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The Surgical Treatment of Neuromuscular Planovalgus “The Role of Staple Arthroereisis” Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute.

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Presentation on theme: "The Surgical Treatment of Neuromuscular Planovalgus “The Role of Staple Arthroereisis” Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute."— Presentation transcript:

1 The Surgical Treatment of Neuromuscular Planovalgus “The Role of Staple Arthroereisis” Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana

2 Neuromuscular Planovalgus zSevere PlanoValgus of the Foot in a Neuromuscular Child is a Complicated Matter to Treat zAltered Biomechanics and Secondary Changes can occur zBiomechanical Changes occur in the Subtalar Joint and Midfoot zSecondary Changes include: Altered Gait, Genu Recurvatum and Plantar Callous

3 Neuromuscular Planovalgus Functional Anatomy zTo Understand Planovalgus we need to look at the Functional Concepts of the Subtalar Joint zFrom a Functional Standpoint the Subtalar Joint is a Single Axis zThe Axis of Rotation Averages 41 deg. To the Horizontal and 23 deg. To the Midline of the Foot

4 Neuromuscular Planovalgus Functional Anatomy zThis Allows the Foot in Stance to Absorb the Torsion of the Tibial zThe Hindfoot Everts allowing the Talonavicular and Calcaneocuboid Joints to become Parallel giving free Motion to the Mid and Fore Foot zWeightbearing Forces are Transmitted Medial to the Calcaneous

5 Neuromuscular Planovalgus Functional Anatomy zMild Pronation in the Forefoot allows even Distribution of Weight on the Plantar Surface of the Foot zValgus Positioning of the Hindfoot allows the Center of Gravity to Pass over the Subtalar Joint easily zVarus Positioning, on the other hand, Results in a Semi-Rigid Foot with Abnormal Gait Pattern

6 Neuromuscular Planovalgus Biomechanics zIn a Neuromuscular Child, the Deformity is Produced through a Combination of Spasticity, Weakness, and Altered Motion during Gait zEquinus in the Hindfoot prevents Normal Dorsiflexion zShifts Dorsiflexion to the Midfoot zProduces a Rocker Bottom Foot with Valgus Hindfoot and Abducted Forefoot

7 Neuromuscular Planovalgus Biomechanics zThe Talus assumes a more Vertical and Medial Position zThe Calcaneus rotated Posterolaterally from its Normal Position zSustentaculum Tali loses its Supporting Position beneath the Neck of the Talus as the Calcaneus Subluxes Laterally zPosterior Tibialis loses its Function adding to the Planovalgus Deformity

8 Neuromuscular Planovalgus Biomechanics zTo Correct This Deformity, we must Address all aspects due to the altered biomechanics zCalcaneus Placed Beneath the Talus zReduction of the Hindfoot Equinus zMuscle Balance Must be Present zAvoidance of Varus Hindfoot zBest Achieved while Foot is Supple and not Fixed with Secondary Changes

9 Neuromuscular Planovalgus Etiology zSeen in A Variety of Paralytic Disorders zUpper Motor Neuron lesions producing Spasticity zLower Motor Neuron lesions zFlaccid Paralysis zCerebral Palsy zMyelodysplasia zPoliomyelitis

10 Neuromuscular Planovalgus Treatment Options zNONOPERATIVE Orthotics zOPERATIVE Subtalar Stabalization

11 Neuromuscular Planovalgus NonOperative Treatment zUCBL orthosis with medial wedge limited if equinus present as it will exaggerate midfoot collapse during gait zSMO when equinus and valgus deformity are marked and talus plantarflexed into vertical position

12 Neuromuscular Planovalgus Operative Treatment zSubtalar Extra-articulat Arthrodesis (Grice) zBatchelor Subtalar Arthrodesis zDennyson-Fulford Stabalization (Princess Margaret Rose) zStayPeg Procedure(Millar) zCalcaneal Osteotomies zTriple Arthrodesis

13 Neuromuscular Planovalgus Extra-Articular Arthrodesis zPreserves the Talonavicular and Calcaneocuboid Joints zCorrects Valgus deformity of Hindfoot zRestores Longitudinal Arch Height zDoes Not Correct Fixed Deformity zCan Produce loss of Lateral Mobility of the Hindfoot zMust Address Hindfoot Equinus (leading cause of failure)

14 Neuromuscular Planovalgus Extra-Articular Arthrodesis zVariable Success Rates reported (50- 85%) zTohen (JBJS 1969) 76% zBanks (CORR 1977) 76% zRoss & Lyne (CL.OR. 1980) 64% failure zBleck (1987) 50% failure zDvrark (1989) 94%

15 Neuromuscular Planovalgus Extra-Articular Arthrodesis zReasons for Failure Persistant ankle valgus Nonunion Migration of the Graft Ankle Varus

16 Neuromuscular Planovalgus Batchelor Subtalar Arthodesis zDoes not Expose the Subtalar Joint zInsert Fibular Graft from the Neck of the Talus across the sinus tarsi into the Calcaneus with Neutral Hindfoot zBrown (JBJS 1968) 17 out of 20 patients had stability with survival of the graft at 4 years

