Undercorrection of planovalgus deformity after calcaneal

Undercorrection of planovalgus deformity after calcaneal lengthening
in patients with cerebral palsy
Byung Chae Cho, MD1; In Hyeok Lee, MD2; Chin Youb Chung, MD1; Ki Jeong Kim, MD4; Ju Seok Ryu, MD5; Kyoung Min Lee, MD1;
Soon Sun Kwon, PhD3; Gye Wang Lee, MD1; Myoung Ki Chung, MD1; Moon Seok Park, MD1
1 Department
of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Korea.
2 Department of Orthopaedic Surgery, Sungkyunkwan University Samsung Changwon Hospital, Changwon, Korea.
3 Department of Mathematics, College of Natural Science, Ajou University, Gyeonggi, Korea
4 Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi, Korea
5 Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Gyeonggi, Korea.
OBJECTIVES
RESULTS
Calcaneal lengthening(CL) is one of the treatment options for
planovalgus deformity in patients with cerebral palsy.
A total of 44 patients (77 feet) were included in this study. Mean age at the time
of surgery was 10.5 ± 4.0 years, and the mean follow-up was 5.1 ± 2.2 years.
However, the its indication still needs to be clarified according to the
functional status of cerebral palsy.
Patients with GMFCS III/IV was achieved less correction than those with
GMFCS I/II in the AP talus-first metatarsal angle (p = 0.001), lateral
talocalcaneal angle (p = 0.028) and lateral talus-first metatarsal angle (p
< 0.001)(Table 1).
The aim of this study was to investigate the radiographic outcome after
CL in patients with CP and to evaluate the risk factors causing
undercorrection of planovalgus deformities.
Table 1. Estimation of the amount of correction
AP Talus-First
Metatarsal Angle
Intercept
The rate of undercorrection in the GMFCS III/IV group was 1.6 times higher
than that in the GMFCS I/II group in the AP talus-first metatarsal angle (OR: 1.6;
95% CI: 1.2-2.0; p < 0.001), and 1.6 times higher in the lateral talus-first
metatarsal angle (OR:1.6; 95% CI: 1.3-1.9; p < 0.001) (Table 2).
Age
Sex (male)
Side
Estimatio
n
(95% CI)
(deg)
-16.9
0.6 (-0.1
to 1.2)
-1.1 (-6.6
to 4.2)
p value
Estimatio
n
(95% CI)
(deg)
-
4.6
0.079
0.662
0.4
Lateral
Talocalcaneal
angle
Calcaneal pitch
angle
-0.2 (-0.7
to 0.3)
3.8 (-0.2
to 7.9)
p value
Estimatio
n
(95% CI)
(deg)
p value
-
-16.8
-
0.437
0.061
0.7 (0.2 to
1.2)
-1.0 (-4.8
to 2.8)
1.8
0.004
0.606
-1.3
Lateral Talus-First
Metatarsal Angle
Estimatio
n
(95% CI)
(deg)
p value
1.2 (0.5 to
1.9)
-5.1 (-10.9
to 0.6)
<0.001
0.077
-1.4
GMFCS
METHODS
We included consecutive patients with CP who underwent calcaneal
lengthening for planovalgus deformity, were followed for more than two
years, and had pre- and postoperative weight-bearing anteroposterior
and lateral foot radiographs.
Six radiographic indices were used to assess the radiographic outcome.
The patient age, sex, and GMFCS level were evaluated as possible risk
factors, and we controlled for the interaction of potentially confounding
variables using multivariate analysis.
Level I/II
(reference)
CONCLUSIONS
We found calcaneal lengthening to be an effective procedure for the correction
of planovalgus foot deformities in GMFCS I/II patients with cerebral
palsy(Figure 1).
Level III/IV
-
-
-
-
-
-
-
-
9.1 (3.8 to
14.5)
0.001
-2.0 (-6.0
to 2.0)
0.328
4.3 (0.5 to
8.1)
0.028
10.3 (4.6
to 16.0)
<0.001
Table 2. Potential risk factor for undercorrection
AP Talus-First
Metatarsal Angle
However, calcaneal lengthening alone results in a high undercorrection rate in
GMFCS III/IV patients with planovalgus deformities(Figure 2).
We believe that additional medial column stabilization procedures or
alternative procedures should be considered to correct the deformity and to
maintain the correction achieved.
Figure 1
Figure 2
Lateral
Talocalcaneal
angle
Calcaneal pitch
angle
Lateral Talus-First
Metatarsal Angle
Adjusted
Adjusted
Adjusted
Adjusted
ORs (95% p value ORs (95% p value ORs (95% p value ORs (95% p value
CI)
CI)
CI)
CI)
Age
1.0 (1.0 to
1.0)
0.688
1.0 (0.9 to
1.0)
0.003
1.0 (1.0 to
1.0)
0.271
1.0 (1.0 to
1.0)
0.158
Sex (male)
1.0 (0.8 to
1.2)
0.807
0.9 (0.7 to
1.1)
0.229
1.0 (0.8 to
1.2)
0.982
1.1 (0.9 to
1.4)
0.363
Side
0.4
1.8
-1.3
-1.4
GMFCS
Level I/II
(reference)
Figure 1. In patients with GMFCS level I/II, the rates of complete correction in
AP talus-first metatarsal angle and lateral talus-first metatarsal angle after
calcaneal lengthening were both 62.8%.
Level III/IV
Figure 2. By contrast, in the GMFCS III/IV group these rates were 20.6% in AP
talus-first metatarsal angle and 14.7% in lateral talus-first metatarsal angle.
-
-
-
-
-
-
-
-
1.6 (1.2 to
2.0)
<0.001
1.3 (1.1 to
1.6)
0.009
1.2 (1.0 to
1.5)
0.105
1.6 (1.3 to
1.9)
<0.001
*AP = anteroposterior, OR = odds ratio, CI = confidence interval