The Reason behind Grice Green Arthrodesis :
Neurological deficit resulting in the lack of motor control in children with myelomeningocele often leads to a valgus position of the feet and ankles, usually in combination with planovalgus or pronation of the forefoot.
This deformity may be difficult to correct by orthoses alone, and surgical correction may be needed to enable the child to walk.
Difficulties in finding suitable shoes are typical. Pain produced by extreme foot deformity and orthoses is sometimes present.
Pressure sores can easily occur in the insensate foot, and correction of a foot deformity to avoid such pressure sores may be necessary.
The neurological condition deteriorates during childhood in some cases due to complications from tethered cord releases, hydrocephalus treatment and scoliosis corrections, and the neurological status cannot in all cases be regarded as non-progressive.
The extraarticular subtalar arthrodesis was originally designed by Grice in the treatment of children with polio and was widely used some decades ago. Recently, other corrective surgical procedures have been more commonly used, such as the medial sliding osteotomy of the calcaneus and the calcaneal lengthening osteotomy.
The Grice procedure has, since the eradication of polio, been more commonly used in the treatment of spastic valgus deformity seen in patients with spastic cerebral palsy. The operation is found to be a demanding one, even among experienced surgeons , but it is a major advantage that it does not affect further bone growth or necessitates the resection of local bone.
The procedure has also been used in children with myelomeningocele, which typically has concomitant valgus instability of the ankles, and correcting the subtalar joint addresses, in many cases, only part of the problem.
Adequate pre-operative radiographs of both the feet and ankles are of the essence to locate the cause of the valgus instability.
Salient Features :
– Extra-articular arthrodesis which is useful in blocking subtalar motion in those patients who have no gross skeletal deformities but have
instability of the hindfoot
– This arthrodesis is particularlly applicable in children, since there is little interference with future growth of the foot
– Spastic pes valgus is more common in patients who have spastic diplegia and is generally resistant to orthotic management
– Subtalar extra-articular arthrodesis that was originally devised by Grice for the management of pes valgus due to flaccid paralysis muscle
imbalance has also been widely used in patients who have cerebral palsy
– Grice procedure is simple method of obtaining fusion of subtalar joint
– It was originally described for use in the immature foot deformed with a hindfoot valgus secondary to CP, poliomyelitis, and other paralytic
– This procedure can be used for calcaneocavus , talocalcaneal coalition, congenital vertical talus, and isolated post
traumatic arthritis of the sub talar joint
– Lateral radiograph of the foot, held in slight equinus and inversion, will confirm whether the valgus deformity of the subtalar joint is fully
– It is necessary that the hindfoot by flexible and corretable passively to a plantigrade position
– Rigid deformed hindfoot is a contraindication to the Grice procedure
– Most older children ( > 10 years) & adults with pathologic hindfoot valgus, will show evidence of secondary degenerative changes of the
talonavicular and calcaneocuboid joints;
– these are relative contraindications for the Grice procedure;
– Grice procedure is not recommended for varus deformities