Calcaneal Osteotomy for Valgus and Varus

Deformities of the Foot in Cerebral Palsy

A PRELIMINARY REPORT ON TWENTY-SEVEN OPERATIONS*

BY CAROLL M. SILVER, M.D.t, STANLEY D. SIMON, M.D.t,

EI)\VARD SPINDELL, 51.1)4, HENRY M. LITCHMAN, M.D.t, AND

MICHAEL SCALA, M.I)., PROVIDENCE, RHOI)E ISLAND

rrh child with (‘erebral palsy usually has multiple deformities of the lower cx-

tremities, the niost. common being talipes equinus and adductiolm contracture of the
hip. Valgusdeformity of the feet is also frequently encountered, while varus deform-
it.y is much less frequemmt.
In the child with brain damage and extensive neuromuscular involvement of the
lower extremities, foot imbalance makes walking significantly more difficult. This
report. will i)e (‘onfined to consideration of the surgical correction of valgus and varus
deformities of the foot ill cerebral palsy.
Stabilization procedures, such as triple arthrodesis, are the treatment of choice
for severe foot #{128}lefomniities when the child is old enough (eleven or twelve years of
age, approximately) to have such a procedure. In the young child, however, triple
arthrodesis is not applicable, since excessive shortenilmg of the foot will result from
resectiohm (If jOihit surfaces in the growing foot.
Tendon transfers alone have been found to be unsatisfactory and unreliable for
the treatment of foot. deformities III cerebra! palsy. The extra-articular subtalar
arthrodesis described by Grice has been used extelisive!y, usually with gratifying
results. However, several reports of recurrence of the va!gus deformity or the devel-
opnuemit of It \OrU5 deformity have appeared Pollock and Carrel!, in a review of
1 12 (irice operations done 01! paralytic varus feet, found that forty-two (37.5 per
ccItt) had utisatisfactot’y results. The major complication was late varus deformity
which required one oi’ nuore subsequent operatioiis for correction. They comicluded
that the yams (‘(Inip!i(’atioli is’as the result of subtalar extra-articular arthrodesis
conul)ined with sifliUitahieOUs transplantation of 1)0th peronea! muse!es, resulting in
nuus(’le imbalance.
Calcaiieal osteotomy, which changes the weight-bearing alignment of the hind
part of the foot while I-etainilig roughly 50 per cent of subtalar motion, appears to
offer SOII1C advantages over extra-articular arthrodesis of the subtalar joint. By
maintaining sonic subtalar mOtiOll, stress on the mid-tarsal joints is decreased alid
the foot retaimms sonue ability to adapt t.o uneven terrain. After subtalar arthrodesis,
alignment, of the foot must be perfect, whereas, after calcaneal osteotonly, retaitied
subt.alar motion allows more flexibility. Osteotomy is also a relatively simple pro-
cedure requiring only a short hospitalization.
Calcaneal ost.eotoniy was originally described by G!eich, ill 1893; he stated that
it was essential to restore the normal angle of the long axis of the calcaneus to the
floor when this angle was lost in a flat. foot. or valgus deformity. He performed an
* Uead at. the Antiual \leetitig of The American Acadenmy of Onthopaedic Sungeotts, Salt

Fnaniclsco, Calhfol’nia, Jalilhan’y 19, 1967.

t 225 Watenmani Street, Providence, lihode Islatid 02906.
203 Watenrmiani Street, Providenice, lihode Island 02906.
81 South Angel! Street, Providence, Rhode Island 02906.

232 THE JOURNAL OF BONE AND JOINT SURGERY

 (‘ALCANEAL OSTEOTOSIY IN CEREBRAL PALSY 233

oi)lique (Isteotomy of the ealca.neus amid shifted the posterior tuberosit.y portion foi-
war(l, tilus increasing the angle between the calcaneal axis and the floor (Fig. 1).
10.11’ l)rIi!ttin, lie reconlnlen(led that a nuedial wedge of bone be resected SO as to
simift tiue po)steriol’ fmagnlent toward the n1i(l-line. Gleich used a stirrup incision umuder
the foot ali(l repo)rte(l on till-ce operations: OhiC in a thirty-year-old mall, and a bi-
lateral opei’atioii iii aiiother a(lult for severe painful flat feet, imi whicil hmc shifted the
I)ostelioi’ (‘htl(’ItIieItl segnuent. dowlnvar(l and niedial!y.
Iii 1923, Lolrd reported the results of fourteen calcamieal ost.eotoniies for severely
i)rotmiate(l all
feet, iii ItdUltS. (July one patient had calcaneal osteotoniy alone; tile
others 1111(1 various su)plenlemitarv pro’e(lures, such as osteotoiny (If the tarsus or
nletatamsals, \.chilles tendon-lengthenimmg, or transfer of tendons in I)araitic or
Spist i e feet.

