Surgical Treatment of Pes Planovalgus in Ambulatory Children with Cerebral Palsy: Static and Dynamic Changes as Characterized by Multi-Segment Foot Modeling, Physical Examination and Radiographs

SLR - December 2020 - Stephanie Behme

Reference: Nahm NJ, Sohrweide SS, Wervey RA, Schwartz MH, and Novacheck TF. Surgical Treatment of Pes Planovalgus in Ambulatory Children with Cerebral Palsy: Static and Dynamic Changes as Characterized by Multi-Segment Foot Modeling, Physical Examination and Radiographs. Gait Posture. 2020 Feb;76:168-174. 

Level of Evidence: Level 4

Scientific Literature Review

Reviewed By: Stephanie Behme, DPM
Residency Program: McLaren Oakland Hospital – Pontiac, MI

Podiatric Relevance: Pes planovalgus deformity is a common deformity among cerebral palsy patients. Correcting this deformity early and preventing spasticity of the peroneal muscles and over tightening of the gastrocnemius muscles may keep patient’s ambulatory longer in their lives. This research may give further clues to keeping cerebral palsy patients remain ambulatory for extended periods by correcting their deformities earlier. Using this study’s multi-segmented foot modeling (MSFM) in three-dimensional gait analysis could keep cerebral palsy patient’s ambulatory longer with more effective surgical intervention. 

Methods: This is a retrospective cohort study examining patients who either had surgical intervention including calcaneal Mosca lengthening, medial cuneiform wedge osteotomy, and tendo-Achilles lengthening (24 patients, with 18 being bilateral) or were treated conservatively with AFO/orthotic management (17 patients). The decision for surgical versus non-surgical management was determined by MSFM modeling using a 12-camera system and evaluating numerous joints and angles. This multi-segment foot modeling was used for serial follow up in both groups along with radiographs to determine joint alignment. Radiographs were compared to that of healthy individuals (30) as a control group. 

Results: A total of 24 surgical and 17 non-surgical patients were identified. The average time between gait analysis pre- and postoperatively was 1.5 years. Radiographic and biomechanical parameters using MSFM were compared in each group before and after intervention. Overall, the surgical group showed statistical significant improvement in hindfoot eversion (p = 0.004), midfoot abduction (p < 0.001), subtalar joint neutral position (STJN) offset in the midfoot (p < 0.001), forefoot varus in non-weightbearing STJN (p < 0.001), dorsal talo-first metatarsal angle (p < 0.001), lateral talo-first metatarsal angle (p < 0.001), and calcaneal pitch (p < 0.001) compared to the non-surgical group.

Conclusions: The authors concluded that the radiographic parameters improved postoperatively compared to those treated non-surgically. Even though post-operative surgical outcomes did not fully restore alignment as measured by MSFM, this method may lead surgeons to identify patients who would benefit from surgical intervention. Furthermore, a more aggressive surgical approach may be needed to achieve normalization since overcorrection was rare. Utilization of these techniques might aid in identifying surgical procedures that can optimize postoperative results. This study could be useful in future studies if investigators are willing to stratify patients into different types of surgical procedures instead of a standard protocol for treatment of cerebral palsy. The MSFM model may also be useful in surgical planning in correcting pes planus, pes cavus, or other congenital conditions.