Extra-articular Subtalar Joint Arthrodesis for Rigid Pediatric Pes … · Extra-articular Subtalar...
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Extra-articular Subtalar Joint Arthrodesis for Rigid Pediatric Pes Planovalgus in a Patient with a Talocalcaneal Coalition Eric Lew, DPM 1 , Lauren Kishman, DPM 1 , Mark Hardy, DPM, FACFAS 2 1 Residents, Podiatric Medicine and Surgery, Kaiser Permanente / Cleveland Clinic 2 Staff, Department of Foot and Ankle Surgery, HealthSpan Physicians Group, Cleveland Ohio Statement of Purpose Rigid pediatric flatfoot is commonly associated with a tarsal coalition, often involving the middle facet of the subtalar joint. Joint stiffness and deformity results in difficulties with ambulation, foot pain, spasms, and frequent foot and ankle injuries 1 . Non-operative care is the first line of recommendation for treating talocalcaneal coalitions 1,2 . Patients who are recalcitrant to non-operative treatment, may require operative management with either resection or arthrodesis 1,3,4 Poor outcomes following resection have been found in patients with severe hindfoot valgus 5,6. Patients with severe deformity, large coalition, or advanced degenerative changes may be treated with subtalar joint arthrodesis 2,4,7 . There is limited focus in the literature regarding extra-articular arthrodesis in pediatric patients with talocalcaneal (TC) coalitions. This case study will highlight our experience in addressing a severe pediatric pes plano valgus deformity with associated TC coalition through the performance of subtalar extra-articular arthrodesis. Long term goals of this treatment include improvement of foot alignment, pain, function, and quality of life. Figure 1. Preoperative Clinical Image Figure 3. Preoperative Computed Tomography Imaging Preop clinical image demonstrating collapse of the medial longitudinal arch and talonavicular joint prominence. Computed tomography scans revealed an osseous talocalcaneal coalition in the coronal, axial, and sagittal reconstructed views (a, b, c). No significant arthrosis of the posterior facet was observed. Figure 4. Middle Facet Coalition Resection A 5 cm linear incision was made 1.5 cm inferior to the medial malleolus to approach the middle facet. Resection of the coalition was performed with an osteotome. Figure 6. Intraoperative Imaging after Coalition Resection Figure 7. Reduction of Subtalar and Talonavicular Joints a) Pronation of the subtalar joint following coalition resection. b) Reduction of subtalar joint pronation to a neutral position following resection of the coalition. Figure 5 Intraoperative Imaging The coalition was identified under C-Arm image intensification prior to resection (a, b). A 0.062 K-wire was placed percutaneously across the talonavicular (TN) joint maintaining reduction of the TN and the subtalar joint in multiple planes (a,b,c). Placement of a 0.062 fashioned like into a large staple acting as a strut across the subtalar joint maintaining the subtalar joint in the corrected position. Figure 8. Fashioning and Placement of Dowel Bone Allograft into the Sinus Tarsi Figure 9. Intraoperative Imaging a) Post op AP radiograph demonstrating midtarsal joint realignment, correction of abnormal talar head uncovering, and reduction of calcaneal-cuboid abduction. a) AP radiograph demonstrating satisfactory correction of the midtarsal joint abduction and talar head uncovering. b) A lateral radiograph demonstrating correction of the patient’s pes planus deformity and normal alignment of the subtalar and midtarsal joints in the sagittal plane. b) Post op lateral radiograph demonstrating restoration of the medial column and correction of the sagittal plane through the subtalar and midtarsal joints. Figure 10. Immediate Post operative Imaging Figure 11. Postoperative Imaging at 5 Months a) Dowel bone allograft was measured and carefully fashioned. b) The dowel bone allograft was placed and tamped into the sinus tarsi. c) Placement of cancellous bone allograft to remaining deficits in the sinus tarsi. a) a) a) b) c) b) b) c) Figure 2. Preoperative Radiographic Imaging a) A weight bearing preop lateral x-ray demonstrates a pes planus foot type along with a sclerotic “c” sign surrounding the sustentaculum tali and slight talar neck beaking. b) Weight bearing preop AP x-ray demonstrating midtarsal joint abduction, increased talar head uncovering, and increased calcaneal cuboid abduction. Case Study Figures History of Present Illness and Preoperative Exam A case is presented of a 7 year-old female complaining of bilateral foot pain for several months of duration. Pain was