Transcript The Surgical Treatment of Neuromuscular Planovalgus “The

The Surgical Treatment
of Neuromuscular Planovalgus
“The Role of Staple Arthroereisis”
Dr. Donald W. Kucharzyk
The Orthopaedic, Pediatric &
Spine Institute
Crown Point, Indiana
Neuromuscular Planovalgus
Severe PlanoValgus of the Foot in a
Neuromuscular Child is a Complicated
Matter to Treat
Altered Biomechanics and Secondary
Changes can occur
Biomechanical Changes occur in the
Subtalar Joint and Midfoot
Secondary Changes include: Altered
Gait, Genu Recurvatum and Plantar
Callous
Neuromuscular Planovalgus
Functional Anatomy
To Understand Planovalgus we need to
look at the Functional Concepts of the
Subtalar Joint
From a Functional Standpoint the
Subtalar Joint is a Single Axis
The Axis of Rotation Averages 41 deg.
To the Horizontal and 23 deg. To the
Midline of the Foot
Neuromuscular Planovalgus
Functional Anatomy
This Allows the Foot in Stance to
Absorb the Torsion of the Tibial
The Hindfoot Everts allowing the
Talonavicular and Calcaneocuboid Joints
to become Parallel giving free Motion to
the Mid and Fore Foot
Weightbearing Forces are Transmitted
Medial to the Calcaneous
Neuromuscular Planovalgus
Functional Anatomy
Mild Pronation in the Forefoot allows
even Distribution of Weight on the
Plantar Surface of the Foot
Valgus Positioning of the Hindfoot
allows the Center of Gravity to Pass
over the Subtalar Joint easily
Varus Positioning, on the other hand,
Results in a Semi-Rigid Foot with
Abnormal Gait Pattern
Neuromuscular Planovalgus
Biomechanics
In a Neuromuscular Child, the
Deformity is Produced through a
Combination of Spasticity, Weakness,
and Altered Motion during Gait
Equinus in the Hindfoot prevents
Normal Dorsiflexion
Shifts Dorsiflexion to the Midfoot
Produces a Rocker Bottom Foot with
Valgus Hindfoot and Abducted Forefoot
Neuromuscular Planovalgus
Biomechanics
The Talus assumes a more Vertical and
Medial Position
The Calcaneus rotated Posterolaterally
from its Normal Position
Sustentaculum Tali loses its Supporting
Position beneath the Neck of the Talus
as the Calcaneus Subluxes Laterally
Posterior Tibialis loses its Function
adding to the Planovalgus Deformity
Neuromuscular Planovalgus
Biomechanics
To Correct This Deformity, we must
Address all aspects due to the altered
biomechanics
Calcaneus Placed Beneath the Talus
Reduction of the Hindfoot Equinus
Muscle Balance Must be Present
Avoidance of Varus Hindfoot
Best Achieved while Foot is Supple and
not Fixed with Secondary Changes
Neuromuscular Planovalgus
Etiology
Seen in A Variety of Paralytic Disorders
Upper Motor Neuron lesions producing
Spasticity
Lower Motor Neuron lesions
Flaccid Paralysis
Cerebral Palsy
Myelodysplasia
Poliomyelitis
Neuromuscular Planovalgus
Treatment Options
NONOPERATIVE
Orthotics
OPERATIVE
Subtalar Stabalization
Neuromuscular Planovalgus
NonOperative Treatment
UCBL orthosis with medial wedge
limited if equinus present as it
will exaggerate midfoot collapse
during gait
SMO when equinus and valgus
deformity are marked and
talus plantarflexed into vertical
position
Neuromuscular Planovalgus
Operative Treatment
Subtalar Extra-articulat Arthrodesis
(Grice)
Batchelor Subtalar Arthrodesis
Dennyson-Fulford Stabalization
(Princess Margaret Rose)
StayPeg Procedure(Millar)
Calcaneal Osteotomies
Triple Arthrodesis
Neuromuscular Planovalgus
Extra-Articular Arthrodesis
Preserves the Talonavicular and
Calcaneocuboid Joints
Corrects Valgus deformity of Hindfoot
Restores Longitudinal Arch Height
Does Not Correct Fixed Deformity
Can Produce loss of Lateral Mobility of
the Hindfoot
Must Address Hindfoot Equinus (leading
cause of failure)
Neuromuscular Planovalgus
Extra-Articular Arthrodesis
Variable Success Rates reported (5085%)
Tohen (JBJS 1969) 76%
Banks (CORR 1977) 76%
Ross & Lyne (CL.OR. 1980) 64% failure
Bleck (1987) 50% failure
Dvrark (1989) 94%
Neuromuscular Planovalgus
Extra-Articular Arthrodesis
Reasons for Failure
Persistant ankle valgus
Nonunion
Migration of the Graft
Ankle Varus
Neuromuscular Planovalgus
Batchelor Subtalar Arthodesis
Does not Expose the Subtalar Joint
Insert Fibular Graft from the Neck of
the Talus across the sinus tarsi into the
Calcaneus with Neutral Hindfoot
Brown (JBJS 1968) 17 out of 20
patients had stability with survival of
the graft at 4 years
Neuromuscular Planovalgus
Batchelor Subtalar Arthrodesis
Seymour and Evans (JBJS 1958) reason
for success: simplicity of insertion and
retention, fixation of the foot after