Fmo. 1
Illiist l’at.ioti fnttnm ( ileichm’s an’t.icle ( 1893) depi(’t ing m’edge osteotonmy (If t lie calcantetis to chmatige
t hie mveighit-beam’inig statm(’s of the foot.

l)ivvei’ 3,4.3.6 ll!15 i)eeii the leadimig )rotagOfliSt of calcaneal osteot.oniy during the
1)itst temi years. He first used it in the t.reatnlent. of pes cavus In subsequent iaems
he (lis(’ussed his results in the correction of forty-six grossly everted (valgus) feet I

( thirtv-four of tilelll ill l)Ittielits ivith cerebral pali) aII(l imi tile treatmemit of fifty-
six re!apse(! (varus) (lul) feet. by the ihisertioli of a tibial-bone wedge imito the medial
tsh)eo’t of the caicaneus
II! the tieat.nuent (If the va!gus foot, Dw’yer stated that the basic l)riilcil)ies ai’e
tue same w’hether the patient suffers fronl “mobile flat.feet” or cerebra! palsy. rfiie
aim-il is to) brimig the lice! into yams position to place it under the line of w’eigiut-bear-
big. rfiiis iniproves tile balance (If the foot. and changes the force of the Achilles temi-
(10)1! froiui till everting force to a neutral or inverting force. In namiy of his l)atielits
witim cerebral palsy, lie did a simultaneous lengthening of the Achilles tendon. lie-
o’emitlv, in a personal (onlmunirati(In, he stated that, if a flexion contracture (If time
knee is present, he prefei’s to defer leimgthening of the Achilles tendon to) a later
Peru Id.
Chambers desci’ibed a small homme block under the floor of the sinus t.arsi for the
correct IOu (If flexible flat feet. His aim, based on experimental work done in time
anatomy laboratory, was to block abduction of the foot by interfering with tile for-
W’IlI’(l 1111(1 do)wflW’ard sliding (If the talus on the calcaneus.
Baker and Hill reported a series of forty-six calcaneal osteotomies in which tue
post eriom’ articular proo’ess of the calcaneus was pried upward after a lateral lion-
zontal osteoltomy and wedge grafts were placed in t.he osteotoniy site. This procedure
i mpro IS-ed the weight-hearing alignment, of the calcaneus without interfering s’it iu
Vol., 49-A, No. 2, MARCH 1967
234 C. SI. SILVEIt ANI) ASSOCIATES

sUi)tltlal’ misot 1(111. Althi(tugh t.i#{236}e

site (If tilis calcaneal osteotoniy is diffei’ent, the basic
llic(’hitIhi(’!tl l)i’iII(il)le is not unlike that. enun(’iate(l by Cileich audi i)y J)w’yer.
( ai’gel’ l)l’cselitNl tW’elitV-tW’t I cases of (‘alcamieal osteotoniy, foui’teen of these
Pi’0’((lt1i’t’5 pei’foi’nied in IMitiehits w’ith progres1ive (lisease of the ceiiti’al Iiel’vous
svst clii. I Ic o’ono’ludeol that l’e(’urlences s’ere (‘oluuilon ill SU(’ii feet, since furt.lici hieti-

ial tlegeiiem’ttioii 1011(1 pal’ItlysiS eventually vitiated tile beneficial effects of tue (:tl-
(‘ithi(ll O)Ste(ttOflsv.