17 Neuromuscular Planovalgus Batchelor Subtalar Arthrodesis zSeymour and Evans (JBJS 1958) reason for success: simplicity of insertion and retention, fixation of the foot after insertion of the graft is stable zHsu, Yau, Obrien and Hodgson (JBJS 1972) complication of the procedure being late development of ankle valgus

18 Neuromuscular Planovalgus Dennyson-Fulford Stabalization zCortical screw inserted into the talar neck and laterally into the calcaneus zSinus Tarsi denuded and decorticated and grafted zMaintains correction of the deformity with rapid fusion

19 Neuromuscular Planiovalgus Dennyson-Fulford Stabalization zReported Fusion Success Rates of 94% (JBJS 1976) zBarrasso (JPO 1984) 95% fusion success rates zDeLuca (1990) similar fusion rates of 94-95% with the use of allograft

20 Neuromuscular Planovalgus Subtalar StayPeg Arthrorisis zCorrects heel Valgus zEliminates Abnormal Pronation zIncreased Medial Longitudinal Arch zPrevents forward movement of Talus zAllows readaptation of the foot via secondary bone and soft tissue changes

21 Neuromuscular Planovalgus Subtalar StayPeg Arthrorisis z92% success rate at 4 years (CORR 1983) zNo Major Complications zLow Incidence of the need for Mechanical Support PostOp zOnly Risk is Dislodgement of Stay Peg

22 Neuromuscular Planovalgus A NEW PROCEDURE SUBTALAR STAPLE ARTHROEREISIS zEliminates the need for Subtalar Arthrodesis in a Young Child zEliminates the need to insert a screw or graft across neck of talus zProduces predictable correction and results zDelays Arthrodesis till Older Age

23 Subtalar Staple Arthroeresis Biomechanical and Functional zStabalizes the Subtalar Joints zRequires a Supple Foot zRequires the Equinus to be corrected prior to the Procedure zBest Suited for Children less than Six years of age zContraindicated when forefoot can’t be placed plantigrade when hindfoot placed in neutral position

24 Subtalar Staple Arthroereisis Technique zLateral Arm of the Cincinnati Incision zTalocalcaneal Subluxation is corrected via release anterior, lateral and posterior articulations of subtalar joint zCalcaneus reduced and held in place zEquinus evaluated and corrected zVitallium Staple placed across joint with foot in 15 degrees of plantar flexion

25 Subtalar Staple Arthroereisis Clinical Study zCincinnati Children’s Hospital z20 patients (31 feet) zSpastic Planovalgus (CP and Myelo) zFollowup was on average 4 years (2 to7) zRadiographic evaluation included lateral talocalcaneal angle (preop, postop, and recent followup) zClinical, Radiographic Assessment zComplications

26 Subtalar Staple Arthroereisis Radiographic Assessment zLoss of Correction/Loss Talocalcaneal Angle zDivided into Excellent, Good, Fair and Poor zExcellent: less than 5 degree loss zGood: 5-10 degree loss zFair: over 10 degree loss zPoor: over 10 degree loss and worse than preop

27 Subtalar Staple Arthroereisis Radiographic Results zPreOp Talocalcaneal Angle: 50 degrees ( Range was from 32 deg. To 65 deg.) zPostOp Talocalcaneal Angle: 32 degrees ( Range was from 3 deg. To 44 deg.) zAverage Amount of Correction was 18 degrees

28 Subtalar Staple Arthroereisis Radiographic Results zExcellent: 15 (48%) zGood: 11 (36%) zFair: 2 ( 6%) zPoor: 3 (10%) EXCELLENT-GOOD RESULT: 84% FAIR- POOR: 16% Bank’s Criteria ( CORR 1977 )

29 Subtalar Staple Arthroereisis Complications zMINOR Breakdown of Wound: 1 Superficial Infection: 1 zMAJOR Migration of Staple: 1

30 Subtalar Staple Arthroereisis Recent Additional Study z10 patients (14 feet) zSpastic Cerebral Palsy zFollow-up: 2 plus 3 years (2 to 7) zRadiographic Results: Preop angle: 55 deg. Postop angle: 32 deg. Average Correction: 20 deg.

31 Subtalar Staple Arthroereisis Recent Additional Study zRadiographic Results: Excellent-Good: 85% Fair-Poor: 15% zComplications: Prominence of Staple: 1

32 Subtalar Staple Arthroereisis CLINICAL CASE

33 Subtalar Staple Arthroereisis Conclusions zSuitable for Stabalization of the planovalgus foot in Children less than Six years of age zStabalizes the joint while Secondary Adaptive Changes Occur (osseous and soft tissue) zDelayed and Eliminated the need for Osseous Fusion of the Growing Foot

34 Subtalar Staple Arthroereisis Conclusions zComparing 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)

35 Subtalar Staple Arthroereisis CONCLUSIONS

36 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

37 Neuromuscular Planovalgus Subtalar Staple Arthroereisis THANK YOU Dr. Donald W. Kucharzyk

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