Extra-articular Subtalar Arthrodesis Research Articles

Preliminary Results of Calcaneal Lengthening Osteotomy Combined With Extra-articular Subtalar Arthrodesis for Severe Pes Planovalgus Deformity in Children With Cerebral Palsy: A New Surgical Technique.

Pes planovalgus is the most common foot deformity seen in patients with cerebral palsy (CP). There are several different treatment modalities to treat this condition. Single or double calcaneal osteotomies, extra-articular arthrodesis, calcaneo-cuboido-cuneiform osteotomy, intraarticular arthrodesis, and arthroereisis are some of these modalities. Currently, there is insufficient information to determine the most effective treatment approach for pes planovalgus in children with CP. The aim of this study is to show the short to mid-term results of the new technique which combines calcaneus lengthening osteotomy, extra-articular subtalar arthrodesis, and soft tissue reconstruction that aims to decrease recurrence and complication rates of pes planovalgus surgery for patients with ambulatory CP. Patients with CP who were treated with calcaneal lengthening surgery and extra-articular subtalar arthrodesis between 2018 and 2021 were investigated retrospectively. All patients were ambulatory and Gross Motor Function Classification System I-II-III. Functional levels of the patients were assessed with the American Orthopaedic Foot and Ankle Society, Ankle-Hindfoot Score, and the Foot and Ankle Ability Score (Foot and Ankle Ability Measure) in preoperative and postoperative periods. On anteroposterior x-rays, talus-first metatarsal, talocalcaneal, talonavicular coverage angle and on lateral x-rays talus-first metatarsal, talocalcaneal, calcaneal inclination angle and talar tilt angle were evaluated. The mean follow-up was 46 (range: 36 to 60) months. The mean American Orthopaedic Foot and Ankle Society increased from 41 (20 to 79) to 74 (38 to 93; P < 0.001). The mean Foot and Ankle Ability Measure increased significantly from 35 (7 to 73) to 54 (29 to 96; P <0.001). Clinical results were "satisfactory" for 32 feet, while they were "unsatisfactory" for 2 feet. Significant deformity correction was observed in all radiologic parameters. Our technique is found to be efficient for patients with Gross Motor Function Classification System I-II-III CP with pes planovalgus deformity. In short to mid-term follow-up, the technique achieved successful clinical and radiologic results with low complication rates. Superiority of this technique compared with the traditional ones can only be shown with randomized prospective studies. Level III-retrospective cohort study.

Lečenje bolnog ravnog stopala kod dece korišćenjem minimalno invazivne hirurške procedure nakon neuspelog konzervativnog lečenja

Introduction/Aim: Flexible flatfoot (FFF) is one of the most common skeletal deformities in the pediatric population, especially in preadolescence. This retrospective observational study evaluates results of a calcaneal subtalar extra-articular arthrodesis (subtalar arthroereisis) with one cannulated screw for the treatment of painful flexible flatfoot in children, after previously failed conservative treatment. Material and Methods: Preadolescent and adolescent pediatric patients were observed at the Department of Pediatric Orthopedic Surgery. The study included 28 feet of 15 children (5 girls and 10 boys) during a 6-year period, from 2016 to 2021 (average 36 months). The average age was 11.46 years (range 8-15 years). We performed the same operative technique under fluoroscopy for all patients. Radiographic parameters were taken before, after operative treatment, and after hardware removal. The following radiological parameters were measured: talo-calcanear (TC), talo-navicular (TN), talo-first metatarsal bone (T1MT) and calcanear pitch (CP) angles, in the anteroposterior and/or lateral views. Functional outcomes (extension and eversion of the foot) before surgery and after hardware removal were compared. Results: After operative treatment, the midfoot radiographic parameters were not statistically significantly altered; however, the subtalar joint and forefoot were statistically significantly improved: both radiologically and clinically. The range of extension and eversion of the foot were remarkably reduced without disturbing the morphological and functional aspects of the talocrural and subtalar joints. Conclusion: Extra-articular arthrodesis, using a cannulated screw is a minimally invasive technique, represents an optimal method for the operative treatment of symptomatic flexible flatfoot in children. This technique is simple, efficient and does not disrupt the anatomy of the foot.

