400 Review article
Pes planovalgus deformity in children with cerebral palsy: review article Muayad Kadhim and Freeman Miller Pes planovalgus deformity is common in children with cerebral palsy. In planovalgus foot, the talus subluxates medially, the calcaneus is in valgus, and the forefoot is in supination and external rotation related to the midfoot. In young children, mild planovalgus feet can be managed with orthotics. Surgery is indicated if the deformity is not reducible or if the patient cannot tolerate orthotics during functional activities. The surgery can be calcaneal lengthening or subtalar fusion to restore a stable plantigrade foot and achieve hindfoot correction. Medial column fusion is important to reconstruct the medial arch in severe planovalgus feet. J Pediatr Orthop B 23:400–405
Cerebral palsy (CP) is a static nonprogressive injury to the brain that occurs in childhood [1]. CP can be classified into three types on the basis of the pattern of extremity involvement, which gives a general sense of severity and possible problems. Hemiplegic patients show unilateral involvement (upper or lower extremity), diplegia affects the lower extremities with a mild effect on the upper extremity, and quadriplegia affects all four limbs. Children with CP have permanent motor deficit with different levels of involvement. Ambulation and transfer differ widely, ranging from no concerns in mildly affected patients to severe handicaps in quadriplegic patients. Muscle tone disorder is common among CP children, most likely because of spasticity, which leads to abnormal forces across joints and abnormal postures. Muscle contracture develops subsequently and causes common orthopedic problems in CP patients. Pes planovalgus is one of the most common foot deformities in patients with CP, especially among diplegic and quadriplegic patients [2]. The aim of this review was to describe planovalgus foot deformity development, treatment, and outcome.
The pathoanatomy Equinus is commonly recognized early among children with CP, at ages between 18 and 24 months [1]. Equinus begins as a dynamic ankle posture and then gradually turns into muscle contracture [3]. Walking with fixed equinus leads to increased forces on the forefoot during gait cycles, which causes stress in the midfoot and hindfoot and eventually leads to foot collapse [3]. In the planovalgus deformity, the calcaneus is in equinus and valgus and the midfoot and forefoot move into external rotation, valgus, and dorsiflexion related to the talus. 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Journal of Pediatric Orthopaedics B 2014, 23:400–405 Keywords: calcaneal lengthening, cerebral palsy, medial column fusion, pes planovalgus, subtalar fusion Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA Correspondence to Freeman Miller, MD, Department of Orthopaedics, Nemours/ Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA Tel: + 1 302 651 5921; fax: + 1 302 651 5951; e-mail: [email protected]
Therefore, the talar head subluxates to the medial and plantar directions and loses its coverage by the navicular bone. As a result of these anatomic changes, the midfoot is included in the weight-bearing part with subsequent development of skin callus and navicular tuberosity hypertrophy. Midfoot changes include cuneonavicular and calcaneocuboid joint subluxation and forefoot supination with hallux valgus. External tibial torsion commonly develops, which leads to gait disturbance and crouch due to lever arm disease [4]. Similar changes develop in nonambulatory children because of severe spasticity and overpowering of one muscle group over the other muscles [3].