insertion of the graft is stable
Hsu, Yau, Obrien and Hodgson (JBJS
1972) complication of the procedure
being late development of ankle valgus
Neuromuscular Planovalgus
Dennyson-Fulford Stabalization
Cortical screw inserted into the talar
neck and laterally into the calcaneus
Sinus Tarsi denuded and decorticated
and grafted
Maintains correction of the deformity
with rapid fusion
Neuromuscular Planiovalgus
Dennyson-Fulford Stabalization
Reported Fusion Success Rates of 94%
(JBJS 1976)
Barrasso (JPO 1984) 95% fusion
success rates
DeLuca (1990) similar fusion rates of
94-95% with the use of allograft
Neuromuscular Planovalgus
Subtalar StayPeg Arthrorisis
Corrects heel Valgus
Eliminates Abnormal Pronation
Increased Medial Longitudinal Arch
Prevents forward movement of Talus
Allows readaptation of the foot via
secondary bone and soft tissue changes
Neuromuscular Planovalgus
Subtalar StayPeg Arthrorisis
92% success rate at 4 years (CORR
1983)
No Major Complications
Low Incidence of the need for
Mechanical Support PostOp
Only Risk is Dislodgement of Stay Peg
Neuromuscular Planovalgus
A NEW PROCEDURE
SUBTALAR STAPLE ARTHROEREISIS
Eliminates the need for Subtalar
Arthrodesis in a Young Child
Eliminates the need to insert a screw or
graft across neck of talus
Produces predictable correction and
results
Delays Arthrodesis till Older Age
Subtalar Staple Arthroeresis
Biomechanical and Functional
Stabalizes the Subtalar Joints
Requires a Supple Foot
Requires the Equinus to be corrected
prior to the Procedure
Best Suited for Children less than Six
years of age
Contraindicated when forefoot can’t be
placed plantigrade when hindfoot placed
in neutral position
Subtalar Staple Arthroereisis
Technique
Lateral Arm of the Cincinnati Incision
Talocalcaneal Subluxation is corrected
via release anterior, lateral and
posterior articulations of subtalar joint
Calcaneus reduced and held in place
Equinus evaluated and corrected
Vitallium Staple placed across joint with
foot in 15 degrees of plantar flexion
Subtalar Staple Arthroereisis
Clinical Study
Cincinnati Children’s Hospital
20 patients (31 feet)
Spastic Planovalgus (CP and Myelo)
Followup was on average 4 years (2 to7)
Radiographic evaluation included lateral
talocalcaneal angle (preop, postop, and
recent followup)
Clinical, Radiographic Assessment
Complications
Subtalar Staple Arthroereisis
Radiographic Assessment
Loss of Correction/Loss Talocalcaneal
Angle
Divided into Excellent, Good, Fair and
Poor
Excellent: less than 5 degree loss
Good:
5-10 degree loss
Fair:
over 10 degree loss
Poor:
over 10 degree loss and
worse than preop
Subtalar Staple Arthroereisis
Radiographic Results
PreOp Talocalcaneal Angle: 50 degrees
( Range was from 32 deg. To 65 deg.)
PostOp Talocalcaneal Angle: 32 degrees
( Range was from 3 deg. To 44 deg.)
Average Amount of Correction was 18
degrees
Subtalar Staple Arthroereisis
Radiographic Results
Excellent: 15 (48%)
Good:
11 (36%)
Fair:
2 ( 6%)
Poor:
3 (10%)
EXCELLENT-GOOD RESULT: 84%
FAIR- POOR:
16%
Bank’s Criteria ( CORR 1977 )
Subtalar Staple Arthroereisis
Complications
MINOR
Breakdown of Wound: 1
Superficial Infection: 1
MAJOR
Migration of Staple: 1
Subtalar Staple Arthroereisis
Recent Additional Study
10 patients (14 feet)
Spastic Cerebral Palsy
Follow-up: 2 plus 3 years (2 to 7)
Radiographic Results:
Preop angle: 55 deg.
Postop angle: 32 deg.
Average Correction: 20 deg.
Subtalar Staple Arthroereisis
Recent Additional Study
Radiographic Results:
Excellent-Good: 85%
Fair-Poor:
15%
Complications:
Prominence of Staple: 1
Subtalar Staple Arthroereisis
CLINICAL CASE
Subtalar Staple Arthroereisis
Conclusions
Suitable for Stabalization of the
planovalgus foot in Children less than
Six years of age
Stabalizes the joint while Secondary
Adaptive Changes Occur (osseous and
soft tissue)
Delayed and Eliminated the need for
Osseous Fusion of the Growing Foot
Subtalar Staple Arthroereisis
Conclusions
Comparing these results to Various
Authors results of subtalar arthrodesis
Arthrodesis Arthroereisis
Excellent-Good
70.9%
84%
Fair-Poor
29.1%
16%
Complications
27%
1%
( valgus, varus, nonunion, graft migration)
Subtalar Staple Arthroereisis
CONCLUSIONS
Subtalar Staple Arthroereisis
Conclusions
An Excellent Procedure for the
Management of Subtalar Instability in
the Young Child who has Severe
Talocalcaneal Subluxation secondary to
Neuromuscular Imbalance
Neuromuscular Planovalgus
Subtalar Staple Arthroereisis
THANK YOU
Dr. Donald W. Kucharzyk