Outcome of surgical management of plano-valgus foot in cerebral palsy with batchelor’s extra-articular subtalar arthrodesis

Introduction: Foot deformities caused by altered or abnormal muscle forces are common in patients with cerebral palsy. The incidence of foot deformities in cerebral palsy is approximately 70% to 90%. The most common deformity is ankle equinus, with equinovarus and equinovalgus deformities being equally common. A foot deformity can have significant effects on the patient's overall ambulatory level. The purpose of this study was to assess the functional outcome of batchelor’s extra-articular subtalar arthrodesis in spastic planovalgus foot in cerebral palsy children. Materials and Methods: This is a prospective study of 40 patients (68 feet) with spastic planovalgus foot deformity presenting to BIRRD (T) Hospital from October 2015 to October 2017. Children with spastic planovalgus foot between 6 yrs-14 yrs were included in study. There were 24 male and 16 female children. The mean age at the time of surgery was 10 yrs. Both feet were involved in 28 children, 8 had right foot involvement and 4 had left foot involvement. In our study we had 12 hemiplegics and 28 diplegics. Children with mental retardation, extra pyramidal type of cerebral palsy, rigid plano-valgus foot, spastic quadriplegia were excluded from the study. All patients underwent batchelor’s arthrodesis with fibular graft and were immobilized in below knee POP cast for 8 weeks. 24 patients underwent gastrosoleus lengthening along with batchelor’s arthrodesis. Clinical and functional outcome was assessed based on AOFAS (American orthopaedic foot and ankle score) clinical rating system. Radiological assessment was done by measuring Lateral talocalcaneal angle and Talar declination angle. The results of batchelor’s arthrodesis are stated as satisfactory and unsatisfactory. Satisfactory: Clinical and roentgenographic stabilization of the hind foot and no recurrence of planovalgus deformity. Unsatisfactory: Clinical and roentogenographic evidence of failure of stabilization. Results and Discussion: All children had spastic type of cerebral palsy. Post-operatively children were followed-up for an average period of 14 months, with range from 4 to 24 months. Among 40 patients (68 feet), 8 feet (12 percent) had residual valgus, 12 feet (18 percent) had graft absorption, 4 feet (6 percent) had fracture of the graft and none had varus deformity after an average follow-up of 14 months. Out of 68 feet, 44 feet had “satisfactory” result (65 percent) and 24 feet had “unsatisfactory” result (35 percent). Conclusion: Our experience concludes that batchelor’s extra-articular arthrodesis of sub-talar joint is a good procedure for correction of plano-valgus foot deformity in cerebral palsy patients. Advantages of the procedure are simplicity of the technique, immediate firm fixation and early weight bearing. Keywords: Cerebral palsy, Batchelor’s subtalar arthrodesis, Planovalgus foot, AOFAS clinical rating system.

