J Child Orthop (2009) 3:179–183

DOI 10.1007/s11832-009-0168-7

ORIGINAL CLINICAL ARTICLE

Talonavicular joint arthrodesis for the treatment of pes planus

valgus in older children and adolescents with cerebral palsy
Camilo Andrés Turriago Æ Myriam Fernanda Arbeláez Æ
Luis Carlos Becerra

Received: 27 September 2008 / Accepted: 3 March 2009 / Published online: 24 March 2009
Ó EPOS 2009

Abstract treatment of severe pes planus valgus in older children and

Purpose The purpose of this report is to review our adolescents with CP. Careful examination should rule out
experience with talonavicular joint arthrodesis for the concomitant ankle valgus deformities. A stable fixation of
treatment of severe valgus foot deformities in older chil- the arthrodesis is recommended.
dren and adolescents with cerebral palsy (CP).
Methods The clinical, radiographic, and gait parameters Keywords Talonavicular arthrodesis

results after talonavicular joint arthrodesis were retro- Pes planus valgus
Orthopedic procedures
Cerebral palsy
spectively reviewed in 32 patients (59 feet) with valgus
deformities of the foot. The surgery was performed as part
of multiple simultaneous surgeries for the treatment of gait Introduction
disorders. The mean age of the patients was 13.9 years
(range 9–20 years) and the mean follow-up was 40 months Pes planus valgus is reported to occur in 25% of patients
(range 18.3–66.7 months). with cerebral palsy (CP) [1]. This condition affects 64% of
Results The clinical and radiographic measurements diplegic and quadriplegic children [1] and is a major cause
improved significantly (P = 0.000). There were no sig- of instability during stance [2]. This deformity can be
nificant changes in gait parameters. Symptoms were considered as a flexible lever arm dysfunction [3], and,
relieved in most patients with symptomatic preoperative sometimes, can cause pain and/or skin pressure or break-
feet. The most frequent complication was pseudoarthrosis, down in the region of the talar head [4]. Surgical correction
which occurred in seven feet. We found a high rate of of the deformity is then recommended.
satisfaction of patients (or parents) and most of them rec- In the older child and in the adolescent, pes planus
ommended the procedure to other patients with the same valgus becomes severe, therefore, some authors recom-
condition. mend subtalar arthrodesis, os calcis lengthening [5–7],
Conclusion Talonavicular joint arthrodesis is a reliable triple arthrodesis, or some variations of these techniques [8,
technique that provides both functionally and cosmetically 9]. Some papers report that, in CP, the results of these
good results with a low rate of complications in the techniques have a high failure rate and are not as efficient
as in other conditions [10–12]. In our experience, the
clinical and radiographic correction obtained with these
C. A. Turriago (&)
M. F. Arbeláez
L. C. Becerra techniques is often unsatisfactory, obtaining rigid and
Gait Analysis Laboratory, Instituto de Ortopedia Infantil
deformed feet, unable to provide stability during stance
Roosevelt, Bogotá, Colombia
e-mail: [email protected] [13]. One of the authors (C. A. Turriago) noticed that the
longitudinal arch of the spastic pes planus could be ade-
C. A. Turriago
L. C. Becerra quately restored when reducing and shortening the internal
Cll 109 18 B 31 Of 204, Bogotá, Colombia
column with talonavicular joint arthrodesis. The mid-foot
M. F. Arbeláez instability and hind-foot valgus are corrected as well.
Cra. 4a. Este (Avda Circunvalar) No. 17-50, Bogotá, Colombia Although talonavicular joint arthrodesis has been useful in

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the treatment of acquired flat foot in the adult [14–16], BTS), and a satisfaction questionnaire answered by patients
arthritis and arthrosis of the talonavicular joint [16–19], and/or parents.
residual deformities of club foot [20], and sequels of The information was analyzed with the SSPS v10 sta-
trauma or talus necrosis [21], there are no clinical reports tistical program, applying Wilcoxon’s test of ranges or
about its use in the spastic flat foot in CP. We report our Fisher’s test.
experience with this technique.