Patient evaluation The major concern of the family or caregivers of children with CP is the impaired lower extremity function and disability. For better evaluation of function and mobility in children with CP, five functional levels have been described and presented by the Gross Motor Function Classification System (GMFCS) [5]. Patients in GMFCS 1 and 2 are independent and community ambulators. Patients in GMFCS level 3 use assistive devices for walking. Patients in GMFCS 4 can stand and walk limitedly with assistance but they are mostly dependent on a wheelchair and have antigravity control of the neck and head. Patients in GMFCS 5 are totally dependent, with no control of the neck. The Functional Mobility Scale is another useful and more comprehensive classification system, which classifies mobility and ambulation into three categories based on distance (5, 50, and 500 m) [6]. Six levels were described based on the use of assistive devices (level 1: wheelchair, level 2: walker, level 3: two crutches, level 4: one crutch or two sticks, level 5: DOI: 10.1097/BPB.0000000000000073
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Pes planovalgus in cerebral palsy Kadhim and Miller 401
independent on level surfaces, and level 6: independent on all surfaces). Children with CP usually present with multilevel deformities; therefore, attention needs to be directed toward recognizing the concomitant pathologies in addition to the foot deformities, including knee contractures, tibial and femoral torsional malalignment, hip dysplastic changes, and spinal deformities. Ambulatory CP patients with planovalgus foot deformity commonly complain of unstable and painful feet. Gait observation is part of the clinical evaluation of ambulatory children with CP and is helpful in assessing foot collapse and deformity severity in addition to knee, hip, and trunk evaluation. Radiographic evaluation using weight-bearing radiographs is helpful in better understanding the anatomic changes in the foot and the extent of medial subluxation of the talar head. The increase in the talonavicular uncoverage index and the talonavicular angle was found to be correlated with an increase in the midfoot pressure during gait, and they can be utilized as radiographic markers to evaluate the severity of planovalgus foot deformity [7]. Gait analysis is very useful in understanding gait impairment; specifically, pedobarography to evaluate the changes in foot segment impulse during gait. The natural history of planovalgus foot deformity has not yet been clearly described and seems to be variable and unpredictable. CP patients may have early planovalgus resolve around the age of 5–6 years; however, heel valgus and foot pronation commonly tend to progress, especially during late childhood, and may become painful during adolescence. Therefore, treatment indications and required follow-up duration continue to vary widely. The clinical approach toward management of planovalgus foot deformity in patients with CP differs based on the level of function in ambulatory patients and on spasticity and muscular imbalance, especially in quadriplegic patients. CP children with foot deformities need to be examined to assess for flexibility and reducibility to determine the proper treatment.
Treatment options Ankle–foot orthoses and physical therapy are the primary options for young patients with planovalgus foot deformity (younger than 8 years). The optimal approach is to support the ankle with orthotics, beginning with a solid ankle–foot orthosis (AFO) in toe walkers with dynamic equinus. When the child begins to walk and gains more weight, a hinged (articulated) AFO is used to allow for ankle dorsiflexion and to prevent ankle plantarflexion. Hinged AFOs work as long as the child does not fall into a severe crouch posture. Hinged AFOs are also indicated for patients with back-kneeing (recurvatum) due to gastrocnemius contracture. Hinged AFOs do not work well for patients with severe planovalgus foot, and the reason
is that ankle motion cannot be separated from subtalar motion, which causes severe skin breakdown from high pressure. External tibial torsion can be treated using orthotics if it arises mainly from the foot deformity. If there is more than 20° external tibial torsion causing gait problems, tibial derotation is indicated [4]. Options and indications of foot orthoses become variable in older patients on the basis of deformity severity and level of function. Patients who can control ankle plantarflexion and dorsiflexion can be treated with supramalleolar orthotics. When a crouched gait develops due to increased knee flexion and increased ankle dorsiflexion in the stance phase, solid AFO can be used with wide straps. This brace becomes less useful when the patient gains weight (over 25 kg); therefore, ground reaction AFO (GRAFO) is used. To benefit from this brace, neutral ankle dorsiflexion should be achieved when the knee is in extension with no rotation between foot and knee axes. GRAFO is more effective when the child becomes heavier but it needs to be stronger. Hinged GRAFO allows for ankle plantarflexion and prevents dorsiflexion and is indicated primarily during postsurgical operative rehabilitation. Quadriplegic patients with low functional abilities, who walk using assistive devices, are better kept in solid AFOs, which provide stable feet and therefore allow the child to focus on hip and knee control. Surgery is indicated for planovalgus foot deformity when the deformity is severe and the foot is no longer stable, with less tolerance to orthoses, which cause a decrease in the ability of and interest in standing and ambulation. Plantarflexion spasticity is a primary pathological factor of planovalgus foot deformity in many children with CP, and when orthoses are no longer tolerated to control the equinus, botulinum injection may be considered for the nonfixed equinus [3]. When the ankle cannot be reduced to the neutral position – that is, there is gastrocnemius or soleus contracture – gastrocnemius recession or Achilles tendon lengthening, respectively, are indicated. As mentioned previously, progressed planovalgus foot deformity results from bony changes and disturbances in the relationship between the tarsal bones. Therefore the aim of surgery is to reduce the subtalar joint and restore the forefoot and midfoot alignment with the purpose of establishing a stable plantigrade foot and improving functional ability such as walking and standing. Hindfoot correction can be performed using different surgical techniques. Lateral calcaneal lengthening is an intra-articular osteotomy of the calcaneus bone, specifically between the middle and the anterior facets. From the practical and anatomical perspectives, calcaneal osteotomy commonly involves the articular surface [8]. Evans [9] described this procedure as the cutting of a calcaneus bone at about 1.5 cm proximal to the calcaneocuboid joint. The concept of this procedure is to equalize the lateral and
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402 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
medial foot column lengths. The benefits of mobilizing the forefoot and midfoot segments through the osteotomy site are tightening of the plantar fascia and reduction in the position of the talus over the calcaneus without damaging the joint motion. Calcaneal lengthening has been commonly used for CP children with planovalgus foot deformity with good results [10–16]. Another option for hindfoot correction is to reduce the subtalar joint and maintain this reduction by extra-
articular or intra-articular fusion to construct a stable hind foot. The difference between intra-articular and extra-articular techniques is the preservation of the articular surfaces, which are the growing surfaces of the tarsal bones. Grice’s [17] subtalar extra-articular fusion has been utilized and recommended to treat planovalgus foot deformity in young children with CP [18–21]. Modifications to the Grice technique have been described in the literature like inserting the fibular bone graft through the talar neck into the calcaneus [22,23]. Another
Fig. 1
(a–c) A 13-year-old girl, GMFCS 2, showing bilateral planovalgus deformity and severe progressive crouch gait. (d–h) She was treated with calcaneal lengthening in both feet. GMFCS, Gross Motor Function Classification System.