CORRECTION OF PES PLANOVALGUS IN CEREBRAL PALSY: A SHORT TERM OUTCOME OF EXTRA-ARTICULAR SUBTALAR ARTHRODESIS

Background: Pes planovalgus is the most common foot deformity observed in cerebral palsy (CP) patients causing pain, gait abnormality, instability and in severe deformity. It can lead to brace intolerance. The treatment of this deformity should be directed to correct the foot malalignment, secure the stability of the foot during stance and correct the abnormal gait. After failure of conservative treatment, surgical treatment is the option. It varies from simple soft tissue procedures to tarsal osteotomies, subtalar extra-articular arthrodesis, intra-articular arthrodesis and triple arthrodesis. When these are compared, all techniques have advantages and disadvantages. Aim of the Work: This prospective clinical study is conducted to evaluate the short term outcome of the extra-articular subtalar arthrodesis using fibular graft that harvested from the junction between the proximal 1/3 and the distal 2/3 of the fibula in correction of flexible pes planovalgus in children with cerebral palsy. Patients and methods: We conducted a prospective study involving 13 patients (22 feet) with cerebral palsy who failed conservative treatment for more than 6 months. Postoperative complications were recorded. Assessment of the patients clinically and radiologically was done and compared to that of the preoperative data. Results: Clinical results were satisfactory in 21 feet and unsatisfactory in 1 foot according to kim et al scoring system. Radiologically; the anteroposterior talocalcaneal angle decreased from the median of 2°6 (range 1°1 – 5°6 ) preoperative to 9°.5 (range °1 – 3°5 ) post operative. The lateral talocalcaneal angle deceased from the mean of 42.0°5 ± 7.3°5 preoperative to 28.7°3 ± 8.5°1 postoperative. The anteroposterior talus-first metatarsal angle decrease from the median of 2°4 (range° 3 – 5°5 ) preoperative to° 8 (range° 1 – 3°9 ) postoperative. The lateraltalus-first metatarsal angledecreased from the median of 2°0 (range °3 – 4°7 ) preoperative to 8°.5 (range °0 – 1°8 ) postoperative and the calcaneal pitch angle increased from the median of °5 (range -1°9 – 2°2 ) preoperative to 1°0 (range °2 – 1°7 ) postoperative. The postoperative changes were statistically highly significant. Conclusion: The extra-articular subtalar arthrodesis in our study as in others had been proved to be effective, safe, simple and non expensive procedure for correction of flexible pes planovalgus feet in children with cerebral palsy.

Mistakes and complications in the surgical treatment of ambulatory equino planovalgus foot deformities in patients with cerebral palsy using extra-articular subtalar arthrodesis

Aim.To evaluate the results of a modified technique for extra-articular arthrodesis of the subtalar joint for patients with cerebral palsy with an ambulatory form of equine-planovalgus deformity of the foot. The mistakes and complications that occurred during treatment with this technique are discussed.Materials and methods.Between 2005 and 2015, this surgical method for performing arthrodesis of the subtalar joint, was performed on 544 patients (989 feet) between 4 and 15 years old. Correction of equinus contracture was performed using Achilles tendon plasty or dissection of the tendon of the gastrocnemius muscle. Abnormal muscle tone was reduced either by administering Dysport® in the calf muscle or by selective neurotomy of the tibial nerve.Results. Good results were achieved for 72% of cases, satisfactory for 23% of cases, and unsatisfactory for 5% of cases. Unsatisfactory results of treatment were associated with overvaluation of the degree of mobility of the deformity and with a number of technical and tactical mistakes.Conclusion.This analysis of mistakes and complications of extra-articular arthrodesis of the subtalar joint will allow surgeons to avoid these issues in the future and improve the quality of treatment for similar patients.

Extraartikulární subtalární artrodéza podle Grice u pacientů s dětskou mozkovou obrnou: zhodnocení střednědobých výsledků

Extraartikulární subtalární artrodéza podle Grice u pacientů s dětskou mozkovou obrnou: zhodnocení střednědobých výsledků

Results of Extra-Articular Subtalar Arthrodesis in Children with Cerebral Palsy

Grice-Green extra-articular subtalar arthrodesis is considered to be a valid surgical method which improves foot alignment in patients with spastic pes planovalgus deformity. The purpose of the present study was to examine the long-term results of Grice-Green procedure and whether it can achieve significant correction of each of the components of pes planovalgus deformity. Eleven children (16 feet) with cerebral palsy who underwent Grice extra-articular subtalar arthrodesis were reviewed retrospectively. The mean age of patients at the time of surgery was 9 years and 8 months (range, 6 years 5 months to 12 years 4 months). The mean followup was 3 years and 7 months (range, 2 years 1 month to 8 years 3 months). Seven radiographic parameters of each patient before surgery, after surgery and at the latest followup were used. In addition, position of the graft relative to the weightbearing axis of the tibia was evaluated. Most of the examined parameters showed statistically significant correction which was maintained in the long run. Moreover, the placement of the graft along the mechanical axis seemed to play an important role for stability and preservation of correction of the planovalgus deformity. On the other hand, there were three cases where the osseous graft was absorbed and two cases where triple arthrodesis was necessary due to recurrence of the deformity. Grice-Green extra-articular subtalar arthrodesis improves foot alignment in patients with spastic pes planovalgus deformity and can achieve significant correction, postoperatively as well as on a long-term basis, of each of the components of pes planovalgus deformity.

