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Clinical Problems
1) abnormal weight bearing forces
2) instability of the foot and ankle
3) restricted mobility
4) difficulty in fitting shoes
2 Types:
1) Rigid
2) Flexible
"High Arch" may be noted in stance exam or only in non-weight bearing, if present in
stance represents a more rigid deformity may be result of neuromuscular imbalance.
1 study showed 75% had associated neuromuscular disease, 16.3% incidence occurring in
women > men.
Congenital –
Spina Bifida, myelodisphasias, familial degeneration nerve disorders, hypertrophic
interstitial neuropathy, CP, MD, congenital syphilis, scoliosis, TEV, myelomeningocele
CMT, Freidrich’s ataxia, Roussy Levy syndrome.
Acquired –
Tumors, trauma, infection, psychiatric conditions, choristoma of sciatic nerve, tarsal
coalition, spinal conditions of the first 2 segments.
2) Roussy Levy –
- Similar to CMT –
- Important distinction = tremors in hands and ataxia
- Autosomal dominant
- Considered intermediate between CMT and FA
- Atrophy mirrors CMT but disease less severe and less rigid
- Decrease DTR's
7) Poliomyelitis
- Until 20th century was primary cause of pes cavus
- Infantile form is leading cause of post cavus
- Affects anterior horn cells in spinal cord
- Leads to weakness of DF and PF and claw toes
Classification pg 765
Biomechanics
1) Anterior Cavus
4 types:
A) Metatarsus cavus
B) Lesser Tarsus cavus
C) Forefoot cavus
D) Combined Anterior cavus
A) Metatarsus Cavus –
- Declination of mets with apex at Lis Franc's
- Palpable bone dorsally usually at first met cuneiform joint
- More rigid
C) Forefoot Cavus –
- Occurs at Chopart’s
- Dorsal lateral head of talus is pathognemonic sign in NWB
- More flexible
- Use Hibbs and Meary's angles for evaluation
Meary's = center of talus and first met
Hibb's = calcanenus and first met
- On lateral view where they intersect represents the apex of deformity
D) Combined Anterior Cavus –
- Excessive plantar flexion occurring at 2 or more axises
Pseudoequinus
- Dorsiflexion of ankle can compensate for anterior cavus
- This leads to increase CIA
- If there is not enough ankle dorsiflexion remaining for gait the result is
Psuedo Equinus
Associated Conditons
Forefoot Varus
Forefoot valgus
Plantar flexion of first ray
Met Adductus
Equinius
Rearfoot varus
Type I –
- Flexible
- Deformity disappears on stance
- May have rigid/flexible hammer toes
Type II –
- May be apparent weight bearing
- Deformities for Type I may present as well
- Callous lesions on first and fifth mets
- Treatment – dorsiflexion osteotomy of 1st met/ Dwyer with tendon transfers
and/or lengthenings
Type III –
- Marked deformity in multiplanes
- Gait abnormalities and instability
- Painful plantar lesions
- Treatment = Cole or arthrodesis
- Decision for diagnosis of type II vs III often made if patient complains of
painful lesions vs instability
Application
Rigid vs Flexible
- Rigid requires osteotomy/release –
- if any component is compensating may not need surgical correction
- In types II and III rearfoot assessed first
- Two planes may exist – sagittal (dorsiflexion of rearfoot compared to
forefoot) and/or frontal (rearfoot varus)
Subcutaneous Fasciotomy –
- Peds with moderate plantar fascial contracture with little muscle involvement
- Blade inserted flat against skin then rotated 90 degrees with sharp against
fascia
- Cut 2 levels 2.5 cm apart with pressure from index finger on heel
- Then forefoot dorsiflexed
- BK walking cast changed every 2-3 weeks with forefoot dorsiflexed on
rearfoot
Steindler Stripping
- Peds with contracture of plantar fascia and musculature
- No effect on fixed deformities
- Care of Nuerovascular bundle
- Sagittal plane release only
- If multiplanar – need more incision along medial side of calcaneous distal to
approx. 3.75 cm anterior to medial tubercle
- Release plantar fascia/ abductor hallcis, FDB, Abductor DQ, and long plantar
ligament
- The foot forced in corrected position
- After care same as SubQ Fasciotomy
Tendon Transfers
- Provide better results for patients older than 10 years
- There must be adequate ROM across the joint in which the tendon is to be
transferred in order for the transfer to be successful
- These procedures aren’t meant to correct the deformity but to establish a more
normal equilibrium
- Helps to load the midtarsal joint by dorsiflexing the forefoot on the rearfoot
attempting to balance extensors and flexors
- PIPJ fusions may be necessary when performing ETT
Jones Suspension
- Isolated transfer of EHL to the head of the 1st met
- May be used for overpowering of Peronoues Longus of FHL
- Must have adequate ROM of the 1st ray and absent ankle equines
- Should fuse hallux IPJ
- Be careful not to produce iatrogenic limitus
- Jones is effective for correction of hallux malleus but not predictable for
submet 1 lesions
Heyman Procedure
- Transfer of all 5 long extensor tendons to their met heads.