located to the bottoms of her feet and affected her ability to participate in athletic activity, run and exercise. Symptoms were worse on her right foot. Treatment had consisted of orthotics, bracing, and use of over-the counter analgesics without significant relief. Other relevant medical history included genu valgum, pes planus, and sickle cell trait. She had no abnormalities during development or birth. She had normal neurovascular and dermatologic status on exam. Full muscle strength was observed. Subtalar joint range of motion was restricted. Non weight bearing exam revealed a pes plano valgus foot type with complete collapse of the medial longitudinal arch and prominent talonavicular bulge (Figure 1). This was also observed with the patient weight bearing. Pt was able to perform double and single limb heel rise, but no inversion of the heel was observed. Gait analysis revealed increased pronation through midstance and propulsive phases of gate, early heel off and absence of resupination of the midtarsal joint at toe-off. Imaging Radiographic evaluation revealed medial arch collapse with increased talar declination, and anterior translation of the talonavicular joint. Other significant findings were talar head uncovering and increased calcaneal cuboid abduction angle. Dorsal talar beaking was also observed as well as a circumferential sclerotic appearance around the middle facet (Figure 2a and 2b). These radiographic findings increased our suspicion for a tarsal coalition. Subsequently computed tomography was ordered revealing an osseous talocalcaneal coalition involving the middle facet (Figure 3a – 3c). The surgical approach for treatment of this rigid pediatric pes planovalgus deformity with a tarsal coalition involved a combination of tarsal coalition resection, extra-articular subtalar joint arthrodesis with dowel allograft, and lengthening of the posterior muscle group. This procedure requires a period of prolonged NWB. Benefits of this procedure include preservation of the articular surface of the posterior facet thus allowing continued osseous maturation of the talus and calcaneus. A contraindication for this procedure would include arthroses of the posterior facet or adjacent joints. Higher level studies are needed to determine the long-term success of this procedure in pediatric patients with TC coalitions and severe rigid pes planovalgus deformity. In 2010, Fentes-Nucamendi published a prospective study evaluating 26 patients (average age of 12) with tarsal coalitions who underwent this procedure. Reported complications included: one reflex sympathetic dystrophy, 4 superficial infections, 4 graft resorptions, and 4 patients with persistent pain. Average follow-up was 5 years. A determining factor for persistent pain was obesity. Overall, this surgical technique was successful as treatment for the majority of these patients. This case report is presented to demonstrate a method of resecting a middle facet (TC) coalition, while addressing profound hindfoot valgus deformity through extra-articular STJ arthrodesis. The patient in this case has demonstrated successful return to activity with improvement of pain and function over the short and midterm followup periods. Procedure The operation was performed with the patient placed in the supine position. The patient was administered general anesthesia and supplemented with a popliteal block. Following standard prepping and draping, a thigh tourniquet was inflated for hemostasis. A 5 cm linear incision was made 1.5 cm inferior to the medial malleolus (Figure 4). Through this incision, the coalition wasresected with an osteotome. Identification of the coalition was verified with image intensification and fluoroscopy prior to resection (Figure 5a and 5b). Following resection, the subtalar joint (STJ) was found to be mobile and reducible (Figure 6a and 6b). Reduction of the talonavicular (TN) and STJ was maintained with a 0.062 K-wire placed percutaneously (Figure 7a – 7c). Next, a small linear incision was placed over the sinus tarsi, which was then prepared for fusion and placement of allograft material. Dowel allograft was then sized, fashioned, inserted, and tamped into the sinus tarsi. Cancellous bone chips were also used to fill in any remaining deficit (Figure 8a – 8c). A 0.062 K-wire was fashioned as a large staple and placed across the subtalar joint acting as a strut to further augment position and alignment (Figure 9). Post operatively, radiographic imaging demonstrated correction of the pes planus deformity in multiple planes (Figure 10). A gastrocnemius recession was also performed adjunctively addressing the patient’s equinus deformity. Postoperative Course Postoperatively, the patient was placed in a well-padded posterior splint for 1 week. Her activity was non-weight bearing (NWB) in a short leg cast for an additional 7 weeks, followed by K-wire removal at 8 weeks. After removal of the hardware, she was NWB for 2 weeks. At 12 weeks, patient was advanced to protected weight bearing (WB) in a pneumatic CAM boot. She progressed to full WB and regular shoe gear by 16 weeks. 