the valgus foot in cerebral palsy equinovalgus – not plano ......subtalar neutral, varus or valgus...
TRANSCRIPT
The Valgus Foot in Cerebral Palsy Equinovalgus – not Plano-Valgus
Alfred D. Grant, M.D.David Feldman, M.D.N Ot k M DNorman Otsuka, M.D.
THE PURPOSE OF THIS PRESENTATION IS TO STATE CLEARLY THAT
THE VALGUS FOOT SEEN IN THE CEREBRAL PALSY PATIENT IS NOT PLANO-VALGUS BUT EQUINOVALGUS.
This Distinction Is Critical To Understanding The Extent And Evolution Of The Deformity,
As Well As The Rational For Non-surgical And SurgicalAs Well As The Rational For Non surgical And Surgical Management
Three Types Of Feet That Appear Flat
PLANO-VALGUS
LOW ARCHED SUPPLE FOOT
PLANO VALGUS•
EQUINOVALGUS FOOT
THREE TYPES OF FEET THAT APPEAR FLATTHAT APPEAR FLAT
PLANO VALGUSPLANO-VALGUS (Classic Flat Foot)
•Dropped longitudinal medial arch•Post Tibial too weak to elevate arch •Weight is born on the medial foot •Callosities along the entire medial arch g•HEEL CORD NOT TIGHT•
THREE TYPES OF FEET THAT APPEAR FLAT
LOW ARCHED SUPPLE FOOTLOW ARCHED SUPPLE FOOT (Runners)
•Low medial arch, •When weight is born the arch is
elevated by Post Tibial muscle •No callosities are seen medially. y•HEEL CORD NOT TIGHT
THREE TYPES OF FEET THAT APPEAR FLATTHAT APPEAR FLAT
EQUINOVALGUS FOOTQ(Paralytic i.e. CP. Polio)
•Primary problem - TIGHT HEEL CORD (possperonei)peronei)
•TIGHT HEEL CORD (peronei) LIMITS DORSIFLEXION
•Post Tibial not excessively tight or spastic•Post Tibial not excessively tight or spastic•Foot forced in valgus to be plantar grade
REVIEWING THE CP LITERATURE 184 PAPERS WERE FOUNDREVIEWING THE CP LITERATURE - 184 PAPERS WERE FOUND DESCRIBING THE FOOT AS PLANO-VALGUS OR VALGUS,
NONE EQUINOVALGUS.
In Correcting The Foot, The Focus Was Uniformly On The Valgus
Although Adjunctively StatedAlthough Adjunctively Stated,Those That Achieved Lasting Correction
All Corrected Equinus (W k d Th C lf(Weakened The Calf
I.E. Botox, Lengthened The Heel Cord (Peronei) Or Released The Gastrocnemius)
The Equinovalgus Foot
ALL EQUINOVALGUS FEET HAVE A TIGHT HEEL CORD
ANKLE DORSIFLEXION LIMITED BY THE TIGHT HEEL CORD
Not Limited WithNot Limited With Plano-valgus Or Low Arched Feet
The Equinovalgus Foot
CLINICAL TEST FOR THE CLINICAL TEST FOR THE EQUINOVALGUS FOOT
ANKLE DORSIFLEXION LIMITED BY THE TIGHT HEEL CORD
1
EQUINUS EVIDENT WHEN HEEL HELD IN NEUTRAL TO SLIGHT VARUS
2IN NEUTRAL TO SLIGHT VARUS
CLINICAL TEST FOR THE EQUINOVALGUS FOOT’ con’t
THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF PLANTARGRADE POSITION IF
THE FOOT IS IN VALGUS3
CLINICAL TEST FOR THE EQUINOVALGUS FOOT
THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF PLANTARGRADE POSITION IF
THE FOOT IS IN VALGUS3
CLINICAL TEST FOR THE EQUINOVALGUS FOOT
THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF PLANTARGRADE POSITION IF
THE FOOT IS IN VALGUS3
WHERE ELSE IS THERE DORSIFLEXIION?
