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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • Medial callosities • Hallux valgus • Shoe wear • Pain • Gait disturbance due to lever arm dysfunction Introduction SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Lateral talocalcaneal angle SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Lateral talus-first metatarsal angle SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Naviculocuboid overlap (B/A) SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Relative calcaneal length (a/b) SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Calcaneocuboid subluxation SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL AP talus-first metatarsal angle SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Operative procedure SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ` SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • Inter-observer reliability (3 observer) • 36 radiographs • ICC (intraclass correlation coefficient) & 95% confidence interval Statistical analysis SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Results SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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 SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL • 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. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Thank you !