Grice-Green Procedure for Severe Hindfoot Valgus in Ambulatory Patients with Cerebral Palsy

Grice-Green extra-articular subtalar arthrodesis is a treatment option for advanced valgus rearfoot deformity of neuromuscular origin in young patients. The purpose of this study was to evaluate long-term results of the procedure in ambulatory cerebral palsy patients. From January 1975 to December 1993, 57 operations were performed in 39 patients (22 males, 17 females) with a mean age of 7.8 ± 2.7 (range 3.9–14.4) years for excessive symptomatic hindfoot valgus. Thirty-five patients (51 feet) were followed for a mean 22.6 ± 4.6 (range 16.0–32.3) years. Preoperative GMFCS score, ambulation, hindfoot position, podoscopic view of the weight-bearing feet, and radiological examinations, along with complications and orthotic use, were compared. Based on a clinical rating scale, 39 results were excellent or good, 8 were fair, and 4 were poor. The poor results were attributed to hindfoot valgus recurrence or varus overcorrection. One case needed revisional surgery owing to slippage of the graft. Overall, the GMFCS score, level of ambulatory distance, and use of foot orthoses improved. Grice-Green subtalar arthrodesis did not result in early degenerative changes at the midterm follow-up. The procedure offers safe and long-lasting correction for severe and symptomatic hindfoot disorders in patients with cerebral palsy. Together with physiotherapy and orthotic use, it can improve ambulation. Whereas a slight hindfoot valgus in patients with cerebral palsy is tolerable without lack of function, overcorrection should be avoided.

Extraarticular Subtalar Arthrodesis for Pes Planovalgus: An Interim Result of 50 Feet in Patients with Spastic Diplegia

BackgroundThere are no reports of the pressure changes across the foot after extraarticular subtalar arthrodesis for a planovalgus foot deformity in cerebral palsy. This paper reviews our results of extraarticular subtalar arthrodesis using a cannulated screw and cancellous bone graft.MethodsFifty planovalgus feet in 30 patients with spastic diplegia were included. The mean age at the time of surgery was 9 years, and the mean follow-up period was 3 years. The radiographic, gait, and dynamic foot pressure changes after surgery were investigated.ResultsAll patients showed union and no recurrence of the deformity. Correction of the abduction of the forefoot, subluxation of the talonavicular joint, and the hindfoot valgus was confirmed radiographically. However, the calcaneal pitch was not improved significantly after surgery. Peak dorsiflexion of the ankle during the stance phase was increased after surgery, and the peak plantarflexion at push off was decreased. The peak ankle plantar flexion moment and power were also decreased. Postoperative elevation of the medial longitudinal arch was expressed as a decreased relative vertical impulse of the medial midfoot and an increased relative vertical impulse (RVI) of the lateral midfoot. However, the lower than normal RVI of the 1st and 2nd metatarsal head after surgery suggested uncorrected forefoot supination. The anteroposterior and lateral paths of the center of pressure were improved postoperatively.ConclusionsOur experience suggests that the index operation reliably corrects the hindfoot valgus in patients with spastic diplegia. Although the operation corrects the plantar flexion of the talus, it does not necessarily correct the plantarflexed calcaneus and forefoot supination. However, these findings are short-term and longer term observations will be needed.