Subtalar Joint Axis Is Downward And I M i P t i T A t iIn Moving Posterior To Anterior
INVERSION AND
EVERSION AND
EQUINUSAND
DORSIFLEXION
With Inversion (Varus) With Eversion (Valgus)With Inversion (Varus) Equinus Occurs
With Eversion (Valgus) Dorsiflexion Occurs
EQUINOVALGUS FOOT
Plantargrade Position Only Achieved By ThePlantargrade Position Only Achieved By The Foot Everting In to Valgus With Associated
DorsiflexionDorsiflexion
EQUINOVALGUS + CROUCH Compensatory Valgus Accentuated
If The Heel Cord Is Tight
Compensatory Valgus Accentuated
If The Heel Cord Is Tight (Equinus)
Additional Dorsiflexion Can Only Occur In The
Subtalar Joint
But
Subtalar Dorsiflexion Always Accompanied By Valgus**
Equinovalgus
**Rockerbottom With Mid Tarsal Break May Occur As WellRockerbottom With Mid Tarsal Break May Occur As Well
EQUINOVALGUS
SEVERITY VARIESSEVERITY VARIES
SEVEREMILD SEVEREMILD
FIXEDSUPPLEHEEL CORDS ALWAYS TIGHT
EQUINOVALGUS MILD AND SUPPLE to MODERATE AND SLIGHTLY STIFFMILD AND SUPPLE to MODERATE AND SLIGHTLY STIFF
HEEL EQUINUS AND VALGUSMILD MODERATEHEEL EQUINUS AND VALGUSMILD MODERATE
MIDFOOT VALGUS
FOREFOOT APPEARS PRONATED BUT
SUPPLE TO SLIGHTLY STIFFSUPPLE TO SLIGHTLY STIFF
SUPPLE SLIGHTLY STIFF
EQUINOVALGUS SEVERE +/- FIXED
HEEL EQUINUS AND VALGUS
SEVERE
HEEL EQUINUS AND VALGUS
MIDFOOT VALGUS
FOREFOOT APPEARSFOREFOOT APPEARS PRONATED
BUTSUPINATED TO HIND AND
HALLUX VALGUS
MIDFOOT - FIXED
FIXED
EVOLUTION OF SEVEREEVOLUTION OF SEVERE EQUINOVALGUS DEFORMITY
From Mild And Supple To Severe And Fixed
EVOLUTION OF SEVERE EQUINOVALGUS DEFORMITYEQUINOVALGUS DEFORMITY
1. Patient Rolls Over The Medial Side Of The Foot
23
2. Drives The Head Of The 1st
Metatarsal Up –
1
Accentuating The Entire Foot Pronation
3. Rolls Over The Medial Aspect Of The Hallux –Creating The Hallux Valgus
EVOLUTION OF SEVERE EQUINOVALGUS DEFORMITY
4. The Forefoot Is Less Pronated Th Mid A d Hi df t A d Fi d
56
Than Mid And Hindfoot And Fixed
5. Hind And Mid Foot Valgus Is Corrected To Neutral By Rotation
78
Corrected To Neutral By Rotation Around Subtalar Axis
6 When This Rotation Occurs The
4
6. When This Rotation Occurs The Fixed Forefoot Rotates Into Supination In Relation To The Neutral Hind And Mid FootNeutral Hind And Mid Foot
7. Elevation Of 1st Metatarsal Is The Main Cause Of This Supination
4. Pronated foot7. Head of the 1st metatarsal up8 Hallux valgus
p
8. Hallux valgus
Treatment StrategiesNon SurgicalNon-Surgical
Reduce Contractures – Stretching - Casts R d S ti it Bl k (B t t )Reduce Spasticity - Blocks (Botox etc.) Bracing
S i lSurgical
BRACING IS ABRACING IS A PROBLEM
Patients’ With A Spastic Calf Walk In EquinusPatients With A Spastic Calf Walk In Equinus Subtalar Neutral, Varus Or Valgus
Brace Is Needed To Gain And Maintain A Plantargrade Position
The AFO - Usually Has A Molded Scaphoid Arch Set At 90 Degrees Dorsiflexion The Heel And Subtalar Position Neutral
PROBLEM – The Equinovalgus Foot Cannot Achieve Plantar Grade Position In This Brace Subtalar Valgus And Pronation Needed
BRACING IS A PROBLEM
The AFO at 90 degree These Feet Cannot Achieve gsubtalar position set in
neutralPlantargrade Position In This
Brace
As The Foot Goes Into Valgus BRACING PROBLEM
gThe Talar Head “Slams” Against The Medial Wall
Of The Neutrally Positioned Brace
THE MEDIAL WALL AND THE MOLDED SCAPHOID ARCH PREVENT VALGUSPREVENT VALGUS
IRRITATION, CALLOUSITY AND PAIN OCCUR.
UNTREATED EQUINUS IS THE PROBLEM IN BRACING THE EQUINOVALGUS FOOT!THE EQUINOVALGUS FOOT!
SurgicalTreatmentSurgicalTreatment
THE MILD SUPPLE CP EQUINOVALGUS FOOT
Tight Heel Cords (And Possibly Spastic Peronei)Hindfoot, Forefoot And Midfoot Is Flexible.
