The Valgus Foot in Cerebral Palsy Equinovalgus not Plano-Valgus. Alfred D. Grant, M.D. David Feldman, M.D.
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1 The Valgus Foot in Cerebral Palsy Equinovalgus not Plano-Valgus Alfred D. Grant, M.D. David Feldman, M.D. Norman Otsuka, MD M.D.
2 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 Surgical Management
3 Three Types Of Feet That Appear Flat PLANO-VALGUS LOW ARCHED SUPPLE FOOT EQUINOVALGUS FOOT
4 THREE TYPES OF FEET THAT APPEAR FLAT PLANO-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 HEEL CORD NOT TIGHT
5 THREE TYPES OF FEET THAT APPEAR FLAT LOW ARCHED SUPPLE FOOT (Runners) Low medial arch, When weight is born the arch is elevated by Post Tibial muscle No callosities are seen medially. HEEL CORD NOT TIGHT
6 THREE TYPES OF FEET THAT APPEAR FLAT EQUINOVALGUS FOOT (Paralytic i.e. CP. Polio) Primary problem - TIGHT HEEL CORD (poss peronei) TIGHT HEEL CORD (peronei) LIMITS DORSIFLEXION Post Tibial not excessively tight or spastic Foot forced in valgus to be plantar grade
7 REVIEWING THE CP LITERATURE PAPERSWEREFOUND DESCRIBING THE FOOT AS PLANO-VALGUS OR VALGUS, NONE EQUINOVALGUS. In Correcting The Foot, The Focus Was Uniformly On The Valgus Although Adjunctively Stated, Those That Achieved Lasting Correction All Corrected Equinus (Weakened The Calf I.E. Botox, Lengthened The Heel Cord (Peronei) Or Released The Gastrocnemius)
8 The Equinovalgus Foot ALL EQUINOVALGUS FEET HAVE A TIGHT HEEL CORD ANKLE DORSIFLEXION LIMITED BY THE TIGHT HEEL CORD Not Limited With Plano-valgus Or Low Arched Feet
9 The Equinovalgus Foot CLINICAL TEST FOR THE EQUINOVALGUS FOOT 1 ANKLE DORSIFLEXION LIMITED BY THE TIGHT HEEL CORD 2 EQUINUS EVIDENT WHEN HEEL HELD IN NEUTRAL TO SLIGHT VARUS
10 CLINICAL TEST FOR THE EQUINOVALGUS FOOT con t 3 THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF THE FOOT IS IN VALGUS
11 CLINICAL TEST FOR THE EQUINOVALGUS FOOT 3 THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF THE FOOT IS IN VALGUS
12 CLINICAL TEST FOR THE EQUINOVALGUS FOOT 3 THE LIMB CAN ONLY ACHIEVE A PLANTARGRADE POSITION IF THE FOOT IS IN VALGUS WHERE ELSE IS THERE DORSIFLEXIION?
13 Subtalar Joint Axis Is Downward And In Moving Posterior To Anterior INVERSION AND EQUINUS EVERSION AND DORSIFLEXION With Inversion (Varus) Equinus Occurs With Eversion (Valgus) Dorsiflexion Occurs
14 EQUINOVALGUS FOOT Plantargrade Position Only Achieved By The Foot Everting In to Valgus With Associated Dorsiflexion
15 EQUINOVALGUS + CROUCH 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 Well
16 EQUINOVALGUS SEVERITY VARIES MILD SUPPLE HEEL CORDS ALWAYS TIGHT SEVERE FIXED
17 EQUINOVALGUS MILD AND SUPPLE to MODERATE AND SLIGHTLY STIFF MILD HEEL EQUINUS AND VALGUS MODERATE MIDFOOT VALGUS FOREFOOT APPEARS PRONATED BUT SUPPLE TO SLIGHTLY STIFF SUPPLE SLIGHTLY STIFF
18 EQUINOVALGUS SEVERE +/- FIXED SEVERE HEEL EQUINUS AND VALGUS MIDFOOT VALGUS FOREFOOT APPEARS PRONATED BUT SUPINATED TO HIND AND MIDFOOT - FIXED HALLUX VALGUS FIXED
19 EVOLUTION OF SEVERE EVOLUTION OF SEVERE EQUINOVALGUS DEFORMITY From Mild And Supple To Severe And Fixed