Grice arthrodesis in the treatment of valgus feet in children with myelomeningocele: A 12.8-year follow-up study

Neurological deficit resulting in the lack of motor control in children with myelomeningocele often leads to a valgus position of the feet and ankles, usually in combination with planovalgus and pronation of the forefoot. The purpose of the study was to evaluate long-term patient satisfaction and clinical effects in ambulating children with lumbosacral myelomeningocele after having performed a Grice arthrodesis of a valgus unstable foot. The clinically most relevant radiographic measurements, such as the frontal and lateral talo-calcaneal angles, were used to evaluate the anatomical effects of the surgery, whereas the main research question was to reveal the patient satisfaction and usefulness of the procedure. The modified Grice-Green extraarticular subtalar arthrodesis was performed by the same surgeon on one standing and 22 walking patients (12 female) with lumbosacral myelomeningocele and valgus instability during the period 1985-1999. Twelve patients had bilateral surgery, giving a total of 35 operated feet. The patients attended a thorough check-up at a mean of 12.8 years (standard deviation [SD] +/- 3.2, range 7.7-20.2 years) after surgery. The mean age at surgery was 6.6 years (SD +/- 1.8) and at follow-up 19.4 years (SD +/- 3.8). Functional parameters, such as walking ability, pain and skin problems, and the need for braces and supportive orthopaedic shoes were noted at the follow-up interview. The parents were interviewed along with the patients in order to obtain all of the necessary information. Loaded radiographs in the lateral and frontal planes were taken of both feet and ankles pre-operatively and at follow-up, except for pre-operative radiographs in six patients that were not loaded and, thus, not included, except for the assessment of ankle valgus. Ankle valgus was assessed from lateral and frontal views of the ankle on a scale from grade 0 to grade 3 according to Malhotra. Frontal and lateral talo-calcaneal angles were measured for the assessment of subtalar varus or valgus. Lateral talo-first-metatarsal (Meary's) angles were measured to investigate the longitudinal arches of the feet. The mean lateral talo-calcaneal angle was reduced significantly (P < 001) from 55.1 degrees (SD +/- 8.9) to 38.8 degrees (SD +/- 8.1). The mean frontal talo-calcaneal angle was reduced from 24.7 degrees (SD +/- 9.7) pre-operatively to 16.6 degrees (SD +/- 6.3) at follow-up (P < 0.001). The mean lateral talo-first-metatarsal angle improved significantly from -16.1 degrees (SD +/- 24.7) pre-operatively to 0.9 degrees (SD +/- 15.1) at follow-up (P = 0.0015). The calcaneal pitch did not change significantly. In general, ankle valgus worsened during follow-up time, but not significantly (P = 0.113). The visual analogue scale (VAS) score of patient satisfaction improved significantly from 3.7 (SD +/- 1.7) prior to surgery to 7.2 (SD +/- 1.5) at follow-up (P < 0.005). Nineteen patients (83%) were satisfied with the surgery and would thus recommend the procedure. Based on the radiological findings and patient satisfaction, the patients participating in this study benefited from having had Grice arthrodeses performed on their valgus unstable feet. The results indicate good long-term correctional effect on valgus deformity after Grice arthrodesis, as the talo-calcaneal and talo-first-metatarsal angles improved significantly. A great majority of the patients were content with the surgery, and none claimed that any residual deformity was the cause for any reduced ability to ambulate.

A comparison of two different techniques in the surgical treatment of flexible pes planovalgus: calcaneal lengthening and extra-articular subtalar arthrodesis

