Pes Cavus - PowerPoint by DrWarrenDO

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									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

Spina Bifida Talipes Equinovarus Myelodysplasia

Post surgery or trauma Peroneal nerve injury Weak anterior muscles Overpowering posterior muscles

Syphillis Poliomyelitis

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

Trouble obtaining shoe gear

AJ instability Lack of coordination

Complete History (1st)
Include developmental, familial, and a good medical history

Neurological Consultation
Evaluate motor & sensory systems, assess reflexes and coordination tests.

check strength, ROM, DTR, rotational deformities (hips, knees, tibia, etc.)

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)

Calcaneal Inclination Angle is best

Radiographic Views
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
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

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

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

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

DFWO at MTJ base is dorsal & apex is proximal often do plantar release also preserves STJ & MTJ motion indications:
 anterior cavus

V shaped MTJ osteotomy with apex proximal long incision, runs along EDL to the 3rd digit maintains length More normal looking foot


Disadvantages of MTJ Osteotomies
long term stiffness non-unions over/ under correction edema N-V compromise

lateral closing wedge osteotomy wider laterally than medially,  heel varus Indications:
calcaneal varus posterior cavus non-reducible deformity

reducible calcaneal varus 2° to PF 1st ray

Important to do Coleman Block test here



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

 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.

 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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