Pes Cavus Renae L. Daniels Synonyms for Cavus Foot Anterior Equinus Pes Cavo Varus Contracted Foot Talipes (Pes) Arcuatus Talipes Plantaris Schaffer Foot Bolt Foot Claw Foot Vault Foot Hollow Foot What Is It? Extraordinarily high plantar longitudinal arch Arch fails to flatten out with WB Forefoot is plantarflexed to rearfoot Primarily sagittal plane deformity Etiology of Pes Cavus Neurological Congenital Iatrogenic Infection Idiopathic Etiology - Neurological # 1 cause; estimated at about 75% lesions in the nervous system Charcot Marie Tooth disease Friedrich’s Ataxia Roussy-Levy syndrome Poliomyelitis Etiology Congenital Spina Bifida Talipes Equinovarus Myelodysplasia Iatrogenic Post surgery or trauma Peroneal nerve injury Weak anterior muscles Overpowering posterior muscles Etiology Infection Syphillis Poliomyelitis Idiopathic Must eliminate everything else first Presenting Complaints Pain and/or weakness Discomfort and fatigue of the foot Pain in the soles of the feet caused by callus formation at the ball of the foot Deformity Trouble obtaining shoe gear AJ instability Lack of coordination Evaluation Complete History (1st) Include developmental, familial, and a good medical history Neurological Consultation Evaluate motor & sensory systems, assess reflexes and coordination tests. Musculoskeletal check strength, ROM, DTR, rotational deformities (hips, knees, tibia, etc.) Evaluation Biomechanical Exam Include gait analysis Wide based gait with short steps neurological High stepping weak AJ DF Blood Tests Blood smear shows acanthocytosis (BassenKornzweig syndrome) Radiographs Calcaneal Inclination Angle is best Radiographic Views AP Evaluate transverse plane deformities met adductus FF adductus FF abductus AP Ankle deformity may not be at foot; ankle in varus Radiographic Views Lateral - best view Evaluate: Calcaneal inclination angle (C.I.A.) Talar declination angle Meary’s angle Hibb’s angle Metatarsal declination angle (25-35°) • evaluate sinus tarsi Meary’s Angle Talometatarsal angle Bisection of talus intersects with bisection of the 1st met. Normal: lines should be parallel Abnormal: > 4° Intersects at apex of the deformity Hibb’s Angle long axis of calcaneus as it intersects with bisection of the 1st met. Intersects at apex of the deformity Calcaneal Inclination Angle Best angle - changes little with supination or pronation Inferior pitch of calcaneus to WB surface of calcaneus to 5th metatarsal head Normal: 24.5° Moderate pes cavus: 31°- 40° Severe pes cavus : > 40° Calcaneal Pitch Angle Classifications Anterior Cavus Foot Posterior Cavus Foot Combined Cavus Foot Pes Cavus Rearfoot Varus Structural (Rigid) Positional (Flexible) soft tissue procedures will not fix a rigid deformity Compensations Contracted digits Claw toes Extensor substitution Reverse buckling at MPJ and ankle joint Anterior Cavus Foot Sagittal plane deformity Excessive PF of FF on RF Metatarsal Cavus (apex at Lisfranc’s joint) Lesser Tarsal Cavus Forefoot Cavus (apex at Chopart’s joint) Combined Cavus Foot (2 or more listed above) Anterior Cavus Foot Local = PF of 1st ray only Global = entire FF is PF Differentiating these two is important in determining proper surgical procedure Anterior Cavus Foot C.I.A. < 30° Meary’s angle > 10° Meary’s angle intersects at base of 1st metatarsal or Lisfranc’s joint Posterior Cavus Foot Primarily STJ deformity Increased C.I.A. Less common than anterior pes cavus C.I.A. > 30° Meary’s angle < 10° Meary’s angle intersects proximal to Chopart’s joint Combined Cavus Foot Anterior and Posterior components C.I.A., talar declination angle, & met. declination angle Combined Cavus Foot Primary Anterior C.I.A. ~ 30° Meary’s angle intersects at N-C joint Primary Posterior C.I.A. > 30° Talar varus Meary’s angle intersects at Chopart’s joint Pes Cavus Rearfoot Varus Functional FF deformity with a rigid RF varus Coleman Block test used to determine if RF varus is 1° or 2° deformity Coleman Block Test Pt. Stands with 1st ray hanging over the edge If RF is vertical or pronated, then RF is compensating for a rigidly PF 1st ray As a compensation, RF inverts when FF is on the ground RF is 2° deformity Treatment Goals Correct the deformity Relieve pain Maintain a balanced foot Principles of Treatment Underlying etiology MUST be determined The plane of the deformity is critical Cavus foot requires multilevel correction ie. Digits, Lisfranc’s joint, Midfoot, Rearfoot Non Operative Treatment Indications: mild pes cavus or when surgery is contraindicated Shoe