20 EVOLUTION OF SEVERE EQUINOVALGUS DEFORMITY 1. Patient Rolls Over The Medial Side Of The Foot Drives The Head Of The 1 st Metatarsal Up Accentuating The Entire Foot Pronation 1 3. Rolls Over The Medial Aspect Of The Hallux Creating The Hallux Valgus
21 EVOLUTION OF SEVERE EQUINOVALGUS DEFORMITY 4. The Forefoot Is Less Pronated Than Mid And Hindfoot And Fixed Hind And Mid Foot Valgus Is Corrected To Neutral By Rotation Around Subtalar Axis 6. When This Rotation Occurs The Fixed Forefoot Rotates Into Supination In Relation To The Neutral Hind And Mid Foot Elevation Of 1 st Metatarsal Is The Main Cause Of This Supination 4. Pronated foot 7. Head of the 1 st metatarsal up 8. Hallux valgus
22 Treatment Strategies Non-Surgical Reduce Contractures Stretching - Casts Reduce Spasticity it - Blocks (Botox etc.) Bracing Surgical
23 BRACING IS A BRACING IS A PROBLEM
24 Patients 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
25 BRACING IS A PROBLEM The AFO at 90 degree subtalar position set in neutral These Feet Cannot Achieve Plantargrade Position In This Brace
26 BRACING PROBLEM As The Foot Goes Into Valgus The Talar Head Slams Against The Medial Wall Of The Neutrally Positioned Brace THE MEDIAL WALL AND THE MOLDED SCAPHOID ARCH PREVENT VALGUS IRRITATION, CALLOUSITY AND PAIN OCCUR. UNTREATED EQUINUS IS THE PROBLEM IN BRACING THE EQUINOVALGUS FOOT!
27 SurgicalTreatment
28 THE MILD SUPPLE CP EQUINOVALGUS FOOT Tight Heel Cords (And Possibly Spastic Peronei) Hindfoot, Forefoot And Midfoot Is Flexible. Equinovalgus Post Heel Cord Rx Good Dorsiflexion Dropped Inner Arch Equinovalgus Pre Heel Cord Rx Limited Dorsiflexion Plantargrade Pronation TREATMENT Primarily Lengthening The Heel Cord (And Peronei) or Gastrocnemius
29 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS EQUINUS CALF WEAKENING PROCEDURE VALGUS (Prominent Talar Head) MOSCA, GRICE GREEN. DENNYSON FIXED HEEL VALGUS OS CALCIS OSTEOTOMY SUBTALAR/TRIPLE FUSION FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED PLANTARFLEX FIRST METATARSAL MID TARSAL OSTEOTOMY HALLUX VALGUS CORRECT HALLUX VALGUS
30 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS SPASTIC CONTRACTED HEEL CORD, PERONEI VALGUS (Prominent Talar Head) TAL, STRAYER, LENGTHEN PERONEI FIXED HEEL VALGUS FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED HALLUX VALGUS
31 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS EQUINUS VALGUS (Prominent Talar Head) MOSCA LENGTHEN LATERAL COLUMN Correct Choparts Subluxation TIGHTEN MEDIAL STRUCTURES Plicate Spring Ligament, Use Post & Ant Tibial Tendons For Added Medial Suppport FIXED HEEL VALGUS FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED HALLUX VALGUS SUBTALAR (Extra-Articular) Fusion) GRICE GREEN Sinus Tarsi Graft DENNYSON-S-T Graft + Screw Talar Neck To Calcaneus)
32 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS EQUINUS VALGUS (Prominent Talar Head) MOSCA LENGTHEN LATERAL COLUMN Correct Choparts Subluxation TIGHTEN MEDIAL STRUCTURES Plicate Spring Ligament, Use Post & Ant Tibial Tendons For Added Medial Suppport FIXED HEEL VALGUS FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED SUBTALAR (Extra-Articular) Fusion) GRICE GREEN Sinus Tarsi Graft DENNYSON-S-T Graft + Screw Talar Nec K To Calcaneus) HALLUX VALGUS FAIL UNLESS EQUINUS AND SUPINATION CORRECTED
