Amount of correction after calcaneal
lengthening for planovalgus foot deformity in
patients with cerebral palsy
Ki Hyuk Sung, MD
Seoul National University Bundang Hospital
Introduction
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• 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
Introduction
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• Medial callosities
• Hallux valgus
• Shoe wear
• Pain
• Gait disturbance due
to lever arm
dysfunction
Introduction
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• 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
Introduction
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• 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
Purpose of the study
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• 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
Materials and Methods
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• 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
Materials and Methods
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• 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
Radiographic measurement
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• 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
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
Reliability of radiographic measurement
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• Inter-observer reliability (3 observer)
• 36 radiographs
• ICC (intraclass correlation coefficient) &
95% confidence interval
Statistical analysis
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• 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)
Age (year)
Geographic type
(hemiplegia/diplegia/triplegia/quadriplegia)
Follow-up duration (year)
51 / 24
11.0±5.2 (range 5.4 to 30.1)
5 / 48 / 3/ 19
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
Preoperative
Postoperative
Mean
difference
p-value
Normal
alignment
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
-
Parameters
AP talo-1MT (˚)
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
No. of subject
(corrected group)
No. of subject
(under-corrected
group)
Area under the
ROC curve
95% CI
p- value
Cut-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%
Parameters
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.
Conclusions
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• 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.
Conclusions
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• For the patients with more than 23˚of AP talusfirst 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 !