Outcomes of Extra-Articular Subtalar Arthrodesis for Valgus Deformity of the Hindfoot in Patients with Cerebral Palsy

Abstract

Background: Extra-articular subtalar arthrodesis generally has been recommended for treating severe valgus deformities of the hindfoot in patients with cerebral palsy (CP). However, it is unknown whether restricted subtalar joint motion affects the shape of the foot during continued growth in children. The purpose of the present study was to evaluate the effectiveness and longevity of extra-articular subtalar arthrodesis in ambulatory patients with spastic CP, with a specific focus on its impact on the final foot shape and plantar pressure distribution.

Methods: The present retrospective study included 99 feet in 60 children with a mean age (and standard deviation) of 7.6 ± 2.1 years at the time of surgery and 16.6 ± 4.7 years at the latest follow-up. Radiographic changes were analyzed both during the early postoperative period and at extended follow-up. At the latest follow-up, the feet were classified into 3 categories (hindfoot valgus, neutral, or varus) on the basis of the valgus/varus index obtained from dynamic pedobarographs.

Results: All radiographic parameters improved at 6 months after surgery. However, at the latest follow-up, all measurements except for the lateral talocalcaneal angle indicated overcorrection of the hindfoot valgus deformity. The overall valgus/varus index decreased from 0.54 ± 0.25 before surgery to -0.29 ± 0.35 at the latest follow-up. Five feet (5.1%) were classified as hindfoot valgus, 41 feet (41.4%) as neutral, and 53 feet (53.5%) as varus. Patients with hindfoot varus were younger at the time of surgery, and a lower anteroposterior talus-first metatarsal angle at 6 months after surgery was found to be the only significant radiographic predictor of the development of hindfoot varus. Revision procedures were performed on 22 feet (41.5%) in the varus group.

Conclusions: Extra-articular subtalar arthrodesis is associated with a high risk of progressive hindfoot varus deformity in patients with CP. Our findings highlight the need to reevaluate traditional surgical indications for correcting hindfoot valgus deformity, which have largely been based on the severity of the deformity observed on radiographs. Decision-making also should account for growth-related changes associated with restricted subtalar motion and the intraoperative position of the hindfoot and forefoot.