Case Material
\\e 1110..’ pi’esentimtg onu’ eXl)elieIl(eS with twenty-seven cal(’anea! ost.eotoniies

1)(’i’f( )l’mmi((l in tw’emitv (‘imildi’emi w’itii valgus or val’US (lefomnlities (If the foot cIlUSe(l i’
(‘em’eili’ll 1)itl5Y. rii 1):tt ieuits have been fo!!ow’ed for front tw’o to five and one-half
Veti’s SiIi(’e (tl)ei’atiOll, t’etitv-six Of the feet. having been observed foi’ over two yeah’s.
ru S(i’i(S is snuall aiid time follow’-up is too) short to tlmai’ definite conclusions. 110.1W’-

evel’, I lie early i’esult .s ai’e encouraging enough to warnamit preseutatio III of pre-
limlmihutm’v results ill tin’ iio)pe timat more wi(lespi’ead use will he nlade of this rational
1111(1 1 (‘(‘lilll(’itilV simple P1’0 I(’edtlI’e.
All t tf tue o’huldi’ehi had hut(l extensive treatmnent. for their lo)wem’ exti’eniities )i’i0r
to ostet do mv, ino’ludihlg braces, shoe o’orrectio)mls, and physiotherapy. Five (‘hi!dren
l’iad had Achilles I chi(lo)n-lemigthening, p!antai’ fasciot.omy, oi’ transfer of the
Pei’ttmt1s longus tendon, alone or in combination, without benefit. Calcaneal os-
te(It(tmmmy \\‘ts pei’fo)i’meo! aftei’ therapy ilad failed. At the time of osteotomy,
all tithe chihli’en were \vtlkihig and then’ ages i’anged from two an(l (Inc-half to) thin-

tech veal’s.
It’ll feet (liilie ‘it im valgus ahid one with varuS deformity) were in (‘ilildl’eli less
thani live years old, thmil’teehi (eight with valgus and five withu varus deformities) in

FIG. 2

)l tliti to’ t tste tt t mv ttf t Ito’ calcatteits wit Ii time ittset’t ion ttf time .&chilles tetmdoti seeti at (lie cud of
I lit vttuiuit.1 tut t Ito, tight

THE JOURNAL (IF BONE AND JOINT SURGERY

 (AL(’ANEAL Os’h’EO’i’OSIY IN (‘EitEBItAL PALSY 23

Fio. 3
A.utt(tg(’tittuls l)tttt(.’ graft front tin’ (‘al(’alte(ts in the !)m’ietl-t)Pemi ostetttuiiy. Note the tnialigtilal’ (IC-
fert a t t lit’ stil)(’l’it 1’ l)05te1’i( )i’ end tf t lie ralcamietis j ttst ati I el’ion’ to) t he Achilles teli(loti. \e prefer
lit tmiit gehit )u ts t.ibial-bomte graft s ‘ti ice t lie canicellttuts gm’aft fn’onu t lie calcaniet is tehi(ls to collapse.

(‘imil(ll’(’hi live t(t nne \‘(.‘ai’s 01(1, 1111(1 four (three with valgus 1111(1 ome svit.h vam’us
(lelOl’ImiitV) ihi (‘imil(lreli 11101-c tilali iiiiie years old.
_\.lthmo)ughi foul’ (If the children vith valgiis (lefoIIIulit.ies svere ol)eI’ate(! oH \‘hehi

tii(\’ \‘(‘l’e less than three years 011(1 tIl(l had good resuits, w’e agree vith I)vyer that
l)clt)I’e tue age (If tiiiee time oalcahmeus is generally too small to) pernuit optimum (‘oi’-

1(01 0 )hi. I n I he fiitul’e W’e P!1i11 tO) use thus age as the muiihiimuuum foi’ cali’aneal ()steotonly.
Iiio t )l)t ililUlii age i’ange w’oi.i!t! appear to he thiee to nine yeal’s. Aftei’ tile age of lime,
011 1 ii(’ h)15i5 (If O)t1I’ I)l’esent expel’ience, W’e W’Otll(I 1)e ili(’!iIie(l to defer surgio’al treat-
humchit ft)m’ ahiothiel’ yeai’ 0)1’tW’oI alit! thuehi (10) a triple artimi’odesis. However, it shoul(1 be
holed that l)wyer has done a large series of ca!caneal osteotohulies in adults with
gl’at tying i’esults.
iwehity of our ol)erat.iohis w’ei’e l)elformed for correction of valgus deformities
:lhi(l sevei foIl’ corm’ectio)Ii of vam’us defol’nlitieS.