33 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS EQUINUS VALGUS (Prominent Talar Head) FIXED (Stiff) HEEL VALGUS OS CALCIS OSTEOTOMY SUBTALAR/TRIPLE FUSION FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED HALLUX VALGUS
34 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS EQUINUS VALGUS (Prominent Talar Head) FIXED HEEL VALGUS FOREFOOT SUPINATION First Metatarsal Elevation Fixed PLANTARFLEX FIRST METATARSAL Osteotomy 1 st Cuneiform, 1 st Metatarsal Or Fuse 1 st Metatarsal Cuneiform Joint MID TARSAL OSTEOTOMY HALLUX VALGUS
35 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS EQUINUS FIXED HEEL VALGUS VALGUS (Prominent Talar Head) FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED CORRECT HALLUX VALGUS Fuse IPJoint HALLUX VALGUS
36 Failure 1 UNTREATED OR INADEQUATELY TREATED EQUINUS IS THE MAJOR CAUSE OF FAILURE WHEN TREATING THE EQUINOVALGUS FOOT! DS Grice, Further Experience With Extraarticulatt Arthrodeses Of The Subtalar Joint, JBJS A, pp. 246 FAILURES WERE DUE TO: Failure To Correct The Equinus Deformity Inadequate Placement Of The Calcaneus Under The Talus
37 Failure 2 CROUCH Tight Heel Cord And Hamstrings HEEL CORD ONLY TAL ONLY - INCREASES CROUCH Correct Proximal Deformities And Imbalances (SEML)
38 Failure 3 ANKLE VALGUS CAN BE MISSED AP X-ray Of The Ankle Should Be Obtained Before Treating Severe Valgus TRIPLE ANKLE VALGUS MISSED
39 Failure 4 If The Hind Foot Valgus And Eversion Is Corrected The Forefoot Supination Must 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 Corrected
40 THE SEVERE EQUINOVALGUS FOOT VARYING STIFFNESS SPASTIC CONTRACTED HEEL CORD (+/-Peronei) VALGUS Prominent Talar Head ELONGATED MEDIAL COLUMN FIXED HEEL VALGUS FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED HALLUX VALGUS
41 THE CP EQUINOVALGUS FOOT USUAL Rx DIRECTION SPASTIC CONTRACTED HEEL CORD VALGUS (Prominent Talar Head Elongated Medial Column) FIXED HEEL VALGUS TAL, STRAYER MOSCA LENGTHEN LATERAL COLUMN CORRECT CHOPARTS SUBLUXATION TIGHTEN MEDIAL STRUCTURES PLICATE SPRING LIGAMENT, USE POST & ANT TIBIAL TEMDONS FOR ADDED MEDIAL SUPPPORT EXTR-ARTICULAR FUSION- GRICE GREEN, DENNYSON OS CALCIS OSTEOTOMY SUBTALAR/TRIPLE FUSION FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED PLANTARFLEX FIRST METATARSAL OSTEOTOMY 1 st CUNEIFORM, FUSE 1 st METATARSAL CUNEIFORM JOINT MID TARSAL OSTEOTOMY HALLUX VALGUS CORRECT HALLUX VALGUS FUSE IP JOINT
42 THE CP EQUINOVALGUS FOOT DON T FORGET!! SPASTIC CONTRACTED HEEL CORD, Peronei VALGUS (Prominent Talar Head Elongated Medial Column) FIXED HEEL VALGUS TAL, STRAYER Lengthen Peronei MOSCA LENGTHEN LATERAL COLUMN CORRECT CHOPARTS SUBLUXATION TIGHTEN MEDIAL STRUCTURES PLICATE SPRING LIGAMENT, USE POST & ANT TIBIAL TEMDONS FOR ADDED MEDIAL SUPPPORT EXTR-ARTICULAR FUSION- GRICE GREEN, DENNYSON OS CALCIS OSTEOTOMY SUBTALAR/TRIPLE FUSION FOREFOOT SUPINATION FIRST METATARSAL ELEVATION FIXED HALLUX VALGUS PLANTARFLEX FIRST METATARSAL OSTEOTOMY 1 st CUNEIFORM, FUSE 1 st METATARSAL CUNEIFORM JOINT MID TARSAL OSTEOTOMY CORRECT HALLUX VALGUS FUSE IP JOINT
43 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
44 THANK YOU
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