5 month postoperative radiographs revealed correction of her pes planus deformity in multiple planes (Figure 11). At final 14 month follow-up, patient was asymptomatic and demonstrated normal gait and foot position with no recurrence of her deformity. Literature Review In 1945, David Grice initially described the subtalar extra-articular arthrodesis as a treatment for juvenile paralytic valgus foot 8 . The purpose of the extra-articular arthrodesis was to provide for correction of the deformity, and allow for tendon transfer without retarding the foot’s growth. By the end of his career, Grice reported on 108 procedures over multiple publications with expansion of indications including valgus deformities associated with cerebral palsy, myelodysplasia, congenital vertical talus, idiopathic planovalgus, and talocalcaneal coalitions 8,9 Since then, several studies have demonstrated successful use of this procedure for pediatric patients with valgus foot deformities secondary to neuromuscular conditions such as poliomyelitis, cerebral palsy, and myelodysplasia 10,11,12,13,14,15,16,17 . To our knowledge, only one study has reported on the utility of this procedure specifically for addressing rigid pes planus deformity with an associated talocalcaneal coalition 18 . 1. Lemley et al, Current Concepts Review: Tarsal Coalition. FAI, 2006, Vol 27 No. 12 2. Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone Joint Surg. 1948;30B:624-634. 3. Cass et al. A Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning. The Journal of Foot & Ankle Surgery 49 (2010) 274–293 4. Blitz, N Pediatric and Adolescent Flatfoot reconstruction in Combination with Middle Facet Talocalcaneal Coalition Resection. Clin Podiatr Med Surg 27 (2010) 119-133 5. Wilde, PH; Torode, IP, Dickens, DR; Cole, WG: Resection for symptomatic talocalcaneal coalition. J. Bone Joint Surg. 76-B:797 – 801, 1994. 6. Luhmann, SJ; Schoenecker, PL: Symptomatic talocalcaneal coalition resection: Indications and results, J. Pediatr. Orthop. 18:748 – 754, 1998. 7. Bohne WH. Tarsal coalition. Curr Opin Pediatr. 2001;13:29-35. References 8. Grice, DS, Further Experience with Extra-articular Arthrodesis of the subtalar joint. The Journal of Bone and Joint Surgery. 1954 9. Bourelle S, Cottalorda J, Gautheron V, Chavrier Y, Extra-articular subtalar arthrodesis, A Long-Term Follow-up In Patients with Cerebral Palsy. Journal of Bone and Joint Surgery (BR). 2004 86-B, No. 5 10. Leidinger B, Hyse TJ, Fuchs-Winkelmann S, Paletta JR, Naturarum R, Roedl R, Grice-Green Procedure for Severe Hindfoot Valus in Ambulatory Patients with Cerebral Palsy. The Journal of foot and Ankle Surgery 50(2011) 190-196 11. Guven m, Eren A, Akman B, Unay K, Ozkan NK, The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy, Act Orthop Traumatol Turc 2008, 42(1): 31-37 12. McCall RE, Lillich JS, Harris JR, Johnston FA, The Grice Extraarticular Subtalar Arthrodesis: A Clinical Review. Journal of Pediatric Orthopedics 5:442-445, 1985 13. Mallon WJ, Nunley JA, The Grice Procedure Extra-Articular Subtalar Arthrodesis. Orthopedic Clinics of North America, Vol. 20, No. 4 1989 14. Ross PM, Lyne ED, The Grice Procedure: Indications and Evaluation of Long-term Results, Clinical Orthopaedics and Related Research, No. 153, 1980 15. Mazis GA, Sakellariou VI, Kanellopoulos AD, Papagelopoulos PJ, Lyras DN, Soucacos PN, Results of Extra-Articular Subtalar Arthrodesis in Children with Cerebral Palsy. Foot and Ankle International, 2012, 33: 469 16. Dravic DM, Schmitt EW, Nakano JM, The Grice Extra-Articular Subtalr Arthrodesis in the treatment of Spastic Hindfoot Valgus Deformity. Developmental Medicine and Child Neurology, 1989, 31, 665-669 17. Aronson, J Nunley J, Frankovitch K, Lateral Talcocalcaneal Angle in Assessment of Subtalar Valgus: Follow-up of Seventy Grice-Green Arthrodeses. Foot and Ankle 1983 18. Fuentes-Nucamendi MA, Ojeda JRB, Martinez MAV, Coalicion tarsal, Tecnica de Grice, Acta Ortopedica Mexicana 2010; 24(3): 139-145 Analysis and Discussion
Transcript of Extra-articular Subtalar Joint Arthrodesis for Rigid Pediatric Pes … · Extra-articular Subtalar...
