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![Page 1: Ki Hyuk Sung, MD Amount of correction after calcaneal lengthening for planovalgus foot deformity in patients with cerebral palsy Seoul National University.](https://reader036.fdocuments.us/reader036/viewer/2022062423/56649e8a5503460f94b8faab/html5/thumbnails/1.jpg)
Ki Hyuk Sung, MD
Amount of correction after calcaneal lengthening for planovalgus foot
deformity in patients with cerebral palsy
Seoul National University Bundang Hospital
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Introduction
• Planovalgus foot deformity is common in patients with cerebral palsy
• A complex 3-D malalignment– hindfoot valgus, plantar flexed talus– midfoot planus and pronation– relatively short lateral column– forefoot abduction and supination
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Introduction
• Medial callosities
• Hallux valgus
• Shoe wear
• Pain
• Gait disturbance due to lever arm dysfunction
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Introduction
• Surgical options
– medial displacement osteotomy of calcaneus
– subtalar extra-articular arthrodesis
– lengthening of the lateral column
– triple arthrodesis
• Calcaneal lengthening osteotomy
– most commonly used to correct the deformity
and not sacrifice joint motion in patients with CP
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Introduction
• Additional procedures, such as, medial soft tissue
procedure, medial bony procedure, or triple
arthrodesis could be performed concomitantly with
calcaneal lengthening depending on severity of
deformity.
• However, there has been no guideline to determine
the necessity of these procedures
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Purpose of the study
• To investigate the amount of correction
after calcaneal lengthening for the
treatment of planovalgus foot deformity in
patients with CP
• To guide a surgical indication in terms of
the severity of the foot deformity
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Materials and Methods
• Retrospective design
• Inclusion
– patients with cerebral palsy who underwent
calcaneal lengthening for planovalgus deformity
between 2003 and 2011
– patients who had preop and postop weight bearing
AP and lateral foot radiographs
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Materials and Methods
• Exclusion
– patients who had concomitant medial column
procedures with calcaneal lengthening
– patients with a history of previous foot surgery
– patients with inadequate foot radiographs for
measurement
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Radiographic measurement
• Lateral foot weight bearing radiograph
– Calcaneal pitch angle
– Lateral talocalcaneal angle
– Lateral talus-first metatarsal angle
– Naviculocuboid overlap
– Relative calcaneal length
– Calcaneocuboid subluxation
• Anteroposterior foot weight bearing radiograph
– Anteroposterior talus-first metatarsal angle
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Calcaneal pitch angle
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Lateral talocalcaneal angle
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Lateral talus-first metatarsal angle
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Naviculocuboid overlap (B/A)
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Relative calcaneal length (a/b)
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Calcaneocuboid subluxation
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AP talus-first metatarsal angle
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Operative procedure
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`
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• Corrected group
– a group of patients whose radiographic indices
improved beyond the value of normal alignment
after calcaneal lengthening
• Under-corrected group
– a group of patients whose radiographic indices
did not reach the value of normal alignment
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Reliability of radiographic measurement
• Inter-observer reliability (3 observer)
• 36 radiographs
• ICC (intraclass correlation coefficient) &
95% confidence interval
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Statistical analysis
• Comparison between preop radiographic
measurement and postoperative measurement
– Paired t-test
• Define the cut-off values of the preop radiographic
measurements between the corrected and the
under-corrected group
– ROC curve
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Results
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Table 1. Patients demographics and surgical procedures
Gender (M / F) 51 / 24
Age (year) 11.0±5.2 (range 5.4 to 30.1)
Geographic type (hemiplegia/diplegia/triplegia/quadriplegia)
5 / 48 / 3/ 19
Follow-up duration (year) 3.1±2.2 (range 0.3 to 8.4)
Calcaneal lengthening (bilateral/ unilateral) 54 / 21
Number of surgical procedures per patient 6.7 ± 3.0 (range 2 to 14)
Data are presented as mean ± SD
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Table 2. Inter-observer reliability of radiographic parameters
Radiographic parameters ICC 95% CI
AP talus-1st metatarsal angle 0.736 0.595 to 0.844
calcaneal pitch angle 0.918 0.864 to 0.954
Lateral talocalacneal angle 0.722 0.521 to 0.848
Lateral talus-1st metatarsal angle 0.793 0.641 to 0.887
Naviculocuboid overlap 0.915 0.859 to 0.953
Relative calcaneal length 0.817 0.709 to 0.895
Calcaneaocoboid subluxation 0.794 0.673 to 0.881
ICC, intraclass correlation coefficient
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Table 3. Change in radiographic measurements after calcaneal lengthening in patients with cerebral palsy
Parameters Preoperative PostoperativeMean
differencep-
valueNormal
alignment
AP talo-1MT (˚) 22.3±11.3 2.4±13.6 19.9±14.4 <0.001 10±7.0
CP (˚) 2.9±8.8 7.3±8.1 -4.4±7.2 <0.001 17±6.0
Lat TC (˚) 47.0±9.5 37.9.±9.2 9.1±8.5 <0.001 49±6.9
Lat talo-1MT (˚) 30.2±15.6 11.6±13.1 18.5±13.8 <0.001 13±7.5
NC overlap (%) 69.0±17.2 37.8±22.1 31.2±22.9 <0.001 47±13.8
Relative calcaneal length 1.9±0.2 2.0±0.3 -0.1±0.3 0.016 -
CC subluxation (˚) 0.2±1.5 1.4±1.9 -1.2±1.8 <0.001 -
AP talo-1MT, anteroposterior talus-first metatarsal angle; CP, calcaneal pitch angle; Lat TC, lateral talocalcaneal angle; Lat talo-1MT, lateral talus-first metatarsal angle; NC overlap, naviculocuboid overlap; CC subluxation, calcaneocuboid joint subluxation.
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Table 4. Cut-off values of the preoperative radiographic measurements between the corrected and the under-corrected group after calcaneal lengthening in patients with cerebral palsy
ParametersNo. of subject
(corrected group)
No. of subject (under-corrected
group)
Area under the ROC curve
95% CI p- valueCut-off value
AP talo-1MT (˚) 54 21 0.729 0.614 to 0.825 0.0001 >23˚
Lat talo-1MT (˚) 45 30 0.754 0.641 to 0.847 <0.0001 >36˚
NC overlap (%) 47 28 0.645 0.526 to 0.752 0.0319 >72%
AP talo-1MT, anteroposterior talus-first metatarsal angle; Lat talo-1MT, lateral talus-first metatarsal angle; NC overlap, naviculocuboid overlap; ROC curve, Receiver Operating Characteristic curve.
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Conclusions
• Calcaneal lengthening with concomitant
peroneus brevis lengthening is the effective
procedure for correcting planovalgus foot
deformity while preserving subtalar joint
motion in patients with cerebral palsy.
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Conclusions
• For the patients with more than 23˚of AP
talus-first MT angle, more than 36˚of Lat.
talus-first MT angle, and more than 72% of NC
overlap, the additional procedures should be
considered due to the possibilities of
insufficient correction with calcaneal
lengthening alone.
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Thank you !