SLR - July 2022 - Saul Rodriguez, DPM
Reference: Ramirez-Barragan, Ana, MD, PhD, Galan-Olleros, Maria, et al. Long-term Outcomes of Talonavicular Arthrodesis for the Treatment of Planovalgus Foot in Children With Cerebral Palsy. J. pediatr. orthop.. 2022;42(4):e377-e383. doi:10.1097/BPO.0000000000002081.Level of Evidence: Level III
Scientific Literature Review
Reviewed By: Saul Rodriguez, DPM
Residency Program: University Hospital Newark, New Jersey
Podiatric Relevance:
Foot and ankle pathology can have a tremendous impact on a patient’s functional status and mobility, especially in the presence of a neurological condition like cerebral palsy (CP). Procedures like subtalar joint fusions and triple arthrodesis have their clinical indications, however, studies show that osteoarthritis tends to develop down the line in the adjacent joints. When focusing on CP patients, categorized as level III and IV in the Gross Motor Function Classification System (GMFCS), talonavicular arthrodesis can significantly improve function, pain and can even eliminate the need for a CFO in some cases.
Methods:
This is a retrospective comparative study that followed 49 CP patients with planovalgus foot (PVF) deformity for a period of at-least 10 years. Radiographic evaluations were made to compare the foot, prior to surgery and approximately ten years later, specifically looking at the following angles: Meary’s ankle, calcaneal pitch, lateral talocalcaneal ankle, Moreau-Costa Bartani ankle, talus first-metatarsal ankle, AP talo-calcaneal angle and talus coverage ankle. Foot function index (FFI) was used to measure the impact of that pathology in terms of pain, disability and activity restriction at least a decade after the intervention.
Results:
Of the 49 patients, 25 were male and 24 females with the average age of 12 at the time of the surgery and 23 years old at the time of the study. It is important to note that the correction of the deformity had been sustained for at least ten years. Specifically: AP talocalcaneal angle improved from 37.61 to 22.61, talus-first metatarsal angle from 27.92 to 9.69, talus coverage angle from 37.04 to 2.45, calcaneal pitch angle from 3.20 to 13.22, lateral talocalcaneal angle from 42.18 to 25.29, Meary’s angle from 37.86 to 8.37 and Costa-martani anlge from 167.04 to 146.12. FFI at the time of follow up was approximately 33.9 (scale from 0-90, where 0 is an ideal outcome). All patients at the time of follow up were able to be fitted for an AFO, with 8 patients no longer requiring an AFO It is important to note that 14% of patients developed a pseudoarthrosis, most being asymptomatic.
Conclusion:
Talonavicular arthrodesis can have the potential to be a good procedure in CP patients level III and IV, however, it is important to note that this study looked at talonavicular arthrodesis as a single event despite the patient having multi-level surgical procedures to correct the other components of the deformity. It is important to note that many patients may require a triple arthrodesis or subtalar joint fusion as their condition progresses, but TN arthrodesis can be considered successful as an early intervention procedure.