Extra-articular Subtalar Joint Arthrodesis for Rigid Pediatric Pes Planovalgus in a Patient with a Talocalcaneal CoalitionEric Lew, DPM1, Lauren Kishman, DPM1, Mark Hardy, DPM, FACFAS2
1Residents, Podiatric Medicine and Surgery, Kaiser Permanente / Cleveland Clinic2Staff, Department of Foot and Ankle Surgery, HealthSpan Physicians Group, Cleveland Ohio
Statement of PurposeRigid pediatric flatfoot is commonly associated with a tarsal coalition, often involving the middle facet of the subtalar joint. Joint stiffness and deformity results in difficulties with ambulation, foot pain, spasms, and frequent foot and ankle injuries1. Non-operative care is the first line of recommendation for treating talocalcaneal coalitions1,2. Patients who are recalcitrant to non-operative treatment, may require operative management with either resection or arthrodesis1,3,4 Poor outcomes following resection have been found in patients with severe hindfoot valgus5,6. Patients with severe deformity, large coalition, or advanced degenerative changes may be treated with subtalar joint arthrodesis2,4,7. There is limited focus in the literature regarding extra-articular arthrodesis in pediatric patients with talocalcaneal (TC) coalitions. This case study will highlight our experience in addressing a severe pediatric pes plano valgus deformity with associated TC coalition through the performance of subtalar extra-articular arthrodesis. Long term goals of this treatment include improvement of foot alignment, pain, function, and quality of life.
Figure 1. Preoperative Clinical Image
Figure 3. Preoperative Computed Tomography Imaging
Preop clinical image demonstrating collapse of the medial longitudinal arch and talonavicular joint prominence.
Computed tomography scans revealed an osseous talocalcaneal coalition in the coronal, axial, and sagittal reconstructed views (a, b, c). No significant arthrosis of the posterior facet was observed.
Figure 4. Middle Facet Coalition Resection
A 5 cm linear incision was made 1.5 cm inferior to the medial malleolus to approach the middle facet. Resection of the coalition was performed with an osteotome.
Figure 6. Intraoperative Imaging after Coalition Resection
Figure 7. Reduction of Subtalar and Talonavicular Joints
a) Pronation of the subtalar joint following coalition resection.
b) Reduction of subtalar joint pronation to a neutral position following resection of the coalition.
Figure 5 Intraoperative ImagingThe coalition was identified under C-Arm image intensification prior to resection (a, b).
A 0.062 K-wire was placed percutaneously across the talonavicular (TN) joint maintaining reduction of the TN and the subtalar joint in multiple planes (a,b,c).
Placement of a 0.062 fashioned like into a large staple acting as a strut across the subtalar joint maintaining the subtalar joint in the corrected position.
Figure 8. Fashioning and Placement of Dowel Bone Allograft into the Sinus Tarsi
Figure 9. Intraoperative Imaging
a) Post op AP radiograph demonstrating midtarsal joint realignment, correction of abnormal talar head uncovering, and reduction of calcaneal-cuboid abduction.
a) AP radiograph demonstrating satisfactory correction of the midtarsal joint abduction and talar head uncovering.
b) A lateral radiograph demonstrating correction of the patient’s pes planus deformity and normal alignment of the subtalar and midtarsal joints in the sagittal plane.
b) Post op lateral radiograph demonstrating restoration of the medial column and correction of the sagittal plane through the subtalar and midtarsal joints.
Figure 10. Immediate Post operative Imaging
Figure 11. Postoperative Imaging at 5 Months
a) Dowel bone allograft was measured and carefully fashioned.
b) The dowel bone allograft was placed and tamped into the sinus tarsi.
c) Placement of cancellous bone allograft to remaining deficits in the sinus tarsi.
a)
a)
a)
b) c)
b)
b) c)
Figure 2. Preoperative Radiographic Imaging
a) A weight bearing preop lateral x-ray demonstrates a pes planus foot type along with a sclerotic “c” sign surrounding the sustentaculum tali and slight talar neck beaking.
b) Weight bearing preop AP x-ray demonstrating midtarsal joint abduction, increased talar head uncovering, and increased calcaneal cuboid abduction.
