Comparison of mid-term efficacy of spastic flatfoot in ambulant children with cerebral palsy by 2 different methods

Abstract

To compare the treatment efficacy of spastic flatfoot surgery by 2 different surgical methods: nonfusion subtalar arthroereisis using subtalar joint stabilizer (SJS) and Dennyson-Fulford subtalar arthrodesis (D-FSA).A total of 26 cases of ambulant children with cerebral palsy diagnosed as spastic flatfoot were surgically treated from January 2011 to December 2014. Preoperative and postoperative American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) scores, anteroposterior-talocalcaneal angles (ATAs), and lateral talar-first metatarsal angles (Meary angles) of the affected foot were recorded.Among 12 children in the SJS group, the AOFAS-AH scores were median preoperative score of 61 (58-64) versus median postoperative score of 83 (75-92), with significant difference (P < .05). Of the 20 feet treated, only 1 foot developed occasional pain. Postoperative ATA was decreased from preoperative 35° (20°-50°) to 19° (12°-25°); lateral X-ray films showed that the Meary angle was decreased from preoperative 20° (15°-40°) to postoperative 0° (0°-3°). The differences in both findings were statistically significant (P < .05). Fourteen children (22 treated feet) formed the D-FSA group; all demonstrated fusion of the talocalcaneal joint; AOFAS-AH scores were median preoperative score of 61 (58-64) versus median postoperative score of 83 (75-92), with significant difference (P < .05). Only 1 foot had occasional pain. Postoperative ATA was decreased from preoperative 35° (20°-45°) to 16° (12°-25°); lateral X-ray films showed that the Meary angle was decreased from preoperative 19° (10°-40°) to postoperative 2° (0°-5°); the differences in both findings were statistically significant (P < .05).Both nonfusion subtalar arthroereisis using SJS and D-FSA were effective for the surgical treatment of spastic flatfoot, with similar clinical outcomes.

Figure 1

Boy, aged 6, Case No. 10, bilateral spastic flatfoot, Gross Motor Function Classification System grade II in the subtalar joint stabilizer group. Right foot American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) scoring was 64 points during preoperative assessment and 92 points at 30 months follow-up. The talocalcaneal angle was 30° in the preoperative assessment and 15° at 30 months follow-up. The Meary angle was 30° during the preoperative assessment and 0° at 30 months follow-up. Left foot AOFAS-AH scoring was 61 points during the preoperative assessment and 83 points at 30 months follow-up. The talocalcaneal angle was 40° during the preoperative assessment and 20° at 30 months follow-up. The Meary angle was 40° during the preoperative assessment and 0° at 30 months follow-up.

Figure 2

Boy, aged 6, Case No. 2, bilateral spastic flatfoot, Gross Motor Function Classification System grade I in the Dennyson–Fulford subtalar arthrodesis group. Right foot American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) scoring was 61 points during preoperative assessment and 75 points at 48 months follow-up. The talocalcaneal angle was 35° during the preoperative assessment and 15° at 48 months follow-up. The Meary angle was 15° during the preoperative assessment and 2° at 48 months follow-up. Left foot AOFAS-AH scoring was 64 points during the preoperative assessment and 75 points at 48 months follow-up. The talocalcaneal angle was 30° during the preoperative assessment and 20° at 48 months follow-up. The Meary angle was 24° during the preoperative assessment and 0° at 48 months follow-up.

Figure 3

Boy, aged 6, Case No. 1, bilateral spastic flatfoot, Gross Motor Function Classification System grade II. Screw fracture of the right foot was found at 18 months follow-up. Right foot American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) scoring was 58 points during the preoperative assessment and 75 points at the last (60 months) follow-up. The talocalcaneal angle was 35° during the preoperative assessment and 20° at the last follow-up. The Meary angle was 20° during the preoperative assessment and 2° at the last follow-up. Left foot AOFAS-AH scoring was 61 points during preoperative assessment and 83 points at the last follow-up. The talocalcaneal angle was 45° during the preoperative assessment and 25° at the last follow-up. The Meary angle was 24° during the preoperative assessment and 3° at the last follow-up.