Transcript Pes Cavus - Muayad Kadhim's WebSite

Pes Cavus
Amjad Moiffak Moreden, M.D.
The General Assembly of Damascus Hospital
Ministry of Health
Damascus, Syria
Jan. 30, 2007
Synonyms

high arch, cavus foot, cock-up deformity,
clawtoe deformity, foot pain, talipes cavus,
contracted foot, exaggerated arch
Definition

Pes cavus is a high
arch that does not
flatten with
weightbearing. No
specific radiographic
definition of cavus
foot exists. The
deformity can be
located in the
forefoot, midfoot, or
hindfoot or in a
combination of these
sites.
What’s the problem?

clawing of the toes,
posterior hindfoot
deformity (described as
an increased calcaneal
angle), contracture of the
plantar fascia, and cockup deformity of the great
toe. This can cause
increased weightbearing
for the metatarsal heads
and associated
metatarsalgia and callus.
Etiology


80% of the time caused from malunion of
calcaneal or talar fractures, burns,
sequelae of compartment syndrome,
residual clubfoot, and neuromuscular
disease.
20% of cases are idiopathic and
nonprogressive .
Residual clubfoot
Etiology Cont…
Neuromuscular diseases

cause muscle imbalance that leads to an
elevated arch. These diseases include muscular
dystrophy, Charcot-Marie-Tooth (CMT) disease,
spinal dysraphism, polyneuritis, intraspinal
tumors, poliomyelitis, syringomyelia, Friedreich
ataxia, cerebral palsy, and spinal cord tumors. A
patient with new onset of a unilateral deformity
but without history of trauma must be evaluated
for spinal tumor.
Etiology Cont…
Multiple theories :
-Intrinsic muscle imbalance causing the elevated arch
-Extrinsic muscle causes the muscle imbalance.
-Combination of the intrinsic and extrinsic muscles
is the cause of the imbalance.

Etiology Cont…
Charcot-Marie-Tooth (CMT)

The anterior tibialis muscle and the peroneus muscle
develop weakness. Antagonist muscles, posterior tibialis
and peroneus longus, pull harder than the other
muscles, causing deformity. Specifically, the peroneus
longus pulls harder than the weak anterior tibials,
causing plantarflexion of the first ray and forefoot
valgus. The posterior tibialis pulls harder than the weak
peroneus brevis, causing forefoot adduction. Intrinsic
muscle develops contractures while the long extensor to
the toes, recruited to assist in ankle dorsiflexion, causes
cock-up or clawtoe deformity. With the forefoot valgus
and the hindfoot varus, increased stress is placed on the
lateral ankle ligaments and instability can occur.
Etiology Cont…
Polio

The deformity is in the hindfoot and
caused by the weakness in the
gastrocsoleus complex, leading to a
marked increase in the calcaneal pitch
angle with normal forefoot alignment.
Polio
Normal
Clinical presentation


Patients can present with lateral foot pain from
increased weightbearing on the lateral foot.
Metatarsalgia is a frequent symptom, as is
symptomatic intractable plantar keratosis. Ankle
instability can be a presenting symptom,
especially in patients with hindfoot varus and
weak peroneus brevis muscle.
Patients with neuromuscular disease complain of
weakness and fatigue, the severity of the
presenting symptoms is as variable as the
symptoms themselves.
Orthopaedic Residents
Work Up
- Family history
- Neuro exam
- X-rays of entire spine
- EMG and nerve conduction studies
- MRI meylogram
Evaluation

Thorough history and complete examination
in an attempt to try to determine the
etiology.
Imaging Studies

Standing radiography of the
feet and ankles is essential.
Radiographs should be
inspected for degenerative
arthritis, positioning of the
calcaneus, and forefoot
alignment. A calcaneal pitch
angle can be measured by
drawing a line along the
plantar aspect of the
calcaneus and the ground. An
angle greater than 30° is
significant for hindfoot varus.
The positioning of the first ray
compared to the axis of the
talus viewed on the lateral
radiograph determines if the
first ray is plantar flexed.
Imaging Studies Cont…

MRI of the spine should be obtained if
unilateral progressive cavus is present in a
patient without history of trauma.
Treatment


The goal of treatment is to produce a
plantigrade foot that allows even
distribution of weight.
Failure to maintain an asymptomatic
plantar grade foot is an indication for
surgery. The contraindication to surgery is
poor vascularity, and ulcers.
Treatment Cont…
Medical therapy



Ambulate with symptomatic relief
Physical therapy to stretch tight muscles and
strengthen weak muscles.
Orthotics with extra-depth shoes to offload
bony prominences and prevent rubbing of the
toes. lateral wedge sole modification to the
shoes can improve function. Bracing for supple
deformities or foot drop, and Plastizote linings
for sensation deficite.
Treatment Cont…
Surgical therapy

Patient must understand the rationale for
treatment and understand that surgical
reconstruction does not provide a normal
foot. The goal of surgery is to produce a
plantigrade foot and pain relief. Also,
repeat surgical procedures may be
required, especially if the deformity is
progressive.
Treatment Cont…
Surgical therapy