EquinovalgusPost Heel Cord RxGood Dorsiflexion
Dropped Inner Arch
EquinovalgusPre Heel Cord RxPre Heel Cord Rx
Limited DorsiflexionPlantargrade Pronation
TREATMENTPrimarily Lengthening The Heel Cord (And Peronei) or
GastrocnemiusGastrocnemius
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS
CALF WEAKENING PROCEDURE
VALGUS MOSCA, GRICE GREEN. DENNYSON(Prominent Talar Head)
OS CALCIS OSTEOTOMY
DENNYSON
FIXED HEEL VALGUS OS CALCIS OSTEOTOMYSUBTALAR/TRIPLE FUSION
FOREFOOT SUPINATIONFIRST METATARSAL
ELEVATION FIXED
PLANTARFLEX FIRST METATARSAL MID TARSAL OSTEOTOMY
HALLUX VALGUS
CORRECT HALLUX VALGUS
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS
SPASTIC CONTRACTED HEEL CORD,
PERONEI
VALGUS SVALGUS(Prominent Talar Head)
FIXED HEEL VALGUS
TAL, STRAYER, LENGTHEN PERONEI
FIXED HEEL VALGUS
FOREFOOT SUPINATIONFIRST METATARSAL
ELEVATION FIXED
HALLUX VALGUS
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS
MOSCAEQUINUS MOSCALENGTHEN LATERAL COLUMNCorrect Choparts Subluxation
VALGUS(Prominent Talar
Head)
TIGHTEN MEDIAL STRUCTURESPlicate Spring Ligament,
Use Post & Ant Tibial Tendons For Added Medial SuppportHead)
FIXED HEEL VALGUS SUBTALAR (Extra Articular)
Added Medial Suppport
FOREFOOT SUPINATIONFIRST METATARSAL
SUBTALAR (Extra-Articular) Fusion)
GRICE GREEN – Sinus Tarsi GraftFIRST METATARSAL ELEVATION FIXED
GRICE GREEN Sinus Tarsi Graft
DENNYSON-S-T Graft + Screw Talar Neck To Calcaneus)
HALLUX VALGUS
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS
MOSCAEQUINUS
VALGUS
MOSCALENGTHEN LATERAL COLUMNCorrect Choparts Subluxation
VALGUS(Prominent Talar
Head)
TIGHTEN MEDIAL STRUCTURESPlicate Spring Ligament,
Use Post & Ant Tibial Tendons For Added Medial Suppport
FIXED HEEL VALGUS SUBTALAR (Extra Articular) Fusion)
Added Medial Suppport
FOREFOOT SUPINATIONFIRST METATARSAL
SUBTALAR (Extra-Articular) Fusion)
GRICE GREEN – Sinus Tarsi Graft
FIRST METATARSAL ELEVATION FIXED DENNYSON-S-T Graft + Screw
Talar Nec K To Calcaneus)
HALLUX VALGUSFAIL UNLESS EQUINUS AND SUPINATION CORRECTED
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS
VALGUS(Prominent Talar Head)
FIXED (Stiff)OS CALCIS
OSTEOTOMYFIXED (Stiff) HEEL VALGUS
OSTEOTOMY
SUBTALAR/TRIPLE FUSION
FOREFOOT SUPINATIONFIRST METATARSAL
ELEVATION FIXED
HALLUX VALGUS
ELEVATION FIXED
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS
VALGUS(Prominent Talar Head) PLANTARFLEX FIRST
METATARSALFIXED HEEL VALGUS
FOREFOOT
METATARSAL Osteotomy 1st Cuneiform, 1st Metatarsal Or Fuse 1st
Metatarsal Cuneiform JointFOREFOOT SUPINATION
First Metatarsal Elevation Fixed
Metatarsal Cuneiform Joint
MID TARSAL OSTEOTOMY
Elevation Fixed
HALLUX VALGUS
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS EQUINUS
FIXED HEEL VALGUS
VALGUS(Prominent Talar Head)
FIXED HEEL VALGUS
( )CORRECT HALLUX
VALGUSFuse IPJoint
FOREFOOT SUPINATIONFIRST METATARSAL
ELEVATION FIXED
HALLUX VALGUS
Failure 1
UNTREATED OR INADEQUATELY TREATED EQUINUS IS THE MAJOR CAUSE OF FAILURE WHEN TREATING
THE EQUINOVALGUS FOOT!THE EQUINOVALGUS FOOT!