The Operation

/‘o,’ ( o)1’)’C(’IiOfl of 1 alu’us Deformities

\\‘ith a tourniquet applied to time low’er part of the thigh, a slightly curved Il-
oision is nmade () time lateral aspect of the foot about OhiC celmtinleter below the lateral
mmiahlcolus, extehidilig from time Achmilles telmdon downward and forward t.o tue I’egiohi

(If the calcalieocuh)Oi(1 joinmt. Iime in(’ision is deepehied to time ca!camieus, which is cx-
l)ose(l upw’ai’d to time peroliea! tenido)ns amid dowhiward to the infel’ior nlargili of the
c:ilo’amieus. Ammtel’iorly the calcahieodui)oid joimmt is i(lchitified but not entered, and
postem’lo)l’ly tue distal cud of the A(’hilles teimdon is exposed to’) avoid iumjury to this

VOl.. 49.A. NO). 2, MAR01) 1967

236 (‘. SI. 5ILVEIt ANI) ASSOCIATES

st l’ll(t tile dul’inig ost (9 tt t tnmv. I I’ ani \.chulles teuidoui !ehigt.iiehiilig is plalihie(!, time skini
i lio’isi( Oh is (Xt(’hi(le(! uIl)\\’it 1(1 ha t (‘1111 tO) the teumdoum.
,\hi t ti)li(!lic ostet ttt tummy is mm-iaole ihi t.iue caicahmeus, extehidilmg forvard alid (lO)W’hi-
\\‘:ll’ol tI’Ohim just beiliniol t lie l)Ostei’i( 01. ttl’ti(’lIlIiI’ process (If time calcuieus to the inifel’ioi’
r:o h’aliea I sui’f:u’e just I st (‘I’It 0’ t 0) I lie (‘alo’aneO(’uho)i(l jOihit ( !‘ig. 2) . \. St.iykeu’ s:ow’ is
used lot himake time ostet tb tnmy whio’h is pried opemi sufficiently to swiig the posteriol’

I It ut 101 i tot time O’ah’ahieus ( ahid l’o d ) ihito) mieutral posit iOIi.

)l’igihial lv. a t I’iahiglilai’ wedge of ho we was takehi fi’ 1111 the superior 1)01st eu’it Ii’

sliI’lao’e t of’ the ho ody of I hue o’alo’auieus ( Fig. 3) aumd used as a bone gi’aft. At l)I’eSehit, we
usc a veolge-shuaped segnmehit of aut tolaved homogemious tibia! bohie (Figs. 4-A alid
4-B vhiio’h is iniseu’ted into tue osteoto)mV gap. The bolhie graft is hueld snugly anal
min.’ta 1lie lixat it )hi is hO )t hietessal’y. (‘ale should be takehm that a suifficiently wide graft
iS tiS(’( 1 ttt (IIIt a Ii (‘(lImit )let e (‘t trl’et’tio thi (If t.hue previo )us valguis defo )rnlity. Fime deep
fastia is closed with mu eh’i’lipted chil’oimmic o’atgut sutures, and time i’est o)f thue w’Ottlhid is
closed mi a rout inc f’ashiitui.

‘ ):l(lde(l I Ilast el’-t t- I 1a1’is cast is applied 110111 t hie t il)ial t uil)eI’o’le to the t a’s
wit hi t hie to to tt at a right alugle tot I lie leg and iim mmeut i’al p Isit n hi as I’egal’ds vaI’us ahi(l
valgu’. :ihigulat on.

Fi;. 4-A
Tin. vo’oIge-’.Ii:tto’oIIitttttttgctttttu gt’aft (atttttclavo’oI ) before inisertioni in 1 lie osteottoniuv of I lie (‘a!-
o’auteuis. The graft lutIst Ito’ I Iiit’k o’uittutgli
tot cot’n’eo’ttime valgmus olefon’mitv conmpletelv at the t mime tI’
the ttpo’u’atittti,

‘1111; J0t’RNAJ. Oh” BONE ANt) JOINT SI.’ht(hEhtV

 CALUANEAL os’rEoToMv IN CEREBRAL I’ALSY 237

Fio. 4-B
‘Flue atittn.’!aved hntrnotgemuous tibial-llolue graft mu l)osit ittli. ‘ibis gt’aft is st m’ttmtg, attol, imi otuim sem’ies,
it huts hleemu iti(’(Il’l)ton’Ztte(l )n’otgl’essively ‘ithottt imi(’ident.

