Pes Cavus Deformity

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Pes Cavus Deformity

• Kentucky Podiatric Residency Program
• Crystal Kincaid OCPM
• Jeff Loveland Barry

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Synonyms for Cavus Foot

• Schaffer Foot
• Lotus Flower Foot
• Bolt Foot
• Claw Foot
• Vault Foot
• Hollow Foot

• Anterior Equinus
• Pes Cavo Varus
• Contracted Foot
• Talipes (Pes) Arcuatus
• Talipes Plantaris

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What Is It?

• Extraordinarily high plantar longitudinal arch
• Arch fails to flatten out with WB
• Forefoot is plantarflexed to rearfoot
• Primarily sagittal plane deformity

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Etiology of Pes Cavus

• Neurological
• Congenital
• Iatrogenic
• Infection
• Idiopathic

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Etiology

• Neurological - 1 cause estimated at about 75
• Charcot Marie Tooth disease
• Friedrichs Ataxia
• Roussy-Levy syndrome
• Poliomyelitis
• Cerebral Palsy
• Dejerine-Sottass interstitial hypertrophic
  neuritis

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Etiology

• Congenital
• Spina Bifida
• Talipes Equinovarus
• Myelodysplasia
• Clubfoot
• Iatrogenic
• Post surgery or trauma
• Peroneal nerve injury
• Weak anterior muscles
• Overpowering posterior muscles

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Etiology

• Infection
• Syphillis
• Poliomyelitis
• Idiopathic
• Must be considered

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Presenting Complaints

• Pain and/or weakness
• Discomfort and fatigue of the foot
• Pain related to callus formation at the ball of
  the foot
• Deformity
• Trouble obtaining shoe gear
• Ankle Joint instability
• Lack of coordination

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Evaluation

• Complete History
• Include developmental, familial, and a good
  medical history
• Neurological Exam
• Evaluate motor sensory systems, assess reflexes
  and coordination tests.
• Musculoskeletal
• check strength, ROM, DTR, rotational deformities
  (hips, knees, tibia, etc.)

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Evaluation

• Biomechanical Exam
• Include gait analysis
• Wide based gait with short steps ? neurological
• High stepping ? weak AJ DF
• Kelikian push-up test test for flexible or rigid
  digital deformities
• Coleman Block Test
• Assess ankle equinus

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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

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BiomechanicsRearfoot Varus

• Block Test
• FF hanging off an edge
• Bisected Calcaneus is vertical
• STJ is Compensating
• No rearfoot frontal plane component
• Bisected Calcaneus is in varus
• STJ is partially Compensated or uncompensated
• Rearfoot frontal plane component

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BiomechanicsRearfoot Varus
Partial or Uncompensated
Tibial Varum
Compensated
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Other Diagnostic Tests

• Electromyography (EMG)
• Nerve conduction velocity
• Muscle biopsy
• Nerve biopsy
• Blood Tests
• Blood smear shows acanthocytosis
  (Bassen-Kornzweig syndrome)

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Radiographs

• AP
• Evaluate transverse plane deformities
• Metatarsus adductus
• Kites Angle
• T-N articulation
• AP Ankle
• deformity may not be at foot ankle in varus

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Metatarsus Adductus Angle

• Is formed by a line perpendicular to the
  bisection of the lesser tarsus and a line
  representing the lesser metatarsus
• The lesser metatarsus is represented by the
  bisection of the dorsal longitudinal axis of the
  shaft of the second metatarsal
• Normal MA is less than 21o
• As the foot becomes more adducted, this angle
  increases and a greater chance exists for
  abductus deformity at the first MPJ joint

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Talocalcaneal Angle (Kites Angle)

• Is formed by the bisection of the longitudinal
  axis of the rearfoot and head and neck of the
  talus
• Normal is 15-30o and 75 of talus head
  articluates with the navicular
• Supination is 16o or less and greater than 75
  articulation

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Radiographs

• Lateral
• Evaluate
• Calcaneal inclination angle
• Talar declination angle
• Mearys angle
• Hibbs angle
• Metatarsal declination angle
• Evaluate sinus tarsi and cyma line

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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 gt 40

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Calcaneal Inclination Angle
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Talar Declination Angle

• Is formed by the weight bearing surface of the
  foot and the bisection of the head and neck of
  the talus
• Normal is 21o

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Mearys Angle

• Talometatarsal angle
• Bisection of talus intersects with bisection of
  the 1st met.
• Normal lines should be parallel
• Abnormal gt 4
• Intersects at apex of the deformity

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Hibbs Angle

• long axis of calcaneus as it intersects with
  bisection of the 1st met.
• Intersects at apex of the deformity
• Represented by angle A

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Pes CavusClassification

• Anterior Can be
  
• Posterior Structural(Rigid)
• Combined Positional(Flexible)

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Anterior Cavus Foot

• Sagittal plane deformity
• Excessive PF of FF on RF
• Metatarsal Cavus (apex at Lisfrancs joint)
• Lesser Tarsal Cavus
• Forefoot Cavus (apex at Choparts joint)
• Combined Cavus Foot (2 or more listed above)

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Anterior Cavus Foot

• Local PF of 1st ray only
• Global entire FF is PF
• Differentiating these two is important in
  determining proper surgical procedure

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Anterior Cavus Foot

• C.I.A. lt 30
• Mearys angle gt 10
• Mearys angle intersects at base of 1st
  metatarsal or Lisfrancs joint