DS Grice Further Experience WithDS Grice, Further Experience With Extraarticulatt Arthrodeses Of The Subtalar Joint, JBJS 1955 37A, pp. 246
FAILURES WERE DUE TO: • Failure To Correct The Equinus Deformityq y• Inadequate Placement Of The Calcaneus
Under The Talus
Failure 2 CROUCH Tight Heel Cord And HamstringsTight Heel Cord And Hamstrings
HEEL CORD ONLY
TAL ONLY INCREASES CROUCH
ONLY
TAL ONLY - INCREASES CROUCH –Correct Proximal Deformities And Imbalances (SEML)
Failure 3
ANKLE VALGUS CAN BEANKLE VALGUS CAN BE MISSED
AP X Of Th A klAP X-ray Of The Ankle Should Be Obtained Before
T ti S V lTreating Severe ValgusTRIPLE
ANKLE VALGUSANKLE VALGUS MISSED
Failure 4
If The Hind Foot Valgus And e d oo a gus dEversion Is Corrected
The Forefoot Supination Must Be Corrected (if fixed)Be Corrected (if fixed)
Weight Bearing On The Uncorrected Fixed Supinated Forefoot
Will Force The Hind Foot Back Into Eversion And Valgus
Even If Everything Else Is Properly y g p yCorrected
SPASTIC CONTRACTED
THE SEVERE EQUINOVALGUS FOOTVARYING STIFFNESS
HEEL CORD (+/-Peronei)
VALGUSVALGUSProminent Talar Head
ELONGATED MEDIAL COLUMN
FIXED HEEL VALGUS
FOREFOOT SUPINATIONFIRST METATARSAL
ELEVATION FIXED
HALLUX VALGUS
THE CP EQUINOVALGUS FOOT
SPASTIC CONTRACTED HEEL CORD
TAL, STRAYER
CORDMOSCA
LENGTHEN LATERAL COLUMNCORRECT CHOPARTS SUBLUXATION
TIGHTEN MEDIAL STRUCTURESVALGUS
USUAL Rx DIRECTION
PLICATE SPRING LIGAMENT, USE POST & ANT TIBIAL TEMDONS FOR ADDED MEDIAL SUPPPORT
EXTR-ARTICULAR FUSION-GRICE GREEN DENNYSON
VALGUS(Prominent Talar Head
Elongated Medial Column)
FIXED HEEL VALGUSOS CALCIS OSTEOTOMY
GRICE GREEN, DENNYSON
FOREFOOT SUPINATIONFIRST METATARSAL
ELEVATION FIXED
SUBTALAR/TRIPLE FUSION
PLANTARFLEX FIRST METATARSAL OSTEOTOMY 1st CUNEIFORM, FUSE
ELEVATION FIXED 1st METATARSAL CUNEIFORM JOINT
MID TARSAL OSTEOTOMY
HALLUX VALGUSCORRECT HALLUX VALGUS
FUSE IP JOINT
THE CP EQUINOVALGUS FOOT SPASTIC CONTRACTED
HEEL CORD, PeroneiTAL, STRAYERLengthen PeroneiHEEL CORD, Peronei
MOSCALENGTHEN LATERAL COLUMN
CORRECT CHOPARTS SUBLUXATIONTIGHTEN MEDIAL STRUCTURESVALGUS
DON’T FORGET!!
TIGHTEN MEDIAL STRUCTURESPLICATE SPRING LIGAMENT, USE POST & ANT
TIBIAL TEMDONS FOR ADDED MEDIAL SUPPPORT
EXTR-ARTICULAR FUSION-GRICE GREEN, DENNYSON
VALGUS(Prominent Talar Head
Elongated Medial Column)
FIXED HEEL VALGUSOS CALCIS OSTEOTOMY
SUBTALAR/TRIPLE FUSION
GRICE GREEN, DENNYSON
FOREFOOT SUPINATION
SUBTALAR/TRIPLE FUSION
PLANTARFLEX FIRST METATARSAL OSTEOTOMY 1st CUNEIFORM FUSEFOREFOOT SUPINATION
FIRST METATARSAL ELEVATION FIXEDOSTEOTOMY 1st CUNEIFORM, FUSE1st METATARSAL CUNEIFORM JOINT
MID TARSAL OSTEOTOMYHALLUX VALGUS
CORRECT HALLUX VALGUSFUSE IP JOINTFUSE IP JOINT
SUMMARY
ALL EQUINOVALGUS FEET HAVE A TIGHT HEEL CORD
UNTREATED OR INADEQUATELY TREATED EQUINUS IS THE MAJOR CAUSE OF FAILURE WHEN TREATING
THE EQUINOVALGUS FOOT!
TREATMENT OF THE SEVERE EQUINOVALGUS FOOT FAILS UNLESS EQUINUS AND SUPINATION CORRECTED
THANK YOU