SLR - May 2021 - Zab’di L. Sanchez Prada
Reference: Rethlefsen SA, Hanson AM, Wren TAL, Kay RM; Children’s Orthopaedic Center, Children’s Hospital Los Angeles. Calcaneal Sliding Osteotomy Versus Calcaneal Lengthening Osteotomy for Valgus Foot Deformity Correction in Children With Cerebral Palsy. J Pediatr Orthop. 2021 Mar 17Level of Evidence: Level III, retrospective comparative study
Scientific Literature Review
Reviewed By: Zab’di L. Sanchez Prada, DPM
Residency Program: LIJ Forest Hills at Northwell Health – Queens, New York
Podiatric Relevance: Children with cerebral palsy (CP), a chronic disabling condition, often present with progressive foot deformity that affects their ambulatory function as they age. The role of a podiatric surgeon is to stabilize the lower extremity and facilitate the patient’s ability to ambulate independently. The purpose of this study was to examine the effectiveness of the medial calcaneal sliding (CS) osteotomy and lateral column lengthening (LCL) in relieving pain, improving transverse plane alignment and gait stability in children with CP with valgus foot deformities. The authors hypothesized that the two surgical approaches would have similar success with deformity correction and gait improvement, but that pes varus complications would result more often from LCL than CS.
Methods: A retrospective comparative study was performed in 72 children with CP and GMFCS levels I-III who underwent LCL (26) and CS (46) for valgus deformity correction as part of multi-level surgery. Surgical techniques and concomitant procedures, including talonavicular (TN) fusion in CS were described. The mean age was 11.1 and an average follow-up time of 3.2 years. Complications were examined via the Modified Clavien-Dindo system, change in standing foot position, and change in gait kinematics and kinetics preoperatively and postoperatively were recorded via Vicon Motion Systems and data examined via the Modified Yoon system. Statistical analysis between the two groups was performed using t tests, fisher exact test and survivorship analyses using Cox proportional hazard models.
Results: Complication rates were low in both groups (P=0.14) with transient neuropraxia due to hamstring lengthening and plantar hypersensitivity from cast pressure in CS group only. Deformity correction was successfully maintained in 71 percent of the CS group and 36 percent of the LCL group for an average of 8 years, with discrepancies likely due to longer follow-up in the LCL group. Both approaches may result in recurrent valgus deformity and need for additional surgeries. However, patients with lower ambulatory function and obligate brace wearers who underwent concomitant TN fusion with CS did not experience this recurrence. No changes preoperatively or postoperatively were observed in ankle kinematics and kinetics during gait in both groups.
Conclusions: The authors concluded that CS and LCL have similar effectiveness in providing long-term correction of valgus foot deformities in children with CP. Concomitant TN fusion successfully improved the effectiveness of CS in lower functioning patients with severe deformities and obligate brace wearers. Despite the higher incidence of pes varus development in the LCL group, it was not statistically significant to confirm the authors’ hypothesis. CP is considered a non-progressive condition with changing motor and sensory impairments that worsen as patients age; surgical intervention is employed to address pain and functional ambulation. Prior to this study, comparisons between CS and LCL had not been previously reported. Understanding the long-term effectiveness of the various surgical approaches for pes valgus deformity can guide surgical-decision making for the podiatric surgeon while ensuring excellent outcomes in patients with severe deformities as observed in children with CP.