The Batchelor-Grice extra-articular subtalar arthrodesis

Grice extra-articular subtalar fusion for spastic pes planovalgus

INTRODUCTION

A pes planovalgus deformity, an unstable foot deformity, affects the gait of children with cerebral palsy (CP). Treatments, including subtalar fusion, were proposed. The Grice procedure maintains foot stability, but bone graft non-union poses a challenge. This study aimed to identify the rate and factors related to post-operative bone graft non-union.

METHODS

Thirty-one paediatric CP patients (age, 8.9 ± 1.8 years) who underwent the Grice procedure (53 feet) using ipsilateral tibial bone grafts were reviewed. Pre-operative gross motor function classification system (GMFCS) classes were class 1 in five, 2 in five, 3 in 14, and 4 in seven patients. Standing foot radiographs were assessed for signs of non-union, and parameters (talocalcaneal and talar declination angles and talar head uncovering index) measured pre-operatively, post-operatively, and at the most recent evaluation were compared. Factors associated with bone graft non-union were analysed by regression analysis. P < 0.05 was considered statistically significant. Degenerative changes in hindfoot joints were evaluated by Bargon's criteria.

RESULTS

At the average follow-up evaluation at 5.4 ± 4.3 years, the GMFCS class was improved or was maintained in 29/31 patients. Post-operative radiographic measurements were restored and were maintained over the follow-up period (P < 0.001). A total of 14/53 feet (26%) had non-union. The pre-operative lateral talocalcaneal angle (OR 1.08, p = 0.04) and follow-up duration (OR 1.18, p = 0.03) were identified in univariate analysis as potential factors related to non-union but were not confirmed in a multivariate model. Hindfoot joints in most feet showed mild degenerative changes.

CONCLUSION

Grice subtalar fusion in patients with a higher pre-operative lateral talocalcaneal angle might lead to bone graft non-union.

Long-term outcome of extraarticular subtalar arthrodesis in children with cerebral palsy using modified Grice technique

The purpose of the study is to describe and analyse long-term results of the modified Grice procedure with specially prepared pre-shaped autograft from iliac crest. 54 patients (101 feet) who underwent modified Grice procedure, were retrospectively analysed. Before and after the surgery, talocalcaneal (TC) angle and calcaneal inclination (CI) angle were measured and compared with post-operative values. Furthermore, AOFAS score was assess pre-and postoperatively as well as the subjective evaluation of the patients or their parents. Detailed analysis was performed separately for patients with different forms of CP. Postoperatively, TC angle and subjective assessment decreased, and CI angle and AOFAS score increased significantly compared to pre-operative values. The significant difference was observed among different CP groups in all observed parameters. Severe complications were not observed. The modified Grice procedure with specially prepared pre-shaped autograft showed promising long-term results.

Subtalar Fusion Preparation: What Are We Really Doing? A Cadaver Study

Introduction. The open, lateral sinus tarsi approach is the most commonly used technique for subtalar arthrodesis. In this cadaver study, we measured the maximum joint surface area that could be denuded of cartilage and subchondral bone through this approach. Methods. Nine fresh frozen above-knee specimens were used. The subtalar joint was accessed through a lateral incision from the fibular malleolus distally over the sinus tarsi area to the level of the calcaneocuboid joint. Cartilage was removed from the anterior, middle, and posterior facets of the calcaneus and talus using an osteotome and/or curette. ImageJ was used to calculate the surface areas of undenuded cartilage. Results. No specimens were 100% denuded of cartilage on all 6 measured surfaces. The greatest percentages of unprepared surface area remained on the middle facet of the talus (18.66%) and the middle facet of the calcaneus (14.51%). The anterior facet of the talus was 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 specimens. The anterior facet of the calcaneus was also 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 and 4 specimens, respectively. The average total unprepared surface area per specimen was 8.67%. Conclusion. The lateral sinus tarsi approach provides adequate denudation of cartilage of the subtalar joint in most cases. Total percentage of unprepared joint surface may range from approximately 2% to 18%. Future clinical studies are warranted to assess whether this technique results in optimal union rates. Levels of Evidence:V, Cadaveric Study.