Operative technique
Materials and methods
The talonavicular joint is approached through a 3-cm
Between February 2002 and December 2005, as part of medial incision over the joint following skin folds. After
multilevel simultaneous surgery for the treatment of gait identification and preservation of the tibialis posterior
disorders, 38 ambulatory patients (68 feet) with spastic CP tendon and saphenous vein, the joint capsule is generously
underwent talonavicular joint arthrodesis in order to treat removed and articular surfaces are exposed and resected
their pes planus valgus deformity. We included 59 feet in with an oscillating saw. Care should be taken to remove
32 patients (26 of them bilateral); six patients were dis- just enough bone to obtain good cancellous surfaces for
carded because of incomplete data. Sixteen (30 feet) fusion so as not to overly shorten the medial column, else
patients were females and 16 (29 feet) males. The average the forefoot will go into adductus. Remaining cartilaginous
age was 13.9 years (range 9–20 years). Thirty feet were tissue is totally removed with a curette. Special care is
left and 29 were right. The average follow-up was 3 years required when restoring foot alignment by properly
and 4 months (range 18.3–66.7 months). The concomitant reducing the talonavicular joint and adequately pronating
simultaneous procedures are listed in Table 1. Twenty-one the forefoot. When the correct position is achieved, the
feet had previous surgeries: five os calcis lengthening arthrodesis is then fixated with a 3-mm percutaneous
(Evan’s procedure), 11 subtalar joint arthroereisis, and five Steinmann pin or a 4.5 cannulated cortical screw, with the
posterior tibial tendon lengthening. Thirteen extremities help of an image intensifier. The foot is immobilized in a
had previous Achilles tendon lengthening. short leg cast for 6 weeks. When a Steinmann pin is used,
Twenty-nine patients had spastic CP; 12 of them were removal is performed after 6 weeks. Proper ankle foot
diagnosed as quadriplegic, 16 diplegic, and one triplegic. orthosis are adapted and gait rehabilitation is started.
Two patients had mixed CP and one had dystonic CP.
Data were obtained from clinical history, preoperative
and postoperative weight-bearing X-ray films, gait parame- Results
ters from computerized gait analysis (Ariel Dynamics and
Clinical evaluation
Table 1 Concomitant simultaneous procedures
The preoperative clinical description of the foot was as
Surgery No.
follows: planovalgus 23 feet (39%), equino-valgus 23 feet
Intertrochanteric femoral derotational osteotomy 18 (39%), calcaneo-valgus 13 feet (22%). Postoperatively,
Over the brim psoas lengthening 12 eight feet (13.5%) were described as planus valgus. Pre-
Adductor longus tenotomy 23 operatively, all feet had midtarsal hypermobility and none
Hamstrings lengthening 28 had this feature postoperatively (Fig. 1).
Rectus femoris transfer 37 The preoperative hindfoot valgus (measured in a static
Supracondylar femoral osteotomy 30 barefoot video) averaged 20.96° (range 12°–34°) and the
Patellar tendon advancement 35 postoperative hindfoot valgus was 9.5° (range 3°–35°),
Distal tibial derotational osteotomy 21 P = 0.000 (Wilcoxon’s test of ranges). Ankle valgus
Intramuscular posterior tibial lengthening 5 (C10°) was diagnosed in six feet and was considered as the
Peroneus tendon lengthening 18 cause of the residual hindfoot valgus. This finding was not
Gastrocnemius (Strayer’s) resections 27 noticed preoperatively as a contributing factor of the
Anterior tibial lengthening/transfer 7 deformity.
Dorsal bunion or hallux valgus correction 9 Thirty-five feet had no preoperative or postoperative
Claw toe correction 6 pain. Twenty-four feet had pain before surgery. Nineteen
Botulinum toxin injection in hamstrings 4 feet improved, four showed no improvement, and one had
Botulinum toxin injection in psoas 9 severe pain postoperatively. This last case had inappro-
priate reduction of the talonavicular joint and the valgus

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Fig. 1 Pre- and postoperative

clinical aspect of an equinus
valgus foot submitted to
talonavicular joint arthrodesis

Fig. 2 Pre- and postoperative

X-ray lateral views of a foot
submitted to talonavicular joint
arthrodesis

worsened from 25° to 35° (talocalcaneal X-ray AP view);

this foot required surgical revision. One of the feet with no
improvement of the pain had a painful pseudoarthrosis,
with no correction of the deformity, and also required
revision.
Forty-six feet had no preoperative or postoperative skin
pressure or breakdown; 13 feet had preoperative evidence
of increased pressure over the tarsal head and 12 of them
improved after surgery.
Twenty-eight of the 32 patients (87.5%) were satisfied
with the surgical correction and four patients (or parents)
were partially satisfied and none were unsatisfied. Thirty-
one patients (or parents) indicated that they would rec-
ommend the surgery to other patients in the same situation.
One stated that he was not sure he would recommend it.

Radiographic evaluation

Preoperatively, the talocalcaneal angle on the X-ray AP

view averaged 42.9° (range 26°–55°). The postoperative
angle averaged 21.7° (range 10°–31°), P = 0.000. The
preoperative lateral talocalcaneal angle averaged 51.9°
(range 12°–90°) and the postoperative averaged 32.2° Fig. 3 Pre- and postoperative X-ray AP views of a foot submitted to
(range 13°–58°), P = 0.000 (Figs. 2 and 3). talonavicular joint arthrodesis
The preoperative AP first metatarsal–talus angle on the
AP X-ray view averaged 25.7° (range 14°–40°) and the Gait parameters
postoperative angle averaged 5.3° (range -11° to 26°),
P = 0.000. The preoperative first metatarsal–talus angle in No significant changes were seen in the gait parameters.
the lateral X-ray view averaged 22.6° (range 4°–46°) and The preoperative gait speed averaged 0.51 m/s (range
the postoperative angle averaged 7.5° (range -9° to 25°), 0.11–1.04 m/s) and the postoperative speed averaged
P = 0.000 (Fig. 4). 0.49 m/s (range 0.09–0.85 m/s), P = 0.2. The preoperative

