med Child Neurol 1982;24:499-503.
Calcaneal Lengthening for Valgus Deformity of the Hindfoot.
Mosca V.S. MD
JBJS. Vol. 77-A, No. 4, Apr 1995.
