3) Pes Cavus Procedures Flashcards
Pes cavus simple definition
- Primarily a sagittal plane deformity
- Forefoot is plantarflexed on the rearfoot
- With or without plantarflexed 1st metatarsal
Pes cavus etiology
- Idiopathic
- Congenital
- Neuromuscular* (mostly CMT)
- Acquired
Goals of pes cavus tx
- Look at function requirements and goals of patient
- Consider conservative options first
- Most effective with mild flexible deformities
- Often limited / provide symptomatic relief
- Accommodative orthotics
- Bracing (AFO)
Pes cavus surgical tx goals
- Plantigrade, stable foot
- Resist deforming forces
- Long lasting
Preoperative assessment
- Thorough family history
- Growth Milestones
- Patients progression of deformity
- Rule out paralytic disease (neurological consult)
- Type of cavus
Neurological consult for pes cavus procedures
- Myelodysplasias or Spinal Dysraphisms (spinal bifida occulta)
- Hereditary motor and sensory neuropathies (CMT)
- Hereditary Degeneration of spinocerebellar tracts
- Nerve conduction and EMG studies
Type of cavus determination
- Locate apex of deformity
- Position of hindfoot
JAPAS classification
- Anterior cavus
- Posterior cavus
- Combined
Local anterior cavus
- First metatarsal is plantar flexed lower than the weightbearing area of the heel
Global anterior cavus
- Metatarsals I through V lie lower than the weightbearing of the heel and providing the main deforming force
Posterior cavus
- Vertical heel – High calcaneal inclination angle
- Calcaneal varus
Combined cavus
- Frontal
- Saggital
Flexible versus rigid deformity
- Coleman block test
- Posterior block for evaluation of ankle component
- Does heel evert past inverted or neutral position
- Can forefoot be reduced with rearfoot
Weightbearing AP radiographic evaluation
- Decreased Talocalcaneal angle
- Normal or decreased Cuboid Abduction angle
- Increased forefoot Adductus angle
- Increased TN joint “congruency”
Weightbearing lateral radiographic evaluation
- Increased calcaneal inclination
- Normal Cyma line to POSTERIOR break
- Accentuated “bullet hole” sinus tarsi
- Decreased talar declination
Calcaneal axial view to rule out
- Structural varus
Meary’s angle
- Formed between lines drawn through the longitudinal axis of the talus and its reference to the bisection of the first metatarsal
Hibb’s angle
- Bisection of the longitudinal axis of the calcaneus in reference to the first metatarsal
- Overall angle number determines the degree of cavus deformity
Cavus deformity utilizing the Hibb’s angle is determined by
- Anything that is < 130°
- Posterior cavus, this angle will approach 90°
- Anterior cavus, it will approach 130°
Coleman Block Test
- Build up the lateral column, suspending 1st ray
- Removing influence of the 1st metatarsal
- “Stress pronation x-ray of the STJ” (evaluating the position of the lateral process of the talus)
Coleman Block Test flexible vs. rigid
- Lateral process of the talus hits the floor of the sinus tarsi = Flexible Cavus
- DF wedge of the 1st metatarsal indicated, allowing STJ pronation
Cavus procedure categories
- Soft tissus
- Corrective Osteotomies
- Fusions (IPJ)
Soft tissue cavus procedures
- ST releases
- Tendon Transfers
- Tendon lengthening
Corrective osteotomy cavus procedures
- Hindfoot (Dwyer)
- Midfoot (Cole)
- Forefoot (Metatarsal bases)
IPJ fusion
- Malleous correction
- IPJ release – allowing 1st met dorsiflexion
- Strengthen flexor power
Stage II cavus deformity clinical presentation
- Calcaneus - Rigid
- MTP - Flexible
- First Ray - Rigid
Stage II cavus deformity surgical approach
- Calcaneus – Dwyer
- No MTP Release
- First Ray - DFWO
Osseous procedures
- Midtarsal osteotomies
- Metatarsal osteotomies
- Tarsal osteotomies
- Tarsal arthrodesis
Soft tissue releases
- Fasciotomies (Pediatric or adolescent patient, adjunctive procedure)
- Subcutaneous fasciotomy
- Steindler Stripping
Steindler Stripping
- Plantar fascia
- Abductor hallucis
- Flexor digitorum brevis
- Abductor digiti quinti
- Long plantar ligament is released
- Casted 3 weeks subsequent to correction - Walking cast 2-3 weeks
Cavus foot tendon transfers
- Reduce supination
- Increase pronation
- Reduce dropfoot
- Increase dorsiflexion
Tendon transfer considerations
- > 10-11 years of age
- Rarely effect permanent correction
- Removal of deforming force in controlling progressive deformity
Types of tendon transfers
- Extensor Tendon Transfers (Jones Suspension, Heyman Prodedure, Hibbs)
- Split Tibialis Anterior Tendon Transfer
- Peroneus Longus Tendon Transfer
- Tibialis Posterior Tendon Transfer
- Peroneus Anastomosis
Jones Suspension indications
- Flexible cavus