Pes planovalgus deformity in children with cerebral palsy: review article

Pes planovalgus deformity is common in children with cerebral palsy. In planovalgus foot, the talus subluxates medially, the calcaneus is in valgus, and the forefoot is in supination and external rotation related to the midfoot. In young children, mild planovalgus feet can be managed with orthotics. Surgery is indicated if the deformity is not reducible or if the patient cannot tolerate orthotics during functional activities. The surgery can be calcaneal lengthening or subtalar fusion to restore a stable plantigrade foot and achieve hindfoot correction. Medial column fusion is important to reconstruct the medial arch in severe planovalgus feet.

The results of Grice Green subtalar arthrodesis of valgus foot in spina bifida

BACKGROUND

Valgus foot is a common foot deformity in spina bifida. The most popular operation for the valgus deformity has been the Grice talocalcaneal blocking. It has not been studied primarily in children with spina bifida. We report a prospective series, we present the results of hind foot valgus deformity of children with spina bifida, using Grice talocalcaneal arthrodesis with a tricortical iliac bone graft.

MATERIALS AND METHODS

Between May 2000 and December 2003, 21 patients with bilateral (42 feet) valgus deformity of feet underwent surgery. There were 7 males and 14 females. The mean age of patients was 67.7 months (range 50-108 months).

RESULTS

The total number of feet that had nonunion was 11, in 7 of them the grafts were completely reabsorbed and the outcome of all these feet was unsatisfactory. Four feet had partial union of which three had unsatisfactory and one had satisfactory outcome. Sixteen feet had residual valgus deformity at the last followup visit, 10 patients had nonunion, and 6 had inadequate correction. Mean preoperative talocalcaneal and calcaneal pitch angles were 48.5° and 31.9°, respectively, which decreased to 38.5° and 29.1°, respectively, postoperatively. The decrease in talocalcaneal angle and calcaneal pitch was significant between preoperative and postoperative measurements (P<0.05).

CONCLUSION

Grice subtalar arthrodesis technique is still a valuable option for valgus foot in patients with spina bifida. In this study, we found more encouraging results in older patients.

Overview of subtalar arthrodesis techniques: options, pitfalls and solutions

BACKGROUND

Subtalar arthrodesis (SA) is the preferred treatment for painful isolated subtalar disease. Although results are generally favourable, analysis of current operative techniques will help optimizing this treatment. The aim was to give an overview of SA-techniques and their pitfalls. Possible solutions were identified.

MATERIALS AND METHODS

A literature search was performed for papers that presented SA operative techniques. The general technique was divided into phases: surgical approach, cartilage removal, bone graft selection, hindfoot deformity correction and fixation.

RESULTS

The published series were invariably retrospective reviews of small heterogenous groups of different hindfoot pathologies. The weighted outcome rate for SA was 85% (68-100%) performed in 766 feet and for SA requiring correction of malalignment 65% (36-96%) in 1001 feet. Non-union (weighted percentage 12%), malalignment (18%), and screw removal (17%) were the prevailing late complications.

PITFALLS

The following pitfalls were identified: 1) early complications related to the incisions made in open approaches, 2) insufficient cartilage removal, improper bone graft selection and fixation techniques, all possibly leading to non-union, 3) morbidity caused by bone graft harvesting and secondary screw removal, 4) under- or overcorrection of the hindfoot possibly due to improper intraoperative verification and 5) inadequate assessment of bony fusion.

SOLUTIONS

The review provides solutions to possibly overcome some pitfalls: 1) if applicable use an arthroscopic approach in combination with distraction devices and new burrs, 2) if possible use local bone graft or allografts, 3) use two screws for fixation to prevent rotational micromotion, and 4) improve assessment of operative outcome by application of appropriate assessment of bony fusion and alignment.

CONCLUSION

The review provides practical suggestions to optimize SA-techniques.