Case Study FiguresHistory of Present Illness and Preoperative ExamA case is presented of a 7 year-old female complaining of bilateral foot pain for several months of duration. Pain was located to the bottoms of her feet and affected her ability to participate in athletic activity, run and exercise. Symptoms were worse on her right foot. Treatment had consisted of orthotics, bracing, and use of over-the counter analgesics without significant relief. Other relevant medical history included genu valgum, pes planus, and sickle cell trait. She had no abnormalities during development or birth. She had normal neurovascular and dermatologic status on exam. Full muscle strength was observed. Subtalar joint range of motion was restricted. Non weight bearing exam revealed a pes plano valgus foot type with complete collapse of the medial longitudinal arch and prominent talonavicular bulge (Figure 1). This was also observed with the patient weight bearing. Pt was able to perform double and single limb heel rise, but no inversion of the heel was observed. Gait analysis revealed increased pronation through midstance and propulsive phases of gate, early heel off and absence of resupination of the midtarsal joint at toe-off.
ImagingRadiographic evaluation revealed medial arch collapse with increased talar declination, and anterior translation of the talonavicular joint. Other significant findings were talar head uncovering and increased calcaneal cuboid abduction angle. Dorsal talar beaking was also observed as well as a circumferential sclerotic appearance around the middle facet (Figure 2a and 2b). These radiographic findings increased our suspicion for a tarsal coalition. Subsequently computed tomography was ordered revealing an osseous talocalcaneal coalition involving the middle facet (Figure 3a – 3c).
The surgical approach for treatment of this rigid pediatric pes planovalgus deformity with a tarsal coalition involved a combination of tarsal coalition resection, extra-articular subtalar joint arthrodesis with dowel allograft, and lengthening of the posterior muscle group. This procedure requires a period of prolonged NWB. Benefits of this procedure include preservation of the articular surface of the posterior facet thus allowing continued osseous maturation of the talus and calcaneus. A contraindication for this procedure would include arthroses of the posterior facet or adjacent joints. Higher level studies are needed to determine the long-term success of this procedure in pediatric patients with TC coalitions and severe rigid pes planovalgus deformity. In 2010, Fentes-Nucamendi published a prospective study evaluating 26 patients (average age of 12) with tarsal coalitions who underwent this procedure. Reported complications included: one reflex sympathetic dystrophy, 4 superficial infections, 4 graft resorptions, and 4 patients with persistent pain. Average follow-up was 5 years. A determining factor for persistent pain was obesity. Overall, this surgical technique was successful as treatment for the majority of these patients.
This case report is presented to demonstrate a method of resecting a middle facet (TC) coalition, while addressing profound hindfoot valgus deformity through extra-articular STJ arthrodesis. The patient in this case has demonstrated successful return to activity with improvement of pain and function over the short and midterm followup periods.
ProcedureThe operation was performed with the patient placed in the supine position. The patient was administered general anesthesia and supplemented with a popliteal block. Following standard prepping and draping, a thigh tourniquet was inflated for hemostasis. A 5 cm linear incision was made 1.5 cm inferior to the medial malleolus (Figure 4). Through this incision, the coalition wasresected with an osteotome. Identification of the coalition was verified with image intensification and fluoroscopy prior to resection (Figure 5a and 5b). Following resection, the subtalar joint (STJ) was found to be mobile and reducible (Figure 6a and 6b). Reduction of the talonavicular (TN) and STJ was maintained with a 0.062 K-wire placed percutaneously (Figure 7a – 7c). Next, a small linear incision was placed over the sinus tarsi, which was then prepared for fusion and placement of allograft material. Dowel allograft was then sized, fashioned, inserted, and tamped into the sinus tarsi. Cancellous bone chips were also used to fill in any remaining deficit (Figure 8a – 8c). A 0.062 K-wire was fashioned as a large staple and placed across the subtalar joint acting as a strut to further augment position and alignment (Figure 9). Post operatively, radiographic imaging demonstrated correction of the pes planus deformity in multiple planes (Figure 10). A gastrocnemius recession was also performed adjunctively addressing the patient’s equinus deformity.
Postoperative CoursePostoperatively, the patient was placed in a well-padded posterior splint for 1 week. Her activity was non-weight bearing (NWB) in a short leg cast for an additional 7 weeks, followed by K-wire removal at 8 weeks. After removal of the hardware, she was NWB for 2 weeks. At 12 weeks, patient was advanced to protected weight bearing (WB) in a pneumatic CAM boot. She progressed to full WB and regular shoe gear by 16 weeks. 5 month postoperative radiographs revealed correction of her pes planus deformity in multiple planes (Figure 11). At final 14 month follow-up, patient was asymptomatic and demonstrated normal gait and foot position with no recurrence of her deformity.