- Flexible plantarflexed 1st ray
Jones Suspension
- EHL transected at IPJ of Hallux, rerouted through hole in 1st Met head
- Sutured back to itself, proximally
- Distal stump sutured to EHB
- IPJ fusion - prevents hammering
Jones Suspension mechanics
- Compensates for overpowering peroneus longus and flexor hallucis longus
- Retrograde plantar buckling of 1st MPJ is released
- Adjunct to transfers
Hibbs Tenosuspension indications
- Flexible Forefoot or metatarsal equinus
- Flexible Cavus with Extensor Substitution
Hibbs tenosuspension
- EDL (2,3,4,&5) detached from insertion
- Tenodesed as group into dorsal foot
- Distal stumps sutured to corresponding Brevis tendon (4&5 go to 4th Brevis)
Hibbs procedure components
- Extensors transfer to the lateral cuneiform
- Plantar fascia and plantar muscle release
- TAL
Heyman procedure
- Transfer of all five long extensor tendons to respective metatarsal heads
- of distal stumps of long extensor tendons to short
- 4th and 5th to short extensor of 4th
Heyman procedure complications
- Technically difficult
- Flexion or abduction deformity of digitis
- Metatarsal fractures
- Dehiscence of skin
STATT
- Effective adjunctive procedure with flexible cavus
- Pronatory influence across the ST and Midtarsal joints
STATT procedure steps
- Tendon split to its insertion site
- Lateral fibers drawn up through proximal incision
- Rerouted down peroneus tertius sheath
- Sutured to peroneus tertius tendon, peroneus brevis, or tenodesed to cuboid
STATT incisions (3)
- Near TA insertion site
- Anterior surface of leg above cruciate ligament
- Over peroneus tertius, 1 inch proximal to insertion
Peroneus Longus tendon transfer
- Detached near cuboid
- Retrograded proximally, rerouted through lateral intermuscular septum to the anterior compartment, through extensor tendon sheath
- Inserted into the lesser tarsal area
Peroneus longus tendon transfer mechanics
- Increases ankle joint DF power
- Decreased associated dropfoot deformity
- Removes deforming force
- Increases ankle DF and eversion
- Posterior Tibial tendon transferred through interosseous membrane to dorsal midfoot
Posterior tibial tendon transfer attachment points
- Anastomosis to P. Brevis
- 3rd cuneiform / cuboid (interference screw or anchor)
Posterior tibial tendon transfer indications
- Anterior group weakness leading to drop foot
Posterior tibial tendon transfer complications
- Progressive pes valgus
- Triple arthrodesis or Talocalcaneal fusion
Peroneal anastomosis
- Peroneus longus to peroneus brevis at the level of the lateral ankle or at the base of 5th metatarsal
- Decrease plantarflexory force on the first ray
- Increasing eversion
Midtarsal osteotomies
- Cole
- Japas
- McElvenny-Caldwell
Metatarsal osteotomies
- DFWO
- Pan metatarsal osteotomies
Tarsal osteotomies
- Dwyer
- Samilson
Cole procedure
- Dorsal tarsal wedge to reduce fixed anterior cavus
- Extends from cuboid to navicularcuneiform
- Wider at medial aspect
- Subtalar and midtarsal joint motion preserved
Cole procedure fixation
- Forefoot manipulated into dorsiflexion
- Fixated (pins or screws)
- Non-WB cast immobilization 8 weeks
- WB cast for additional 4-6 weeks
Cole procedure complications
- Delayed union
- Poor cosmesis and function
- Results in a shorter, wider, thicker foot
JAPAS procedure
- Midtarsal V osteotomy at the apex of the deformity ( navicular )
- No bone is excised
- Forefoot shifted dorsally on rearfoot
Mcelvenny-Caldwell Procedure
- 1st Metatarsal-cuneiform arthrodesis
- Elevation of 1st metatarsal correcting anterior cavus
DFWO
- Dorsiflexory Wedge Osteotomy
- Preserves function of major joints
Dwyer Osteotomy
- Lateral closing wedge of the body of the calcaneus
- Indicated with a rigid calcaneovarus deformtiy
- Caution with tibial varus
- Goal is perpendicular calcaneus
- Sural nerve
- Staple/Screw fixation
- Drain
Samilson
- Dorsiflexory calcaneal osteotomy
- Dorsal displacement of posterior calcaneus
Tarsal Arthrodesis
- Before or after tendon transfers
- Medial double (STJ and TN fusion)
- CC arthroplasty vs. fusion
- Triple arthrodesis
Stage II cavus deformity clinical –> surgical decision
- Calcaneus, Flexible –> No Dwyer
- MTP, Rigid –> MTP release
- First Ray, Flexible –> No DFWO
Forefoot driven cavus
- DFW 1st Metatarsal osteotomy (1st TMT fusion, Jones tenosuspension / IPJ fusion)
- Plantar fascial release
- Steindler stripping
- Peroneal anastomosis vs. tendon transfer
Digital – Anterior global/local Flexible deformity and procedure selection
- IPJ – Flexion contracture –> IPJ fusion
- MPJ – Extension –> Extensor hood release, EHL and EDL lengthening
- MET – Retrograde plantarflexion –> Jones, Hibbs