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Pes planovalgus in cerebral palsy Kadhim and Miller 403
option to reduce and stabilize the subtalar joint is to put an insert in the subtalar joint after reduction [24]. This procedure is called subtalar arthroereisis and was initially described as using a staple in the sinus tarsi [25]. Intra-articular subtalar fusion has been also utilized in CP children for correction of planovalgus deformity [15,16, 26]. The utilization of two screws to reduce the subtalar joint was previously described by Judet as Cavalier's Procedure, where no decortication of the articular surfaces was performed [27]. Cavalier claimed that the subtalar movement was preserved and that the medial arch could be rebuilt and maintained during growth. Dennyson and Fulford described a technique using an autogenous bone graft and screws for internal stabilization of the subtalar joint [28]. Intra-articular subtalar
fusion has been commonly described as part of triple arthrodesis. Resection of the subtalar and midfoot joints was found to be reliable in reconstructing a stable and solid foot in children with CP [29–31]. Degenerative articular changes in the ankle joint were described after triple arthrodesis in CP patients and were related to pain [29]. However, loss of function was not found to be related to the degenerative changes in a long-term follow-up study after triple arthrodesis in CP patients [30]. Calcaneal osteotomy is also an option to correct hindfoot valgus with either a wedge osteotomy [32] or sliding osteotomy [33,34]. Although some surgeons used calcaneal sliding/wedge osteotomy in children with CP, there is no published report of this procedure, and experience
Fig. 2
(a, b) A 10.7-year-old boy, GMFCS 3, showing severe right planovalgus foot, instability during walking, and progressive crouch gait. (c–f) He was treated with subtalar fusion. GMFCS, Gross Motor Function Classification System.
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Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
with calcaneal sliding/wedge osteotomy is lacking in children with CP. After reduction of the hind foot, attention needs to be paid to the associated pathologies, including forefoot supination and hallux valgus deformities. There is debate on the indications of each surgical technique for the treatment of planovalgus foot in children with CP, specifically on calcaneal lengthening. The debate on whether severe planovalgus feet can be corrected with calcaneal lengthening in children with CP [10,11] or whether this technique is applicable only for flexible and less severe planovalgus feet in good ambulators [12–16,34] persists; however, the exact indications are not very widely established. Our preferred technique of surgical treatment for planovalgus foot deformity in CP children differs on the basis of the functional and ambulatory abilities, as well as the rigidity of the deformity. Good ambulatory patients who
do not use assistive devices (GMFCS I, II) commonly present with flexible flat feet and pain. Our indications for calcaneal lengthening are in GMFCS I, II, and highfunctioning GMFCS III walkers with mild-to-moderate planovalgus deformity (Fig. 1) [12,14,15]. Patients with low functional abilities and severe rigid planovalgus foot deformity are commonly managed with subtalar fusion (Fig. 2). The talonavicular joint needs to be visualized through a separate medial incision to perform excision of the navicular tuberosity and advancement of the tibialis posterior tendon. If the calcaneocuboid joint is unstable and oblique, fusion can be performed simultaneously. Medial column correction is crucial to build the medial arch with fusion in severe planovalgus feet (Fig. 3). We recently reviewed the outcome of surgical management of planovalgus foot deformity using calcaneal lengthening or subtalar fusion and we realized that cuneonavicular joint fusion was used more than talonavicular fusion. Total medial column fusion was performed for very
Fig. 3
(a–c) A 14-year-old girl, GMFCS 5 (dependent for all activities), showing severe bilateral planovalgus foot deformity. The patient could not tolerate the orthotics or wear shoes for weight bearing while standing. (d–h) She was treated with subtalar fusion in both feet with talonavicular-cuneiform firstmetatarsal fusion. GMFCS, Gross Motor Function Classification System.