The objective of this study was to compare the results of calcaneal lengthening and Dennyson-Fulford extra-articular subtalar arthrodesis operations performed in patients with flexible pes planovalgus owing to various etiologies and to compare their effectiveness in realigning the foot. Two patient groups were retrospectively formed out of the patients in whom calcaneal lengthening (25 feet of 13 patients) and subtalar extra-articular arthrodesis (27 feet of 15 patients) operations were performed. The modified Evans technique for the calcaneal lengthening operation and the Dennyson-Fulford technique for the subtalar extra-articular arthrodesis operation were applied. Any special criterion to choose the indication was not considered. The main indication for the surgery was pain during daily routine activities in both groups. The patients were evaluated preoperatively and during the last visit, both clinically and radiographically. The groups were homogenous for sex and mean age for the process, but in the subtalar extra-articular arthrodesis group, the deformity was more severe in some parameters, mean follow-up period was significantly longer and neurologic etiologies were more dominant. Anteroposterior talocalcaneal and talonavicular angles were worse in the subtalar extra-articular arthrodesis group preoperatively (P<0.05). Both groups showed significant correction (P<0.05) in all parameters postoperatively. In the last visit, lateral talocalcaneal, anteroposterior, and lateral talonavicular angles were worse in the calcaneal lengthening group (P<0.05) and calcaneal pitch angle was worse in the subtalar extra-articular arthrodesis group (P<0.05). Both groups showed significant clinical correction (P<0.05) in all parameters postoperatively, but there was no significant difference between the groups during the last visit in terms of total clinical scores (P>0.05). Pain, the parameter that was the main indication for surgery, was eliminated in all patients except for one in the calcaneal lengthening group. The evaluation of the effectiveness of the surgical technique on the results made by performing repeated measures from general linear models showed significantly better correction in anteroposterior and lateral talocalcaneal angles, anteroposterior and lateral talonavicular angles, and medial longitudinal arc angle in the subtalar extra-articular arthrodesis group (P<0.05). In conclusion, in this study group, the subtalar extra-articular arthrodesis technique was superior in talocalcaneonavicular joint complex reduction and medial longitudinal arc reconstruction in the surgical treatment of flexible pes planovalgus, and calcaneal lengthening provided better correction of calcaneal equinus. Therefore, it is better to use the calcaneal lengthening technique in mild or moderate deformities because of its physiological advantages, and subtalar extra-articular arthrodesis technique in severe and/or rigid deformities because of its superior potential to correct the deformity and stabilize the foot in the corrected position.

Progressive Neuromuscular Planovalgus Foot Deformity Treated with a Modified Extra-articular Subtalar Fusion

Obtaining a successful subtalar fusion in the pediatric population can be challenging. We present our results with a modified extraarticular method. - We retrospectively evaluated 12 patients (17 feet) with progressive neuromuscular planovalgus foot deformity that underwent an extra-articular subtalar arthrodesis with the combined Batchelor-Grice procedure. All patients were ambulatory and were treated conservatively with braces prior to the operation. The average followup was 10 (range, 5 to 17) years. Postoperatively the feet were immobilized in short leg casts for 6 weeks. Preoperative and postoperative appearance of the feet, the clinical symptoms and radiographic measurements were recorded. Sustained correction and solid fusion took place in all feet. Foot appearance and gait pattern of the patients were improved, while preoperative complaints were reduced. Radiographic healing was noted in all cases. This technique is an effective treatment for the correction of the deformity as it gives a greater assurance of solidarity than when either of the two procedures is used alone.

Changes in Dynamic Foot Pressure After Surgical Treatment of Valgus Deformity of the Hindfoot in Cerebral Palsy

Calcaneal lengthening osteotomy and extra-articular arthrodesis of the subtalar joint are two methods used for the correction of valgus deformity of the heel and forefoot abduction. The purpose of this study was to compare the operative results of these procedures in patients with cerebral palsy who were able to walk. We focused primarily on changes in radiographic parameters and how altered mobility of the subtalar joint by the two operative methods would modify pressure distribution over the plantar surface of the foot. A total of eighty-one feet in forty-seven patients were included in the study. The mean age at the time of surgery was eight years and one month, and the mean follow-up period was thirty-nine months. The subjects were divided into two groups; Group I consisted of thirty-seven feet in twenty-two patients who underwent a calcaneal lengthening osteotomy, and Group II comprised forty-four feet in twenty-five patients who underwent an extra-articular subtalar arthrodesis. Preoperative and final follow-up radiographs and dynamic pedobarographs were used to evaluate the results. The feet in both groups were found to be similarly deformed before surgery, by radiographic measurements and dynamic foot-pressure analysis. Both operative procedures led to improved radiographic indices; however, calcaneal pitch failed to improve after the subtalar arthrodesis. After surgery, the relative vertical impulse was decreased for the hallux, first metatarsal head, and medial aspect of the midfoot in both groups, while it was increased for the lateral aspect of the midfoot and calcaneus. On the other hand, postoperatively, the relative vertical impulse of the medial aspect of the midfoot was higher and the relative vertical impulse of the first through fourth metatarsal heads was lower in the group that had subtalar arthrodesis compared with the group that had a calcaneal lengthening osteotomy and the normal control subjects. Extra-articular subtalar arthrodesis appears to be an effective means to achieve predictable correction of severe valgus deformity of the heel in patients with cerebral palsy who are able to walk; however, supination deformity of the forefoot remains and calcaneal equinus is not corrected. On the other hand, we believe that the calcaneal lengthening osteotomy is the treatment of choice because postoperative foot-pressure distribution more closely approximates the normal foot-pressure distribution.