Grice arthrodesis in the treatment of valgus feet in children with myelomeningocele: a 12.8-year follow-up study

PURPOSE

Neurological deficit resulting in the lack of motor control in children with myelomeningocele often leads to a valgus position of the feet and ankles, usually in combination with planovalgus and pronation of the forefoot. The purpose of the study was to evaluate long-term patient satisfaction and clinical effects in ambulating children with lumbosacral myelomeningocele after having performed a Grice arthrodesis of a valgus unstable foot. The clinically most relevant radiographic measurements, such as the frontal and lateral talo-calcaneal angles, were used to evaluate the anatomical effects of the surgery, whereas the main research question was to reveal the patient satisfaction and usefulness of the procedure.

METHODS

The modified Grice-Green extraarticular subtalar arthrodesis was performed by the same surgeon on one standing and 22 walking patients (12 female) with lumbosacral myelomeningocele and valgus instability during the period 1985-1999. Twelve patients had bilateral surgery, giving a total of 35 operated feet. The patients attended a thorough check-up at a mean of 12.8 years (standard deviation [SD] +/- 3.2, range 7.7-20.2 years) after surgery. The mean age at surgery was 6.6 years (SD +/- 1.8) and at follow-up 19.4 years (SD +/- 3.8). Functional parameters, such as walking ability, pain and skin problems, and the need for braces and supportive orthopaedic shoes were noted at the follow-up interview. The parents were interviewed along with the patients in order to obtain all of the necessary information. Loaded radiographs in the lateral and frontal planes were taken of both feet and ankles pre-operatively and at follow-up, except for pre-operative radiographs in six patients that were not loaded and, thus, not included, except for the assessment of ankle valgus. Ankle valgus was assessed from lateral and frontal views of the ankle on a scale from grade 0 to grade 3 according to Malhotra. Frontal and lateral talo-calcaneal angles were measured for the assessment of subtalar varus or valgus. Lateral talo-first-metatarsal (Meary's) angles were measured to investigate the longitudinal arches of the feet.

RESULTS

The mean lateral talo-calcaneal angle was reduced significantly (P < 001) from 55.1 degrees (SD +/- 8.9) to 38.8 degrees (SD +/- 8.1). The mean frontal talo-calcaneal angle was reduced from 24.7 degrees (SD +/- 9.7) pre-operatively to 16.6 degrees (SD +/- 6.3) at follow-up (P < 0.001). The mean lateral talo-first-metatarsal angle improved significantly from -16.1 degrees (SD +/- 24.7) pre-operatively to 0.9 degrees (SD +/- 15.1) at follow-up (P = 0.0015). The calcaneal pitch did not change significantly. In general, ankle valgus worsened during follow-up time, but not significantly (P = 0.113). The visual analogue scale (VAS) score of patient satisfaction improved significantly from 3.7 (SD +/- 1.7) prior to surgery to 7.2 (SD +/- 1.5) at follow-up (P < 0.005). Nineteen patients (83%) were satisfied with the surgery and would thus recommend the procedure.

CONCLUSIONS

Based on the radiological findings and patient satisfaction, the patients participating in this study benefited from having had Grice arthrodeses performed on their valgus unstable feet. The results indicate good long-term correctional effect on valgus deformity after Grice arthrodesis, as the talo-calcaneal and talo-first-metatarsal angles improved significantly. A great majority of the patients were content with the surgery, and none claimed that any residual deformity was the cause for any reduced ability to ambulate.

A comparison of two different techniques in the surgical treatment of flexible pes planovalgus: calcaneal lengthening and extra-articular subtalar arthrodesis