modifications and inserts build up shoe AFO Physical Therapy Stretching Surgical Correction Soft tissue procedures indicated for flexible deformities often used in conjunction with osseous procedures Osseous procedures Soft Tissue Procedures Plantar Fascia Release Steindler Stripping Garceau & Brahms Tendon Transfers Jones Hibbs STATT PT Tendon Transfer PL Tendon Transfer S.T. Procedures Steindler Stripping: release plantar fascia, abductor hallucis, FDB, abductor digiti quinti, and often the quadratus plantae muscle attachment to the heel Garceau & Brahms: selective plantar muscle denervation. Resect motor branches of medial and plantar nerve. Historical procedure Tendon Transfers Jones Suspension: transfer EHL from the hallux to the 1st metatarsal indications: flexible PF 1st ray, weak Tib. Ant., helps DF ankle to met declination angle Hibbs Suspension: transfer EDL from each toe out to the midfoot (lateral cuneiform or cuboid) indications: flexible anterior cavus, flexible claw toes, pts. with extensor substitution, pts. with weak tib. Ant./ EDL /EHL Hibbs Suspension Split Tibialis Anterior Tendon Transfer (STATT) Split Tib. Ant. in half. Lateral half is transferred to insert with the peroneus tertius, lat. cuneiform, or cuboid. Indications: weak anterior m., swing phase supination Tendon Transfers Posterior Tibial Tendon Transfer: Very difficult. Out of phase transfer. Transfer Tib. Post. to dorsum of foot through EDL, peroneus tertius or Tib. Ant. tendon sheath. Indications: weak anterior muscle group TAL: only indication is spastic equinus Peroneus Longus Tendon Transfer/ Lengthening PL Transfer: transfer PL to dorsum of lesser tarsus through EDL tendon sheath or split through Tib. Ant. & peroneus tertius sheaths. STOP procedure: suture PL to PB indications: flexible 1st ray, heel varus PL Lengthening: decreases PF of 1st ray Indications: flexible 1st ray, weak tibialis anterior m. Osseous Procedures Digital Reduction DFWO metatarsals COLE JAPAS Dwyer McElvenny-Caldwell Triple Arthrodesis Digital Reduction restore MPJ alignment PIPJ arthrodesis Extensor hood resection Extensor tendon lengthening flexor plate release Fixate (K-wire) Metatarsal DFWO Proximal metaphysis dorsal distal to proximal plantar maintain hinge if possible fixation (screws or K-wires) Indications: local FF cavus rigid PF 1st met COLE DFWO at MTJ base is dorsal & apex is proximal often do plantar release also preserves STJ & MTJ motion indications: anterior cavus JAPAS V shaped MTJ osteotomy with apex proximal long incision, runs along EDL to the 3rd digit maintains length More normal looking foot JAPAS Disadvantages of MTJ Osteotomies long term stiffness non-unions over/ under correction edema N-V compromise Dwyer lateral closing wedge osteotomy wider laterally than medially, heel varus Indications: calcaneal varus posterior cavus non-reducible deformity Contraindications: reducible calcaneal varus 2° to PF 1st ray Important to do Coleman Block test here Dwyer Dwyer McElvenny-Caldwell Fuse 1st metatarsocuneiform navicular joints in a DF position Triple Arthrodesis T-C, T-N, C-C can correct all planal deformities common for severe cases of pes cavus Must decide the deformity 1st! Adducted FF? Correct at MTJ Sagittal plane deformity at MTJ? Cut wider wedge dorsally vs. plantarly RF varus? Fix at STJ (cut wider laterally than medially) Triple Arthrodesis Triple Arthrodesis Bibliography Canale, S. Terry, M.D.. Campbell’s Operative Orthopaedics. Mosby. St. Louis, 1998. Jahass, Melvin, M.D.. Disorders of the Foot and Ankle, 2nd edition. W.B. Saunders Company. Philadelphia, 1991. Kelikian, Armen. Operative Treatment of the Foot and Ankle. Appleton & Lange. Stamford, 1999. McGlamry, E. Dalton, D.P.M.. Comprehensive Textbook of Foot Surgery. Williams & Wilkins. Baltimore, 1992. Resnick, Donald, M.D.. Bone and Joint Imaging, 2nd edition. W.B. Saunders Company. Philadelphia, 1996. Bibliography Cavus deformity of the foot secondary to a neuromuscular choristoma (hamartoma) of the sciatic nerve. Journal of Bone and Joint Surgery. Vol. 79, no. 9 (1997 Sep): 1398-401 The modified Robert Jones tendon transfer in cases of pes cavus and clawed hallux. Foot and Ankle International. Vol 15, no. 2 (1994 Feb): 68-71 Investigation of muscle imbalance in the leg in symptomatic forefoot pes cavus. Foot and Ankle. Vol. 13, no. 9 (1992 NovDec): 489-501 Surgery Class Lecture Notes 1999. Dr. Boike. Surgery Class Lecture Notes. Lawrence G. Lazar, D.P.M.
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