ki hyuk sung, md amount of correction after calcaneal lengthening for planovalgus foot deformity in...
TRANSCRIPT
Ki Hyuk Sung, MD
Amount of correction after calcaneal lengthening for planovalgus foot
deformity in patients with cerebral palsy
Seoul National University Bundang Hospital
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Introduction
• Planovalgus foot deformity is common in patients with cerebral palsy
• A complex 3-D malalignment– hindfoot valgus, plantar flexed talus– midfoot planus and pronation– relatively short lateral column– forefoot abduction and supination
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Introduction
• Medial callosities
• Hallux valgus
• Shoe wear
• Pain
• Gait disturbance due to lever arm dysfunction
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Introduction
• Surgical options
– medial displacement osteotomy of calcaneus
– subtalar extra-articular arthrodesis
– lengthening of the lateral column
– triple arthrodesis
• Calcaneal lengthening osteotomy
– most commonly used to correct the deformity
and not sacrifice joint motion in patients with CP
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Introduction
• Additional procedures, such as, medial soft tissue
procedure, medial bony procedure, or triple
arthrodesis could be performed concomitantly with
calcaneal lengthening depending on severity of
deformity.
• However, there has been no guideline to determine
the necessity of these procedures
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Purpose of the study
• To investigate the amount of correction
after calcaneal lengthening for the
treatment of planovalgus foot deformity in
patients with CP
• To guide a surgical indication in terms of
the severity of the foot deformity
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Materials and Methods
• Retrospective design
• Inclusion
– patients with cerebral palsy who underwent
calcaneal lengthening for planovalgus deformity
between 2003 and 2011
– patients who had preop and postop weight bearing
AP and lateral foot radiographs
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Materials and Methods
• Exclusion
– patients who had concomitant medial column
procedures with calcaneal lengthening
– patients with a history of previous foot surgery
– patients with inadequate foot radiographs for
measurement
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Radiographic measurement
• Lateral foot weight bearing radiograph
– Calcaneal pitch angle
– Lateral talocalcaneal angle
– Lateral talus-first metatarsal angle
– Naviculocuboid overlap
– Relative calcaneal length
– Calcaneocuboid subluxation
• Anteroposterior foot weight bearing radiograph
– Anteroposterior talus-first metatarsal angle
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Calcaneal pitch angle
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Lateral talocalcaneal angle
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Lateral talus-first metatarsal angle
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Naviculocuboid overlap (B/A)
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Relative calcaneal length (a/b)
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Calcaneocuboid subluxation
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
AP talus-first metatarsal angle
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Operative procedure
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
`
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
• Corrected group
– a group of patients whose radiographic indices
improved beyond the value of normal alignment
after calcaneal lengthening
• Under-corrected group
– a group of patients whose radiographic indices
did not reach the value of normal alignment
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Reliability of radiographic measurement
• Inter-observer reliability (3 observer)
• 36 radiographs
• ICC (intraclass correlation coefficient) &
95% confidence interval
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Statistical analysis
• Comparison between preop radiographic
measurement and postoperative measurement
– Paired t-test
• Define the cut-off values of the preop radiographic
measurements between the corrected and the
under-corrected group
– ROC curve
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Results
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Table 1. Patients demographics and surgical procedures
Gender (M / F) 51 / 24
Age (year) 11.0±5.2 (range 5.4 to 30.1)
Geographic type (hemiplegia/diplegia/triplegia/quadriplegia)
5 / 48 / 3/ 19
Follow-up duration (year) 3.1±2.2 (range 0.3 to 8.4)
Calcaneal lengthening (bilateral/ unilateral) 54 / 21
Number of surgical procedures per patient 6.7 ± 3.0 (range 2 to 14)
Data are presented as mean ± SD
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Table 2. Inter-observer reliability of radiographic parameters
Radiographic parameters ICC 95% CI
AP talus-1st metatarsal angle 0.736 0.595 to 0.844
calcaneal pitch angle 0.918 0.864 to 0.954
Lateral talocalacneal angle 0.722 0.521 to 0.848
Lateral talus-1st metatarsal angle 0.793 0.641 to 0.887
Naviculocuboid overlap 0.915 0.859 to 0.953
Relative calcaneal length 0.817 0.709 to 0.895
Calcaneaocoboid subluxation 0.794 0.673 to 0.881
ICC, intraclass correlation coefficient
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Table 3. Change in radiographic measurements after calcaneal lengthening in patients with cerebral palsy
Parameters Preoperative PostoperativeMean
differencep-
valueNormal
alignment
AP talo-1MT (˚) 22.3±11.3 2.4±13.6 19.9±14.4 <0.001 10±7.0
CP (˚) 2.9±8.8 7.3±8.1 -4.4±7.2 <0.001 17±6.0
Lat TC (˚) 47.0±9.5 37.9.±9.2 9.1±8.5 <0.001 49±6.9
Lat talo-1MT (˚) 30.2±15.6 11.6±13.1 18.5±13.8 <0.001 13±7.5
NC overlap (%) 69.0±17.2 37.8±22.1 31.2±22.9 <0.001 47±13.8
Relative calcaneal length 1.9±0.2 2.0±0.3 -0.1±0.3 0.016 -
CC subluxation (˚) 0.2±1.5 1.4±1.9 -1.2±1.8 <0.001 -
AP talo-1MT, anteroposterior talus-first metatarsal angle; CP, calcaneal pitch angle; Lat TC, lateral talocalcaneal angle; Lat talo-1MT, lateral talus-first metatarsal angle; NC overlap, naviculocuboid overlap; CC subluxation, calcaneocuboid joint subluxation.
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Table 4. Cut-off values of the preoperative radiographic measurements between the corrected and the under-corrected group after calcaneal lengthening in patients with cerebral palsy
ParametersNo. of subject
(corrected group)
No. of subject (under-corrected
group)
Area under the ROC curve
95% CI p- valueCut-off value
AP talo-1MT (˚) 54 21 0.729 0.614 to 0.825 0.0001 >23˚
Lat talo-1MT (˚) 45 30 0.754 0.641 to 0.847 <0.0001 >36˚
NC overlap (%) 47 28 0.645 0.526 to 0.752 0.0319 >72%
AP talo-1MT, anteroposterior talus-first metatarsal angle; Lat talo-1MT, lateral talus-first metatarsal angle; NC overlap, naviculocuboid overlap; ROC curve, Receiver Operating Characteristic curve.
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Conclusions
• Calcaneal lengthening with concomitant
peroneus brevis lengthening is the effective
procedure for correcting planovalgus foot
deformity while preserving subtalar joint
motion in patients with cerebral palsy.
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Conclusions
• For the patients with more than 23˚of AP
talus-first MT angle, more than 36˚of Lat.
talus-first MT angle, and more than 72% of NC
overlap, the additional procedures should be
considered due to the possibilities of
insufficient correction with calcaneal
lengthening alone.
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL
Thank you !