1”oi’ ( ‘OI’I’e(’tiOfl ()j 1 ai’u.s’ 1)ef’omni ities

,.\. siIflilItI’ ihl(’isiO)hl is I’iIIt(ie 0111 time lateral aspect (If the foot s’it hi a t Imigh tourlui-

otuiet applied. ( )steotonuy (If time (‘alclilmeus is 0.’arnie(l out as )I’e\’iously described, alid
a we(lge-ShI1)e(i segIllehit iS l’efliove(l fI’olnl the oalcatieus vmtiu thme 1)ase o)f the s’edgc
IaterahW’ar(l ( l”igs. 5-\,. ahi(l .5-Is ) ( )ne shoulld
. tt\’o )i(! i’eIuiolva! of excessive 1)0 )fl smno’e It

valgus (lefOI’fluity (If t.iue hilid l)iti’t (If tue foot. muity result. \Vhehu the wedge-shaped
gap is o’lose(l, time foot simoluld he Ihi uieuiti’al position. A sihugle staple is ilisel’te(I, str’ad-
dhiuig tIme oosteo)tolnuv, tot hold time (ttli.ItIleItl fu’agmuuemits ihi fimni appi’o)xiummatiolm (l”ig. 6).
After routine clotsuu’e, a padded l)lltstei’-Of-PaI’is caSt is applied 1u’om below time knee
to) the totes, vithm time foot ill hmeutral polsitmoli, at right anig!es to the leg and ill no
varus 01’ valgus.

P()s1o/)el’atiI’e (‘are

Ill thus series, unless cono’ul’i’elit. Achuilles t.ehudolm-lellgtileluihig or gast I’o)(.huelmuius-

mmmuscle recessioli \vas perfot-med, a below-the-knee cast was applied. TIue foot was
mmiailit.ailued Di a Ileutl’al ott’ a shigiutlv o’ei’correo’ted posit ioni. Time cast was woO’hi fOr’

emghut weeks.
Time chmild was diso.’hal’ged (Di thue thuird or fonlm’tiu (lIly aftel’ opeu’at io ni, as a h’tlle.
i’igiut chiildreli ‘ere dist’hiarged on thue se(’ond h)OStol)ei’mLti\’e day. \\emghut-bearmuig
\va4 hot Pei’Iluit.ted until after u’emoval (If the cast.

en (a i’y Pi’ocedu i’es

It. should be emulphasized that calcahieal o)steotolnmy is mmot tiue solution lou’ all v:ul-
gus an 1(1 va ruts defo )rmi ties of tIme fo tot. If a defo Dliii rug s )ft-t issue st i’uct ul’e is l)h’eselut,

Vol.. 49-A. NO. 2, MARCH 1967

2:* C’. SI. SILVE1t ANt) ASSOCIATES

Fun. 5-A
Ft tt’ t’ttu’u’o’rt it mt t f vu ‘1 is left mmmiit v, a wedge-shaped segmnem it t tf t he calca t tot is \Vi t hi its I I:tSO’ oh-
n’et’toth lu I cu’alw’:u md bus I cei t I itt! ii ted ( loft ftlot , hued I t t hue u’ughmt ).

Fio. 5-13
A w(’(!go.’-’.huape(! segnmoutl ttf the t’alcatieuis hi:ts beeti u’emtmttved ftti’ of t lie varuis
(‘ont’t.’(’titttt deft tnmiiit y

(left fttttt, lice! Ott I hue nughut

it simould he i’eleased (Ii’ ti’ansfei’red during the same operation.

I hi elevehi of the t\vehuty-sevehi operations in thuis series, OhiC 01’ muuom’e supplelnelu-
t:tl’y pu’o(’(’(lul’es were carried out at. the same time. In five limbs, Aciuml!es teuutlouu-

TIlE J(It’IONAL 011” BONE ANI) JOIN’i’ SI RGi;RY

 CAL(’ANEAL OSTEOTOMY iN CEREBRAL PALSY 239

FIG. 6

The weo lgo’ 0 tst o’oott ummy hills beem i o’!osed amid fixed wit ha single staple, o Inrect inmg I he pu’eviotts vant s
(loft trout V.