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Pes planovalgus in cerebral palsy Kadhim and Miller 405
severe deformities and provided excellent correction of severe planovalgus deformities [14]. We obtained good results, with maintenance of reduction of the planovalgus after a mean of 8 years of follow-up [15].
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Children with CP commonly present with different complaints pertaining to lower extremities involving the ankle, knee, and hip joints. Multilevel surgical planning has been found to be efficient in correcting deformities from hips to toes in one multilevel surgical encounter with improvement in gait abilities [35,36]. Still, some CP children present with planovalgus foot deformity as the major complaint, with minimal complaints with regard to proximal joints. Ambulatory CP children who have a combination of external tibial torsion and planovalgus foot deformity commonly complain of severe crouched gait [3–4]. Evidence was found that single-level surgical correction of planovalgus foot deformity can affect proximal joints specifically on crouched gait [37].
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Conclusion
The management in young children is with ageappropriate and function-appropriate foot orthotics. As children reach adolescence, the increase in weight and increased foot deformity often lead to a requirement for surgical correction. Severity of the deformity and the child’s functional abilities need to be considered during surgical correction.
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Acknowledgements Conflicts of interest
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There are no conflicts of interest.
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Andreacchio A, Orellana CA, Miller F, Bowen TR. Lateral column lengthening as treatment for planovalgus foot deformity in ambulatory children with spastic cerebral palsy. J Pediatr Orthop 2000; 20:501–505. Ettl V, Wollmerstedt N, Kirschner S, Morrison R, Pasold E, Raab P. Calcaneal lengthening for planovalgus deformity in children with cerebral palsy. Foot Ankle Int 2009; 30:398–404. Yoo WJ, Chung CY, Choi IH, Cho TJ, Kim DH. Calcaneal lengthening for the planovalgus foot deformity in children with cerebral palsy. J Pediatr Orthop 2005; 25:781–785. Kadhim M, Holmes L, Church C, Henley J, Miller F. Pes planovalgus deformity surgical correction in ambulatory children with cerebral palsy. J Child Orthop 2012; 6:217–227. Kadhim M, Holmes L Jr, Miller F. Long-term outcome of planovalgus foot surgical correction in children with cerebral palsy. J Foot Ankle Surg 2013; 52:697–703. Grice DS. An extra-articular arthrodesis of the subastragalar joint for correction of paralytic flat feet in children. J Bone Joint Surg Am 1952; 34:927–940. Bourelle S, Cottalorda J, Gautheron V, Chavrier Y. Extra-articular subtalar arthrodesis. A long-term follow-up in patients with cerebral palsy. J Bone Joint Surg Br 2004; 86:737–742. Güven M, Eren A, Akman B, Unay K, Ozkan NK. The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy. Acta Orthop Traumatol Turc 2008; 42:31–37. Yoon HK, Park KB, Roh JY, Park HW, Chi HJ, Kim HW. Extraarticular subtalar arthrodesis for pes planovalgus: an interim result of 50 feet in patients with spastic diplegia. Clin Orthop Surg 2010; 2:13–21. Mazis GA, Sakellariou VI, Kanellopoulos AD, Papagelopoulos PJ, Lyras DN, Soucacos PN. Results of extra-articular subtalar arthrodesis in children with cerebral palsy. Foot Ankle Int 2012; 33:469–474. Brown A. A simple method of fusion of the subtalar joint in children. J Bone Joint Surg Br 1968; 50:369–371. Hsu LC, Jaffray D, Leong JC. The Batchelor-Grice extra-articular subtalar arthrodesis. J Bone Joint Surg Br 1986; 68:125–127. Vedantam R, Capelli AM, Schoenecker PL. Subtalar arthroereisis for the correction of planovalgus foot in children with neuromuscular disorders. J Pediatr Orthop 1998; 18:294–298. Crawford AH, Kucharzyk D, Roy DR, Bilbo J. Subtalar stabilization of the