Foot in CMT Polio Upper motor neuron Pes Cavus and surgical correction

Pes Cavus and Surgical Correction; (including CMT, Polio) Justice Missirian 1/24/6 Pes Cavus  = High arched foot, does not flatten with wt-bearing  Hindfoot, forefoot, global  Contracted plantar aponeurosis  MTP clawing (hyperext)  Decr wt-bearing surface  Subtalar joint vertical thus decr rotation w/ gait Bony Deformity  Calcaneus Dorsiflexed – “Pitch Angle” >30 deg  +/- calcaneus varus  Forefoot Plantarflexed (equinus)  +/- forefoot adduction  Foot looks suppinated, walk on lat borders of feet  Incr stress on subtalar/ankle jt (esp if weak peroneals Soft Tissue Deformity  Plantar Aponeurosis Contracture  Normally: Windlass mechanism elevates longitudinal arch to invert heel  Intrinsic/Extrinsic Muscle imbalance  Overall – decreased contact area of foot  MT pain Etiology      CMT (30% of cavus) Myelodysplasia, polio (2nd most common) Friedrich’s Ataxia Idiopathic (50% FHx) Other:  Duchenne’s MD, Spinal Dysraphism, Polyneuritis, intraspinal tumor, CP, cerebellar dz, resid clubfoot, crush/burn, arthrogryposis Symptoms       MT/Heel pain Fatigue w/ walking/standing Thick plantar callus Multiple ankle sprains Toe ulceration (claw toe) Drop foot + 1st Toe cock-up in Swing Phase Conservative Treatment       Stretching Well-molded, semiflexible orthosis Decrease pressure on MT heads +/- custom shoe Short leg brace Observe for progression Surgery  Goal: Plantigrade, stable foot  Must do muscle strength testing prior to surgery  If Supple: soft tissue procedures     Plantar fascial release Tendon transfer Prevent future bony deformity Osteotomy to correct single deformity/maintain flexible foot  Rigid Foot: Fuse Polio  Weak Posterior Calf musculature  Unopposed Tibialis Anterior  Transfer Tib Ant  Sometimes not even anterior calf functions  Unopposed intrinsics  Treat with Plantar Fascial Release Charcot-Marie-Tooth  Inherited peripheral motor neuron  SLR 20’s, AR <10 yo, AD 30 yo  Progressive muscular atrophy of feet/legs     1) Peroneal muscles 2) Foot Intrinsics 3) Foot Dorsiflexors 4) Ankle Plantarflexors  Steppage Gait/shuffling feet Charcot-Marie-Tooth  Normal Posterior Musculature  Anterior Musculature is weak  Weak Tib Ant & Peroneus Brevis  Unopposed Peroneus Longus & Tib Post  Lengthen Tib Post  Posterior Tib Thru Interosseus Membrane  Transfer Longus to Brevis (improves eversion) Steindler Stripping  = Plantar Fascial Release  For flexible foot  In conjunction with osteotomy/arthrodesis  Dwyer  Tripple arthrodesis  1st MT osteotomy  Risk calcaneal nerve to fat pad First Toe Jones Procedure  For hyperextension of 1st MTP  due to weak Tib Ant  EHL acts as accessory DF of ankle thus hyperext MTP, flex IP  Move EHL insert to base of 1st MT  Maintains DF w/out toe ext  Fuse MP joint Claw Toes  If fixed MTP deformity:  release ext tndn, jt capsule  Flx tndn tranfer to balance  Fixed IP deformity (hammer toe):  prox phalanx removal (DuVries arthroplasty)  Or IP fusion  If passively correctible:  Flx tndn transfer only 1st MT Osteotomy  In conjunction with plantar fascial release/tendon transfer  Esp. CMT: plantar flexed 1st MT  Sometimes involves 2nd, rarely 3rd MT  Twists foot into inversion  Very unstable ankle esp if varus calcaneus, weak peoroneus brevis, contracted fascia  Make sure 2nd MT head not too PF Dwyer Calcaneal Osteotomy  In conjunction with plantar fascial release/tendon transfer  And usu 1st MT osteotomy  For severe fixed varus calcaneus  Excessive wt-bear on lat heel  Unstable ankle  Lat closing wedge Crescentic/Sliding Calcaneal Osteotomy  Calcaneus DF Pitch angle >30 deg  In conjunction with plantar fascial release Tripple Arthrodesis     Fixed Rigid Deformity, Mature foot Subtalar, calcaneocuboid, talonavicular Usu need plantar fascial release in addition Stripping Neck of talus can disrupt blood supply Midtarsal Osteotomy  Cole, Japas  Results not as good  Thru multiple joints  arthritis The End