p2.ch3.4-3

4. Hallux Valgus Deformity
          Hallux valgus deformity is an another serious deformity of 
the foot, observed in older patients.

Historical Reviews
          As Bleck stated in his book, on cerebral palsy, the hallux 
valgus deformity is commonly associated with pes valgus 
deformity in cerebral palsy, and causes excessive pressure on the 
medial border of the foot. In hallux valgus deformity, pressure is 
concentrated on the metatarsophalangeal joint of the great toe, 
causing intolerable pain, at the time of weight bearing, associated 
with destruction of the medial arch of the foot.270-272 For treatment 
of hallux valgus deformity in non-paralytic patients, numerous 
procedures have been proposed.269-272 However, in the hallux 
valgus in cerebral palsy, in which total body weight is centered on 
the first metatarsophalangeal joint, bony procedures alone will not
be recommended. We have seen 3 feet of 2 patients with 
discouraging results having persistent pain after bony surgery. One 
of them showed osteonecrotic change in the head of the first 
metatarsal bone, after McBride procedure, and the other patient 
complained of difficulty in walking, due to stiffness and pain at 
the MP joint in both feet, after arthrodesis of the 
metatarsophalangeal joint.273 All these three operations were 
performed long time ago, by another orthopaedic surgeon. We did 
not get any other opportunity to experience effects of bony surgery. 
          In our institute, lateral release operation which has been 
used for correction of pes valgus was applied even for correction 
of hallux valgus, in order to shift the weight bearing from the 
medial border of the foot to the lateral border, and to reduce 
concentration of the load of the whole body on the first
metatarso-phalangeal joint. Release of the adductor hallucis and 
flexor hallucis brevis at the sole have also been carried out for 
correction, as a combined surgery (Fig. 122 AB).

Fig. 122AB: Plantar release for hallux valgus deformity
Under consruction

Surgical Approach
(See clause of pes valgus deformity)


     
5. Pes Calcaneus Deformity
          In cerebral palsy patients, especially in severely involved 
patients, pes calcaneus deformity is frequently observed, and 
presents difficulty in obtaining antigravity stability. 
          Postoperative pes calcaneus deformity after Achilles tendon 
lengthening is another disaster. We have experiences of 
intramuscular lengthening of the tibialis anterior and peroneus 
brevis in 5 feet, for salvage surgery of calcaneus feet due to 
overlengthening of the Achilles tendon. Correction was attained to 
some extent, but increase in supporting power was not fully 
attained in all the feet. We can reserve pantalar arthrodesis for 
correction of calcaneus deformity to provide weight-bearing 
stability. However, before we use this salvage procedure, we have 
to make every effort to prevent occurrence of pes calcaneus 
deformity and to avoid loss of stability after Achilles tendon 
lengthening. 
          Stable feet are a necessity of active daily life. Acquisition of 
stable foot is the fundamental aim of treatment of cerebral palsy. 
Hence all critical concerns should be focused, on achieving a 
well-balanced antigravity stability on the feet.

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