planovalgus foot by staple arthroereisis in young children who have neuromuscular problems. J Bone Joint Surg Am 1990; 72:840–845. Senaran H, Yilmaz G, Nagai MK, Thacker M, Dabney KW, Miller F. Subtalar fusion in cerebral palsy patients: results of a new technique using corticocancellous allograft. J Pediatr Orthop 2011; 31:205–210. Judet J. Indications for an technics of the “cavalier” operation. Rev Chir Orthop Reparatrice Appar Mot 1977; 63:780–781. Dennyson WG, Fulford GE. Subtalar arthrodesis by cancellous grafts and metallic internal fixation. J Bone Joint Surg Br 1976; 58-B:507–510. Angus PD, Cowell HR. Triple arthrodesis. A critical long-term review. J Bone Joint Surg Br 1986; 68:260–265. Tenuta J, Shelton YA, Miller F. Long-term follow-up of triple arthrodesis in patients with cerebral palsy. J Pediatr Orthop 1993; 13:713–716. Lankosz W, Jurkowski J, Zarzycki D, Koniarski A. Triple tarsal arthrodesis in the treatment of spastic foot in cerebral palsy. Ortop Traumatol Rehabil 2002; 4:30–32. Dwyer FC. Osteotomy of the calcaneum for pes cavus. J Bone Joint Surg Br 1959; 41-B:80–86. Koutsogiannis E. Treatment of mobile flat foot by displacement osteotomy of the calcaneus. J Bone Joint Surg Br 1971; 53:96–100. Kim JR, Shin SJ, Wang SI, Kang SM. Comparison of lateral opening wedge calcaneal osteotomy and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy for correction of planovalgus foot deformity in children. J Foot Ankle Surg 2013; 52:162–166. Gannotti ME, Gorton GE 3rd, Nahorniak MT, Masso PD. Walking abilities of young adults with cerebral palsy: changes after multilevel surgery and adolescence. Gait Posture 2010; 32:46–52. Rutz E, Tirosh O, Thomason P, Barg A, Graham HK. Stability of the Gross Motor Function Classification System after single-event multilevel surgery in children with cerebral palsy. Dev Med Child Neurol 2012; 54:1109–1113. Kadhim M, Miller F. Crouch gait changes after planovalgus foot deformity correction in ambulatory children with cerebral palsy. Gait Posture 2014; 39:793–798.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pes planovalgus deformity in children with cerebral palsy: review article Muayad Kadhim and Freeman Miller Pes planovalgus deformity is common in children with cerebral palsy. In planovalgus foot, the talus subluxates medially, the calcaneus is in valgus, and the forefoot is in supination and external rotation related to the midfoot. In young children, mild planovalgus feet can be managed with orthotics. Surgery is indicated if the deformity is not reducible or if the patient cannot tolerate orthotics during functional activities. The surgery can be calcaneal lengthening or subtalar fusion to restore a stable plantigrade foot and achieve hindfoot correction. Medial column fusion is important to reconstruct the medial arch in severe planovalgus feet. J Pediatr Orthop B 23:400–405
Cerebral palsy (CP) is a static nonprogressive injury to the brain that occurs in childhood [1]. CP can be classified into three types on the basis of the pattern of extremity involvement, which gives a general sense of severity and possible problems. Hemiplegic patients show unilateral involvement (upper or lower extremity), diplegia affects the lower extremities with a mild effect on the upper extremity, and quadriplegia affects all four limbs. Children with CP have permanent motor deficit with different levels of involvement. Ambulation and transfer differ widely, ranging from no concerns in mildly affected patients to severe handicaps in quadriplegic patients. Muscle tone disorder is common among CP children, most likely because of spasticity, which leads to abnormal forces across joints and abnormal postures. Muscle contracture develops subsequently and causes common orthopedic problems in CP patients. Pes planovalgus is one of the most common foot deformities in patients with CP, especially among diplegic and quadriplegic patients [2]. The aim of this review was to describe planovalgus foot deformity development, treatment, and outcome.