13 tt It feet otf a ho, muitue yeBh’s 0)1(1,wit Ii nman’keol i)ilateh’al va!gtis o!efo u’inity, five mo ott t los after
‘:ilc:o mto’:oh otsto’oot0111105 ‘it ii t ho intsen’t bIt otf aoutooclaved hiomogemuomts t ibial-homte gu’aft s. Note mi-
do 011)0 ot’:ut 10th of thio’ l)otnue grafts bilaterally ( Figs. 9-A thmn’otthgh 9-I)),
 Li 1 1.Y ; Li’
ocIA’rlis T !

Fin. S-B
“hut owimug vel’t o’a! aluguumuuemutof t lie calcauuei withi sttmmue lateral I

:i ‘! H.

.l’n’eo’lfixed equihius (lefornmmtmes; ill three, with equl-

)u’eselut with tile kliee extended but l)assively correctable
was flexed to 90 degrees, a gastl’ocnenlius recession

it ha neurectonmy of the umuotor nerves to the nme(lial :‘

.,two lilmibs, ten(Ioli transpositiomis were performed for
 CALCANEAL OSTEOTOMY IN CEREBRAL PALSY 241

FIG. 8-C
Weight-bearing noenutgenognanus made three motuths after calcaneal osteotomies amid homogenous
tibial-hone grafts. Note improved alignumenut in both feet, inucludimug the posit iomm of t.he talus in eachu
foot. Roenutgeuuolgnams show thiat iuuo’onporatiohi 0)1 the huonmogemioltns honue grafts was proceeding
sat i,f:uctonilv.

FIG. 8-I)
Axial l’oemmtgehmognanmS o)f both heels niade three mouutims after operation. Note thme yams angula-
lonu of h)olth calcanuei, inudio’at mug a shmifting of the weight-I)eanilug line ihi eachm foot.

nuuscle ililb)alahice the peroneus longus amid bnevis to the second cuuueiforni in one
and t.iue ahmterior tibial t.o the euboid in another; 111 three feet, with metatarsus ad-
duction deformities, a plantan fasciotoniy was done in two and a mid-tarsal cap-
suhotonuy in ouie iii ne l)atiellt with bilateral prommllence of the navicular and as-
sociated pain amid tenderness, the prominermces were excised.

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242 C. SI. SILVER ANI) ASSOCIATES

.y--’

.b0.

l”to;. S-I’ Fio;. 8-F

Fig. S-I’ : Heft ole 0 st e ott tmn\’ t huem’o’ ale muuan’ked valgus defon’mit ies of 11(11 hi feet. iltoemot genuo ogm’anuis of
O ho’.o’ foot :110’ 1(1)10 odttced but Figs. S-A t hn’ootugh 8-1).
l”ig. S-I”: Pt osto’m’it on’ views of boot Ii feet. I)o’fo tue osteotomy. Note lonugit idum al SoRt’s oV(’l’ I hue .o’iuulles
to’u to It tt t. ( ‘l’huo’ 11:10 dl it. bath hmad I wt t p’o’vit Otis operations mi aniot lien o’it’).

F’in. S-( Fun. 8-Il

Fig. S-( : Sux tilt tu ths aft (‘I’ cah’auteal (1st eootonmy penfonumued bilaterally ill which Iuoluioogehuo otts I ibial-
h)tott(’ gm’:uft 5 wet’e ned, weighut-beat’imug amid gait aI’e appreo’ihil)ly immmpro.oveo.l.
1”ug. S-Il: Pt ostento or views 0 of Iltot Ii feet aften osteotomy. Coonmpare with F’ig. 8-F’.

Ii g. 0-A Plot 1 ognaphi nuuade I lefo one o penltI io ott shows nmanked valgus deformity i Ii but hi feet. (If a bt oy,
ltttto’ ye:ots told, Wit hi spast to’ tthatIh’i)legia.
lug. #{182}
-13: Po Istet’iotI’ view 0 of hot Ii feet befion’e Openatiohi.