Treatment of the progressive neuromuscular planovalgus foot deformity with the combined Batchelor–Grice procedure

Twelve patients (17 feet) with progressive neuromuscular planovalgus foot deformity underwent an extra-articular subtalar arthrodesis with the combined Batchelor-Grice procedure. All patients were ambulant and received conservative treatment with braces and special orthopaedic shoes before the operation. Postoperatively the feet were immobilized in short leg casts for 6 weeks. Evaluation was based on the appearance of the feet, the clinical symptoms and radiographic measurements. Solid fusion and sustained correction took place in all feet. Foot appearance and mobility of the patients were improved, whereas preoperative complaints were reduced. The gap at the graft donor site was bridged with new bone in all cases.

The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy

We evaluated the results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy and its effectiveness in providing hindfoot alignment. Grice subtalar extra-articular arthrodesis was performed for pes planovalgus deformity in 14 feet of nine patients (5 males, 4 females; mean age 10.3 years; range 6 to 12 years) with cerebral palsy. Six patients were diplegic, two patients were paraplegic, and one patient was hemiplegic. Four patients had unilateral, five patients had bilateral involvement. A fibular graft taken from the distal third of the fibula above the syndesmosis was used in all the patients without any fixation material. The patients were assessed with the AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot scoring system pre- and postoperatively. The mean follow-up was 30 months (range 6 to 81 months). Compared with the preoperative values, the mean AOFAS hindfoot score increased from 53 (range 41 to 81) to 68.4 (range 51 to 96), the mean talocalcaneal angle decreased from 52.6 degrees to 30.4 degrees , and from 55.8 degrees to 35.9 degrees in frontal and sagittal planes, respectively (p<0.05). The mean ankle valgus angle measured on anteroposterior radiographs remained unchanged (mean 5 degrees ). Of five patients who underwent bilateral surgery, three (21.4%) developed donor-site fibular nonunion on one side. One (7.1%) of these patients also had graft nonunion and displacement. Treatment was rated as satisfactory by the parents of seven patients (77.8%; p<0.05). Despite donor-site morbidity, the Grice subtalar extra-articular arthrodesis is an effective procedure for the correction of hindfoot alignment in patients with pes planovalgus deformity secondary to cerebral palsy.

The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy

The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy

The Use of a Working Model for Teaching Functional and Applied Surgical Anatomy of the Subtalar Joint