Literature ReviewIn 1945, David Grice initially described the subtalar extra-articular arthrodesis as a treatment for juvenile paralytic valgus foot8. The purpose of the extra-articular arthrodesis was to provide for correction of the deformity, and allow for tendon transfer without retarding the foot’s growth. By the end of his career, Grice reported on 108 procedures over multiple publications with expansion of indications including valgus deformities associated with cerebral palsy, myelodysplasia, congenital vertical talus, idiopathic planovalgus, and talocalcaneal coalitions8,9 Since then, several studies have demonstrated successful use of this procedure for pediatric patients with valgus foot deformities secondary to neuromuscular conditions such as poliomyelitis, cerebral palsy, and myelodysplasia10,11,12,13,14,15,16,17. To our knowledge, only one study has reported on the utility of this procedure specifically for addressing rigid pes planus deformity with an associated talocalcaneal coalition18.
1. Lemley et al, Current Concepts Review: Tarsal Coalition. FAI, 2006, Vol 27 No. 122. Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone Joint Surg. 1948;30B:624-634.3. Cass et al. A Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination, Diagnostic Imaging, and Surgical Planning. The Journal of Foot & Ankle Surgery 49 (2010) 274–2934. Blitz, N Pediatric and Adolescent Flatfoot reconstruction in Combination with Middle Facet Talocalcaneal Coalition Resection. Clin Podiatr Med Surg 27 (2010) 119-1335. Wilde, PH; Torode, IP, Dickens, DR; Cole, WG: Resection for symptomatic talocalcaneal coalition. J. Bone Joint Surg. 76-B:797 – 801, 1994.6. Luhmann, SJ; Schoenecker, PL: Symptomatic talocalcaneal coalition resection: Indications and results, J. Pediatr. Orthop. 18:748 – 754, 1998.7. Bohne WH. Tarsal coalition. Curr Opin Pediatr. 2001;13:29-35.
References8. Grice, DS, Further Experience with Extra-articular Arthrodesis of the subtalar joint. The Journal of Bone and Joint Surgery. 19549. Bourelle S, Cottalorda J, Gautheron V, Chavrier Y, Extra-articular subtalar arthrodesis, A Long-Term Follow-up In Patients with Cerebral Palsy. Journal of Bone and Joint Surgery (BR). 2004 86-B, No. 510. Leidinger B, Hyse TJ, Fuchs-Winkelmann S, Paletta JR, Naturarum R, Roedl R, Grice-Green Procedure for Severe Hindfoot Valus in Ambulatory Patients with Cerebral Palsy. The Journal of foot and Ankle Surgery 50(2011) 190-19611. Guven m, Eren A, Akman B, Unay K, Ozkan NK, The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy, Act Orthop Traumatol Turc 2008, 42(1): 31-3712. McCall RE, Lillich JS, Harris JR, Johnston FA, The Grice Extraarticular Subtalar Arthrodesis: A Clinical Review. Journal of Pediatric Orthopedics 5:442-445, 198513. Mallon WJ, Nunley JA, The Grice Procedure Extra-Articular Subtalar Arthrodesis. Orthopedic Clinics of North
America, Vol. 20, No. 4 198914. Ross PM, Lyne ED, The Grice Procedure: Indications and Evaluation of Long-term Results, Clinical Orthopaedics and Related Research, No. 153, 198015. Mazis GA, Sakellariou VI, Kanellopoulos AD, Papagelopoulos PJ, Lyras DN, Soucacos PN, Results of Extra-Articular Subtalar Arthrodesis in Children with Cerebral Palsy. Foot and Ankle International, 2012, 33: 46916. Dravic DM, Schmitt EW, Nakano JM, The Grice Extra-Articular Subtalr Arthrodesis in the treatment of Spastic Hindfoot Valgus Deformity. Developmental Medicine and Child Neurology, 1989, 31, 665-66917. Aronson, J Nunley J, Frankovitch K, Lateral Talcocalcaneal Angle in Assessment of Subtalar Valgus: Follow-up of Seventy Grice-Green Arthrodeses. Foot and Ankle 198318. Fuentes-Nucamendi MA, Ojeda JRB, Martinez MAV, Coalicion tarsal, Tecnica de Grice, Acta Ortopedica Mexicana 2010; 24(3): 139-145
Analysis and Discussion