The pathoanatomy Equinus is commonly recognized early among children with CP, at ages between 18 and 24 months [1]. Equinus begins as a dynamic ankle posture and then gradually turns into muscle contracture [3]. Walking with fixed equinus leads to increased forces on the forefoot during gait cycles, which causes stress in the midfoot and hindfoot and eventually leads to foot collapse [3]. In the planovalgus deformity, the calcaneus is in equinus and valgus and the midfoot and forefoot move into external rotation, valgus, and dorsiflexion related to the talus. 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Journal of Pediatric Orthopaedics B 2014, 23:400–405 Keywords: calcaneal lengthening, cerebral palsy, medial column fusion, pes planovalgus, subtalar fusion Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA Correspondence to Freeman Miller, MD, Department of Orthopaedics, Nemours/ Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA Tel: + 1 302 651 5921; fax: + 1 302 651 5951; e-mail: [email protected]
Therefore, the talar head subluxates to the medial and plantar directions and loses its coverage by the navicular bone. As a result of these anatomic changes, the midfoot is included in the weight-bearing part with subsequent development of skin callus and navicular tuberosity hypertrophy. Midfoot changes include cuneonavicular and calcaneocuboid joint subluxation and forefoot supination with hallux valgus. External tibial torsion commonly develops, which leads to gait disturbance and crouch due to lever arm disease [4]. Similar changes develop in nonambulatory children because of severe spasticity and overpowering of one muscle group over the other muscles [3].
Patient evaluation The major concern of the family or caregivers of children with CP is the impaired lower extremity function and disability. For better evaluation of function and mobility in children with CP, five functional levels have been described and presented by the Gross Motor Function Classification System (GMFCS) [5]. Patients in GMFCS 1 and 2 are independent and community ambulators. Patients in GMFCS level 3 use assistive devices for walking. Patients in GMFCS 4 can stand and walk limitedly with assistance but they are mostly dependent on a wheelchair and have antigravity control of the neck and head. Patients in GMFCS 5 are totally dependent, with no control of the neck. The Functional Mobility Scale is another useful and more comprehensive classification system, which classifies mobility and ambulation into three categories based on distance (5, 50, and 500 m) [6]. Six levels were described based on the use of assistive devices (level 1: wheelchair, level 2: walker, level 3: two crutches, level 4: one crutch or two sticks, level 5: DOI: 10.1097/BPB.0000000000000073
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pes planovalgus in cerebral palsy Kadhim and Miller 401
independent on level surfaces, and level 6: independent on all surfaces). Children with CP usually present with multilevel deformities; therefore, attention needs to be directed toward recognizing the concomitant pathologies in addition to the foot deformities, including knee contractures, tibial and femoral torsional malalignment, hip dysplastic changes, and spinal deformities. Ambulatory CP patients with planovalgus foot deformity commonly complain of unstable and painful feet. Gait observation is part of the clinical evaluation of ambulatory children with CP and is helpful in assessing foot collapse and deformity severity in addition to knee, hip, and trunk evaluation. Radiographic evaluation using weight-bearing radiographs is helpful in better understanding the anatomic changes in the foot and the extent of medial subluxation of the talar head. The increase in the talonavicular uncoverage index and the talonavicular angle was found to be correlated with an increase in the midfoot pressure during gait, and they can be utilized as radiographic markers to evaluate the severity of planovalgus foot deformity [7]. Gait analysis is very useful in understanding gait impairment; specifically, pedobarography to evaluate the changes in foot segment impulse during gait. The natural history of planovalgus foot deformity has not yet been clearly described and seems to be variable and unpredictable. CP patients may have early planovalgus resolve around the age of 5–6 years; however, heel valgus and foot pronation commonly tend to progress, especially during late childhood, and may become painful during adolescence. Therefore, treatment indications and required follow-up duration continue to vary widely. The clinical approach toward management of planovalgus foot deformity in patients with CP differs based on the level of function in ambulatory patients and on spasticity and muscular imbalance, especially in quadriplegic patients. CP children with foot deformities need to be examined to assess for flexibility and reducibility to determine the proper treatment.