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in CP as in other diseases, such as polio sequels, cavus

deformities, and flat foot secondary to other disorders.
Tenuta et al. [11] found that triple arthrodesis in patients
with CP, with a mean follow-up of 17.8 years, had
degenerative changes at the ankle joint in 43% of the feet,
and that the worst results were correlated to residual
deformity, especially pes planovalgus. Stein et al. [24]
found that poor results of triple arthrodesis were correlated
to residual mid-foot deformities, especially valgus flat foot
deformities. In our experience, too, the result of conven-
tional triple arthrodesis in CP was disappointing [13].
Although talonavicular joint arthrodesis has been
Fig. 4 Pre- and postoperative X-ray measurements after talonavic- reported to be useful in the treatment of acquired flat foot
ular joint arthrodesis. T-C talocalcaneous; T-MT1 talo-first metatarsal in the adult [14, 15], arthritis and arthrosis of the talona-
angle
vicular joint [16–19], residual deformities of club foot [20],
step length averaged 0.3 m (range 0.04–0.68 m) and the and after trauma or talus necrosis [21], there are no clinical
postoperative length averaged 0.32 m (range 0.03–0.78 m), reports of its use in the spastic flat foot.
P = 0.3. The preoperative single stance percentage during In general, the clinical appearance of the foot showed
the gait cycle averaged 28.8 (range 9.6–49.1%) and post- postoperative improvements with respect to both stability
operative, it averaged 26.7% (range 7.6–78%), P = 0.14. and hindfoot valgus, and most patients (or parents) were
satisfied with the procedure and recommended it to other
Fixation method and complications patients with the same disorder.
The radiographic evaluation showed improvement in the
Percutaneous Steinmann pins were used to fix the talona- relationship between the talus and the calcaneus, and
vicular arthrodesis in 35 feet and 4.5 cortical screws in especially of the talo-first metatarsal angle on the AP X-ray
24 feet. view.
Pseudoarthrosis: seven feet developed pseudoarthrosis The effects on gait parameters showed no statistical
(11.8%) of the talonavicular joints. Six of these cases were significance and were difficult to evaluate because of the
fixed with Steinman pins and one with a cortical screw. association with other simultaneous procedures. Many of
There was no statistical significance between the occur- these patients preoperatively had a severe compromise and
rence of pseudoarthrosis and the fixation method crouch gait. Even if gait parameters do not improve, it does
(P = 0.639, Fisher’s test). not mean that function does not improve (e.g., reverting
Over- or under-correction: two feet were considered to crouch gait many times does not correlate well with gait
be under-corrected and one over-corrected. There was no parameters, but the prognosis and function improves).
correlation with the fixation method and under-correction Complications such as pseudoarthrosis and the loss of
(P = 0.3). correction had no statistical correlation with the fixation
Seven feet required revision surgery: five because of method (Steinmann pins or cortical screws). Although not
pseudoarthroses and two due to insufficient correction. all of the patients with postoperative pseudoarthrosis
referred pain, most of them did, and some showed loss of
correction. We encourage the use of a secure fixation with
Discussion one or two 4.5 cannulated screws with image intensifier
control.
Surgical correction of pes planus is recommended when it In six feet (10%), residual valgus could be attributed to
interferes with the function of the foot as a lever arm or pre-operative ankle valgus, which was missed on preop-
support structure, or causes symptoms such as pain or skin erative evaluation. As such, we feel strongly that the
pressure or breakdown in the region of the talar head. In the preoperative evaluation of the spastic flat foot should
older child and adolescent, spastic flat foot becomes severe carefully establish the origin of the valgus (rule out more
and its surgical treatment is difficult; various techniques than 10° ankle valgus) and the origin of the mid-foot
have been described in order to obtain functional and instability, since it can be distal to the talonavicular joint. If
cosmetically acceptable results [5–8, 22, 23]. Triple an ankle valgus deformity is diagnosed, it should be
arthrodesis is one of the most commonly used techniques simultaneously corrected. Also, contractures of the peron-
for the treatment of this condition. Monson and Gibson eus and gastrocnemius muscles should be simultaneously
[10] found that the result of triple arthrodesis is not as good treated.

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Our results suggest that the goal of obtaining a stable 12. Andreacchio A, Orellana CA, Miller F, Bowen TR (2000) Lateral
lever arm with simultaneous recovery of the foot’s arch, column lengthening as treatment for planovalgus foot deformity
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