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 CALCANEAL OSTEOTOMY IN CEREBRAL PALSY 243

1”uo;, #{182}0-C Fmn. 9-I)

l”ig. #{182}0-(
‘: Phtttognaphu of the feet, lwanihig weight, onue and ohue-half years after operat 1o)hi.
Fig. 9-I): Postel’iooh’ view of booth feet, Iuuade with time patienut stanidinug, onue anud one-half years after
openat iottt.

Fun. 10-A FIG. 10-B

Fig. It 0-A: Equlimutovan’tis olefornmit y, tight foot, in a boy, t.huint eenu years old. Imu inofamucy he had been
treated ‘tt h plaster oasIs: mu chmildho)od lie had been treated with I )eniis Bnovmue sp!lnots and Achilles
temudoimu-lemigthuemuinug.
Fig. 10-B: Poostel’iool’ view shiowinig vanots deformity of the huiuid pant of time rIght foot anud time old

&un’gic:ul “cat’.
-I
1’

F’uo;. 10-C Fin. 10-1)

l”ig. 10-C: Impnooved weighmt-beanihug midappearanuce of the foot two anal onie-half years after
ca!camuo’al wedge osOeootoonuy (‘o)nmblmued wIt ii Achilles tenudon-lehugo henilug anud stubctttanieotis plalutar
fascio ott nay.
l”ig. 10-1.): Posteniton view of btlth feet if ten operatiomu OBi the night foot two and one-half years
prey oui’.ly.
244 C. SI. SILVER AND ASSOCIATES

Correction of Varus Deformities

A single staple to maiumtain closure of the wedge after wedge-osteotomy of the

calcaneus is advised. This ensures that the corrected position is maintained ii the
immediate postoperative period. In the one patient in our series in whom a staple
was not used, the calcaneal wedge had opened five days after operation as shown by
roentgenogram. Manipulation of the foot under general anesthesia one week after
operation restored correction and a good result ensued.

Correction of Valgus Deformities

In the earlier operations in the series, an autogenous bone graft from the dorsal
posterior portion of the calcaneus was used to wedge open the osteotomy and main-
tam the corrected position. We wished to avoid a separate surgical procedure on the
tibia and additional surgical trauma to the child.
III the last ten operations for valgus deformities, we used homogenous auto-
claved tibial cadaver bone since it seemed desirable to employ cortical rather thaui
cancellous bone to prevent collapse of the wedge. There were no instances of unto-
ward reaction to the homogemious grafts, and all grafts remained in position very
well. Satisfactory incorporation of the homogenous grafts took place (Fig. 7), and in
all patients solid bone healing about the homogenous graft was noted on roentgeno-
grams by three months after surgery.
In these children homogenous bone appeared to be as satisfactory as auto-
genous bone for correction of valgus deformities and had the advantage of shorten-
ing the operative time, as well as avoiding additional surgical trauma.
Al! the wedge grafts remained in position, indicating that metallic fixation is not
required.
Dwyer observed that after calcaneal osteotomy with insertion of a bone graft
to correct va!gus deformity, an axial roentgenogram of the calcaneus showed varus
angulation. In his judgment, this angulation ensured an appropriate shifting of the
weight-bearing line of the foot and was significant in maintaining correction. This
had been appreciated by Gleich, in 1893, and we noted it to be a routine finding on
the postoperative roentgenograms (Figs. 8-B and 8-D).

Results
rI.eI1ty feet with valgus deformities were operated on-eight unilateral and six

bilateral cases.
Seven varus deformities were treated by osteotomy-five unilateral and one
bilateral.
Of the twenty operations for valgus deformity, fourteen produced excellent con-
rectiouu, four resulted in a mild residual valgus deformity, and two were followed by
overcorrection and progressive varus deformity.
In the fourteen feet with excellent results, the foot was in neutral position while
weight-bearing, gait was appreciably improved, and both parents and surgeon were
gratified by the result..
In the four feet with mild residual valgus deformity, correction was inadequate.
In each instance autogenous cancellous bone grafts from the calcaneus had been used.
Some collapse of the graft undoubtedly occurred since the residual valgus deviation
was first noted shortly after weight-bearing was resumed. Such loss of position did
not occur when the honiogenous tibia! graft was used.
Of the two patients in whom a progressive varus deformity developed within
eighteen months of the calcaneal osteotomy, one was a child, five years old, with left
spastic hemiplegia, who had severe valgus deformity of the left foot with apparent
THE JOURNAL OF BONE AND JOINT SURGERY
 CALCANEAL OSTEOTOMY IN CEREBRAL PALSY 245