Treatment options Ankle–foot orthoses and physical therapy are the primary options for young patients with planovalgus foot deformity (younger than 8 years). The optimal approach is to support the ankle with orthotics, beginning with a solid ankle–foot orthosis (AFO) in toe walkers with dynamic equinus. When the child begins to walk and gains more weight, a hinged (articulated) AFO is used to allow for ankle dorsiflexion and to prevent ankle plantarflexion. Hinged AFOs work as long as the child does not fall into a severe crouch posture. Hinged AFOs are also indicated for patients with back-kneeing (recurvatum) due to gastrocnemius contracture. Hinged AFOs do not work well for patients with severe planovalgus foot, and the reason
is that ankle motion cannot be separated from subtalar motion, which causes severe skin breakdown from high pressure. External tibial torsion can be treated using orthotics if it arises mainly from the foot deformity. If there is more than 20° external tibial torsion causing gait problems, tibial derotation is indicated [4]. Options and indications of foot orthoses become variable in older patients on the basis of deformity severity and level of function. Patients who can control ankle plantarflexion and dorsiflexion can be treated with supramalleolar orthotics. When a crouched gait develops due to increased knee flexion and increased ankle dorsiflexion in the stance phase, solid AFO can be used with wide straps. This brace becomes less useful when the patient gains weight (over 25 kg); therefore, ground reaction AFO (GRAFO) is used. To benefit from this brace, neutral ankle dorsiflexion should be achieved when the knee is in extension with no rotation between foot and knee axes. GRAFO is more effective when the child becomes heavier but it needs to be stronger. Hinged GRAFO allows for ankle plantarflexion and prevents dorsiflexion and is indicated primarily during postsurgical operative rehabilitation. Quadriplegic patients with low functional abilities, who walk using assistive devices, are better kept in solid AFOs, which provide stable feet and therefore allow the child to focus on hip and knee control. Surgery is indicated for planovalgus foot deformity when the deformity is severe and the foot is no longer stable, with less tolerance to orthoses, which cause a decrease in the ability of and interest in standing and ambulation. Plantarflexion spasticity is a primary pathological factor of planovalgus foot deformity in many children with CP, and when orthoses are no longer tolerated to control the equinus, botulinum injection may be considered for the nonfixed equinus [3]. When the ankle cannot be reduced to the neutral position – that is, there is gastrocnemius or soleus contracture – gastrocnemius recession or Achilles tendon lengthening, respectively, are indicated. As mentioned previously, progressed planovalgus foot deformity results from bony changes and disturbances in the relationship between the tarsal bones. Therefore the aim of surgery is to reduce the subtalar joint and restore the forefoot and midfoot alignment with the purpose of establishing a stable plantigrade foot and improving functional ability such as walking and standing. Hindfoot correction can be performed using different surgical techniques. Lateral calcaneal lengthening is an intra-articular osteotomy of the calcaneus bone, specifically between the middle and the anterior facets. From the practical and anatomical perspectives, calcaneal osteotomy commonly involves the articular surface [8]. Evans [9] described this procedure as the cutting of a calcaneus bone at about 1.5 cm proximal to the calcaneocuboid joint. The concept of this procedure is to equalize the lateral and
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402 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
medial foot column lengths. The benefits of mobilizing the forefoot and midfoot segments through the osteotomy site are tightening of the plantar fascia and reduction in the position of the talus over the calcaneus without damaging the joint motion. Calcaneal lengthening has been commonly used for CP children with planovalgus foot deformity with good results [10–16]. Another option for hindfoot correction is to reduce the subtalar joint and maintain this reduction by extra-
articular or intra-articular fusion to construct a stable hind foot. The difference between intra-articular and extra-articular techniques is the preservation of the articular surfaces, which are the growing surfaces of the tarsal bones. Grice’s [17] subtalar extra-articular fusion has been utilized and recommended to treat planovalgus foot deformity in young children with CP [18–21]. Modifications to the Grice technique have been described in the literature like inserting the fibular bone graft through the talar neck into the calcaneus [22,23]. Another
Fig. 1
(a–c) A 13-year-old girl, GMFCS 2, showing bilateral planovalgus deformity and severe progressive crouch gait. (d–h) She was treated with calcaneal lengthening in both feet. GMFCS, Gross Motor Function Classification System.