Some aspects of functional and applied anatomy may be difficult to conceptualize if taught by conventional methods. In such situations, alternative methods of teaching may need to be adopted. This study was undertaken to evaluate whether a working model can facilitate understanding of the functional and applied surgical anatomy of the subtalar joint. A working model of the articulated talus and calcaneus was constructed and used to explain the mechanics of motion of the subtalar joint, the rationale of release of structures to correct hindfoot deformity in clubfoot, principles of tendon transfers, and the rationale of extra-articular subtalar joint arthrodesis. Twenty-four orthopedic residents were divided into two groups (A and B). Group A was taught these specific concepts of functional and applied anatomy with the help of the model, while Group B was taught the same concepts with a written text and diagrams. The level of knowledge of both groups was evaluated by a test with multiple-choice questions. A week later, Group A was given the text while Group B was shown the model. Both groups then answered a questionnaire assessing the value of the model in enhancing their understanding of the subject. In the test, the performance of students in Group A was better than those in Group B. Students of both groups felt that the model gave them a much clearer understanding of the functional anatomy of the subtalar joint. We conclude that this simple, inexpensive model is a valuable teaching aid that helps students to understand the surgical anatomy of the subtalar joint. Surgeons can use this model to effectively teach trainees in this field about the mechanics and anatomy of the subtalar joint and other relevant applications.

Der Talus vertikalis

Summary Congenital vertical talus is a rigid rocker-bottom flat-foot deformity, which was first described by Henken in 1914. Although this rare deformity may occur as an isolated primary deformity, it is usually associated with other congenital or neuro-muscular abnormalities such as neural tube defects, neuromuscu-lar disorders, malformation syndromes and chromosomal aberrations. Patients can be grouped by these associated conditions to different classification systems. The congenital vertical talus deformity is characterized by a primary irreducible dislocation of the talonavicular joint, in which the navicular articulates with the dorsal aspect of the talus. It should be differentiated from flat-foot deformities such as talipes calcaneovalgus, oblique talus deformities or hypermobile flatfeet, because prognosis and treatment are different. The objectives of treatment of congenital vertical talus are to reduce the navicular and calcaneus in a normal anatomic relationship to the talus and maintain the reduction, so that a plantigrade, weightbearing surface within the sole of the foot can be provided. Conservative means alone have had a very poor success rate, consequently open reduction has been advocated as the treatment of choice for congenital vertical talus by many authors. A number of techniques for operative treatment have been proposed, including open reduction of the talonavicular or calcaneocuboid joints with or without excision of the navicular, partial or complete talectomy, one stage or two stage techniques with open reduction in combination with different tendon transfers. Our approach to congenital vertical talus is a peritalar release using the Cincinnati approach, reduction of malposition of sub-talar joint complex and adjustment of tendons involved in the deformity, including reinforcement of the calcaneonavicular ligament. Furthermore it is recommended that for children aged from 3 to 4 years a concomitant Grice extraarticular subtalar arthrodesis can be performed to maintain correction. In older, untreated children or those in whom previous treatments have failed, a subtalar or triple arthrodesis may be necessary.

Post poliomyelitis invertor paralysis: Which tendon to transfer?

A prospective study was carried out on 14 patients mean age of 10 years; they were suffering from invertor muscle paralysis (both tibialis anterior and posterior) due to poliomyelitis. This study is showing the results of surgery after a follow up of 4 years (range 1–6 years). It is concluded that the peroneus brevis tendon transfer anterior to the ankle in to the base of the second metatarsal bone together with a proper sub-talar extra articular arthrodesis is consistent with good results. The outcome is poor transferring behind the medial malleolus and when peroneus longus tendon is used.

Extra-articular subtalar arthrodesis. A long-term follow-up in patients with cerebral palsy.

Of 23 children (35 feet) with cerebral palsy who had undergone a Grice extra-articular subtalar arthrodesis for a valgus hindfoot between 1976 and 1981, we reviewed 17 (26 feet), at a mean of 20 years (17 years 3 months to 22 years 4 months) after operation. Seven were quadriplegic, eight spastic diplegic, and two hemiplegic. They were all able to walk at the time of operation. Thirteen patients (20 feet) were pleased with the Grice procedure, 13 had no pain and 15 (23 feet) were still able to walk. The clinical results were satisfactory for most feet. Radiography showed that the results had been maintained over time but 14 feet developed a mean ankle valgus of 11 degrees (6 to 18) with a compensatory hindfoot varus in 12 feet. No deformity of the talus or arthritis of adjacent joints was noted. The Grice procedure gives good long-term results in children with cerebral palsy.