absence of power in the anterior tibial and extensor hallucis longus muscles. A cal-
calleal osteotomy was performed, using an autogenous calcaneal graft, with simul-
tamieous transfer of both the peroneus longus and peroneus brevis tendons to the see-
ond cummeiforni houme. During the next eighteen months, active function became evi-
dent in thie anterior tibial muscle amid progressive varus of the foot developed, es-
pecial!y ill the fore part of the foot. Twenty-one months after operation, a second
operation was l)eIfOn11ied, transferring the two peroneal tendons back to the region
of the cuboid bohie with moderate
improvement of the deformity. Further correction
of time metatarsus adductus may be necessary.
The second was a four-year-old girl with right spastic heniiparesis and right
equihmovalgus deformity. A caleaneal osteotomy using an autogenous calcaneal graft
was done, together with a Z-lengthening of the Achilles tendon. Within eighteen
months, a varus deformity gradually developed because of progressive increase in
the streumgth of the anterior tibial muscle. At a second operation, two and one-half
years after the initial procedure, the anterior tibial tendon was transferred to the
cuboid bone. When the child was last examined, eighteen months later, the result was
excellemut.
Of time seven operations for varus deformities, six produced excellent correction
up to three auid one-half years later (Figs. 10-A through 10-D) and one resulted in a
definite valgus deformity because too large a wedge was removed. This was evident
shortly after removal of the postoperative cast two months following operation.
One must avoid removal of too large a wedge from the calcaneus when cor-
recting a varus deformity. To facilitate accurate aliguiment of the foot at operation,
tile foot from the ankle down is left exposed with no covering of stockinet or towels.
When the alignment appears to be correct, as judged by the appearance of the foot,
it. is plantar flexed and dorsiflexed to make sure that it remains in neutral position.
Ill addition, iressure oh the sole of the foot should umot produce more thaum a few de-
grees of valgus iui a foot with a valgus deformity or a few degrees of varus in a foot
with a vanis deformity.

Complications
Two wound iumfectioums occurred in our series. One was a minor cellulitis which
healed in two weeks on antibiotic therapy. The other was a major infection, due to
heniolytic Staphylococcus albus, coagulase negative. The orgauiism was sensitive to
ehioromycetin, and good healing took place, but drainage persisted for four months
postoperatively. Iui addition to the is-edge osteotomy of the calcaneus for a varus de-
formity, lengtheuming of the Achilles tendon and an anterior tibial transfer to the
dorsuni of the foot were performed at the same procedure. ‘I’hree and one-half years
after operatioum, the aumtenior tibial transplaimt was functioning well, and the pa-
tieumt had aim excellent clinical result.

Summary

Valgus deformities of the foot are relatively common in children with cerebral
palsy; varus deformities are much less frequent. These deformities add significantly
to the difficulty these children have in walking.
Calcaneal osteotomy is an effective corrective procedure for these deformities;
it improves weight-bearing alignment of the foot and does not impair subtalar or
mid-tarsal joint function. However, calcaneal osteotomy of itself is hot the solution
for all valgus and varus deformities of the foot. Frequently, supplementary soft-
tissue procedures may be required which can be carried out at the same operation.
This osteotoniy is not technically difficult and can be carried out in children as young
as three years of age.

VOL. 49-A. NO. 2. MARCH 1967

246 C. SI. SILVER AND ASSOCIATES

A review of tweuity-seven calcaneal osteotomies in twenty children with cerebral

palsy is presented ; twelmty operations were for correction of valgus and seven for cor-
rection of varus deformities. The patients have been followed for from two to five
amid one-half years since calcaneal osteotomy, twenty-six of the feet have been ob-
served for more than two years since osteotomy.
rrh operative technique, postoperative care, and complications are discussed.
l’wemity of the twenty-seven operations produced excellent results. Four of the valgus
feet showed residual nuild valgus deformity at follow-up, and in one varus foot over-
correction and valgus deformity developed. In two patients with valgus deformity a

progressive varus deformity developed within eighteen months of the calcaneal

osteotoniy, and further surgery was required.

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