The objective of this study was to compare the results of calcaneal lengthening and Dennyson-Fulford extra-articular subtalar arthrodesis operations performed in patients with flexible pes planovalgus owing to various etiologies and to compare their effectiveness in realigning the foot. Two patient groups were retrospectively formed out of the patients in whom calcaneal lengthening (25 feet of 13 patients) and subtalar extra-articular arthrodesis (27 feet of 15 patients) operations were performed. The modified Evans technique for the calcaneal lengthening operation and the Dennyson-Fulford technique for the subtalar extra-articular arthrodesis operation were applied. Any special criterion to choose the indication was not considered. The main indication for the surgery was pain during daily routine activities in both groups. The patients were evaluated preoperatively and during the last visit, both clinically and radiographically. The groups were homogenous for sex and mean age for the process, but in the subtalar extra-articular arthrodesis group, the deformity was more severe in some parameters, mean follow-up period was significantly longer and neurologic etiologies were more dominant. Anteroposterior talocalcaneal and talonavicular angles were worse in the subtalar extra-articular arthrodesis group preoperatively (P<0.05). Both groups showed significant correction (P<0.05) in all parameters postoperatively. In the last visit, lateral talocalcaneal, anteroposterior, and lateral talonavicular angles were worse in the calcaneal lengthening group (P<0.05) and calcaneal pitch angle was worse in the subtalar extra-articular arthrodesis group (P<0.05). Both groups showed significant clinical correction (P<0.05) in all parameters postoperatively, but there was no significant difference between the groups during the last visit in terms of total clinical scores (P>0.05). Pain, the parameter that was the main indication for surgery, was eliminated in all patients except for one in the calcaneal lengthening group. The evaluation of the effectiveness of the surgical technique on the results made by performing repeated measures from general linear models showed significantly better correction in anteroposterior and lateral talocalcaneal angles, anteroposterior and lateral talonavicular angles, and medial longitudinal arc angle in the subtalar extra-articular arthrodesis group (P<0.05). In conclusion, in this study group, the subtalar extra-articular arthrodesis technique was superior in talocalcaneonavicular joint complex reduction and medial longitudinal arc reconstruction in the surgical treatment of flexible pes planovalgus, and calcaneal lengthening provided better correction of calcaneal equinus. Therefore, it is better to use the calcaneal lengthening technique in mild or moderate deformities because of its physiological advantages, and subtalar extra-articular arthrodesis technique in severe and/or rigid deformities because of its superior potential to correct the deformity and stabilize the foot in the corrected position.

Progressive neuromuscular planovalgus foot deformity treated with a modified extra-articular subtalar fusion

BACKGROUND

Obtaining a successful subtalar fusion in the pediatric population can be challenging. We present our results with a modified extraarticular method.

MATERIALS AND METHODS

- We retrospectively evaluated 12 patients (17 feet) with progressive neuromuscular planovalgus foot deformity that underwent an extra-articular subtalar arthrodesis with the combined Batchelor-Grice procedure. All patients were ambulatory and were treated conservatively with braces prior to the operation. The average followup was 10 (range, 5 to 17) years. Postoperatively the feet were immobilized in short leg casts for 6 weeks. Preoperative and postoperative appearance of the feet, the clinical symptoms and radiographic measurements were recorded.

RESULTS

Sustained correction and solid fusion took place in all feet. Foot appearance and gait pattern of the patients were improved, while preoperative complaints were reduced. Radiographic healing was noted in all cases.

CONCLUSION

This technique is an effective treatment for the correction of the deformity as it gives a greater assurance of solidarity than when either of the two procedures is used alone.

Treatment of the progressive neuromuscular planovalgus foot deformity with the combined Batchelor-Grice procedure

Twelve patients (17 feet) with progressive neuromuscular planovalgus foot deformity underwent an extra-articular subtalar arthrodesis with the combined Batchelor-Grice procedure. All patients were ambulant and received conservative treatment with braces and special orthopaedic shoes before the operation. Postoperatively the feet were immobilized in short leg casts for 6 weeks. Evaluation was based on the appearance of the feet, the clinical symptoms and radiographic measurements. Solid fusion and sustained correction took place in all feet. Foot appearance and mobility of the patients were improved, whereas preoperative complaints were reduced. The gap at the graft donor site was bridged with new bone in all cases.

First cuneiform osteotomy alters hindfoot architecture

Three-dimensional concepts underlie various congenital foot deformities in the midfoot. We wondered whether the first cuneiform osteotomy, usually indicated for forefoot correction, had an effect on the hindfoot. We retrospectively studied 18 patients (31 feet) with metatarsus adductus and varus who had a biplane first cuneiform osteotomy between 1994 and 2001. No patients had associated malformations or neuromuscular disease. All had persistent pain and functional complaints for at least 2 years before surgery, and all had a minimum followup of 2 years. Group A (13 feet) with forefoot adduction without hindfoot valgus had an isolated first cuneiform osteotomy. Group B (18 feet) with slight forefoot adduction, hindfoot valgus, and supination after hindfoot valgus correction had first cuneiform osteotomy and a subtalar arthrodesis. At 5 years mean followup we evaluated multiple measurements on preoperative and followup weightbearing radiographs. Complementary demographic information and clinical patient information were collected. First cuneiform osteotomy was associated with architectural changes in hindfoot bone angles. This finding suggests new surgical approaches.