No single procedure is appropriate for all
patients, and frequently, multiple
individual procedures need to be
performed.
Tendon transfers and osteotomies can
provide correction of the deformity
without performing an arthrodesis which
is used only as a salvage procedure,
preserving the joints if possible is the
current trend .
Treatment of Early Deformity
- treatment involves soft-tissue releases and/or tendon transfers.
- any proposed osseous procedures must not affect growth of
the foot, such as calcaneal and/or metatarsal osteotomies.
Planter release:
- indicated for patients less than 10 years of age w/ cavus
deformity w/ significant plantar flexion of first ray.
Plantar medial release:
- indicated for rigid hindfoot w/ fixed varus angulation.
- involves planter release along w/ medial tarsal structures.
- released medial structures include talonavicular joint capsule,
superficial deltoid ligament, and possibly the long toe flexors.
Tendon transfers:
- indicated for patients w/ a supple inversion deformity w/ weak
evertors.
- a prerequisite for this procedure is a plantagrade foot which is
achieved w/ planter release.
- consider lateral transfer of tibialis antirior tendon into the
mid-tarsal region along the long axis of third ray.
Treatment
of
Rigid
Deformity
- fixed bony deformity is better managed by a combination of
calcaneal and metatarsal osteotomies and may require the use of
AFO's.
Calcaneal osteotomy:
- for correction of hindfoot varus deformity & mid-tarsal osteotomy
for correction of midfoot cavus and varus deformity.
- calcaneal osteotomy does not impede growth since it is not made
thru cartilage growth surface.
- posterior displacement calcaneal osteotomy is effective in
correcting calcaneocavus deformity of the type II neuropathy.
- in young patients w/ milder deformity, translate the distal and
posterior calcaneal fragment laterally w/o removal of an osseous
wedge.
- lateral slide osteotomy is cut slightly obliquely, passing from
superior position on lateral surface to a more inferior position on
the medial surface.
- distal fragment can be translated laterally as much as 1/3 of its
transverse diameter, thus allowing for conversion of wt-bearing
from a varus to a slight valgus position.
Treatment Cont…
Surgical therapy

Plantar fascia release:
Is usually combined with tendon transfer,
osteotomy, or both. This is frequently the
first step in improving the deformity.
Stripping the fascia off the calcaneus and
complete resection of the plantar fascia.
Treatment Cont…
Surgical therapy

Great toe Jones procedure:
Performed for cock-up deformity of the great
toe with associated weakness of the anterior
tibialis muscle. extensor hallucis longus (EHL)
has been recruited to assist in ankle dorsiflexion,
which causes hyperextension at the MTP joint
and hyperflexion at the interphalangeal (IP)
joint. This procedure transfers the EHL to the
neck of the first metatarsal with arthrodesis of
the IP joint to improve the dorsiflexion of the
ankle and remove the deforming force at the
MTP joint.
Treatment Cont…
Surgical therapy

Extensor shift procedure:
Transfer of the EHL and the extensor digitorum
longus (EDL) to the first, third, and fifth
metatarsals. The technique includes completion
of the Jones procedure with incisions in the
second and fourth web space. The tendons are
harvested. The second and third tendons are
transferred through a drill hole on the third
metatarsal, and the fourth and fifth tendons are
transferred to the fifth metatarsal.
Treatment Cont…
Surgical therapy

Girdlestone-Taylor transfer:
This procedure is used for flexible clawtoe
deformities. The deforming force of the
flexor digitorum longus tendon is
transferred to the extensors.
Treatment Cont…
Surgical therapy

Base of the first metatarsal osteotomy:
In patients with a fixed plantar-flexed first ray, a
base of the metatarsal closing wedge osteotomy
corrects the deformity, which is especially
observed in CMT disease. This procedure is
usually combined with a plantar fascia release in
a mild deformity or a Jones procedure.
Treatment Cont…
Surgical therapy

Midfoot osteotomy:
Tarsal osteotomy has been described for
deformities through the midfoot. however,
these osteotomies require cutting through
multiple joints.
Treatment Cont…
Surgical therapy

Peroneus longus to peroneus brevis
tenodesis:
In patients with CMT disease that have a
weak peroneus brevis (PB) and a
preserved peroneus longus (PL), a
tenodesis can be performed to help
stabilize the ankle. This is frequently
combined with a calcaneal osteotomy.
Treatment Cont…
Surgical therapy

Calcaneal osteotomy:
Patients with hindfoot involvement usually
require a calcaneal osteotomy to correct the
deformity. The osteotomy can include a closing
wedge, a vertical displacement, or a combination
(triplanar osteotomy). This procedure is usually
combined with a plantar fascia release and
frequently a tendon transfer.
Treatment Cont…
Surgical therapy

Beak triple arthrodesis:
The Siffert beak triple arthrodesis corrects the
deformity through wedge resection and a triple
arthrodesis. This is used for a rigid fixed
deformity in adults. The technique involves
mortising the navicular into the head. The
technique involves mortising the navicular into
the head of the talus and depressing the
navicular, cuboid, and cuneiforms to improve the
forefoot cavus deformity.
Complications


The complications of these procedures include
nonunion, malunion, infection, undercorrection,
overcorrection, recurrence of the deformity,
progression of the deformity, nerve injury, and
continued pain.
For progressive disorders, deformities can recur;
patients need to be educated about this prior to
the initial surgery.
Thank you
MoKazem.com
‫• هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل األطباء المقيمين‬
.‫ بشار ميرعلي‬.‫ تحت إشراف د‬,‫في شعبة الجراحة العظمية في مشفى دمشق‬
.‫• الموقع غير مسؤول عن األخطاء الواردة في هذه المحاضرة‬
This lecture is one of a series of lectures were prepared and •
presented by residents in the department of orthopedics in
Damascus hospital, under the supervision of Dr. Bashar Mirali.
This site is not responsible of any mistake may exist in this •
lecture.
Dr. Muayad Kadhim
‫ مؤيد كاظم‬.‫د‬