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Pes planovalgus in cerebral palsy Kadhim and Miller 403
option to reduce and stabilize the subtalar joint is to put an insert in the subtalar joint after reduction [24]. This procedure is called subtalar arthroereisis and was initially described as using a staple in the sinus tarsi [25]. Intra-articular subtalar fusion has been also utilized in CP children for correction of planovalgus deformity [15,16, 26]. The utilization of two screws to reduce the subtalar joint was previously described by Judet as Cavalier's Procedure, where no decortication of the articular surfaces was performed [27]. Cavalier claimed that the subtalar movement was preserved and that the medial arch could be rebuilt and maintained during growth. Dennyson and Fulford described a technique using an autogenous bone graft and screws for internal stabilization of the subtalar joint [28]. Intra-articular subtalar
fusion has been commonly described as part of triple arthrodesis. Resection of the subtalar and midfoot joints was found to be reliable in reconstructing a stable and solid foot in children with CP [29–31]. Degenerative articular changes in the ankle joint were described after triple arthrodesis in CP patients and were related to pain [29]. However, loss of function was not found to be related to the degenerative changes in a long-term follow-up study after triple arthrodesis in CP patients [30]. Calcaneal osteotomy is also an option to correct hindfoot valgus with either a wedge osteotomy [32] or sliding osteotomy [33,34]. Although some surgeons used calcaneal sliding/wedge osteotomy in children with CP, there is no published report of this procedure, and experience
Fig. 2
(a, b) A 10.7-year-old boy, GMFCS 3, showing severe right planovalgus foot, instability during walking, and progressive crouch gait. (c–f) He was treated with subtalar fusion. GMFCS, Gross Motor Function Classification System.
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with calcaneal sliding/wedge osteotomy is lacking in children with CP. After reduction of the hind foot, attention needs to be paid to the associated pathologies, including forefoot supination and hallux valgus deformities. There is debate on the indications of each surgical technique for the treatment of planovalgus foot in children with CP, specifically on calcaneal lengthening. The debate on whether severe planovalgus feet can be corrected with calcaneal lengthening in children with CP [10,11] or whether this technique is applicable only for flexible and less severe planovalgus feet in good ambulators [12–16,34] persists; however, the exact indications are not very widely established. Our preferred technique of surgical treatment for planovalgus foot deformity in CP children differs on the basis of the functional and ambulatory abilities, as well as the rigidity of the deformity. Good ambulatory patients who
do not use assistive devices (GMFCS I, II) commonly present with flexible flat feet and pain. Our indications for calcaneal lengthening are in GMFCS I, II, and highfunctioning GMFCS III walkers with mild-to-moderate planovalgus deformity (Fig. 1) [12,14,15]. Patients with low functional abilities and severe rigid planovalgus foot deformity are commonly managed with subtalar fusion (Fig. 2). The talonavicular joint needs to be visualized through a separate medial incision to perform excision of the navicular tuberosity and advancement of the tibialis posterior tendon. If the calcaneocuboid joint is unstable and oblique, fusion can be performed simultaneously. Medial column correction is crucial to build the medial arch with fusion in severe planovalgus feet (Fig. 3). We recently reviewed the outcome of surgical management of planovalgus foot deformity using calcaneal lengthening or subtalar fusion and we realized that cuneonavicular joint fusion was used more than talonavicular fusion. Total medial column fusion was performed for very
Fig. 3
(a–c) A 14-year-old girl, GMFCS 5 (dependent for all activities), showing severe bilateral planovalgus foot deformity. The patient could not tolerate the orthotics or wear shoes for weight bearing while standing. (d–h) She was treated with subtalar fusion in both feet with talonavicular-cuneiform firstmetatarsal fusion. GMFCS, Gross Motor Function Classification System.
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Pes planovalgus in cerebral palsy Kadhim and Miller 405
severe deformities and provided excellent correction of severe planovalgus deformities [14]. We obtained good results, with maintenance of reduction of the planovalgus after a mean of 8 years of follow-up [15].
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Children with CP commonly present with different complaints pertaining to lower extremities involving the ankle, knee, and hip joints. Multilevel surgical planning has been found to be efficient in correcting deformities from hips to toes in one multilevel surgical encounter with improvement in gait abilities [35,36]. Still, some CP children present with planovalgus foot deformity as the major complaint, with minimal complaints with regard to proximal joints. Ambulatory CP children who have a combination of external tibial torsion and planovalgus foot deformity commonly complain of severe crouched gait [3–4]. Evidence was found that single-level surgical correction of planovalgus foot deformity can affect proximal joints specifically on crouched gait [37].
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Conclusion
The management in young children is with ageappropriate and function-appropriate foot orthotics. As children reach adolescence, the increase in weight and increased foot deformity often lead to a requirement for surgical correction. Severity of the deformity and the child’s functional abilities need to be considered during surgical correction.
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Acknowledgements Conflicts of interest
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There are no conflicts of interest.
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