LEVEL OF EVIDENCE

Therapeutic Study. Level IV (Case series). See the Guidelines for Authors for a complete description of levels of evidence.

Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot

Thirty-one severe, symptomatic valgus deformities of the hindfoot in twenty children who had flatfoot (twenty-five feet) or skewfoot (six feet) were corrected with a modification of the calcaneal lengthening osteotomy described by Evans. Despite prolonged non-operative treatment, all patients had pain, a callus, ulceration, or a combination of these signs and symptoms under the head of the plantar flexed talus; they could not tolerate a brace, and shoe wear was excessive. Twenty-six of the deformities were secondary to an underlying neuromuscular disorder. The calcaneal lengthening was combined with an opening-wedge osteotomy of the medial cuneiform to correct the deformities of both the hindfoot and the forefoot in the patients who had a skewfoot. Other concurrent osseous and soft-tissue procedures were frequently performed in the flatfeet and skewfeet to correct adjacent deformities or to balance the muscle forces. Allograft bone was used in twenty-four feet and autogenous bone, in seven. The patients ranged in age from four years and seven months to sixteen years at the time of the operation. The duration of follow-up ranged from two years to three years and seven months after the operation. Satisfactory clinical and radiographic correction of all components of the deformity of the hindfoot was achieved in all but the two most severely deformed feet. These two feet had sufficient correction to eliminate the symptoms despite a small persistent callus under the head of the talus. The pain and callus were eliminated in all of the other feet, the patients were able to tolerate a brace, and shoe wear was improved. Subtalar motion was preserved in all feet except for the four that had had a limited joint arthrodesis performed previously or simultaneously for pre-existing degenerative osteoarthrosis. Calcaneal lengthening is effective for the correction of severe, intractably symptomatic valgus deformities of the hindfoot in children. My patients had resolution of the signs and symptoms associated with the deformity while avoiding the need for an arthrodesis and the many short and long-term complications associated with it.

Results of arthrodesis of the tarsus: talocalcaneal, midtarsal, and subtalar joints

A 10-year prospective study was carried out on arthrodesis surgery of the major tarsal joints of the foot. The guiding principle of the study was that foot symmetry would be preserved, except where both feet were deformed. Correction in the frontal, coronal, and sagittal planes would be used to restore normal talocalcaneal relationships. In patients with normal relationships, triple, subtalar (talocalcaneal), and isolated tarsal arthrodesis would be carried out by iliac-crest-inlay grafting to preserve tarsal relationships. In 41 patients, 47 arthrodeses were carried out. There were 31 triple arthrodeses, 10 talocalcaneal fusions, four talonavicular fusions, and two naviculocuneiform fusions. In patients with deformity, significant improvement in the angles of anteroposterior talocalcaneal divergence and lateral talocalcaneal convergence was recorded. There were 27 good results, 15 fair results, and five poor results. Supplementary bone grafting and the use of internal fixation improved the rate of arthrodesis.

Subtalar arthrodesis in children with cerebral palsy: results using iliac bone plug

Twenty-six extra-articular subtalar arthrodeses were performed on 15 patients with flexible planovalgus feet due to cerebral palsy. Following muscle balancing procedures, an iliac bone plug was used to stabilize the sinus tarsi. A review of the results up to 12 years, average 6.8, is presented. Overall satisfactory results were achieved in 88.4% of the patients, unsatisfactory in 11.6%. All children were immobilized in short-leg walking casts for 6 to 8 weeks. The surgical technique is described. The procedure gave good stability to the subtalar joint and was found to be reliable. Graft acquisition was simple and there were no complications.