- Original gave no resolution to the distal stump, the PI modification sutures
distal stumps to the short extensor tendons the 5th also goes to the fourth
- High complication rate – not used much anymore
- Should fuse PIPJ and release the MPJ to assure adequate stabilization of the
toe.
Hibbs Procedure
- Original procedure included extensor transfer to 3rd cuneiform plantar fascial
release and plantar muscle release and possible Achilles tendon lengthening
- PI includes transfer of extensors to 2nd or 3rd met base or cuneiform, Jones of
EHL and either anastamosis of distal stumps to EDB or PIPJ fusions. Plantar
stripping is omitted to maintain stability of the toes and Achilles tendon
lengthening is rarely needed
Peroneal Anastomosis
- Suturing the PL and PB at the level of the lateral ankle
- Used to decrease plantarflexion of 1st ray and increase eversion.
- As with STAT it is used as an adjunctive procedure. Should not be used as a
stand alone procedure.
- Can also anastamose at the level of PB insertion
Midtarsal Osteomies
Cole –
- Addresses apex at midfoot
- Anterior tarsal resection – dorsal midfoot wedge osteotomy to reduce sagittal
plane anterior pes cavus with little frontal plane correction
- Dorsal wedge laterally from cuboid and medially from navicular/cuneiform
joint
- Medial and lateral incisions normally but 1 dorsal incision has be described
- Width of wedge depends on severity of deformity
- Fixated with pins, staples, or screws
- May need plantar fascitomy
- Post op non weight bearing , BK cast for 8 weeks, then weight bearing cast for
4-6 weeks
- Can add DF wedge of first met or Dwyer if rearfoot involved
JAPAS
- Midtarsal V osteotomy of midfoot
- No bone excised
- Apex of V oriented proximally at apex of deformity usually in navicular
- Lateral arm through cubiod and medial arm through cuneiform
- Osteotomy is displaced dorsally
- Fixation with 2 pins
- If first ray dorsiflexion is needed you can pass medial arm through the first
met base
- Plantar fasciotomy should be preformed
- Post op same as Cole
- Harder to perform than Cole with increased complications
Metatarsal Osteotomies
- Multiple met osteotomies give latitude for correction of anterior cavus with
correction allowed in sagittal, frontal, and transverse planes if needed
- Rarely need plantar fascial releases
- Preformed through 3 dorsal incisions- 1st over first met base, 2nd between
2nd and 3rd met bases, 3rd between 4th and 5th met bases
- The met needing the least correction is done first
- If transverse plane correction needed do 5th met first to allow for lateral
translation
- Fixation with screws
- Non weight bearing cast 6-8 weeks
- Advantages:
o 1) function of rearfoot and midfoot joints are preserved
o 2) less disability –
- Disadvantages:
o extensive soft tissue dissection
o if rearfoot varus can’t return to perpendicular must realign
Tarsal Osteotomies
Dwyer
- Closing wedge of lateral body of calcaneous for rigid rearfoot varus
- Not indicated for rearfoot varus secondary to forefoot valgus
- Effective in peds after 3 years
- Reocurrence associated with neuromuscular disease
- Expose lateral body of calc. including upper and lower surfaces a wedge is
removed laterally just inferior and posterior and parallel to PL tendon
- Fixation staple
- Post op – cast 6-8 weeks
- Tachdjian recommended not to perform prior to 8 years
Tarsal Arthodesis
Triple Arthrodesis
- Hoke described fusion of the STJ and TN Ryserson added CC hince triple
- Aids in Type III pes cavus
- Increases stability
- May be combined with tendon transfers, met osteotomies and digital
procedures
- assess ankle stability
- To correct one may: 1) wedge resect or 2) sliding maneuvers –
- The initial Midtarsal joint resection is minimal until STJ is completed
- Care must be taken to PF calc. and talus in relation to forefoot and not to DF
talus
- If calc. is displaced forward slightly, it creates a wedge effect encouraging DF
of FF on RF
- Once STJ is complete its temporary fixed with pins
- Then wedges are taken from Midtarsal joint as needed
- Frontal plane slides can be used to correct forefoot varus/valgus
- If unsuccessful may need met osteotomy
- Temp. fix MTJ with pins
- Fixate STJ then MTJ
- Post op includes compression dressings and drains
- BK non weight bearing cast for 3 months or
- BK weight bearing cast after 2 months
- If you have rigid internal fixation can place patient in bivalved cast or splint
after 4 weeks to allow for patient and passive ROM