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Rigid Anterior CavusCompensation

• Pseudoequinus
• Functional limitation of AJ dorsiflexion caused
  by premature use of the AJ motion to compensate
  for pure sagittal plane anterior pes cavus
  deformity
• No STJ compensation

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Flexible Anterior CavusCompensation

• FF dorsiflexion at midfoot with WB forces
• Plantar buckling at MPJs
• Retraction of toes at MPJs

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Posterior Cavus Foot

• Primarily STJ deformity
• Less common than anterior pes cavus

• C.I.A. gt 30
• Mearys angle lt 10
• Mearys angle intersects proximal to Choparts
  joint

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Posterior CavusCompensation

• Sagittal plane
• A) Flexible
• Plantarflexion Comp.
• No change in CIA
• B) Rigid
• FF plantarflexion Comp.
• Decreased CIA

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Combined Cavus Foot

• Anterior and Posterior components
• ? C.I.A., talar declination angle, met.
  declination angle

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Combined Cavus Foot

• Primary Anterior
• C.I.A. 30
• Mearys angle intersects at N-C joint

• Primary Posterior
• C.I.A. gt 30
• Talar varus
• Mearys angle intersects at Choparts joint

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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

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Treatment Goals

• Correct the deformity
• Relieve pain
• Maintain a balanced foot

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Principles of Treatment

• Underlying etiology MUST be determined
• The plane of the deformity is critical
• Cavus foot requires multilevel correction
• ie. Digits, Lisfrancs joint, Midfoot, Rearfoot

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Non Operative Treatment

• Indications mild pes cavus or when surgery is
  contraindicated
• Shoe modifications and inserts
• build up shoe
• AFO
• Physical Therapy
• Stretching

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Surgical Correction

• Soft tissue procedures
• indicated for flexible deformities
• often used in conjunction with osseous procedures
• Osseous procedures

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Surgical Treatment Classification

• Type I Mild Pes Cavus
• Flexible, may appear normal w/ WB
• Tylomas and metatarsalgia
• Contracted digits w/ extensor substitution
• Surgery
• MPJ release
• PIPJ fusions
• Hibbs procedure
• Other soft tissue releases

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Surgical Classification

• Type II Moderate Pes Cavus
• More rigid and more evident clinically
• Primarily sagittal plane deformity
• Hammertoes, tylomas, metatarsalgia
• Surgery
• DFWO of 1st metatarsal
• Dwyer calcaneal osteotomy
• Digital procedures

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Surgical Classification

• Type III Severe Pes Cavus
• Marked rigid deformity
• Gait abnormalities
• Multiplanar
• Surgery
• Major tarsal fusions or osteotomies
• Digital procedures
• Triple arthrodesis

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Soft Tissue Procedures

• Plantar Fascia Release
• Steindler Stripping
• Garceau Brahms
• Tendon Transfers
• Jones
• Hibbs
• STATT
• PT Tendon Transfer
• PL Tendon Transfer

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Pes CavusTreatment

• Early deformity
• plantar release
• indicated in pt lt10 y/o with signif pf of 1st ray
• plantar medial release
• indicated for rigid hindfoot w/fixed varus
  angulation
• plantar release w/medial tarsal structures
• tendon transfers
• indicated for supple inversion deformity w/ weak
  evertor
• lateral transfer of Tib Ant T to midtarsal area
  along 3rd ray

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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

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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

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Hibbs Suspension
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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

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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

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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.

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Osseous Procedures

• Digital Reduction
• DFWO metatarsals
• COLE
• JAPAS
• Dwyer
• McElvenny-Caldwell
• Triple Arthrodesis

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Digital Reduction

• restore MPJ alignment
• PIPJ arthrodesis
• Extensor hood resection
• Extensor tendon lengthening
• flexor plate release
• Fixate (K-wire)

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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

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COLE

• DFWO at MTJ
• base is dorsal apex is proximal
• often do plantar release also
• preserves STJ MTJ motion
• indications
• anterior cavus

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JAPAS

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

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JAPAS
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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

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Dwyer
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Dwyer
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McElvenny-Caldwell

• Fuse 1st metatarsocuneiform navicular joints in a
  DF position

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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)

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Triple Arthrodesis
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Triple Arthrodesis
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Pes Cavus

• Disadvantages of midtarsal osteotomies
• Stiffness
• Non-unions
• Under/over correction
• Edema
• Neurovascular compromise

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Important Points

• ID etiology
• ID apex of deformity
• Determine from examination the appropriate
  correction technique.

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Bibliography

• Canale, S. Terry, M.D.. Campbells Operative
  Orthopaedics. Mosby. St. Louis, 1998.
• Hansen, Sigvard, M.D.. Functional Reconstruction
  of the Foot and Ankle. Lippincott Williams
  Wilkins. Philadelphia, 2000.
• 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. Lippincott Williams
  Wilkins. Baltimore, 2001.

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Bibliography

• Myerson, Mark, M.D. Foot and Ankle Disorders.
  W.B. Saunders Company. Philadelphia, 2000.
• Resnick, Donald, M.D.. Bone and Joint Imaging,
  2nd edition. W.B. Saunders Company.
  Philadelphia, 1996.
• Sammarco, James, M.D., Taylor, Ross, M.D..
  Cavovarus Foot Treated with Combined Calcaneus
  and Metatarsal Osteotomies. Foot Ankle
  International. 221 19-30. 2001.

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Thank You